Understanding And Treating Adults With Attention Deficit Hyperactivity Disorder

356 Pages·2006·5.62 MB·English

by  Brian B. Doyle

UNDERSTANDING AND TREATING
ADULTS WITH ATTENTION DEFICIT
HYPERACTIVITY DISORDER
This page intentionally left blank
UNDERSTANDING AND TREATING
ADULTS WITH ATTENTION DEFICIT
HYPERACTIVITY DISORDER
BRIAN B. DOYLE, M.D.
Clinical Professor of Psychiatry and of Family and
Community Medicine, Georgetown University Medical School,
Washington, DC
Washington, DC
London, England
Note: The authors have worked to ensure that all information in this book is
accurate at the time of publication and consistent with general psychiatric and
medical standards, and that information concerning drug dosages, schedules,
and routes of administration is accurate at the time of publication and consis-
tent with standards set by the U.S. Food and Drug Administration and the gen-
eral medical community. As medical research and practice continue to advance,
however, therapeutic standards may change. Moreover, specific situations may
require a specific therapeutic response not included in this book. For these rea-
sons and because human and mechanical errors sometimes occur, we recom-
mend that readers follow the advice of physicians directly involved in their care
or the care of a member of their family.
Books published by American Psychiatric Publishing, Inc., represent the views
and opinions of the individual authors and do not necessarily represent the pol-
icies and opinions of APPI or the American Psychiatric Association.
Copyright © 2006 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
Manufactured in the United States of America on acid-free paper
10 09 08 07 06 5 4 3 2 1
First Edition
Typeset in Adobe’s Palatino and Futura.
American Psychiatric Publishing, Inc.
1000 Wilson Boulevard
Arlington, VA 22209–3901
www.appi.org
Library of Congress Cataloging-in-Publication Data
Doyle, Brian B., 1941–
Understanding and treating adults with attention deficit hyperactivity
disorder / Brian B. Doyle.-—1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 1-58562-221-4 (pbk. : alk. paper)
1. Attention-deficit disorder in adults. 2. Attention-deficit-disordered adults.
[DNLM: 1. Attention Deficit Disorder with Hyperactivity—therapy. 2. Adult.
WM 190 D754u 2006] I. Title.
RC394.A85D69 2006
616.85'89—dc22
2006005232
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
CONTENTS
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
1
ADHD in Children and Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
2
Diagnosing ADHD in Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
3
The Biological Basis of ADHD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65
4
Allies in Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97
5
Treating Adult ADHD With Medication: Introduction . . . . . . . . . . . . . . . . .117
6
Treating ADHD With Central Nervous System Stimulants . . . . . . . . . . . . . .125
7
Treating ADHD With Nonstimulant Medications . . . . . . . . . . . . . . . . . . . . .181
8
Comprehensive Treatment of the Adult With ADHD . . . . . . . . . . . . . . . . . .205
9
Comorbid and Treatment-Refractory ADHD . . . . . . . . . . . . . . . . . . . . . . .225
10
ADHD Issues: Work, Women, and Family. . . . . . . . . . . . . . . . . . . . . . . . .277
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .313
With Ellen Detlefsen, D.L.S., and Colin C. Doyle, B.A.
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .323
PREFACE
What good is like to this?
To do worthy the writing, and to write
Worthy the reading and the world’s delight?
SO WROTE SAMUEL DANIEL IN “Musophilus,” his eloquent poem in defense
of the intellectual life. His words, written in 1599, aptly express my
hopes for this book, Understanding and Treating Adults With Attention
Deficit Hyperactivity Disorder.
The good news is that today attention deficit hyperactivity disorder
(ADHD) in adults is getting the attention it deserves. Information about
the disorder and its treatment is growing rapidly. With that comes en-
hanced life prospects for the many people who have ADHD. Treatment
methods successful in children with ADHD also help adults who have
the disorder. New medications enlarge the available range of options. A
variety of human and technological interventions help adults with
ADHD structure their lives and become more productive. The combi-
nation of available treatment approaches allows them to use their re-
sources consistently in order to be at their best. Working with these
patients is intellectually stimulating and personally rewarding. When
treatment works, adults with ADHD thrive. Their lives can suddenly
and dramatically change for the better. It is gratifying to catalyze that
change.
Yet ADHD is still a controversial diagnosis, even more controversial
in adults than in children. It is not yet listed as a diagnosis for adults in
our current system, DSM-IV-TR. Clinical experience shows daily that
many adults have ADHD. Some resourceful, talented individuals who
have the disorder live successfully and creatively. Many others have di-
minished life prospects and are subject to anxiety, affective disorders,
and substance abuse. Many fail to reach their potential. There is a high
cost in human suffering as well as in lost productivity.
vii
viii Understanding and Treating Adults With Attention Deficit Hyperactivity Disorder
The book begins with a discussion of ADHD in children and adults.
The clinical story of ADHD begins, and continues, with children.
Knowing the evolution of the concept and treatment of ADHD in chil-
dren illuminates current thinking about the disorder in adults. Chapter
2 (“Diagnosing ADHD in Adults”) concerns diagnosis of the disorder,
first in children and now in adults, and discusses the validity of the di-
agnosis, which is still controversial. Because of the strong neurological
underpinnings of ADHD, Chapter 3 (“Biological Basis of ADHD”) fo-
cuses on the biological bases of the disorder.
Chapter 4 (“Allies in Treatment”) deals with the therapeutic alli-
ance. When the clinician is working with adult ADHD patients, as with
any patient, a strong therapeutic alliance is desirable. However, ADHD
presents the clinician with special challenges: working actively with pa-
tients who have special characteristics; taking into account specific cul-
tural, ethnic, and racial issues; and thinking in specifically legal as well
as medical terms. Adult ADHD patients stir strong reactions in the cli-
nicians who care for them, and thus countertransference also requires
more than the usual attention.
Chapters 5 through 7 (“Treating Adult ADHD With Medication: In-
troduction,” “Treating ADHD With Central Nervous System Stimu-
lants,” and “Treating ADHD With Nonstimulant Medications”) deal
with medication issues. Here is detailed information about using med-
ication, with specific information about the central nervous stimulants
and other effective medications. These chapters also discuss medi-
cations that are ineffective, albeit highly touted. Chapter 8 (“Compre-
hensive Treatment of the Adult With ADHD”) covers comprehensive
treatment, which involves far more than using medication. The detailed
clinical example, with material drawn from several patients, illustrates
the issues involved in treating adult ADHD patients over time.
Chapter 9 (“Comorbid and Treatment-Refractory ADHD”) includes
a full discussion of comorbid and refractory ADHD. This chapter deals
with the clinical reality that in adults, ADHD rarely occurs by itself.
These are complex patients. Because of their ADHD, they are even more
likely than other persons to have a full range of psychiatric disorders.
Comorbid conditions may require treatment before the ADHD can be
addressed. Similarly, missed or overlooked ADHD can complicate or
impede the treatment of other disorders, especially affective disorders
and substance abuse. The chapter also contains approaches to the treat-
ment for adult ADHD patients who fail to respond to standard inter-
ventions.
Chapter 10 (“ADHD Issues: Work, Women, and Family”) reviews
special issues that pertain to adults with ADHD. These include issues
Preface ix
related to work, an important life domain often affected by the disorder.
The chapter contains information as well about women and ADHD.
Until recently, women were comparatively neglected as ADHD pa-
tients. However, because of their biology and their social roles and the
effects of ADHD on these aspects, women deserve fuller discussion. Fi-
nally, the chapter provides information about the impact of adult
ADHD on families. Although this book focuses on the individual
ADHD adult patient, the disorder is a family problem. An affected
adult has problems with intimate relationships and is likelier than other
persons to have children with the disorder.
The Appendix indicates how to help patients use the Internet for
high-quality information about ADHD. Clinicians can use this informa-
tion to develop an electronic prescription, or “e-prescription,” to sup-
plement standard ones.
My aim is to provide accurate, timely information about the nature of
ADHD and its treatment in adults. The material is largely evidence
based, with an intermingling of clinical experiences. While I have fully
documented clinical research literature and scientific data, I have tried to
maintain a collegial, reader-friendly style. With this in mind, I have in-
cluded figures and tables as quick reference guides. The clinical examples
are set off from the text. As well as acknowledging the special challenges
of adult ADHD patients, I want to convey the rewards of working with
people who are often resourceful, creative, and persistent.
Brian B. Doyle, M.D.