ADULT ADHD – A NEW ENTITY IN PSYCHIATRY (DSM V)

A t t e n t i o n – d e f i c i t / h y p e r a c t i v i t y d i s o r d e r (ADHD) is characterized by a “persistent pattern of inattentive, hyperactive, and impulsive behavior that begins early in childhood, often persists throughout development, and interferes with adaptive functioning” (1).
Traditionally considered a disorder belonging to the child and adolescent psychiatry, ADHD is now a condition that gathers several simptoms that are recognized also in adult psychopathology. After several years of debating whether or not it should be considered this diagnosis in adult psychiatry, from the DSM V perspective there is a well established diagnosis of adult ADHD.
Historically, the adult ADHD diagnosis has been the subject of many controversies, starting from the mid-1970s, when Wender and colleagues at the University of Utah published initial findings on minimal brain dysfunction in adults. Studies of adults diagnosed as hyperactive in childhood and clinical descriptions of childhood hyperactivity persisting in adults with other psychiatric disorders where the elements that led Wender to consider the possible persistence of ADHD into adulthood .
Today, it is estimated that 5%–8% of school- aged children and 4% of adults in the United States suffer from some form of attention deficit disorder, DSM V suggesting 5% in children and 2,5% in adults. In terms of gender it is considered the following proportion: B/F=2/1 (1,6/1 adults) (1).
In DSM V the perspective on ADHD diagnosis has been changed, in the direction of facilitating the diagnosis: the age of the symptoms’ onset is 12 instead of
7, the number of symptoms necessary for diagnosis is 5 in adults.
As we know, nowadays a corect examination and diagnosis is a clinical examination sustained by a standardised evaluation. To explore the adult ADHD pathology, based on the DSM-IV criteria, clinicians use the Diagnostic Interview for ADHD in Adults (DIVA), scale developed by J.J.S. Kooij and M.H. Francken (2, 3). It follows the earlier Semi-Structured Interview for ADHD in adults. The scale evaluates the symptoms present (18 criteria ) in both chilhood and adulthood and gives examples from everyday life, that makes the evaluation easy to perform. The information is taken from the patient and it can be sustained by another family member. Other instruments used are Wender Utah Rating Scale, Conners Rating Scale (2, 3).
There is considerable interest in development of nonclinical, laboratory tests for adult ADHD, a reason being the fact that these methods are more objective than clinical interviews and clinical diagnostic criteria. There are different researchers that used tests of executive functioning and working memory, laboratory tests of a t t e n t i o n , q u a n t i t a t i v e e l e c t r o e n c e p h a l o g r a p h y , neuroimaging methods using proton magnetic resonance spectroscopy (4, 5, 6, 7).
The research shown neurocognitive and biological differences between persons with and without ADHD.The majority of studies are limited though to small numbers of subjects. Another issue is the financial one, because laboratory assessments involve significantly more expense than rating scales and clinical interviews, and they have no proven advantage over clinical diagnosis of ADHD (8).
Given its history, the disorder has been better studied in children. The latest data show that the persistance of ADHD simptoms in the areas of attention deficit, impulsivity and hiperkinesia in adult life may interfere with functionning. In adults hiperactivity, manifested by reslessness, is less proeminant than in children. Impulsivity leads to hasty actions, potentialy harmful, interrupting others, bad decision making. Inatention leads to bad concentration, disorganised work. Even if in most of the cases the intensity of the simptomatology is weaker than in children, it was shown that in time it is frequently associated with clinical and psychological impairments. ADHD has been associated with poor socioeconomic outcome, functional impairments and high rates of psychiatric comorbidity, or some unpleasant events such as car accidents. For some adults, simptoms can be unrecognised and explained by other diagnoses such as anxiety, depression, cyclothymia, dysthymia, personality disorders, bipolar disorders, substance use disorders (9, 10, 11, 12).
Given the increasing evidence of the impact of this disease on functionality, there has been a growing interest in studying the course of the disease in the adult life. There have been several lines of research in the recent literature.
Some have examined the association between ADHD severity and the lifetime prevalence of other psihiatric conditions in adults with ADHD, such as depressive episodes, anxiety disorders, substance use disorders (9, 10, 11).
Another issue approached was the differential diagnosis of ADHD and he possibility of different interpretation of symptoms. An example is the differential diagnosis with Bipolar Disorder. There are some elements to consider if we are thinking of an affective disorder. The clinical picture in mania includes euphoria, mood changes, irritability, distractibility, inattentiveness, polipragmasia, overactivity, increased energy, insomnia. Some symptoms are similar to those in ADHD. But, to a closer look, in a longitudinal analysis, there are some differences. The course of bipolar disorder is an episodic one, with an intensity variation of symptoms in time, meanwhile, in ADHD the symptoms are somehow constant (10). In depressive disorders the depressive mood can be sometimes accompanied by restlessness, incapacity to relax, even agitation, irritability, but the accent of the patient`s complains is usually on he ideas of incapacity, uselessness.
Let us look closer to the area of personality disorders. Unlike affective disorders, that have an episodic pattern, personality disorders have symptoms that are relatively constant in time, somehow similar to ADHD symptoms.
A personality disorder is “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress and impairment” (DSM V) (1). In DSM V the classic approach of personality disorders remained the same, but it has also been elaborated an alternative model for this pathology. The ten specific personality disorders are grouped as we know in three clusters (cluster A: paranoid, schizoid, schizotypal; cluster B: antisocial, borderline, histrionic, narcissistic; cluster C: avoidant, dependent, obsessive-compulsive) (1). Latest data suggest that 10- 20% of the general population has a personality disorder. The alternative model is a dimensional one. Personality disorders are characterized by impairments in personality functioning (identity, self-direction, empathy, intimacy) and pathological personality traits (Negative affectivity, Detachment, Antagonism, Disinhibition, Psychoticism) (1). This approach is somehow similar to the spectrum approach used in other disorders, having the aim to better evaluate the individual in a population in which traits are continuously distributed (1).
If we are referring to personality disorders in cluster B, antisocial and borderline PD, often associated with substance use pathology (alcohol, opioids, amphetamines, cocaine, etc) and pay attention to the sequence of symptoms and their evolution, there are a few things to be observed. Longitudinal studies show that symptoms that lead to a diagnosis of ADHD are visible at the beginning. In time they may lead to the development of antisocial behavior, evolution thought to be mediated by environmental influences (12, 13).
Another direction in recent literature has been the interest in the characterization of patients with early and late onset of ADHD impairment in terms of neuropsychological and personality characteristics. There were some researchers that describe correlations between the temperament and its dimensions the way it was classically described by Cloniger and symptoms of ADHD. Temperament describes an individual’s profile of biological response patterns to external stimuli, which is reflected in individual differences in emotional responses to the environment. The independent dimensions are: novelty seeking (NS), harm avoidance (HA), reward dependence (RD), and persistence (PS) (14, 15, 16, 17).
A very interesting aproach of the idea that what happens during childhood has an impact on future pathology is described by Henrik Anckarsarter in his study
. His hypothesis is that “ADHD and autism spectrum disorders are associated with specific temperament configurations and an increased risk of personality disorders and deficits in character maturation” (18).
In his study he evaluated adults with specific instruments like TCI, SCID-II for personality disorders disorders and scales for other neuropsychiatric disorders (18). Keeping in mind the Cloninger’s biopsychosocial theory of personality (based on the assumption that personality involves four temperament dimensions and three character dimensions), he assessed the individuals’ abilities such as attention, impulse control, adaptive decision-making strategies, adequate perception, control of voice, posture, mimicry, interpersonal skills, mentalizing (18). Their variation may influence in his opinion personality development to a greater extent than recognized in current personality theory (18). His ideas are that certain childhood temperament profiles may impair healthy character development, producing personality disorders in adulthood (18). Patients with ADHD were shown to have high novelty seeking and high harm avoidance. Cluster B personality disorders were more common in subjects with ADHD, while cluster A and C disorders were more common in those with autism spectrum disorders. The overlap between DSM-IV personality disorder categories was found to be high (18). Personality disorders were found to be common in follow- up studies of subjects with neuropsychiatric disorders. The conclusion was that “a patient with a childhood-onset neuropsychiatric disorder, particularly if previously undiagnosed, might well be diagnosed as having a “primary” personality disorder when assessed in adult age” (18).
If we are to consider the therapeutic area, we find elements to sustain the importance of the ADHD d i a g n o s i s . S t i m u l a n t m e d i c a t i o n ( a t o m o x e t i n e , methylphenidate) has proven its efficacy in treating ADHD symptoms in child for years. Medication has been used with success in adults but the experience is more limited. There is now an interest in studying the efficacy of stimulant medication in reducing the evolution of simptoms in adult life (19). There are however several controversies regarding the risks and benefits of the therapy. One of the concerns is the potential for addiction of the stimulant medication.
As a conclusion, we can say that exploring the area of ADHD pathology, especially the persistance of symptoms in the adult life would lead to an important improvement of the quality of life of some of our patients. Some of the simptoms misdiagnosed at first can benefit of specific treatment that can influence the evolution of the disease and prevent complications.

REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5 ed. Washington, DC: American Psychiatric Publishing, 2013.
2. Faraone S, Biederman J, Spencer T et al. Diagnosing Adult Attention Deficit Hyperactivity Disorder: Are Late Onset and Subthreshold
Diagnoses Valid? Am J Psychiatry 2006;163: 1720-1729. doi:10.1176/appi.ajp.163.10.1720.
3. Searight R, Burke J, Rottnek F et al. Adult ADHD: Evaluation and Treatment in Family Medicine. Family Medicine of Saint Louis Residency Program. Saint Louis, Missouri Am Fam Physician 2000;62(9): 2077-2086.
4. Cortese S, Kelly C, Chabernaud C et al. Toward Systems Neuroscience of ADHD: A Meta-Analysis of 55 fMRI Studies. Am J Psychiatry
2012;169: 1038-1055. doi:10.1176/appi.ajp.2012.11101521
5. Clerkin S, Schulz K, Berwid O et al. Thalamo-Cortical Activation and Connectivity During Response Preparation in Adults With Persistent and Remitted ADHD. Am J Psychiatry 2013;170: 1011-1019. doi:10.1176/appi.ajp.2013. 12070880
6. Nakao T, Radua J, Rubia K et al. Gray Matter Volume Abnormalities in ADHD: Voxel-Based Meta-Analysis Exploring the Effects of Age and Stimulant Medication. Am J Psychiatry 2011;168: 1154-1163. doi:10.1176/appi.ajp.2011.11020281
7. Biederman J, Petty C, Fried R et al. Impact of Psychometrically Defined Deficits of Executive Functioning in Adults With Attention Deficit Hyperactivity Disorder. Am J Psychiatry 2006;163: 1730-1738. doi:10.1176/appi.ajp.163.10.1730
8. Hinnenthal J, Perwien A, Sterling K. A Comparison of Service Use and Costs Among Adults With ADHD and Adults With Other Chronic Diseases. Psychiatric Services 2005. doi: 10.1176/appi.ps.56.12.1593
9. Biederman J, Petty C, Wilens T et al. Familial Risk Analyses of Attention Deficit Hyperactivity Disorder and Substance Use Disorders. Am J Psychiatry 2008;165: 107-115. doi:10.1176/appi.ajp.2007. 07030419
10. Faraone S, Biederman J, Wozniak J. Examining the Comorbidity Between Attention Deficit Hyperactivity Disorder and Bipolar I Disorder: A Meta-Analysis of Family Genetic Studies. Am J Psychiatry 2012;169: 1256-1266. doi:10.1176/appi.ajp.2012.12010087
11. Watts V. Addressing Comorbid ADHD, Substance Abuse Disorder in A d o l e s c e n t s . C l i n i c a l a n d R e s e a r c h N e w s 2 0 1 4 . d o i :
10.1176/appi.pn.2014.12a15
12. Biederman J, Petty C, Monuteaux M et al. Adult Psychiatric Outcomes of Girls With Attention Deficit Hyperactivity Disorder: 11- Year Follow-Up in a Longitudinal Case-Control Study. Am J Psychiatry
2010;167: 409-417. doi:10.1176/appi.ajp.2009.09050736
13. McGough J, Barkley R. Diagnostic Controversies in Adult Attention Deficit Hyperactivity Disorder. Am J Psychiatry 2004;161: 1948-1956. doi: 10.1176/appi.ajp. 161.11.1948
14. Barkley RA, Murphy KR. Deficient emotional self-regulation in adults with attention-deficit/hyperactivity disorders (ADHD): the relative contributions of emotional impulsiveness and ADHD symptoms to adaptive impairments in major life activities. J ADHD Relat Disord
2010; 1: 5-28.
15. Barkley RA. Deficient emotional self-regulation: a core component of attention-deficit/hyperactivity disorder. J ADHD Relat Disord 2010;1: 5-37.
16. Khushmand R, Trampush J, Rindskopf D et al. Association Between Variation in Neuropsychological Development and Trajectory of ADHD Severity in Early Childhood. Am J Psychiatry 2013;170: 1205-1211. doi:10.1176/appi.ajp.2012.12101360
17. Surman C, Biederman J, Spencer T et al. Deficient Emotional Self- Regulation and Adult Attention Deficit Hyperactivity Disorder: A Family Risk Analysis. Am J Psychiatry 2011;168: 617-623. doi:10.1176/appi.ajp.2010. 10081172
18. Anckarsäter H, Stahlberg O, Larson T et al. The Impact of ADHD and Autism Spectrum Disorders on Temperament, Character, and Personality Development. FOCUS Spring 2010;8(2): 269-275.
19. Reimherr FW, Marchant BK, Strong RE et al. Emotional dysregulation in adult ADHD and response to atomoxetine. Biol Psychiatry 2005;58: 125-131.

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