what is the DSM5 definition of ADHD? the subtypes?
attention deficit hyperactivity disorder now called neurodevelopmental disorder
- ADHD combined = whole spectrum (OCD and can’t focus; most kids and adults)
- ADHD inattentive (not hyperactive)
- ADHD hyperactive/impulsive (focused)
- other specified or unspecified
must start before age 12, and symptoms in multiple settings, causing social disability
what is “ADD”?
attention deficit disorder = ADHD inattentive
what are the requirements for “inattention symptoms”?
6 symptoms for 6 mo:
- poor attention to detail –> mistakes
- cannot sustain attention
- doesn’t listen
- doesn’t follow through
- doesn’t organize
- avoids tasks
- loses things
- is distracted
- is forgetful
what are the requirements for “hyperactive/impulsive” symptoms?
6 symptoms for 6 mo:
- fidgets
- leaves seat
- runs/climbs
- not quiet
- talks a lot
- blurts out
- cannot wait turn
- interrupts
what is the course of ADHD?
most often apparent at young age where age-appropriate norms for paying attention and delayed gratification are not met
- mmilder and more attentive cases may not be noticed until later in life when demands are greater
- inattentiveness tends to persist greater than hyperactivity/impulsivity
what are the 5 possible etiology for ADHD?
- genetics and heredity
- neuronal/brain developmental delay
- neurological/neurotransmitter abnormalities
- environmental factors
- psychological factors
explain the genetics of ADHD?
at least 76% heritable; Xm 16 is the most obvious finding
-genes linked to dopamine, NE, serotonin, neurotransmission, and neuronal plasticity
what does hypo or hyperactivity in terms of neuronal firing and tone cause?
major hypo: major depressive disorder, schizophrenia, negative symptoms
mild hypo: ADHD
mild hyper: hypervigilant
major hyper: psychosis
explain the neuronal/brain developmental delay with ADHD?
develop 2 years slower in development and pruning
-anterior cingulate (ACC) doesn’t fire, while other areas are active when they shouldn’t be (prefrontal cortex, basal ganglia, cerebellum, temporal/parietal cortex)
what are the key neurotransmitters involved in ADHD?
NE - decreased tonic NE firing in PFC
DA - decreased tonic DA firing in PFC
5HT - unknown, but controls locomotion and behavioral and cognitive impulsivity
what are environmental factors for ADHD?
- cigarette/alcohol use in pregnancy
- lead poisoning
- head injuries
- possible high sugar, food color additives?
- learned behavior or reaction to stress?
what are differential diagnosis and associated conditions with ADHD?
- autism spectrum disorder
- learning disability
- substance use disorder
- personality disorder
- bipolar disorder
- anxiety disorder (highest correlation)
- depression
medication management for ADHD? information on them?
- stimulant class has great efficacy in adults, teens, children
- promote DA and NE to increase activity
- most carry risk of addiction, paranoia in misuse
- stunted growth (1/4 to 1/2 inch), weight loss (curbed appetite)
- cardiac issues - non-stimulants have less efficacy but no addiction risk
- all are sedating, and some (except NRI) may lower BP
what are examples of non-stimulant medications?
atomoxetine (NRI; NE reuptake inhibitor) and guanfacine/clonidine ER (extended release; a2 NE agonists)
what is psychotherapy management for ADHD?
behavioral modification and training
- self-control therapy
- behavioral parent training
- relaxation
- education support
- distraction control
- attention sustaining
- cognitive restructuring
what are the “steps” for ADHD pharmacy for pre-schoolers?
- behavioral therapy
- amphetamines
- methylphenidate (MPH)
what are the “steps” for ADHD pharmacy for children and adolescents?
- slow-release methylphenidate (MPH)
- slow-release amphetamines
- immediate release stimulants
- clonidine ER, guanfacine ER, atomoxetine (non-stimulants)
what are the “steps” for ADHD pharmacy for adults?
- clonidine ER, guanfacine ER, atomoxetine (non-stimulants)
- slow-release amphetamines
- slow-release MPH (methylphenidate)
- immediate-release stimulants
how do non-stimulants work for ADHD?
HCN channel linked to cAMP has both a2 (NE) and D1; neurosignals go through here
- NE –> closed HCN –> less leakage of signal –> more signal and focus (achieved by NRI; NE reuptake inhibitors)
- -improve signal to noise ratio, allowing neuron to fire appropriately
- DA –> open HCN –> more leakage –> less focus (preferably inhibit this)
what is the prognosis for ADHD?
range from poor to excellent
- sometimes ADHD symptoms promote success and wellbeing, but patients have less school, less powerful jobs, lower self-esteem, more antisocial behavior, greater addiction rates, greater divorce rates, but equal rates of medical illness
- 2/3 showed no psychopathology or mental disorder in adulthood
what are the different non-stimulants and how do they differ?
- atomoxetine: NET inhibitor only (NE reuptake inhibitor)
- guanfacine ER and clonidine ER: agonize or stimulate a2 NE receptor
-
Insomnia11
-
Schizophrenia49
-
ADHD21
-
Bipolar Related Disorders28
-
Addiction Day44
-
Psychotherapy51
-
Somatoform disorders19
-
Major Depressive Disorder26
-
Suicide25
-
Anxiety56
-
Delusions12
-
Child Psychiatry46
-
The Life Cycle44
-
Pain32
-
Dementia59
-
Eating Disorders27
-
Psychodynamics42
-
Personality Disorder25
