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Evidence-Based Reviews


Adult with ADHD? Try medication + psychotherapy

Works ‘top down’ on negative thinking and ‘bottom up’ on ADHD core symptoms.

Vol. 5, No. 2 / February 2006
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Mr. B, age 50, dreams of becoming a computer programmer but fears he will embarrass himself—as he has in many classrooms before. He is seeking evaluation because his teenage son was recently diagnosed with attention-deficit/hyperactivity disorder (ADHD), and he recognizes similar symptoms in himself.

Mr. B received a college degree with great difficulty, putting off assignments until the last minute and “squeaking by.” For years he has changed occupations often, never progressing beyond entry level, and now works as a personal care provider and limousine driver. He reports problems keeping up with work and managing time.

His history includes early childhood hyperactivity, difficulty sitting through classes, sloppy handwriting, disorganization, short attention span, and distractibility. He is restless, fidgety, and has trouble staying on topic. His disorganization has caused marital difficulties, for which he has sought counseling.

After careful evaluation, you determine that Mr. B meets criteria for ADHD, combined type, and for anxiety disorder not otherwise specified. His treatment goals are to increase his ability to focus; procrastinate less; improve his planning, prioritizing, and self-esteem; and to become less sensitive to criticism and less anxious about handling work demands.

Like Mr. B, adults with ADHD need treatment for the disorder’s core symptoms as well as its psychiatric comorbidities and psychosocial consequences. Comprehensive treatment with medications, cognitive-behavioral therapy (CBT), and environmental adaptations is usually recommended.

Comorbidity rules

Core symptoms. ADHD is a lifespan disorder with multiple behavioral, cognitive, and emotional manifestations that impair relationships and academic and vocational functioning. ADHD-like symptoms are seen in other conditions such as mood disorders or substance abuse, but complaints of inattention, distractibility, procrastination, restlessness, and impulsivity—particularly when pervasive and chronic—are highly indicative of ADHD.

In treating adults with ADHD, we have noticed common behavioral patterns that contribute to their psychosocial problems (Table 1). Dysfunctional coping behaviors have short-term advantages, but patients readily admit they would rather accomplish tasks through greater thought and planning.

Chronic frustrations—often associated with deep shame—are typical of adult ADHD. Many patients have maladaptive core beliefs of failure, self-mistrust, and inadequacy (Table 2).

Table 1

Common dysfunctional behavioral patterns in adults with ADHD

Behavior

Description

Short-term gain/long-term loss

Anticipatory avoidance

Magnifying the difficulty of a pending task and doubts about being able to complete it; results in rationalizations to justify procrastination

Defers short-term stress, but often creates a self-fulfilling prophecy because the task looms and may seem overwhelming when facing a deadline

Brinksmanship

Waiting until the last moment (eg, the night before) to complete a task, often when facing an impending deadline

Deadline-associated stress can be focusing, but this tactic leaves little room for error and may yield a substandard result

Pseudoefficiency

Completing several low-priority, manageable tasks (eg, checking e-mail) but avoiding high-priority tasks (eg, a project for work)

Creates sense of productivity by reducing items on to-do list but defers a more difficult project

Juggling

Taking on new, exciting projects and feeling ‘busy’ without completing projects already started

It is easier to become motivated to start a novel project than to complete an ongoing one; pattern usually results in several incomplete projects

Table 2

5 common maladaptive core beliefs of adults with ADHD

Self-mistrust

‘I cannot rely on myself to do what I need to do. I let myself down’

Failure

‘I always have failed and always will fail at what I set out to do.’

Inadequacy

‘I am basically a bad and defective person.’

Incompetence

‘I am too inept to handle life’s basic demands.’

Instability

‘My life will always be chaotic and in turmoil.’

Psychiatric comorbidity is the rule in adults with ADHD (Table 3). For example, among 43 patients who received combined medication and CBT at the University of Pennsylvania Adult ADHD Treatment and Research Program, 75% reported at least one comorbid condition, including:

  • 27 (63%) with mood disorder
  • 23 (54%) with anxiety disorder
  • 5 (12%) with substance abuse.1

Other treatment studies have reported similar comorbidity rates in adults with ADHD.2-4

Table 3

Psychiatric comorbidity in adult ADHD

Disorder

Prevalence

Mood disorders

50% to 65%

  Recurrent depression

  Bipolar disorder

  Cyclothymia

  Dysthymia

  Depressive disorder NOS

Anxiety disorders

40% to 55%

  Generalized anxiety disorder

  Anxiety disorder NOS

Others

Various

  Substance use disorder

  Learning disabilities

  Intermittent explosive disorder

  Tourette syndrome

  Antisocial personality

  Borderline personality disorder

  Dependent personality

NOS: Not otherwise specified

Making the diagnosis

Diagnosis of adult ADHD is based on a comprehensive assessment, including:

  • careful history of presenting complaints
  • thorough review of educational, occupational, and family history
  • standardized rating scales (such as the Barkley ADHD Behavior Checklists, the Conners’ Adult ADHD Rating Scale, or the Brown Attention Deficit Disorder Scales)
  • collateral information
  • assessment of mood, anxiety, substance use, and learning/organizational skills. For details, consult references on adult ADHD.5-8

Case continued: Self-fulfilling prophesies

On standardized rating scales, Mr. B meets criteria for combined ADHD for childhood and current symptoms. Information from his wife and brother also confirms the ADHD diagnosis.

He is motivated, resilient, optimistic, and has a good support system. However, his negative automatic thoughts about his ability to succeed in school and to handle increasing time demands suggest deeper beliefs of inadequacy and failure.

Mr. B struggled academically. Without guidance about how to change his approach to difficult situations, he has repeated old thinking and behavior patterns. Believing he will embarrass himself and fail to learn required material, Mr. B procrastinates and avoids doing assignments. In class, his feelings of inadequacy make him self-conscious, which causes him to lose focus and have trouble concentrating.

See the world through the patient’s eyes

Understanding your patient. Before you start treatment, we recommend that you conceptualize how ADHD has influenced your patient’s life, including:

  • developmental experiences
  • family-of-origin issues, such as conflicts with parents stemming from ADHD symptoms or reciprocal interactions with an ADHD parent
  • world view (“schemata”)
  • patterns of coping with (or avoiding) stress
  • attitudes toward self and important others
  • readiness to change.

Developing a working case conceptualization is a dynamic, collaborative process. You talk with patients, and encourage them to reflect on how ADHD affects their view of themselves and their important relationships. The conceptualization takes shape as you:

  • observe patients’ behaviors
  • elicit how they think and feel
  • assess with them the relevance and accuracies of their belief systems and response patterns.

Seeing the world “through their eyes” prepares you to help them accept the diagnosis and learn to manage ADHD symptoms. Then, by providing a blueprint to manage what patients may see as uncontrollable responses, you can help them take charge of their automatic reactions.

Psychoeducation. To set the stage for treatment, encourage patients to learn about ADHD by reading articles and books and consulting Web sites for adults with ADHD (see Related resources). Psychoeducation helps patients:

  • review possible treatment approaches, including organizational (environmental) management, medication, and psychotherapy (individual or group)
  • become informed participants in setting treatment goals.

Explain the relative contribution of each treatment component. For example, medications can reduce distractibility and improve attention, organizational strategies can reduce disorganization and improve time management, and structured psychotherapy can help the patient develop more effective coping skills.

Case continued: Planning combined treatment

You discuss diagnosis and treatment options with Mr. B, and he agrees to start the methylphenidate compound Concerta, initially at 18 mg/d, and weekly CBT sessions. You recommended a stimulant based on efficacy studies and your clinical experience in treating adults with ADHD. Mr. B wants a medication that will help him focus while working or studying, and he says Concerta has improved his son’s ADHD symptoms.

You instruct Mr. B to increase the dosage by 18 mg each week until he reaches 72 mg/d. You also tell him to keep a medication response log and to note any positive changes and side effects.

If an adult with ADHD expresses preference for a particular medication, we usually prescribe that one first. Most patients to whom we offer both medication and psychotherapy agree to this “top-down” and “bottom-up” approach. “Top down” means giving patients new ways of thinking to help them understand and modify their responses. “Bottom up” refers to the medication reducing their impulsivity, distractibility, and inattentiveness.

CBT for adult ADHD

Medications can ameliorate key symptoms of adult ADHD, but adjunctive interventions are needed to improve functioning and quality of life. Evidence supporting psychosocial treatment for adults with ADHD is limited, but CBT has been studied the most.1,9-13 Safren et al13 found a four-fold greater therapeutic response when patients received adjunctive CBT for residual ADHD symptoms, compared with patients who received medication alone.

We usually provide CBT weekly for 12 weeks and then taper to 8 additional sessions over 3 months (total 20 sessions). We may extend CBT with additional sessions to address complicated issues. CBT helps adults with ADHD to:

  • identify dysfunctional thinking, feeling, and behaving patterns
  • recognize contexts in which patterns arise
  • systematically change these patterns.

CBT can reduce ADHD-associated anxiety and depression and improve coping skills and sense of well-being.1,9,11 Its flexibility allows you to address family issues with patients’ partners, children and other relatives to improve communication, reduce conflict, and develop healthier interactions.

We focus CBT sessions on finding alternate coping strategies. We might try role playing, rehearsing, creating “thought experiments,” and anticipating and preparing to modify typical patterns of avoidance. These approaches have been described elsewhere.10,11,14

We adopt an active stance during therapy to keep ADHD patients’ distractibility from disrupting our conversation. For example, we set the therapeutic agenda, provide feedback about patients’ behaviors, and encourage them to clarify rewards and consequences of using (or avoiding) problem-solving strategies.

Although we typically assign between-session homework, we expect patients to have difficulty completing it. We remain nonjudgmental and collaborative, viewing incomplete assignments as opportunities to learn about patients’ unproductive problem solving and to help them develop more-effective patterns.

Challenging maladaptive beliefs. A strong therapeutic relationship allows adults with ADHD to discuss their chronic frustrations, which often are associated with deep shame. We then shift CBT’s focus to deeper ADHD-related schemata that perpetuate dysfunctional patterns.

We work with patients to elucidate and challenge their maladaptive core beliefs and encourage new ways to view themselves and others. Allowing patients to grieve about the limitations ADHD imposes on their lives also helps to reduce chronic negative self-esteem.

Case continued: ‘less frenetic’

Mr. B achieves good results within 3 weeks of an increasing titration of stimulant medication, reporting significantly less restlessness and greater concentration without significant side effects. His wife confirms that he is less frenetic, can converse without interruptions, and is better at managing his complicated work schedule.

Which medications?

Drug therapy for adult ADHD is not as well-studied as in children and adolescents, but American Academy of Child and Adolescent Psychiatry guidelines and others15-18 recommend stimulant and nonstimulant medications. Your choice depends on the patient’s clinical profile (including risk factors and comorbid conditions), past medication use, treatment goals, preferred medication effects and dosing patterns (once-daily versus multiple times), and potential side effects. Stimulants or atomoxetine are first-line choices for adult ADHD without psychiatric comorbidity.

Stimulants work quickly and are cleared relatively rapidly from the brain without causing euphoria or dependency. They are effective (80% to 90% response rate) and well-tolerated, though long-term effects have not been studied in adults (Table 4).

Stimulants’ effect size of 0.9 is considered substantial. Effect size—a statistical method of reporting an intervention’s effect across different studies—is typically rated as:

  • <0.32 very small
  • 0.33 to 0.54, moderate
  • >0.55, significant or very strong.

When choosing a medication, we usually try methylphenidate and amphetamine first, one after the other. We explain to the patient how stimulants work in the brain and the need for a comparative trial to determine which might work best for him or her. If the patient has tried a stimulant and found it helpful, we start with that class. Similarly, if he/she has not had good results with one type, we start with the other. Approximately one-third of our patients respond equally well to methylphenidate or amphetamine, one-third respond better to methylphenidate, and one-third respond better to amphetamine.

To determine the optimal dosage, we usually titrate up from 10 to 30 mg per dose of an immediate-release preparation. We begin with this form to help patients notice the medication’s onset and duration of action. After we find the optimal dosage, we switch to a longer-acting preparation.

Continued...
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