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Presentations of ADHDAlthough ADHD is often associated with children, this disorder is diagnosed in clients across the lifespan. While many individuals are properly diagnosed and treated during childhood, some individuals who have ADHD only present with subsyndromal evidence of the disorder. These individuals are often undiagnosed until they reach adulthood and struggle to cope with competing demands of running a household, caring for children, and maintaining employment. For this Discussion, you consider how you might assess and treat individuals presenting with ADHD.Learning ObjectivesStudents will:Assess client factors and history to develop personalized therapy plans for clients with ADHDAnalyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for ADHDEvaluate efficacy of treatment plansApply knowledge of providing care to adult and geriatric clients presenting for antidepressant therapyBy Day 3Post a response to the following:Provide the case number in the subject line of the Discussion.List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.List two pharmacologic agents and their dosing that would be appropriate for the patient’s ADHD therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.Case 2: Volume 1, Case #14: The scatter-brained mother whose daughter has ADHD, like mother, like daughter
wk_9_case_study_approaches_to_treatment.pdf

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PATIENT FILE
The Case: The scatter-brained mother whose daughter has ADHD, like
mother, like daughter
The Question: How often does ADHD run in families?
The Dilemma: When you see a child with ADHD should you also
evaluate the parents and siblings?
Pretest Self Assessment Question (answer at the end of the case)
Patients with comorbid ADHD and anxiety should in general not be
prescribed stimulants
A. True
B. False
Patient Intake
• 26-year-old woman
• Has a daughter with ADHD
• Psychiatrist noted symptoms in the mother and suggested she come
in for her own evaluation
• See the previous Case 13, p 133 for presentation of the daughter’s
case
Psychiatric History
• During interviews with the patient’s daughter (also attended by the
patient) over the past several months, it was not only noted that the
daughter has ADHD with comorbid ODD, but that the mother also
exhibited multiple symptoms consistent with lifelong and undiagnosed
ADHD including
– Mother misses appointments or is late for appointments
– Often appears disorganized
– Did not fill out her child’s forms on time
– Did not deliver forms to her child’s teacher, forgot, lost them
– Admits being very disorganized since her second child started
school
– Feels overwhelmed by two children and her life circumstances
– Could also have some signs of depression
– Can’t get organized to take her child to CBT
– Has a hard time keeping a regular schedule and also keeping her
daughter on a regular schedule of going to bed and waking up
– Was unable to remember to remove the daughter’s skin patch
unless she set a cell phone alarm
– All these suggest further evaluation of the mother is indicated
since ADHD commonly runs in families and has a very high
genetic contribution
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PATIENT FILE
• Has always done poorly academically
• Has always felt intimidated by any type of testing
• In addition, reports that she has always been worried about the future
and financial stability of her family
• Says she sometimes mentally “freezes when it gets to be too much”
• When her eight year old daughter was diagnosed with ADHD, she
suddenly realized that she had similar problems as a child
• The psychiatrist explained to her that ADHD was highly heritable and
that there was a 75% chance of having a child with ADHD if both
parents have ADHD and thus was asked to fill out an Adult ADHD
screening form
Social and Personal History







High school drop out, age 17 after getting pregnant
Married age 17, divorced 2 years later
Two children, ages 8 and 6
Smoker
No drug or alcohol abuse
Single mother works full time in retail
Father not much involved with his children
Medical History




None notable
BP normal
BMI normal
Normal lab tests
Family History
• 8-year-old daughter: recently diagnosed with ADHD
• Other family history unknown as the patient was adopted
• See the previous Case 13, p 133 for presentation of the daughter’s
case
Patient Intake
• The last time the patient brought her child to see the psychiatrist, the
mother was asked to fill out her own checklist, the Adult ADHD Self
Report Scale Symptom Checklist
– She endorsed many items, mostly inattentive but not really
hyperactive or impulsive such as:
– Having trouble wrapping up the final details of a project once
the challenging parts have been done
– Difficulty getting things in order
– Difficulty remembering appointments or obligations
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PATIENT FILE





– Making careless mistakes on difficult projects
– Difficulty keeping attention on repetitive work
– Misplacing things at home and work
– Distracted by activity around her
– Difficulty unwinding and relaxing when having time to herself
– Difficulty focusing/listening during conversations
Earlier, the mother was also requested to obtain copies of her report
cards from first and second grade
– Her own mother had kept these in storage
– Showed grades that were quite low
– Her teachers had commented on some of the problems endorsed
in the adult ADHD checklist that she continues to experience as an
adult
Asked how these problems affect her life, she states that:
– They cause great difficulty managing family matters
– She used to be unable to stay focused in conversations with her
ex-husband, which made him feel she did not care about him
Additional complaints include:
– Constantly feeling overwhelmed with taking care of the two
children while working fulltime
– Blaming herself for her daughter’s academic difficulties
– Feeling very emotional and overwhelmed
– “I’m sorry, doctor, but two kids are just too much for this single
mom”
Having difficulty sleeping and being irritable with the children at night,
which she regrets later on
Has many worries, about finances, about the future, about her
children’s futures, about getting a better job, about getting her own
education, about finding a new partner
Based on just what you have been told so far about this patient’s history
and symptoms, what do you think is her diagnosis?
• Appropriate response to her circumstances with her severe
psychosocial stressors
• Mostly just stress and anxiety
• ADHD
• ADHD and stress
• Generalized anxiety disorder (GAD)
• Major depressive episode
• ADHD and GAD
• Other
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PATIENT FILE
Attending Physician’s Mental Notes: Initial Psychiatric
Evaluation
• Here is a case that indeed is ADHD, but her symptoms also suggest
that she suffers from GAD
– Constant worry
– Feeling on edge
– Fatigue
– Difficulty concentrating and her mind going blank
– Irritability
– Trouble sleeping
• Most adults with ADHD are comorbid for a second psychiatric
disorder, and the most common is GAD
• Also, this patient is a smoker which may be related to her ADHD
since a disproportionate number of ADHD patients smoke, perhaps
because of the therapeutic effects of nicotine on ADHD symptoms
How would you treat her?






Stimulant for her ADHD
SSRI/SNRI for her GAD
Benzodiazepine as need for GAD and insomnia
Stimulant plus an SSRI/SNRI or benzo for both ADHD and GAD
CBT for both ADHD and GAD
Other
Attending Physician’s Mental Notes, Initial Psychiatric
Evaluation, Continued
• It seems as though the primary disorder is ADHD and it will be
simplest if this is treated first, with a single drug, probably a stimulant
• An SSRI/SNRI and/or benzodiazepine can be added at a later time
once the actions of the stimulant are evident
• Even though patients with GAD alone or even normal controls may be
“over stimulated” by a stimulant, in many cases of ADHD comorbid
with GAD, the stimulant is paradoxically calming and well tolerated
and even works for GAD symptoms as well as ADHD symptoms
without having to prescribe a second medication for the GAD
• Any stimulant could be chosen but not all are explicitly approved for
treatment of ADHD in adults
• She was started on mixed salts d,l amphetamine XR (Adderall XR)
• She was referred to a local mental health training program where she
could possibly get CBT for free or for a reduced rate from a trainee
receiving supervision
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PATIENT FILE
Case Outcome: First, Second, and Third Interim Followup
Visits, Weeks 4, 8 and 12
• Due to scheduling issues, by the time the patient had her first CBT
session, she had already been titrated to 20 mg of mixed salts of d,l –
amphetamine XR
• She thought that the medication had already started to help her and
in fact that she would not have been able to cooperate with the CBT
assignments had she not been on the medication
• Because of lack of side effects but continuing ADHD and GAD
symptoms, the dose of d,l-amphetamine XR increased to 30 mg (off
label since the maximum approved dosage for adults is 20 mg)
• Her BP and pulse were stable on the 30 mg dose but she felt jittery
particularly in the morning and around noon; she also felt very anxious
about her job situation and being able to provide for her family
• Dose lowered to 25 mg, but the jitteriness persisted so the dosage
was further lowerd to 20 mg
• The jitteriness abated but her ADHD symptoms were not well
controlled on the 20 mg dose anymore
• Instructed to stay on 20 mg for two more weeks as she is going on
vacation and not to change the dose until after her vacation and then
retry the 25 mg dose again
• Complained of feeling overwhelmed and irritable
• For most patients, a week between dosing adjustments for a stimulant
being used to treat ADHD is quite adequate
• Weekly intervals give patients and clinicians a chance to see the way
that the dosage is working though the spectrum of challenges that
occur in a typical week
• As vacations do not represent typical activities for a week, special
consideration must be given to the effectiveness of medication
changes that are done while a patient is on vacation
– Many adults with ADHD may relax on vacation and not challenge
themselves with cognitive loads and multitasking so may appear
to be better even without a medication change
– Other adults with ADHD, especially women with young children,
may actually find vacation more challenging
– For example, a parent with ADHD taking a family vacation with
several children in tow may find the planning and organization for
the trip more taxing than anything encountered at work or during
the normal routine at home
– It can also be difficult to manage timing the medication
appropriately when traveling to different time zones
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PATIENT FILE
Case Outcome: Fourth Interim Followup, Week 16
• “Glad to be back from vacation”
• “I don’t think I could have even got through our vacation without my
medication, but I still have a hard time holding things together”
• On at least 20 mg/day dosage of d,l-amphetamine XR combined with
CBT for 12 weeks, including a couple of weeks back from vacation,
the patient still has problems with
– Organizing her day
– Procrastinating
– Following instructions
– Losing items such as her keys which make her late for
appointments/activities
• On the few days that the patient missed, and thus skipped, her
medication inadvertently she realized that the medication was really
helping her concentrate and get through the day even though she
remains symptomatic
• Knowing that she could achieve better functioning on medication she
asked if other medications might accomplish this without the jittery
and anxious feelings
• While other medication options were discussed, the CBT was
continued which was slightly less helpful
How would you treat her now?
• Start lisdexamfetamine 30 mg once in the morning and titrate the
dosage by 20 mg each week until an optimal dosage is achieved
• Start d-methylphenidate XR 10 mg once in the morning and titrate the
dosage by 10 mg each week until an optimal dosage is achieved
• Start OROS methylphenidate 18 mg once in the morning and titrate
the dosage by 18 mg each week until an optimal dose is achieved
• Start atomoxetine 40 mg a day and increase to 80 mg after one week
Attending Physician’s Mental Notes: Fourth Interim Followup,
Week 16
• Lisdexamfetamine, d-methylphenidate XR, OROS methylphenidate,
and atomoxetine are all FDA-approved for the treatment of adults with
ADHD
• On the one hand, the patient found her amphetamine-based stimulant
to be very effective, and thus another long-acting stimulant would be
reasonable
• On the other hand, she had jitteriness with the stimulant, and thus a
non-stimulant would be equally reasonable
• After explaining the options, the patient elected to try another longacting stimulant
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PATIENT FILE
• d-methylphenidate uses a bead-based technology similar to the mixed
salts amphetamine XR in that 50 percent of the beads are immediaterelease and 50 percent delayed-released
• Methylphenidate LA and d-methylphenidate XR employ the same
patented SODAS technology in their delivery systems, but other longacting forms of stimulants with beaded delivery systems vary due to
proprietary differences in their manufacturing processes
• For instance, one formulation of methylphenidate utilizes a capsule
that contains a ratio of 30 percent immediate-release beads and 70
percent delayed-released beads
• Although the different technologies used in beaded forms of
stimulants can have clinical implications in individual cases, they all
follow a similar design scheme:
– A bolus of stimulant medication becomes bioavailable rather
quickly as the immediate-release beads dissolve
– Over time, the coating on the delayed-release beads deteriorates,
allowing the stimulant contained within the bead to be released
– The medication within the delayed-release bead becomes
bioavailable about four hours after the patient swallows the
capsule
• Lisdexamfetamine is the only stimulant preparation that is a prodrug:
– In its prodrug form, a lysine molecule is attached to
dextroamphetamine
– Dextroamphetamine will not be active until the lysine is cleaved
from it
– Cleaved lysine is an amino acid that does not contribute to the
clinical efficacy of this medication
• Lisdexamfetamine could be a good choice for multiple reasons:
– It uses a different delivery system that appears to have a more
consistent interval to maximum concentration (Cmax)
• It is conceivable that the jitteriness this patient was experiencing was
related more to the l-isomer than to the d-isomer
• A nonstimulant such as atomoxetine may be particularly useful in a
patient who has stimulant related side effects, because atomoxetine
does not cause these side effects
• Also, atomoxetine may be particularly useful in patients with
comorbid anxiety
Case Outcome: Fourth Interim Followup, Week 16, Continued
• In the end, the patient and the attending physician agreed upon a trial
of OROS methylphenidate (Concerta)
• Main reasons for this choice:
– To be able to compare the benefits the patient experienced on
an amphetamine preparation with those of a methylphenidate
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PATIENT FILE
preparation since patients may experience differing tolerabilities as
well as efficacies on methylphenidate versus amphetamine
– To be able to test the uniqueness of the OROS delivery system in
terms of attained efficacy with better tolerability
• OROS methylphenidate uses a delivery system that is quite different
from beaded delivery systems:
– Coating of OROS methylphenidate contains 32 percent of the
medication
– Remainder of medication is contained within a permeable
membrane that allows water from the gut to enter once the coating
of methylphenidate dissolves away
– Different concentrations of methylphenidate in gel form are
contained in two compartments
– A push compartment absorbs water and expands like a sponge
does, pushing the methylphenidate gel out of the hole at the
opposite end
Case Outcome: Fifth Interim Followup, Week 20
• The patient’s dose was titrated from 18 mg to 72 mg over the course
of four weeks
• Although she did not feel jittery, OROS methylphenidate 72 mg once a
day did not seem to work as well as the mixed salts amphetamine at
30 mg a day
• She voiced concerns that the dosage was more than double that of
the mixed salts amphetamine dosage that was tried
• The psychiatrist explained that methylphenidate compounds are half
as potent as amphetamine ones, and that 72 mg/day is an approved
dose in adults
• She was reminded that her blood pressure and pulse had remained
in the normal range throughout the titration, and she was told that
some of the methylphenidate gel may remain inside the delivery
system and not be bioavailable (inherent properties of OROS
technology)
• After documenting that information about off-label use was given
to the patient, the psychiatrist recommended to further increase the
dose of OROS methylphenidate to 90 mg
Case Outcome: Sixth Interim Followup, Week 24
• The patient felt that 90 mg of OROS methylphenidate worked at least as
well as 30 mg of the mixed salts of d,l amphetamine XR
• Her blood pressure and pulse increased a bit from baseline, but they
were still in the middle of the normal range
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PATIENT FILE
• She still has some problems with organization and losing items, but
she indicates she would continue CBT to address these
• Similar to when she was on the amphetamine compound, once her
ADHD symptoms abated, her anxious feelings became more prominent
– “It’s like now that I can concentrate on my daily tasks, I also feel
much more anxious about the financial security of my children,
and I often feel my throat tighten when I think about the financial
impact of the girls going to college”
– “The thought of losing my job or getting sick frightens me . . .
what would happen to the girls?”
– She has trouble falling asleep at night, as her mind does not shut
off
ADHD is often comorbid with other psychiatric disorders and one
disorder can mask the symptoms of another. In the present case, this
patient exhibits symptoms of anxiety, probably generalized anxiety
disorder, especially more prominent every time her ADHD symptoms
abate. How would you address the patient’s anxiety at this point?




Augment with a benzodiazepine
Augment with buspirone
Augment with a selective serotonin reuptake inhibitor (SSRI) or SNRI
Incorporate techniques to resolve anxiety into ongoing CBT
Case Outcome: Seventh and Eighth Interim Followup, Weeks
24 and 36
• Incorporating techniques to resolve anxiety into the patient’s ongoing
CBT would likely be most appropriate, prior to attempting to add a
medication
• A letter was sent suggesting this to the CBT therapist, but after 12
weeks, this led to limited benefit, and thus medication augmentation
was considered
• Benzodiazepines, buspirone, and SSRIs/SNRIs can all be used to
treat generalized anxiety disorder and are not contraindicated with
stimulants
• After discussion of the options, paroxetine was prescribed to augment
her stimulant and her CTB
Case Outcome: Ninth Interim Followup, Week 48
• After three months on OROS methylphe …
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