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The Impact of Undiagnosed ADHD in Adults


Patient History and Introduction

Patient History and Introduction

ND, a 44-year-old attorney, presents upon referral from her husband, an internist, who is concerned about his wife's depression, fatigue, and poor concentration. ND had been receiving physical therapy for the past 4 months since she was involved in a minor automobile accident. Despite her protests, ND was ticketed, which was her third infraction in the past 24 months. Although the anatomic location of her injury could not be determined, she was anergic and complained of generalized muscle pain. Five weeks after the accident ND returned to work, but she was terminated 2 weeks later. She asserted she was unfairly dismissed because of her prolonged medical leave, but her employer insisted that her performance had been declining for some time.

ND agreed to her husband's request for psychiatric consultation ostensibly to discuss her accident and resulting job loss. Upon questioning, the psychiatrist established that ND's depressed mood preceded both her accident and job loss. She reported that her earliest contact with the mental health system was as a child. In fourth grade, the patient was seen by a psychologist to address her persistent separation anxiety. Throughout middle school she did poorly academically and underwent educational testing. She scored very high on the IQ examination and her teachers and counselors were perplexed by the discrepancy between her daily performance and overall aptitude. As she aged, her problems continued. In college, a psychologist informed her that she had borderline personality disorder. Subsequent psychiatric diagnoses included major depressive disorder, bipolar II disorder, and dysthymia.

Other than her muscle pain and intermittent migraine headaches, ND had no other current medical complaints.

Over the past 4½ years, ND has undergone therapeutic trials of lamotrigine, nortriptyline, sertraline, and extended-release venlafaxine. She acknowledged that the medications and courses of individual and family psychotherapy were helpful, but she felt that they yielded limited benefit. In addition to her current selective serotonin reuptake inhibitor, she uses an extensive amount of over-the-counter acetaminophen. ND has struggled with overuse of hydrocodone in the past.

In recent years, ND has been in marital therapy. Her husband complains about her chronic disorganization and impetuous temper. The patient has a tumultuous relationship with her adolescent children and has little patience for them. Her 16-year-old son has a history of oppositional-defiant disorder, academic difficulties, and marijuana dependency. ND's mother has a history of alcohol abuse.

On mental status examination, ND appeared distressed, anxious, and fidgety. She had mild psychomotor agitation and demonstrated mood lability but denied auditory or visual hallucinations. The patient endorsed passive suicidal ideations but had no plan to harm herself.

Recent physical examination and blood test results were unremarkable. Comprehensive psychological screening was pursued. The Hamilton Rating Scale for Depression revealed mild depression. ND's score on the Hamilton Anxiety Scale showed moderate generalized anxiety. The CAGE screening test for alcohol dependence was negative. The Mood Disorder Questionnaire did not reveal the presence of a manic episode. A Millon Index of Personality Styles Revised test identified passive-dependent traits. Notably, the Attention-Deficit/Hyperactivity Disorder (ADHD) Rating Scale (ADHD-RS) and the Conners' Adult ADHD Rating Scale were globally elevated.

ND was frustrated and anxious. She demonstrated inattention, distractibility, hyperactivity, and impulsivity. These longstanding symptoms cause daily functional impairment. Her family history suggests that similar symptoms are present in her mother and possibly her son. Multiple trials of various antidepressants and mood stabilizers proved unsatisfactory.

ND's symptoms met the criteria for ADHD, combined type. She was given an educational video explaining the condition. At the next appointment, ND and her husband reported that the description of adult ADHD accurately described ND's lifelong struggle. They were relieved that her symptoms were being viewed in a different way.

ND was started on extended-release mixed amphetamine salts (MAS-XR), which was chosen because of its high level of efficacy and long duration of action -- typically 10 to 12 hours per dose. In addition, she was referred to a coach with a particular interest and training in the phenomenon of adult ADHD.

ND returned 1 month later. Her medication had been titrated up in 10-mg/wk increments to 30 mg each morning and she reported dramatic improvement. Her focus was better and her concentration was stronger. She had greater motivation and energy, and she noticed more mood stability. ND was more patient with her children and had made progress organizing her house. As a result, her relationship with her husband had improved.

ND did lament that her symptoms seemed to return at 5:00 PM. She established that she was taking her MAS-XR at 6:00 AM. A short-acting dose of MAS was added at 4:30 PM to address the end-of-dose rebound that she was experiencing. Upon return visit 2 weeks later, ND reported that her entire day was smoother and she was no longer experiencing a late afternoon return of symptoms. With little adjustment, this regimen has been maintained for the past 3 years. She has returned to work in law and remains hopeful about her continued recovery.