Adult attention deficit hyperactivity disorder: a case report

INTRODUCTION

Attention-deficit/hyperactivity disorder (ADHD) has been accepted undoubtedly as a neuro-developmental disorder with main symptoms of inattention, hyperactivity and impulsiveness. 60% of children with ADHD continue to have same diagnosis in the adulthood.¹ The expression of ADHD symptoms change as the child grows up. Whereas, the restlessness of childhood ADHD is aimless, adult ADHD present with purposeful restlessness.

Adult ADHD have lots of comorbidities such as anxiety disorder, substance use, depression which obscures the diagnosis of ADHD.² Studies have showed that the DSM-IV criteria for childhood ADHD work as well for adults as they did for children, but that a lower threshold of symptoms (five instead of six) is sufficient for a reliable diagnosis. Although diagnostic criteria for ADHD are the same across the lifespan, presenting symptoms vary by developmental level.³ For example, hyperactivity in a child typically presents as an inability to sit in one place and excessive running and jumping.

Adults with hyperactivity from ADHD may be prone to fidgeting excessively while trying to sit still, or they may engage in speeding while driving. Hyperactive and impulsive symptoms are much common in children, while inattentive symptoms are more common in adults. Inattentive symptoms commonly reported by adults with ADHD include being easily distracted, difficulty sustaining attention, difficulty with sustained mental effort, inability to listen, and tendency to lose things. Procrastination with an inability to complete tasks initiated is another commonly reported symptom. Inattentive symptoms are similar in men and women, although one study showed women more frequently reported “losing things”.

Hyperactive symptoms in adults, other than speeding while driving, include feeling uncomfortable while sitting through meetings, impatience waiting in line, and having workaholic tendencies. Impulsive symptoms include talking too much, talking out of turn, blurting out inappropriate comments, and intruding on others. These symptoms of ADHD must be present in multiple settings (e.g., home, work) and cause functional impairment for at least 6 months to meet criteria for the diagnosis. Childhood diagnosis of ADHD is also prerequisite criteria.⁴

CASE REPORT

A 23 year old male, studied till class 9th and driver by occupation, came to our psychiatric OPD, with the chief complaints of inattention, inability to concentrate, low mood, decreased appetite. Patient reported that there are frequent thoughts coming to his mind that he is unable to do things in way he wants to like to do. He was also suffering from inability to make correct decisions while he was driving a car or talking to someone. He had difficulty in starting and completing any work. He had a past history of frequently breaking the traffic rules. He told he was not able to stop himself from doing that. His mind stopped working whenever decision making or where sustained attention was required. Like while driving the car he had difficulty in maintains attention towards signals, clutch-brake-accelerator sequence. Due to these complaints had been frequently having problems in his work. He was on the verge of losing a job as a driver when showed to us in the OPD. Due to these complaints he started having mood symptoms. In which he used to have low mood, decrease attention and concentration, easy fatigability, decreased interest in pleasurable activities. He told that these complaints would flare up whenever he was at work. And when he was at home taking rest he would feel comfortable. There was family history positive for any psychiatric illness and ADHD. There was no positive history of substance use.

Initially he was kept under observation for obsessive compulsive disorder mainly obsessions and moderate depression. Later on further interview he was given adult ADHD self-report scale (ASRSv1.1) which showed that patient was screen positive for ADHD. The patient was then evaluated in detail on the SCID 1 and SCID II as per the Diagnostic and statistical manual of mental disorders 5th edition text version (DSM-V-TR) criteria and the Wender-Utah criteria for adult ADHD. His IQ was above average.

In childhood, he had persistent problems with academic achievement and behavior. He endorsed a history of eight inattentive and six hyperactive-impulsive DSM-IV ADHD symptoms during early grade school. The patient in the childhood use to have leadership qualities. He always wanted that he should be always on top and for this he always used to take an easy way around. He had difficulties to stand in the queue for long period of time. The ADHD rating scales of childhood behavior confirmed considerable difficulties with inattentive and hyperactive-impulsive symptoms. Ratings of current symptoms were notable for inattention. Clinical review of current DSM symptoms revealed impairment from six inattentive and three hyperactive symptoms. The patient was diagnosed with adult ADHD inattentive type; no evidence was seen of other coexisting psychopathology.

The patient and family were psycho-educated about the nature and course of ADHD, the patient agreed to a medication trial. Escalating doses of a once-a-day stimulant (methylphenidate), this was started at 10 mg sustained release preparation. The dose was increased to 20 mg third day. The doses were titrated over several weeks. At his follow-up visits, we noticed the response during the titration and determined an optimal dose. The patient experienced significant reduction of his inattentive symptoms and reported greatly improved his work stress.

DISCUSSION

The above case presented with typical symptoms of ADHD such as inattention, distractibility, irritability, impulsivity. These had led to feelings of low self esteem and depressive mood. Due to these symptoms patient also had problems in academic, financial, career and interpersonal spheres.⁵ The drug of choice in adult ADHD is methylphenidate and was prescribed to this patient. Patient showed significant improvement in ADHD symptoms, his mood and socio-occupational functioning.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Barkley RA, Fischer M, Edelbrock CS, Smallish L. The adolescent outcome of hyperactive children diagnosed by research criteria an 8 year prospective follow-up study. J Am Acad Child Adolesc Psychiatry. 1990;29:546-57.
2. 2. Lenard A. Clinical presentations of adult patients with ADHD. J Clin Psychiatry. 2004;65(3):8-1.
3. 3. Hirvikoski T, Waaler E, Alfredsson J. Reduced ADHD symptoms in adults with ADHD after structured skills training group: results from a randomized controlled trial. Behav Res Ther. 2011;49:175-85.
4. 4. Dopheide J, Pliszka SR. Attention-deficit–hyperactivity disorder: an update. Pharmacotherapy. 2009;29:656-79.
5. 5. Biederman J, Petty CR, Monuteaux MC. Adult psychiatric outcomes of girls with attention deficit hyperactivity disorder: 11-year follow-up in a longitudinal case-control study. Am J Psychiatry. 2010;167:409-17.