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Lynae Friend

Volume 1, Case #14

COLLAPSE

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Presentations of ADHD

The diagnosis of attention-deficit/hyperactivity disorder (ADHD) in adults is about half of that in children (Stahl, 2013). This is because ADHD is harder to diagnose in adults. Most likely, this is due to adults referring themselves to medical healthcare professionals as opposed to family members noticing the symptoms and referring them (Stahl, 2013). Adults also often have a comorbid condition, such as substance abuse disorder, mood disorder, or anxiety disorder that need stabilized prior to addressing ADHD (Stahl, 2013).

Questions to Ask the Patient

1. Do you often have trouble getting tasks done at work? One of the diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) with primarily inattentive presentation is failing to pay close attention to details or making careless mistakes at work or in other activities (American Psychiatric Association, 2013).

2. Do you lose focus quickly and fail to finish household chores? Another diagnostic criterion for ADHD with inattention presentation is often does not follow through on instructions and fails to finish chores or duties in the workplace (American Psychiatric Association, 2013).

3. Do you often lose or quit jobs frequently? This is a common problem among adults who have undiagnosed ADHD (CHADD, 2020).  

People to Ask Questions to Related to the Patient

1.      Parents- I would want to speak to the patient’s parents to find out if the patient had symptoms of ADHD as child. ADHD can typically be diagnosed by the age of seven because of the abnormalities in the prefrontal cortex (Stahl, 2013). Thus, I would want to ask the parents the following questions:

a.      Did she had difficulty paying attention and finishing tasks?

b.      Did she often lost things, such as school materials, pencils, and books (American Psychiatric Association, 2013)?

c.       Did she often want to run and climb on things when it was inappropriate (American Psychiatric Association, 2013)?

1. Daughter- I would want to ask the patient’s daughter questions because she can provide a picture of what the patient is like at home. The questions are symptoms from the Diagnostic and Statistical Manual 5th edition (DSM-5) in diagnosing ADHD.  The questions I would ask include:

a. Is your mom often forgetful in things such as making your school lunches or signing permission slips (American Psychiatric Association, 2013)?

b. Does your mom often blurt out answers before you have completely asked the question (American Psychiatric Association)?

2. Siblings- The patient’s siblings can also help the provider know if the patient has symptoms of ADHD. Questions I would ask them are also symptoms from the DSM-5 and include:

a. Does your sister seem to listen when spoken directly to (American Psychiatric Association, 2013)?

b. Is she often reluctant to engage in activities that require sustained mental effort (American Psychiatric Association, 2013)?

c. Does she have trouble waiting her turn while in a line (American Psychiatric Association, 2013)?

Physical Exams and Diagnostic Tests

Providers can diagnose ADHD by using the guidelines in the DSM-5 (Centers for Disease Control and Prevention, [CDC], 2019). According to the CDC (2019), a patient can be diagnosed with ADHD primarily inattention if he or she has the following symptoms:

a. Failing to give close attention to detail.

b. Trouble holding attention on tasks.

c. Does not follow through on instructions and fails to finish schoolwork, chores, or duties.

d. Has trouble organizing tasks and activities.

e. Avoids, dislikes, or is reluctant to do tasks that require mental effort.

f. Loses things necessary for tasks and activities.

g. Is easily distracted.

h. Often forgetful in daily activities.

According to the CDC (2019), patients can be diagnosed with ADHD with primarily hyperactivity and impulsivity if he or she have the following symptoms:

a. Often fidgets with or taps hands or feet, or squirms in seat

b. Leaves seat in situations when one is expected to remain in seat.

c. Feelings of restlessness.

d. Unable to take part in activities quietly.

e. Talks excessively.

f. Blurts out answers before the question is completed.

g. Trouble waiting his or her turn.

h. Interrupts or intrudes on others.

Adults who are diagnosed with ADHD only need five or more of the symptoms listed above (CDC, 2019). It is important to note that ADHD is not often diagnosed during one appointment because adults often have other conditions that resemble ADHD (Attention Deficit Disorder Association, [ADDA], 2020). However, adults can also complete an Adult Self-Report Scale (ASRS) Screener that consists of questions to help the provider seek out a formal ADHD diagnosis (ADDA, 2020).

Differential Diagnosis

Attention-Deficit Hyperactivity Disorder, inattention type

Generalized Anxiety Disorder

Major Depressive Disorder

            The most likely diagnosis is attention-deficit hyperactivity disorder (ADHD), inattention type. I chose this diagnosis because after she completed the ASRS she had symptoms such as trouble wrapping up final details of a project, difficulty getting things in order, difficulty remembering appointments, and difficulty listening during conversations (Stahl, 2008). She can have a formal diagnosis of ADHD, inattentive type with five or more symptoms associated with it.

Two Pharmacologic Agents

Adderall XR 10 mg daily in the morning

Stratterra 40 mg daily in the morning

I would choose to start the patient on Adderall XR 10 mg daily in the morning. Adderall works by increasing norepinephrine and dopamine by blocking their reuptake (Stahl, 2017). Additionally, enhancing dopamine and norepinephrine in certain areas of the brain improves attention, concentration, executive function, and wakefulness (Stahl, 2017).  Stratterra is a non-stimulant and works mainly by blocking the norepinephrine reuptake pump (Stahl, 2017). However, it can increase dopamine neurotransmission in the frontal cortex (Stahl, 2017).

Lessons Learned

            I learned that diagnosing ADHD in adults is difficult because there are often other comorbid conditions associated with it. I also learned that just because one stimulant causes a patient to have jitteriness does not mean another stimulant will have the same effect. Thus, it would be appropriate to change the patient to another stimulant when it is effective, even if the first one caused the patient to be jittery. I will apply this to my practice by not limiting myself or the patient on medications because one feels jittery on a stimulant. I will look into other stimulants to see if they can be more effective.

References

Attention Deficit Disorder Association. (2020). Adult ADHD test. Retrieved from https://add.org/adhd-test/

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Centers for Disease Control and Prevention. (2019). Symptoms and diagnosis of ADHD. Retrieved from https://www.cdc.gov/ncbddd/adhd/diagnosis.html

CHADD. (2020). Diagnosis of ADHD in adults. Retrieved from https://chadd.org/for-adults/diagnosis-of-adhd-in-adults/

Stahl, S. M. (2008). Essential psychopharmacology online. Retrieved from https://stahlonline-cambridge-org.ezp.waldenulibrary.org/viewPdf?page=csEP_14

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical    applications (4th ed.). New York, NY: Cambridge University Press.

Stahl, S. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide (6th ed.). San Diego,  CA: Cambridge University Press.

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