impact of unrecognized adhd on treatment of anxiety & depression - adhd … … · ·...

Impact of Unrecognized ADHD on Treatment

of Anxiety & Depression

Thomas E. Brown, PhD

Associate Director,Yale Clinic for Attention and Related Disorders

Department of Psychiatry

Yale Medical School

Psychiatric Comorbiditiesin adults with ADHD (prev 12 mos)

ADHD Prevalence Other disorder in those with: in those with ADHD

Any mood 13.1% 38.3%

Any anxiety 9.5 47.1

Any substance 10.8 15.2

Intermittent Explo. 12.3 19.6

Many with ADHD have anxiety, mood or other comorbid disorder which may be more noticeable than their ADHD.1

(1Kessler, et al. 2006)TE Brown, Ph.D. Yale Medical School

Comorbidity of ADHD in Childrenn=61K, ages 6-17 yrs (Larson, et al, 2011)

Disorder ADHD% Non-ADHD%

Conduct Disorder 27.4 1.8

Anxiety 17.8 2.1

Depression 13.9 1.4

ADHD prevalence = 8.2% No. of Comorbid Disorders: 33% = 1, 16% = 2, 18% =

3 or more

TE Brown, Ph.D. Yale Medical School

Overview

1. Changes in understanding ADHD

2. Changes in understanding interaction of emotion & cognition

3. How ADHD may impact other disorders

4. Implications for dx and treatment


1. Changes in Understanding ADHD

♦ OLD: ADHD = “disruptive behavior disorder of childhood”

♦ NEW: ADHD = developmental impairments of brain’s self-management system-exec function


Executive Functions

♦ Wide range of central control processes of the brain

♦ Connect, prioritize, and integratecognitive functions–moment by moment

♦ Like conductor of a symphony orchestra

TE Brown, Yale Medical School, 2013

“Will you do it and, if so, how and when?”(Lezak, 2004)

Will you do it? Motivation/Activation

How will you do it? Planning/Organizing

When? Timing/Remembering

TE Brown, Yale Medical School, 2013

Brown’s Model of Executive FunctionsImpaired in ADHD

Executive Functions

Organizing, prioritizing,

and activatingto work

1.Activation

Focusing, sustaining focus, and shifting focus to tasks

2.Focus

Regulating alertness, sustaining effort, and processing speed

3.Effort

Managing frustration

and modulating emotions

4.Emotion

Utilizing working memory and

accessing recall

5.Memory

Monitoring and self-regulating action

6.Action

Brown TE. Manual for Attention Deficit Disorder Scales for Children and Adolescents; 2001.

Characteristics of ADHD Symptoms

♦ Dimensional, not “all-or-nothing”• Everyone sometimes has some impairments in these functions; in ADHD: chronic, severe impairment

♦ Situational variability: “If I’m interested”• Most persons with ADHD have a few activities where ADHD impairmentsare absent

ADHD looks like willpower problem, but it isn’t!

T.Brown, Attention Deficit Disorder: The Unfocused Mind in Children & Adults (2005)

The Mystery of ADHD:Situational Variability of Symptoms

♦ Why focus for this, but not that?

“If it really interests me” (attraction)

♦ Why focus then, but not now?

“If I feel the gun to my head” (fear)

TE Brown, Ph.D., Yale Medical School

2 hypotheses re: motivation in ADHD

“Willpower”

vs

Erectile Dysfunction of the Mind


A Working Definition of ADHD(TEBrown, 2013)

♦ a complex syndrome of

♦ developmental impairments of executive functions,

♦ the self-management system of the brain,

♦ a system of mostly unconscious operations.

♦ These impairments are situationally-specific,

♦ chronic, and significantly interfere with functioning in

many aspects of the person’s daily life.

2. Changes in Understanding Emotion/Cognition

OLD: Cognition is separate from emotions

NEW: cognition and emotions are

dynamically intertwined to guide

our getting “turned on” or “turned

off” by each perception, thought or

task.TE Brown, Ph.D. Yale Medical School

Cognition & Emotion are Integrated in learning history of each individual

“Emotion and cognition cannot be dissociated in the

brain…affective significance determines how the

amygdala helps separate the significant from the mundane”

(L. Pessoa, 2013)

“Strictly speaking, there is no cognition without affect and

emotion.” (J. Fuster, 2008)

“All information processing is emotional…emotion is the

energy level that drives, organizes, amplifies and attenuates

cognitive activity” .” (K. Dodge, 1991)


Emotion Often Operates Uncsly

“…the emotional signal can operate totally under the radar of consciousness. It can produce alterations in working memory, attention and reasoning…the individual may not ever be cognizant of this covert operation.”

Antonio Damasio (2003)


How does brain determine what to ignore or attend to, to do or not do now?

♦ Each perception, thought or task is instantly

screened by the brain’s “google search” that pulls

up relevant, usually unconscious memories

throughout cortex; these compete to activate

approach, avoidance and/or disinterest


“google search” to guide responseshow does the brain do it?

♦ Working memory is brain’s search engine---fast, mostly uncs

♦ Response to any stimulus is shaped by search of relevant memories each of which is infused with emotion(s)

♦ Working memory draws on memories of past to anticipate “what’s likely to happen (+/-) if…?


Amygdala is a major hub for connecting perceptions, thoughts, images to rest of the cortex

Schematic Graph of Amygdala Output by Young, et all. (1994)

Amygdala

outputs to

64 of 72

regions

In cortex.

More recent

studies show

1K separate

cortical &

subcortical

pathways.

(Petrovich,

et. al. 2001)Amygdala

Output of Google Search

♦ The rapid-fire calculus of the amygdala and related networks sorts competing priorities emergent from the individual’s learning history to mobilize, shape or defer action.

♦ Output from the amygdala reaching multiple brain regions quickly alters functional connectivity that activates (or doesn’t) both body and brain. TE Brown, Ph.D., Yale Medical School

Amygdala’s “googling” is filtered for context

♦ Amygdala responses are strongly context dependent

♦ Amygdala flexibly integrates stimulus valence with current goals, motivations, and contextual demands. Attar, H. et al (2010)


Context Matters!

Where we are and who we’re with shapes which

of our emotions are most intense in the moment:

A clinical example:

“Would you like a cookie?”


Emotions May Shift as Context Shifts

♦ A student who works hard to get every term paper in on time may suddenly not careabout a paper because his girlfriend broke up with him and is dating someone else.

♦ A student whose interest in completing papers is generally lukewarm may suddenly intensify interest and work hard on paper so he can maintain eligibility to stay on his team.


Bottom-Up

Emotions arise from biological processesbased on appraisal of perceptions

**********************

“…each child is born with a profile of temperamental biases…that creates initial tendencies to be vocal or quiet, vigilant or relaxed, irritable or smiling, energetic or lethargic with regard to particular events or situations”1

(1J. Kagan, 2010)TE Brown, Ph.D. Yale Medical School

Top-DownExecutive Functions Process “Memories”

In ways which can bias attention:

♦ to intensify

AND/OR

♦ to modulate

the way any given stimuli are appraised and responded to


A Dynamic Model

Continuous Multi-Modal Scanning: • of perceptions, sensations, thoughts, imaginings.

To Detect: • Differences from what is expected (dangers, frustrations, rewards)

Identify:• Search personal files of memories for anything relevant for me.

Prioritize:• according to how dangerous, frustrating, rewarding, conflicting

Respond:• by engaging, avoiding, monitoring, or ignoring

Feedback:• monitor & reappraise, continue or drop


Continuous Multi-Modal Scanning:

♦Of perceptions, sensations, thoughts, imaginings…


To Detect:

♦Differences from what is expected (rewards dangers, frustrations)

? ??


Identify:

• What is it? Search personal files of memories for anything relevant for me at this time.


Prioritize:

• Re: According to how dangerous, frustrating, rewarding, or conflicting it might be.


Respond:

• By engaging, avoiding, monitoring, or ignoring


A Dynamic Model

Continuous Multi-Modal Scanning: • of perceptions, sensations, thoughts, imaginings.

To Detect: • Differences from what is expected (dangers, frustrations, rewards)

Identify:• Search personal files of memories for anything relevant for me.

Prioritize:• according to how dangerous, frustrating, rewarding, conflicting

Respond:• by engaging, avoiding, monitoring, or ignoring

Feedback:• monitor & reappraise, continue or drop

��


3. How ADHD May Impact Other Disorders

♦ “without basic attention and working memory there is no prospect of coherent mental activity…” (1)

♦ “…attention serves all the other functions.” (2)

♦ Exec Functions are the “operating system” of the mind

1Damasio (1994); 2Fuster (2003)


In the clinic

♦ Patients who seek assessment and treatment for anxiety and/or depressive problems

♦ May have impairments due to excessive bottom-up intensity

or ADHD-related problems withtop-down modulation of those emotions---or both


3 ways persons with ADHD are likely to have problems with managing emotions

1. Difficulty with Working Memory, keeping

multiple bits of info in mind, (flooding).

2. Difficulty with shifting focus, attentional bias

(telescope).

3. Prioritizing for Present Moment/Context and

Larger/Future contexts


Flooding

♦ While flooded with one emotion, persons with ADHD tend to forget about other relevant facts or emotions

e.g. may forget their love & wish to protect the person—friend, parent, child, co-worker who frustrated or angered them and say or do things that are too hurtful


Stuck in the Now

Some with ADHD report that they often get stuck in the concerns of the moment and lose sight of the bigger picture, the longer term.

e.g. Impulsive purchase using funds needed for a more important upcoming expense


“Hyperfocus” can block the bigger picture

Focused too intensely on one goal or task, you may forget

other goals you have or how actions of the moment may affect

your bigger picture

like one who is watching a basketball game through a

telescope, you may miss other relevant aspects of the situation


Clinical Assessments

♦ Clinicians should know how to recognize and routinely screen for ADHD in every diagnostic eval

♦ Partial response, refractory sx, or patient non-compliance with usual tx for other disorders may be related to unrecognized ADHD

(Barkley & Brown, 2008)


Treatments

♦ Most medications for anxiety or depression are designed to impact bottom-up processes

♦ Cognitive behavioral treatment may strengthen top-down control

♦ Stimulant medications used for ADHD may help to improve top-down control with or without usual meds for anxiety or depression


Reported Benefits of ADHD medsfor treating anxiety & mood problems

♦ improved emotional lability as well as core ADHD sx in children

♦ improved depressive sx in MDD adults who failed SSRI trial

♦ improved stable bipolar pts as add-on to their usual meds

♦ Adding stim reduced anxiety sx in pts unresponsive to SSRI alone.1

(1Sinita & Coghill, 2014)TE Brown, Ph.D. Yale Medical School

Potential Risks of Treating Anxiety or Depression with Stimulants

♦ May increase anxiety

♦ May intensify depressive sx(rebound?)

♦ Often those problems are dose-related (Stims don’t follow mg/kg!)


Key Points

♦ ADHD is developmental impairment of executive functions (EF)

♦ EF play important role in modulating emotions

♦ Anx/depressive disorders may be complicated by ADHD-related EF impairments

♦ Meds for ADHD may improve pt’sanxiety or depressive disorders


Books by Thomas E. Brown, Ph.D.(www.DrThomasEBrown.com)

• “Smart but Stuck: Emotions in Teens and Adults with ADHD ”

– 2014

• “A New Understanding of ADHD in Children and Adults:

Executive Function Impairments” – 2013

• “ADHD Comorbidities: Handbook for ADHD Complications in

Children and Adults” – 2009

• “Attention Deficit Disorder: The Unfocused Mind in Children

and Adults” - 2005

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