Past case 2: ADHD

Question 1

Sam is a 24-year-old trainee real estate agent who presents to your general practice expressing increasing frustration because of difficulty managing workplace demands. He reports longstanding difficulties with organisation and time management, motor restlessness (though less than when he was a child), persistent difficulty concentrating on reading tasks, and trouble retaining revised materials for exams. He has a reputation for being late and he is beginning to lose friendships because of his unreliability and erratic behaviour. He is underperforming at work and has returned home to live after developing debts due to impulsive spending. He denies feeling depressed but is worried about his future. He has a childhood history of Attention Deficit Hyperactivity Disorder (ADHD), and received methylphenidate and biofeedback treatments between 8-13 years. However, he refused all treatments and follow up as a teenager because he did not believe he had a problem. He is polite but appears restless and impatient and asks you for a script for stimulants so that he can perform better at work and in his studies.

Answer 1

Impression
Sounds like a continuation of ADHD symptoms since ceasing medications/relapse of ADHD sup toms. Would of course consider other potential diagnoses in this setting. ADHD in adult setting is diagnosed on the basis of clinical assessment so would like to conduct a full psychiatric assessment.

Ddx to consider/co-morbidities to rule out

• GAD
• SUD
• Other neurocognitive: ASD
• Other psych: Bipolar, depression, psychosis

Question 2

1. What further history you would like and why, in order to define the presenting problem. (5 min)

Answer 2

History
DSM5 definition for ADHD defines it as a pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, as characterised by either (1) inattention, and/or (2) Hyperactivity
1) Inattention: 6 or more of sx for at least 6 months
- fails to pay close attention to details
- cannot sustain attention in tasks
- doesn’t seem to listen
- can’t follow through with instructions
- easily distracted by extraneous stimuli
- avoids tasks which require mental effort
2) Hyperactivity: 6 or more of the sx for at least 6 months
- fidgets
- leaves seat when shouldn’t
- on the go
- difficulty waiting for things
- blurts out an answer in conversation
- interrupts or intrudes on others

• Sx: ask about both inattention and hyperactivity symptoms. Ask about impulsive spending,
• further characterise ADHD in childhood, response to treatment, when was first diagnosis (pre-12 to meet DSM criteria)
• screen for psychotic, mania, depressive sx
• Risk assessment (TOSH - ADHD can have significant functional co-morbidity which can cause depressive sx)
• social: relationships, finances, work, home life
• substances
• developmental history
• fam history (ADHD = hereditary)

Could utiilise Connors adult ADHD rating scale (CAARS) to assist in the assessment

Question 3

2. Differential diagnosis

Answer 3

Differentials
Provisional
- relapse/persistence of ADHD symptoms

Differentials

• rule out organic causes: drugs/alcohol, brain tumour, endocrinological disorder
• Mood disorder: Depression, bipolar, anxiety
• Psychosis: unlikely, but need to exclude as stimulants are not indicated in psychosis
• Anxiety disorders: particularly GAD, OCD

Things to be looking for on MSE

• formal thought disorder
• delusions, hallucinations
• manic symptoms (DIGFAST)
• suicidality
• speech: pressured

Question 4

3. What advice would you give the patient about further assessment and/or management options

Answer 4

Diagnosis of ADHD is made on basis of clinical assessment
Assessment
- refer to psychiatrist/other specialist for review and management decision making input
- GP cannot initiate/prescribe stimulants, they need a special licence/qualification

Management
- take into account patient needs and preferences
Safety/risk
- risk to reputation, relationships, harm to others, occupational stability
-risks of comorbid illnesses
- financial risk

Setting/location
- outpatient most appropriate - referral to ADHD specialist/psychiatrist as available

Biological

• Will likely need to restart 1st line pharmacological treatment with stimulants
• dexamphetamines are best tolerated in adults, could restart lisdexamfetamine.
• Principles: start low, go slow, titrate according to response. Can change short vs long-acting medications depending on patient preference and daily work demands
• A/E. important to rule out psychosis first as stimulants are contraindicated in psychosis, severe depression, suidical ideation.
• other A/E to consider; tachycardia, N/V, movement disorders, palpitations, HTN, insomnia, loss of appetite, weight loss
• treat any comorbidities

Psychological
- psychoeducation, what ADHD is, prognosis, management, reassure that it is a common condition which can be effectively treated
- CBT: assist in controlling thoughts and behaviours
Social