Adhd addiction 2015

Attention deficit Hyperactivity disorder

ADDICION

By

Soheir H. ElGhonemyAssist. Professor of Psychiatry- Ain Shams University

Certified Member of International Society of Addiction Medicine

Member of WPA, EPA, APA

Trainer Approved by [email protected]

While child and adolescent therapists are familiar with the treatment

of attention-deficit/hyperactivity disorder (ADHD), many adult

physicians have had little experience with the disorder.

It is difficult to develop clinical skills in the management of residual

adult manifestations of developmental disorders without clinical

experience with their presentation in childhood.

The definition of ADHD has been updated in the (DSM-5) to more

accurately characterize the experience of affected adults.

ADHD, although a disorder that begins in childhood, can continue

through adulthood for some people.

Previous editions of DSM did not provide appropriate guidance to

clinicians in diagnosing adults with the condition.

By adapting criteria for adults, DSM-5 aims to ensure that children

with ADHD can continue to get care throughout their lives if

needed.

Changes in the Disorder:

ADHD is characterized by a pattern of behavior, present in multiple

settings (e.g., school and home), that can result in performance

issues in social, educational, or work settings.

In DSM-IV, symptoms are divided into two categories of inattention

and hyperactivity and impulsivity that include behaviors like failure

to pay close attention to details, difficulty organizing tasks and

activities, excessive talking, fidgeting, or an inability to remain

seated in appropriate situations.

Children must have at least six symptoms from either (or both)

the inattention group of criteria and the hyperactivity and

impulsivity criteria.

While older adolescents and adults (over age 17 years) must

present with five. While the criteria have not changed from DSM-

IV, examples have been included to illustrate the types of

behavior children, older adolescents, and adults with ADHD

might exhibit.

Using DSM-5, several of the individual’s ADHD symptoms must

be present prior to age 12 years, compared to 7 years as the

age of onset in DSM-IV. No clinical differences between children identified by

7 years versus later in terms of course, severity, outcome, or treatment response.

The prevalence of ADHD in adults estimated from

epidemiological studies is in the range of 2-5%

Childhood Becomes Adulthood

School failure or underachievement

Job failure or underemployment

Multiple injuriesFatal car wrecks or risk

taking

Drug experimentation Drug dependence

Oppositional defiant or conduct disorder

Antisocial personality disorder, criminality

Impulsivity, carelessnessUnwanted pregnancy, sexually transmitted

disease, etc

Repetitive failureHopelessness, frustration,

giving up

Courtesy of W. Dodson, MD

Common Clinical Histories

Difficulties in Elementary or Secondary School

Comments: “not living up to potential,” “spacey,” “hyper”

Behavioral issues: “class clown”

Difficulties in College

Incomplete degree or longer time to complete degree

Difficulty engaging in further education

Difficulties at Work

Underachievement (mixed reviews)

Low efficiency: 4 times longer to complete tasks

Difficulties at Home

Poor organization, does not complete tasks

Strained relationships with spouse and kids(who also may have ADHD)

There are many challenges in identifying undiagnosed ADHD in

SUD settings. This is particularly important since SUD patients

with comorbid ADHD often present with severe forms of SUD

characterized by early onset, extended duration of SUD,

greater impairment and a shorter transition from substance

use to dependence. ADHD has been found to increase suicide

risk in SUD adolescents. Poor treatment outcomes.

Domains of Impairment

Impairments

Academic/

Occupational

Health/Injury

Addiction

Sexual Behavior

CriminalitySocial Functioning

Self-esteem

“ADHD is not a problem with knowing what to

do; it is a problem of doing what you know.”

Barkley, 2006

ADHD impacts each patient differently, depending

on their characteristic strengths and challenges.

It can be helpful to appreciate that at the core, ADHD

symptoms describe problems controlling what a

person engages in—the moment-by-moment

selection of mental and physical activities.

ADHD is linked to an early-appearing and enduring subcortical

dysfunction (weak arousal mechanisms), while symptom

remission is dependent on the extent of maturational changes in

executive control.

The interaction between these two processes, with remission or

persistence of ADHD symptoms related to the emerging balance

between cortical and sub-cortical function.

ADHD cannot be evaluated well without good information about

the patient’s mental health and function (e.g. School records,

early school assessments, and old clinical, spouse and

parent..etc)

A third party offers a chance to evaluate self-observation

capacity, and to characterize the interpersonal context in which

their concerns arise.

The fact that medications for ADHD can be abused or misused

also raises appropriate concern that patients may present as

having ADHD to meet unhealthy goals. Stigma

It is also inappropriate to deny assessment or treatment to

patients with ADHD due to such concern.

Link Between ADHD and Addiction

People with ADHD commonly attempt to soothe their restless

brains and bodies with addictive substances such as alcohol,

marijuana, heroin, prescription tranquilizers and pain killers,

nicotine, caffeine, sugar, cocaine and street amphetamines.

When people use substances to try to improve their abilities, or

decrease and/or numb their feelings it is called self-

medicating.

Initially, self-medicating works. It provides people with ADHD

some relief from their symptoms. For some, drugs such as

nicotine, caffeine, cocaine, diet pills and speed enable them to

focus, think clearly and follow through with ideas and tasks.

Others choose to soothe their ADHD symptoms with alcohol and

marijuana.

What starts out as a solution can cause addiction, impulsive

crimes, domestic violence, increased high-risk behaviors, the

loss of jobs, relationships and families and death. Too many

people with untreated ADHD learning and perceptual disabilities

are incarcerated or dying from co-occurring addiction.

Self-medicating ADHD with alcohol and other drugs is like

trying to put out a fire with gasoline.

The person suffering from ADHD has pain and problems that

are burning out of control and their lives could explode as they

attempt to douse the flames with substance abuse.

Who will become addicted?

People with ADHD are vulnerable to abusing mind-altering

substances.

There are many reasons why one person becomes addicted

and another does not. No single cause for addiction exists;

rather, a combination of factors is usually involved: genetic

predisposition, neurochemistry, family history, trauma, life stress

and other physical and emotional problems contribute.

Combination and timing of these factors.

Prevention and early intervention:

Some individuals’ biological and emotional attraction to drugs is

so powerful that they cannot conceptualize the risks of self-

medication.

This is especially true for the person with ADHD who may have

an affinity for risky, stimulating experiences. This also applies to

the person with ADHD who is physically and emotionally

suffering from untreated ADHD with symptoms including

restlessness, impulsiveness, low energy, shame, attention and

organization problems, and a wide range of social pain.

Untreated ADHD and addiction relapse:

Many individuals in recovery have spent hours in therapy

working through childhood issues, getting to know their inner

child and analyzing why they abuse substances and engage in

addictive behaviors.

Untreated ADHD contributes to addictive relapse, impulsively

quits jobs and relationships, cannot follow through with his or

her goals, and has a fast chaotic or slow energy level.

Treating both ADHD and addictions

It is not enough to treat addictions and not treat ADHD, nor is it

enough to treat ADHD and not treat co-occurring addictions. Both

need to be diagnosed and treated for the individual to have a

chance at ongoing recovery.

I. A professional evaluation for ADHD and co-occuring addiction.

II. Continued involvement in addiction recovery groups or 12-step

programs

III. Education about how ADHD affects each individual’s life and the

lives of those who he cares for.

IV. Building social, organizational, communication and work or

school skills

V. Close monitoring of medication when medication is indicated

Stages of recovery:

Pre-recovery

Early recovery

Middle recovery Long-term

recovery

Pre-recovery:

This is the period before a person enters treatment for their

addictions. It can be difficult to sort out ADHD symptoms from

addictive behavior and intoxication.

The focus at this point is to get the person into treatment for the

chemical and/or behavioral addiction. This is not the time to treat

ADHD.

During this period can sort out ADHD from the symptoms of

abstinence, which include distractibility, restlessness, mood

swings, confusion and impulsivity. Much of what looks like ADHD

can disappear with time in recovery.

Early Recovery:

In most cases, this is not the time to use psycho-

stimulant medication, unless the ADHD is affecting

his or her ability to attain sobriety.

Middle Recovery:

Addicts and alcoholics are settling into recovery, and they

usually seek therapy for problems that did not disappear with

recovery. It is much easier to diagnose ADHD at this stage; and

medication, when indicated, can be very effective.

Long-term Recovery:

This is an excellent time to treat ADHD with medications when

warranted.

By this stage, most people in recovery have lives that have

expanded beyond intense focus on staying clean and sober.

Their recovery is an important part of their life, and they have

the flexibility to deal with their ADHD.

Medication and addiction:

Psycho-stimulant medication when properly prescribed and

monitored is effective for approximately 75 to 80 percent of

people with ADHD.

The problem is that many are hesitant for good reasons to use

medication, especially psycho-stimulants. But, it is important to

note that when these medications are used to treat ADHD the

dosage is much less than what addicts use to get high.

When people are properly medicated they should not feel high or

“speedy,” instead they will report increases in their abilities to

concentrate, control their impulses and moderate their activity

level.