Diagnosis and Treatment of Adult Attention Deficit Disorder

Attention deficit disorder has been recognized as the most common under-diagnosed psychiatric disorder in adults and a major contributor to drug abuse, automobile and industrial accidents and underachievement.  

Characteristics of adult ADHD include: 

• Difficulty concentrating. 

• Inattention. 

• Reading, repeat reading, and rereading again to understand the material. 

• Difficulty initiating and finishing tasks. 

• Disorganized behavior. 

• Difficulty establishing a routine. 

• Forgetfulness. 

• Misplacing things. 

• Shifting activities prematurely. 

• Low frustration tolerance. 

• Frequent daydreaming. 

• Hyperactivity.

Considerable symptom overlap between bipolar disorder and ADD may lead to diagnostic confusion.  Twenty-one percent of childhood ADD patients will develop bipolar disorder and 10 percent of ADD adults have a risk of developing bipolar disorder. 

Key distinguishing features of ADD include rereading material, shifting activities and poor concentration. 

While diagnostic features of BPD include elation, grandiosity, racing thoughts, decreased need for sleep and severe mood instability.  

Untreated ADD can lead to substance abuse as patients seek to relieve symptoms by self-medicating.  If ADD is consistently treated, the risk of substance abuse is the same as in the general population.  

Psychostimulant treatment of ADD appears to protect against the development of substance abuse.  

Medications used to treat ADD include:  

Adderall (dextroamphetamine + amphetamine)—amphetamines enhance the release of presynaptic dopamine and block reuptake of dopamine.  

• A study involving over 2600 subjects showed the efficacy of Adderall exceeding that of other medications. 

• Once the proper dose is reached response is almost immediate. 

• At the proper dose patients often report a feeling as if a spotlight has been focused on the task at hand. 

• Interestingly, patients report less anxiety when taking Adderall because their anxiety about failure to get things done has diminished. 

• If patients report increased anxiety the diagnosis is wrong or the dose is too high.   

Ritalin (methylphenidate)—blocks the reuptake of dopamine. Most often used to treat ADHD in children. 

Strattera (atomoxetine)—a norepinephrine reuptake inhibitor that is the first nonstimulant approved by the FDA for treatment of ADD.  Side effects include hypersomnia, nausea, dizziness and GI distress. I have found this medication to be ineffective in my clinical practice.  

Wellbutrin XL—multisite study showed efficacy.  

Tricyclics—1000 subjects in 13 controlled studies showed TCAs effective in every study.  Side effects limit their use.