Ecase #D-7

Kay English, M.D.

March 3-7, 2003

A 42 y/o man who you saw 8 months ago for symptoms of irritability returns for your opinion.  He has been evaluated by a psychotherapist who diagnosed him with depression.   He has been treated with Zoloft but has continued to have problems with attention to details, trouble being organized at work, and is easily distracted.  His therapist has administered a test from the Amen Clinic for ADHD that is reportedly positive.

You note from your chart that once you had to call him 3 times with the same test result because he kept calling back to get the information again. He has also been married three times, had difficulty in school, and has problems functioning effectively at work.  Interestingly he has several "hyperactive" children.

How is a diagnosis of ADHD made?

DSM-IV criteria:

Diagnosis usually made before the age of 7, present for at least 6 months with impairment in more than one setting. Requires 6 symptoms of inattention or six symptoms of hyperactivity/impulsivity.

Inattention:

1. Neglects details and makes careless mistakes.
2. Difficulty sustaining attention.
3. Doesn't seem to listen when spoken to directly.
4. Difficulty following instructions, finishing tasks.
5. Has difficulty getting organized.
6. Avoids tasks requiring sustained mental effort.
7. Often loses things.
8. Easily distracted.
9. Is often forgetful.

Hyperactivity/impulsivity:

1. Fidgets or squirms.
2. Difficulty staying seated.
3. Runs or climbs excessively at inappropriate times.
4. Has difficulty playing quietly.
5. Is always "on the go", "driven by a motor".
6. Talks excessively.
7. Blurts answers before hearing entire question.
8. Has difficulty awaiting turn.
9. Butts into conversations and activities.

What treatment is available?

First line:  stimulants

1. Rapid onset: Ritalin, Dexedrine
2. Slow onset: Ritalin SR, Metadate ER, Dexedrine spansules or Cylert
3. Rapid onset with long duration: Adderall, Concerta
4. Non-stimulants: Strattera (atomoxetine qd-bid) - NEW

Second line medications - (norepinephrine effect)

• SSRI (depression, hyperfocused on activity, OCD)
• Wellbutrin
• Venlafexine
• TCA's (insomnia, poor appetite, enuresis): imipramine, desipramine

See:

Family Practice Notebook  (www.fpnotebook.com)

DSM-4

AmenClinic.com
"Healing Attention Deficit Disorder" Dr. Amen (contains a self-test used commonly by therapists, per Dr. Lisa Olsson, who does our neuropsych testing).