Counseling Points - Psychiatric Nurse 11/08 - (Page 9)

Table 4. How ADHD Symptoms Differ from Bipolar Disorder Symptoms27,28 The patient with ADHD… • Has tantrums that are triggered by sensory and emotional overstimulation; outbursts occur and resolve quickly and the patient is readily able to calm down • Breaks things due to carelessness • Misbehaves often due to impulsivity • Does not think about possible consequences of actions and is often not aware of the dangers of his/her behavior • Has trouble falling asleep due to the inability to settle down; wakes up easily in the AM and can become alert quickly after awakening • Can be oppositional but defend himself and eventually sees what he/she did wrong • Does not usually suffer from depression as a main symptom and does not have severe and frequent mood changes or violent presentation • Can be irritable, which is seen mostly with medication rebound from stimulants • Often hits impulsively but does not deliberately attack others in rage, and is remorseful afterwards • May talk loud, fast, and too much, but can be redirected to change his/her speech when asked to do so • Acts silly due to an inability to maintain focus and attention but has no loss of contact with reality • Does not typically display sexualized behavior inattentive symptoms. In addition, symptom presentation changes somewhat over the lifespan. It is anticipated that the DSM Task Force of the American Psychiatric Association will adjust the diagnostic criteria for adults in the DSM V, due for publication in 2012, helping to clarify diagnosis in adults. Adult Symptomatology In young adults, ADHD presents with inattentiveness, impulsivity, difficulty focusing, and hyperactivity (a more common symptom in young males than in females). The most hyperactive children, especially males, by adolescence or young adulthood may have come into conflict with school authorities or with law enforcement, or may have suffered a higher than average incidence of serious accidents. ADHD adolescent males in particular tend to be exaggerated risk-takers. Even without engaging in risky behaviors, the inattentiveness and distractibility of ADHD can result in a higher frequency of automobile accidents for these individuals.21 As individuals with ADHD mature, hyperactivity tends to calm down or to become less visible to others; adults with ADHD tend to be more internally restless or fidgety than hyperactive.They may experience difficulty relaxing, concentrating, or persisting with sedentary activities, have poor organizational skills, be chronically late, often lose things, and be serious procrastinators.They may complain of being energetic project starters, but not “deal closers.” They may abuse substances, and can be chronically bored, moody, or short-tempered. In the adult health care setting, people with ADHD frequently present with mood disorders, alcohol and drug abuse, or injuries from accidents or physical confrontations. Women particularly (for whom inattention is more common than hyperactivity) tend to present with anxiety, depression, or a feeling of being overwhelmed. It can be challenging to determine if these individuals are constitutionally depressed along with their ADHD, or if depression reflects the social and intellectual demoralization of a lifetime of feeling inadequate and “not quite knowing” what is wrong.This is a typical pattern described by adult women. Because distraction and school or work difficulties can also be the result of mood instability, substance use, medication interaction, neurological compromise, learning disabilities, or life events, diagnosis in adults is complex. Adults, after all, are not brought to our office by parents frightened by disruptive behaviors. Instead, they refer themselves because their work or relationships are not going well. They may also seek help upon referral of the evaluators of their children, the courts, or be brought to couple’s therapy by a chagrined and frustrated spouse. 9 NOVEMBER 2008 tive impairments as well as attention and memory issues. It is important to take a thorough sleep history and educate individuals and families about sleep hygiene techniques to diminish insomnia. In addition, clinical experience suggests that the effects of some of the long-acting stimulants may last up to 12 hours; therefore they should be given early in the morning to decrease the likelihood of insomnia. If sleep dysregulation persists, it may be important to refer the child, adolescent, or adult with ADHD to a sleep specialist and further evaluate him or her. ADHD in Adults The research literature on ADHD in adults is sparse, so we must rely largely on clinical expertise and patient presentation, along with extrapolations from child research for guidance. Because we often lack early childhood records for adults with ADHD, it is difficult to document an adult’s earliest demonstration of impulsive or

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Counseling Points - Psychiatric Nurse 11/08

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