Attention Deficit / Hyperactivity Disorder in Adults

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The attention deficit / hyperactivity disorder in adults or adult ADHD is the continuing adult form of attention-deficit / hyperactivity disorder ( ADHD ). This is a neurobiological developmental delay in self-regulation that begins in childhood. The disorder is characterized by problems with attention , impulsivity , executive functions, and sometimes hyperactivity .

The diagnostic criteria for ADHD in children and adults are essentially the same. However, a prerequisite for a diagnosis in adulthood is that the symptoms began under the age of 12 and have been chronic since then. According to a large number of studies in several parts of the world, the spread of ADHD among adults is approx. 2.5%; however, these values ​​are still considered provisional.

history

The adult form of the disorder did not receive increased attention until the 1990s. At that time, long-term studies showed more and more clearly that - contrary to what was originally assumed - ADHD often does not go away in adulthood. The research that followed showed that even in adulthood, impairments usually persisted in so many areas of life that a diagnosis continued to appear justified. However, ADHD was discovered in adults much earlier: as early as the late 1970s, Paul Wender examined adults whose minimal cerebral dysfunction (MDB) persisted after childhood. In 1980 this led to the first corresponding diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders .

distribution

In contrast to the prevalence in children and adolescents, there are only preliminary estimates for adults (as of February 2016). According to a meta-analysis from 2009 it was 2.5%, according to another, twice as extensive, but with data mainly from young adults under 25 years of age, from 2012 it was 5%.

A study at the University of Erlangen-Nuremberg from 2012 based on a representative sample of 1,655 people aged 18 to 64 years resulted in a value of 4.7%. An equally representative survey of 2,092 Australians aged 47–54 years showed a rate of 6.2%.

Appearance

Adult ADHD can be mild to extreme difficulties at home, in school, or at work. There is a particular problem with organizing one's life and planning simple daily tasks. This can lead to loss of social contacts and frequent job changes. The problems arise not only from direct behavior, but also from the many things that an affected person forgets in everyday life, especially if someone of a similar age or experience is expected not to.

Adults with pronounced hyperactive impulsive symptoms of ADHD feel extremely driven and restless. To calm themselves down, they keep on going and start activities, but usually fail to do more than one thing at the same time ( multitasking ). They act on their surroundings as if they don't think before acting or speaking. The biggest problem here is developing self-control . The lack of self-regulation is often a reason for drug treatment. A lack of self-assessment and self-control in general also hinders understanding when or how tasks are best performed, and how other people perceive the results.

Signs of ADHD can vary widely from person to person and also vary significantly over the course of life. The most common are disturbances in executive functions , i.e. problems with planning and organizing actions. These executive deficits mean that people with ADHD can have problems acting effectively and realizing their planned projects in a systematic and targeted manner. For this reason, some experts now see ADHD primarily as a disruption in implementation skills and service provision - and not as a lack of skills and knowledge. Another sign is a lack of timing .

Diagnosis

The diagnostic criteria for ADHD and the subtype classification are the same for adults and children. Making a diagnosis can be easier than it is for children because of better history, knowledge, and insight.

Paul Wender developed the following criteria specifically for ADHD in adults:

  • Attention disorder
  • Motor hyperactivity
  • Affect lability
  • Disorganized behavior
  • Affect control
  • impulsiveness
  • Emotional overreactivity

ADHD in adulthood can only be present if these signs were also present in childhood (even if they were not consciously noticed). One way of determining this is with the Wender Utah Rating Scale . In addition, other medical or mental disorders must be excluded as the cause of the symptoms. A decisive condition for the diagnosis is that several signs have been observed in different situations (education, work, at home, etc.) over a period of at least 6 months and have led to noticeable restrictions in several areas of life.

Typically, for a diagnosis of ADHD in adults, ADHD symptoms must have been present since childhood. However, some of the adults who meet the criteria for ADHD did not meet the requirements for a diagnosis of ADHD during childhood. Most cases of late -onset ADHD develop the disorder between the ages of 12 and 16 years. This is called ADHD, which begins in early adulthood or adolescence.

Concomitant and secondary illnesses

An accompanying illness ( comorbidity ) always requires an expansion of the diagnosis so that it can be adequately taken into account in subsequent therapy. Initially, the focus is on accompanying psychological deviations that may be causally related to the underlying disease (ADHD) or coexist without any recognizable connection. In the case of ADHD, behavioral disorders and circumscribed developmental disorders are described as the most common accompanying diseases. Emotional disorders are often overlooked.

Substance abuse

The relationship between ADHD and substance abuse is complex, but of paramount importance given the large number of those affected by both. A large number of studies have shown that of those who sought help for substance abuse, up to 40% met the diagnostic criteria for ADHD. Conversely, ADHD doubles the risk of later substance abuse, with the risk of missed or incomplete treatment being additionally increased.

In a Swedish study from 2016 based on 18,167 twins between the ages of 20 and 45, there was an increased risk of nicotine consumption (factor 1.33), mixed drug use (factor 2.54) and alcohol dependence (factor 3.58). Interestingly, the increased risks did not depend on the ADHD subtypes, on the preferred substance or on the gender. The authors of the study pointed to the necessity that the assessment and therapy of ADHD should be part of the help against substance abuse.

Mood disorders

The affective disorders (mood disorders) comprise a group of mental disorders resulting from the mania over the bipolar disorder to the depression extends. The unifying characteristic is a persistent disturbance of the affects (i.e. the basic mood) .

Anxiety disorders

Anxiety disorders describe a group of mental illnesses in which an inappropriate fear of an object or a situation is in the foreground.

According to the ICD-10, anxiety disorders include:

In the comorbidity of ADHD and anxiety disorders, the interaction of the two disorders changes the external appearance: the impulse control deficit is reduced by the fear, while the working memory problems increase. Conversely, ADHD may make the anxiety disorder less phobic.

Personality disorders

Personality disorders are various persistent patterns of experience and behavior that begin in childhood and adolescence, which differ from flexible, situation-appropriate (“normal”) experience and behavior in a characteristic way. They are characterized by relatively rigid reactions and forms of behavior, especially in situations that are conflicting for the respective person. Personal and social functioning and performance is usually impaired.

Sex hormone fluctuations

In a 2014 review study , it was considered proven that important brain functions - including those affected by ADHD - are affected by changes in sex hormone levels. However, the authors expressly complained that no studies were available to date that had examined the fluctuations of these hormones in the menstrual cycle with regard to possible effects in ADHD. In this respect, guides that establish a connection between the menstrual cycle and ADHD characteristics based on individual reports are generally plausible, but so far (as of February 2016) they have not been able to provide any reliable information on possible adjustments in behavior or medication.

sleep disorders

According to a study in the Netherlands from 2013, 26% of 202 adult ADHD patients were simultaneously affected by delayed sleep-phase disorder (DSPD). In a control group of 189 non-patients, however, DPSD only occurred with a frequency of 2%. In addition, in the ADHD patients, the overall sleep was shorter, the periods of falling asleep longer, and the middle of the entire night's sleep later.

Studies in a Mannheim sleep laboratory had already shown in 2008 that treatment with methylphenidate reduced the sleep disorders typical of ADHD in adults and that this made patients feel better after sleep.

treatment

As a general rule, the treatment options for ADHD are generally even better for adults than for children. Adults usually have more opportunity to participate consciously and systematically. Studies show that ADHD in adulthood can be successfully treated with drug therapy in conjunction with behavior therapy.

This shows how important it is to treat ADHD with a combination of three elements of therapy: drug therapy, psychoeducation and psychotherapy.

medication

The drug therapy is supposed to improve concentration and self-control as well as to reduce the stress of suffering and the limitations of everyday life. It must be taken into account whether the respective drug has a drug approval and whether the costs are covered by the health insurance company. For a long time in Germany there were only approvals for children and adolescents, but not for adults (apart from certain antidepressants, which are sometimes used in ADHD). Given this situation, general practitioners have often prescribed ADHD-specific drugs off-label to adults. As a result, the patient usually had to bear the costs of the drug completely himself; apart from the treatment costs.

As of September 2019, the following drugs are approved for adults:

  • two preparations containing methylphenidate (since April 2011 Medikinet adult and since May 2014 Ritalin adult )

Guanfacine (trade name Intuniv ) is also a candidate for off-label prescribing to adults for whom other substances do not work well enough or are unsuitable for other reasons. It has a different mechanism of action than the approved drugs and has been approved for children and adolescents across the EU since September 2015. There it was found to be superior to atomoxetine in several studies.

Some patients with ADHD can achieve symptomatic improvement ( remission ) according to standard criteria . Nevertheless, despite the use of suitable drug therapy, many, especially adult patients, remain impaired in their way of life due to residual symptoms. It is therefore important for practitioners to take into account that ADHD-related impairments of academic, professional and social functioning do not always completely disappear with an improvement in the core symptoms. Treatment strategies to further improve symptoms when the initial therapy was inadequate include increasing the dose, switching to another drug, and increasing monotherapy with a second drug. These strategies reflect the fact that the goal of treatment for ADHD is not just to reduce symptoms, but to restore near-normal, unimpaired functioning, quality of life and participation.

Psychoeducation

The psychoeducation is to educate patients and their families about ADHD, thus allowing you to better manage the disease. Patients who are better informed about their disease can better assess and / or influence the effects. Your self-image and self-esteem can improve drastically, as the reasons for your own (wrong) behavior have a medical justification. With the necessary knowledge, relatives are also able to better deal with the illness of your confidants and to support them.

psychotherapy

The last element of therapy is psychotherapy , especially behavior therapy for ADHD in adults , which is intended to help learn new ways of thinking / behavior and to discard old, practiced and unsuitable behavior patterns. Behavioral therapy is intended to help those affected to become aware of how they should or could react appropriately in certain (for them difficult) situations. Psychotherapy makes it possible to improve personal well-being and to deal better with the negative consequences of ADHD.

Other effects

In 2004, researchers estimated that due to adult ADHD sufferers in the United States a total of 77 billion US dollars (USD) less income revenue. High school graduates with ADHD earned an average of $ 10,791 less a year than those without ADHD, while college graduates made an average of $ 4,334 less than people with ADHD.

A Danish study published in 2015 showed that adults with ADHD are twice as likely to die prematurely. This was mainly due to accidents.

ADHD in traffic

With driving simulators, the traffic behavior of patients and non-patients can be compared very precisely under laboratory conditions - including eye tracking . In a British study from 2015, ADHD sufferers - after discontinuing their medication 24-36 hours in advance - showed higher driving speeds, poorer vehicle control, more impatience with the behavior of other road users (more negative comments), less safe driving when compared to non-affected persons Changing lanes and overtaking on the motorway as well as more accidents and near-misses in sudden dangerous situations in city traffic.

A Swedish study from 2014 investigated the extent to which 17,408 adult ADHD patients born between 1960 and 1988 were involved in serious traffic accidents (hospital or death) during 2006-2009. The accident rate for men was increased by 47% and for women by 45% compared to the rest of the population. However, it was 58% lower in men on medication than in men without medication. It is estimated from these data that in men who did not take medication, 41–49% of accidents would have been avoided through medication. In women - where the number of accidents was significantly lower overall - the influence of the medication was less and did not reach statistical significance .

A systematic review from 2014 based on 15 individual studies showed that the behavior of ADHD sufferers on the road is positively influenced by medication.

literature

introduction

  • Johanna Krause and Klaus-Henning Krause : ADHD in adulthood. Symptoms - differential diagnosis - therapy . 4th, fully act. and exp. Edition. Schattauer Verlag, 2014, ISBN 978-3-7945-2782-3 .
  • Martin D. Ohlmeier, Mandy Roy (Ed.): ADHD in adults - a life in extremes. A practical book for therapists and those affected. 1st edition. Kohlhammer, Stuttgart 2012, ISBN 978-3-17-021068-4 .
  • Tobias Banaschewski, Wolfgang Retz, Michael Rösler: ADHD in adults: 50 questions and answers. Thieme 2013, ISBN 978-3-13-172371-0 .

counselor

  • Russell Barkley: The Great Handbook for Adults with ADHD. 2nd, unchanged edition. Hogrefe 2017, ISBN 978-3-456-85754-1 .
  • Donald Haupt, Eileen Bailey: The Complete Idiot's Guide to Adult ADHD . Penguin, London 2010, ISBN 978-1-101-19774-5 .
  • Elisabeth Nyberg, Rolf-Dieter Stieglitz , Maria Hofecker Fallahpour: Advisor ADHD in adults: Information for those affected and their relatives . Hogrefe-Verlag, Göttingen 2013, ISBN 978-3-8409-2224-4 .
  • Wolfgang Retz, Roberto D'Amelio, Michael Rösler : ADHD in adulthood: strategies and aids for coping with everyday life . Kohlhammer 2015, ISBN 978-3-17-021171-1 .
  • Helga Simchen: AD (H) S - helping people to help themselves . Learning and behavioral strategies for school, university and work. 1st edition. Kohlhammer, Stuttgart 2015, ISBN 978-3-17-023351-5 .
  • Lynn Weiss: ADS at work. Creative, hyperactive - and successful. 3rd, German edition. Brendow, Moers 2009, ISBN 978-3-86506-258-1 .
  • Anja Greiner, Sylvia Langer, Astrid Schütz : Stress management training for adults with ADHD . Springer-Verlag 2012, ISBN 978-3-642-25801-5 .

Behavioral therapy manuals

  • Roberto D'Amelio, Wolfgang Retz u. a. (Ed.): Psychoeducation and coaching ADHD in adulthood. Elsevier Verlag, 2008, ISBN 978-3-437-22766-0 .
  • Bernd Hesslinger, Alexandra Philipsen u. a .: Psychotherapy of ADHD in adulthood. Hogrefe Verlag, 2004, ISBN 3-8017-1856-5 .
  • Gerhard Lauth among others: ADHD in adults. Diagnosis and treatment of attention disorder / hyperactivity disorder. Hogrefe Verlag, 2009.
  • Steven A. Safren et al.: Cognitive behavioral therapy for ADHD in adulthood. German adaptation by Esther Sobanski, Martina Schumacher-Stien and Barbara Alm. MWV , 2009, ISBN 978-3-939069-65-2 .

Guidelines

Individual evidence

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  3. ↑ David R. Wood, FW Reimherr, PH Wender, GE Johnson: Diagnosis and Treatment of Minimal Brain Dysfunction in Adults . In: Archives of General Psychiatry . tape 33 , no. 12 , 1976, doi : 10.1001 / archpsyc.1976.01770120057005 .
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