adhd addiction 2015
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Attention deficit Hyperactivity disorder
ADDICION
By
Soheir H. ElGhonemyAssist. Professor of Psychiatry- Ain Shams University
Certified Member of International Society of Addiction Medicine
Member of WPA, EPA, APA
Trainer Approved by NCFLDselghonamy@hotmail.com
While child and adolescent therapists are familiar with the treatment
of attention-deficit/hyperactivity disorder (ADHD), many adult
physicians have had little experience with the disorder.
It is difficult to develop clinical skills in the management of residual
adult manifestations of developmental disorders without clinical
experience with their presentation in childhood.
The definition of ADHD has been updated in the (DSM-5) to more
accurately characterize the experience of affected adults.
ADHD, although a disorder that begins in childhood, can continue
through adulthood for some people.
Previous editions of DSM did not provide appropriate guidance to
clinicians in diagnosing adults with the condition.
By adapting criteria for adults, DSM-5 aims to ensure that children
with ADHD can continue to get care throughout their lives if
needed.
Changes in the Disorder:
ADHD is characterized by a pattern of behavior, present in multiple
settings (e.g., school and home), that can result in performance
issues in social, educational, or work settings.
In DSM-IV, symptoms are divided into two categories of inattention
and hyperactivity and impulsivity that include behaviors like failure
to pay close attention to details, difficulty organizing tasks and
activities, excessive talking, fidgeting, or an inability to remain
seated in appropriate situations.
Children must have at least six symptoms from either (or both)
the inattention group of criteria and the hyperactivity and
impulsivity criteria.
While older adolescents and adults (over age 17 years) must
present with five. While the criteria have not changed from DSM-
IV, examples have been included to illustrate the types of
behavior children, older adolescents, and adults with ADHD
might exhibit.
Using DSM-5, several of the individual’s ADHD symptoms must
be present prior to age 12 years, compared to 7 years as the
age of onset in DSM-IV. No clinical differences between children identified by
7 years versus later in terms of course, severity, outcome, or treatment response.
The prevalence of ADHD in adults estimated from
epidemiological studies is in the range of 2-5%
Childhood Becomes Adulthood
School failure or underachievement
Job failure or underemployment
Multiple injuriesFatal car wrecks or risk
taking
Drug experimentation Drug dependence
Oppositional defiant or conduct disorder
Antisocial personality disorder, criminality
Impulsivity, carelessnessUnwanted pregnancy, sexually transmitted
disease, etc
Repetitive failureHopelessness, frustration,
giving up
Courtesy of W. Dodson, MD
Common Clinical Histories
Difficulties in Elementary or Secondary School
Comments: “not living up to potential,” “spacey,” “hyper”
Behavioral issues: “class clown”
Difficulties in College
Incomplete degree or longer time to complete degree
Difficulty engaging in further education
Difficulties at Work
Underachievement (mixed reviews)
Low efficiency: 4 times longer to complete tasks
Difficulties at Home
Poor organization, does not complete tasks
Strained relationships with spouse and kids(who also may have ADHD)
There are many challenges in identifying undiagnosed ADHD in
SUD settings. This is particularly important since SUD patients
with comorbid ADHD often present with severe forms of SUD
characterized by early onset, extended duration of SUD,
greater impairment and a shorter transition from substance
use to dependence. ADHD has been found to increase suicide
risk in SUD adolescents. Poor treatment outcomes.
Domains of Impairment
Impairments
Academic/
Occupational
Health/Injury
Addiction
Sexual Behavior
CriminalitySocial Functioning
Self-esteem
“ADHD is not a problem with knowing what to
do; it is a problem of doing what you know.”
Barkley, 2006
ADHD impacts each patient differently, depending
on their characteristic strengths and challenges.
It can be helpful to appreciate that at the core, ADHD
symptoms describe problems controlling what a
person engages in—the moment-by-moment
selection of mental and physical activities.
ADHD is linked to an early-appearing and enduring subcortical
dysfunction (weak arousal mechanisms), while symptom
remission is dependent on the extent of maturational changes in
executive control.
The interaction between these two processes, with remission or
persistence of ADHD symptoms related to the emerging balance
between cortical and sub-cortical function.
ADHD cannot be evaluated well without good information about
the patient’s mental health and function (e.g. School records,
early school assessments, and old clinical, spouse and
parent..etc)
A third party offers a chance to evaluate self-observation
capacity, and to characterize the interpersonal context in which
their concerns arise.
The fact that medications for ADHD can be abused or misused
also raises appropriate concern that patients may present as
having ADHD to meet unhealthy goals. Stigma
It is also inappropriate to deny assessment or treatment to
patients with ADHD due to such concern.
Link Between ADHD and Addiction
People with ADHD commonly attempt to soothe their restless
brains and bodies with addictive substances such as alcohol,
marijuana, heroin, prescription tranquilizers and pain killers,
nicotine, caffeine, sugar, cocaine and street amphetamines.
When people use substances to try to improve their abilities, or
decrease and/or numb their feelings it is called self-
medicating.
Initially, self-medicating works. It provides people with ADHD
some relief from their symptoms. For some, drugs such as
nicotine, caffeine, cocaine, diet pills and speed enable them to
focus, think clearly and follow through with ideas and tasks.
Others choose to soothe their ADHD symptoms with alcohol and
marijuana.
What starts out as a solution can cause addiction, impulsive
crimes, domestic violence, increased high-risk behaviors, the
loss of jobs, relationships and families and death. Too many
people with untreated ADHD learning and perceptual disabilities
are incarcerated or dying from co-occurring addiction.
Self-medicating ADHD with alcohol and other drugs is like
trying to put out a fire with gasoline.
The person suffering from ADHD has pain and problems that
are burning out of control and their lives could explode as they
attempt to douse the flames with substance abuse.
Who will become addicted?
People with ADHD are vulnerable to abusing mind-altering
substances.
There are many reasons why one person becomes addicted
and another does not. No single cause for addiction exists;
rather, a combination of factors is usually involved: genetic
predisposition, neurochemistry, family history, trauma, life stress
and other physical and emotional problems contribute.
Combination and timing of these factors.
Prevention and early intervention:
Some individuals’ biological and emotional attraction to drugs is
so powerful that they cannot conceptualize the risks of self-
medication.
This is especially true for the person with ADHD who may have
an affinity for risky, stimulating experiences. This also applies to
the person with ADHD who is physically and emotionally
suffering from untreated ADHD with symptoms including
restlessness, impulsiveness, low energy, shame, attention and
organization problems, and a wide range of social pain.
Untreated ADHD and addiction relapse:
Many individuals in recovery have spent hours in therapy
working through childhood issues, getting to know their inner
child and analyzing why they abuse substances and engage in
addictive behaviors.
Untreated ADHD contributes to addictive relapse, impulsively
quits jobs and relationships, cannot follow through with his or
her goals, and has a fast chaotic or slow energy level.
Treating both ADHD and addictions
It is not enough to treat addictions and not treat ADHD, nor is it
enough to treat ADHD and not treat co-occurring addictions. Both
need to be diagnosed and treated for the individual to have a
chance at ongoing recovery.
I. A professional evaluation for ADHD and co-occuring addiction.
II. Continued involvement in addiction recovery groups or 12-step
programs
III. Education about how ADHD affects each individual’s life and the
lives of those who he cares for.
IV. Building social, organizational, communication and work or
school skills
V. Close monitoring of medication when medication is indicated
Pre-recovery:
This is the period before a person enters treatment for their
addictions. It can be difficult to sort out ADHD symptoms from
addictive behavior and intoxication.
The focus at this point is to get the person into treatment for the
chemical and/or behavioral addiction. This is not the time to treat
ADHD.
During this period can sort out ADHD from the symptoms of
abstinence, which include distractibility, restlessness, mood
swings, confusion and impulsivity. Much of what looks like ADHD
can disappear with time in recovery.
Early Recovery:
In most cases, this is not the time to use psycho-
stimulant medication, unless the ADHD is affecting
his or her ability to attain sobriety.
Middle Recovery:
Addicts and alcoholics are settling into recovery, and they
usually seek therapy for problems that did not disappear with
recovery. It is much easier to diagnose ADHD at this stage; and
medication, when indicated, can be very effective.
Long-term Recovery:
This is an excellent time to treat ADHD with medications when
warranted.
By this stage, most people in recovery have lives that have
expanded beyond intense focus on staying clean and sober.
Their recovery is an important part of their life, and they have
the flexibility to deal with their ADHD.
Medication and addiction:
Psycho-stimulant medication when properly prescribed and
monitored is effective for approximately 75 to 80 percent of
people with ADHD.
The problem is that many are hesitant for good reasons to use
medication, especially psycho-stimulants. But, it is important to
note that when these medications are used to treat ADHD the
dosage is much less than what addicts use to get high.
When people are properly medicated they should not feel high or
“speedy,” instead they will report increases in their abilities to
concentrate, control their impulses and moderate their activity
level.
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