Psychiatry (3)

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Psychiatry

Christian Jonathan Haverkampf M.D.

Psychiatry is the medical specialty devoted to the diagnosis, prevention, study, and treatment of mental disorders. These include various abnormalities related to mood, behaviour, cognition, and perceptions. Working on internal and external communication is a central focus in psychiatric treatment.

Keywords: psychiatry, psychotherapy, communication, medicine

Contents

Introduction. 3

Communication. 4

Biological and Social Science. 5

Approaches. 5

Software and Hardware. 5

The biopsychosocial Model 6

Diagnostic systems. 6

Diagnostic manuals. 7

Assessment. 8

Medication. 8

Psychotherapy. 9

Medication and Psychotherapy. 10

Ethics. 10

Health. 11

Into the Future. 11

References. 12

Introduction

The question what psychiatry is begins with the definition of the term ‘psyche’. The term “psychiatry” was first coined by the German physician Johann Christian Reil in 1808. The ancient Greek term ‘psyche’ is often translated as ‘soul’. However, it can also mean ‘butterfly’. While psychiatry was up until about a century ago more an occult art than a science, this has changed dramatically in the twentieth century. Within the last century, psychiatry began to make its terms, observations and inquiry much more structured and ‘scientific’.

Psychiatric illnesses all have in common that communication with others and the own person is disturbed. (Haverkampf, 2010b) These maladaptive communication patterns lead to the symptoms which are commonly observed. For example, in a case of schizophrenia the source of incoming information can no longer be correctly attributed to the outside world or the inside, and in a case of anxiety emotional signals are no longer correctly identified and processed. Communication, the transmission of messages, adheres to rules like any other natural phenomena and is relied on in nature from information carried in a beam of light to cells exchanging DNA. Humans can observe and reflect on these flows of information, also on information flows within themselves. The sense of self and the attribution of a mind to someone or oneself is a result of the ability to observe these flows of information, and as such of the communication one has with oneself or the world around.

Psychiatry refers to a field of medicine focused specifically on the mind, aiming to study, prevent, and treat mental disorders in humans. It is devoted to the diagnosis, prevention, study, and treatment of mental disorders. These include various abnormalities related to mood, behaviour, cognition, and perceptions. Psychiatry focuses on the interaction between patients and therapists in a way, which no other medical specialty does. While it is true that psychiatry has become more biologically based over the last century, it has also begun to look at the finer details of information transmission in the neuronal networks of the brain. Fortunately, gone are the times of lobotomies, where parts of the brain were removed, to make way for much more specific and finer treatment interventions, whether with psychotherapy or medication that works on specific neurotransmitter receptors or mimics certain neurotransmitters. The elaboration of the information transmission at the synaptic level has given us clues on how psychiatric illness is maintained, and medication works, within the larger system of an individual’s neuronal network.

The 20th century introduced a new psychiatry into the world, with different perspectives of looking at mental disorders. For Emil Kraepelin, the initial ideas behind biological psychiatry, stating that the different mental disorders are all biological in nature, evolved into a new concept of “nerves”, and psychiatry linked up with neurology and neuropsychiatry. Sigmund Freud, who early in his career searched intensively for explanations of psychiatric phenomena on a neuronal level, initiated the development of psychoanalysis, which shifted the emphasis on communication as an important instrument in the healing process. The psychoanalytic theory became popular among psychiatrists because it allowed the patients to be treated in private practices at a time when effective psychiatric medication was still in its infancy.

Psychopharmacology became an integral part of psychiatry starting with Otto Loewi’s discovery of the neuromodulatory properties of acetylcholine, which became the first neurotransmitter to be described. The discovery of chlorpromazine’s effectiveness in treating schizophrenia in 1952 revolutionized treatment of the disorder, as did lithium carbonate’s ability to stabilize mood highs and lows in bipolar disorder in 1948. Neuroimaging became an investigatory tool in psychiatry in the 1980s.

Communication

Psychopharmacological changes in the neurotransmission systems, the information interfaces where electrical signals are translated into chemical signals, and back again, affect how and what information is being transmitted. This in turn has an effect on a person’s internal communication and his or her communication with the external world, which are also the target of psychotherapy. (Haverkampf, 2010a, 2017c) Medication and psychotherapy can thus work together synergistically.

Unlike physicians in other medical specialties, psychiatrists specialize in the doctor–patient relationship and should be trained extensively in the use of psychotherapy and other therapeutic communication techniques. Unfortunately, this is not always the case, which can reduce the effectiveness in treating a mental health condition significantly, because treatment of a mental health condition implies working with and understanding communication on different levels. The patient uses communication with other people and the self-talk with him or herself to meat own needs, values, wishes, desires and aspirations, requiring a holistic approach to the communication patterns and mechanisms a patient uses.

Since communication plays such a central role in psychiatric treatment, the author has developed communication-focused therapy (CFT), which focuses on internal and external communication patterns to relieve the symptoms of a wide variety of mental health conditions (Haverkampf, 2017a, 2018c).

Biological and Social Science

Psychiatry is the most multidisciplinary medical specialty using research in the field of neuroscience, psychology, medicine, biology, biochemistry, even physics, and pharmacology. Since psychiatry looks at the patient who is interacting with the larger world around, the social and communication sciences, including even behavioural economics, and the humanities can make important contributions to the field of psychiatry. If one considers psychiatry as a specialty that focuses on improving meaningful communication within wider information systems, the biological and social viewpoints merely represent looking at the same processes with different magnifications.

Psychiatry addresses internal and external communication issues, which are usually multifactorial in their aetiology. Compliance and the effects of medication and psychotherapy depend on the interactions between the patient and the environment. There are branches of psychiatry which look at different environments and how they influence the mental well-being of a patient. Unfortunately, psychiatric hospitals and various public health clinics have been notoriously slow at implementing any recommendations from this research.

Approaches

Psychiatric illnesses can be conceptualized in several different ways. The biomedical approach examines signs and symptoms and compares them with diagnostic criteria. However, unlike the other fields of medicine, psychiatric diagnoses say little about underlying causes on a biological level but are mostly groupings of symptoms which seem to appear together. This is not to say that such groupings are not helpful. They can make it easier to describe conditions and often make it easier to pick specific therapeutic approaches and types of medication. However, since individual symptoms overlap and due to the complexity of the neural networks, it is usually not possible to follow a group of symptoms back to a specific biological variation. Since the brain is highly plastic, synapses rearrange their connections with each other all the time and assign varying weights to them. This means that a symptom of anxiety, for example, can be triggered by information stored over millions of nerve cells, and merely understanding how a biological component, such as a receptor, works does not help in understanding or treating the symptom.

Software and Hardware

Psychiatry is both ‘software’ and ‘hardware’ oriented, where ‘software’ refers to the information stored in the neural network and ‘hardware’ to the cellular network on a biological level. In the latter, there is an overlap with neurology and other medical sciences. What sets psychiatry apart is particularly the concern with information, the flows of information and how information is processed. New diagnostic systems and schemata have been developed on the psychotherapy side, which pay greater attention to the information dynamics. These models and systems can provide additional information to an experienced clinician who can then integrate these additional aspects with the diagnostic systems from the traditional medico-psychiatric side.

The biopsychosocial Model

The biopsychosocial model is commonly used to describe the three factors that play a role in the development and maintenance of a psychiatric condition:

  • Biology
  • Psychology
  • Environment (social)

What is striking about these three domains is that all consist of the transmission of information in one way or another. Some describe more the internal communication (biology, neuroscience, psychology), while others describe the external communication (psychology, sociology, economics and others), but all work in parallel all of the time. Psychiatry thus works with very complex systems, which are much more elaborate than in any other field of medicine. This may also be the reasons why psychiatry was the field within medicine to develop rather late, because it uses the insight gained in several other fields.

Diagnostic systems

Psychiatric diagnoses take place in a wide variety of settings and are performed by many different health professionals. Therefore, the diagnostic procedure may vary greatly based upon these factors. Typically, though, a psychiatric diagnosis utilizes a differential diagnosis procedure where a mental status examination and physical examination is conducted, with pathological, psychopathological or psychosocial histories obtained, and sometimes neuroimages or other neurophysiological measurements are taken, or personality tests or cognitive tests administered. In some cases, a brain scan might be used to rule out other medical illnesses, but at this time relying on brain scans alone cannot accurately diagnose a mental illness or tell the risk of getting a mental illness in the future. A few psychiatrists are beginning to utilize genetics during the diagnostic process but on the whole, this remains a research topic.

The problem with most diagnostic systems in psychiatry is that they do not address the underlying causes of an illness but focus instead on bundles of symptoms. As a descriptive system this makes sense in many instances. However, from a treatment perspective this is often unhelpful. Since medication works on underlying neurotransmission system within a vast network of interconnected neurons, a system that makes diagnosis based on properties within that system and on the individual neuronal level would be more helpful. From a psychotherapeutic perspective, a focus on internal and external communication would be helpful. Both perspectives could lead to systems that would be compatible with each other or even to one system that combines features of the two.

Diagnostic manuals

Three main diagnostic manuals used to classify mental health conditions are in use today. The International Classification of Diseases (ICD-10) is produced and published by the World Health Organization, includes a section on psychiatric conditions, and is used worldwide. The Diagnostic and Statistical Manual of Mental Disorders (DSM-V), produced and published by the American Psychiatric Association, is primarily focused on mental health conditions and is the main classification tool in the United States, although the ICD-10 has official status there as well. It is currently in its fifth revised edition and is also used worldwide. As already mentioned, the diagnostic systems are based on bundles of symptoms. Psychiatry has “a syndrome-based disease classification, which is not based on mechanisms and does not guide treatment, which largely depends on trial and error” (Stephan et al., 2016). The author of this article would not go so far. Greater clarity about a diagnosis or several diagnoses, even if we do not understand fully the underlying biological and psychological mechanisms, can be an important tool in formulating a treatment plan, which often also includes medication (Haverkampf, 2018a)

The diagnostic manuals overlap to a significant degree. One reason is that they describe groups of symptoms which are often seen together, and over time the use of their diagnostic terms has made it easier to provide treatment and conduct research. However, both suffer from the critiques mentioned above. They can give a rough idea of the symptoms, a suitable therapy and the prognosis. However, since the diagnostic systems say nothing about the underlying causes, the actual therapy needs to be individualized and its success depends on several factors inside the person and in the environment. Looking at the patient’s internal and external communication can help individualize the therapy. (Haverkampf, 2010b, 2012, 2013a, 2013b)

It is important to keep in mind the purpose served by diagnosis. It is ultimately to help a patient and raise his or her quality of life. While there may be other uses of it for forensic, insurance or other purposes, they should not lead to a different interpretation of what a diagnosis is for in a treatment context. Diagnoses can at least help to raise the probability that a specific medication or group of medication will alleviate certain symptoms (Haverkampf, 2018a, 2018f).

Assessment

The first step in treatment is traditionally assessment. This usually involves interviewing the person and often obtaining information from other sources such as other health and social care professionals, relatives, associates, law enforcement personnel, emergency medical personnel, and psychiatric rating scales. A mental status examination is carried out, and a physical examination is usually performed to establish or exclude other illnesses that may be contributing to the alleged psychiatric problems. A physical examination may also serve to identify any signs of self-harm; this examination is often performed by someone other than the psychiatrist, especially if blood tests and medical imaging are performed.

However, especially in psychotherapeutic treatment, assessment can still take place after the therapy has commenced. While it is important to have a working hypothesis for the condition, it is important to remain open to any new insights gained from observing and interacting with the patient over time. For this, it is important to be in the interaction with the patient, yet also to be able to take a step outside of the interaction and reflect on the communication dynamics.

Assessment with a focus on the internal and external communication can identify problems which are leading to the symptoms. This information is then helpful to make better decisions with respect to medication and psychotherapy. Communication-Focused Therapy, as developed by the author, focuses on communication patterns an individual uses, whether in everyday life or in a therapeutic setting (Haverkampf, 2010b, 2017a). Rather than looking primarily at the content of what is being communicated, the how it is communicated assumes an additional particularly important role. Since people, and all other living organisms, meet their needs and aspirations through the exchange of information withing themselves and with the world, it is important to encourage awareness, reflection and experimentation with communication to make it more efficient and satisfying for the individual. As life aligns more with the basic parameters, the needs, values and aspirations, as a result of better communication, the symptoms of a mental health condition often receded (Haverkampf, 2017f, 2017b, 2017d) .

Medication

Psychiatric medication represents a very heterogenous group of substances, which are among the most widely prescribe in the world. Psychiatric medication was usually available before one had an understanding for its effects on a cellular or neural network level. However, in all cases it has been shown that psychiatric medication affects the information transmission in the brain. This is a point where psychotherapy and medication could go well with each other hand in hand (Haverkampf, 2018f).

The efficacy of medication can often very significantly among individuals. One antidepressant from the most popular group of antidepressants, the selective serotonin reuptake inhibitor (SSRI), for example, may help against the symptoms of depression and anxiety, while another from the same group does not work in the same patient. The outcome is not always easy to predict, although one can have a sense of the medication that is most likely to work. It requires a proper assessment in the first place, but also a solid understanding of the desired changes and the expectations of the patient.

Like most medications, psychiatric medications can cause adverse effects in patients, and some require ongoing therapeutic drug monitoring, for instance, full blood counts serum drug levels, renal function, liver function, and thyroid function. Electroconvulsive therapy (ECT) is sometimes administered for severe and disabling conditions, such as those unresponsive to medication. Although the literature reports on successes in treatment-resistant cases, its use remains controversial. Often, the available treatment options with medication and psychotherapy have not been fully exhausted when considering ECT.

To summarize, one may say that the support available form medication can be life-changing in some cases and increase the quality of life significantly. In contrast, in others, it may do little or lead to side effects, or there can be both positive and negative effects side by side. Several parameters have been studied to shape the recommendations of the professional. For example, in a study on the variables that could predict a successful treatment outcome in depression, chronic depression, older age, and lower intelligence, each predicted relatively weak response across psychotherapy and medication. On the other hand, marriage, unemployment, and having experienced a higher number of recent life events each predicted superior response to cognitive therapy relative to antidepressant medications (Fournier et al., 2009).

Psychotherapy

As already mentioned, increasingly psychiatrists are limiting their practices to psychopharmacology (prescribing medications), as opposed to previous practice in which a psychiatrist would provide traditional 50-minute psychotherapy sessions, of which psychopharmacology would be a part, but most of the consultation sessions consisted of “talk therapy.” This shift began in the early 1980s and accelerated in the 1990s and 2000s. A major reason for this change was the advent of managed care insurance plans, which began to limit reimbursement for psychotherapy sessions provided by psychiatrists. The underlying assumption was that psychopharmacology was at least as effective as psychotherapy, and it could be delivered more efficiently because less time is required for the appointment. For example, most psychiatrists schedule three or four follow-up appointments per hour, as opposed to seeing one patient per hour in the traditional psychotherapy model. Because of this shift in practice patterns, psychiatrists often refer patients whom they think would benefit from psychotherapy to other mental health professionals, e.g., clinical social workers and psychologists.

However, this approach is short-sighted. It may be easier to prescribe medication, which is a concept familiar to most patients, than to explain how psychotherapy works, whose basic premises, tools and approaches are less well known. Psychotherapy often delivers a lasting effect in the long-term in cases of anxiety, mild to moderate depression and several other conditions, which goes beyond the ongoing support medication can offer (Haverkampf, 2017a). The reason is that changes in the internal and external communications usually bring about changes in a patient’s symptoms (Haverkampf, 2018d). While medication also has an effect on these communication patterns and, through learning effects, it can even last for some time after the drug is discontinued, the changes are usually less specifically tailored to the needs and personal history of the patient.

Medication and Psychotherapy

Psychiatric treatments have changed over the past several decades. In the past, psychiatric patients were often hospitalized for six months or more, with some cases involving hospitalization for many years. Today, people receiving psychiatric treatment are more likely to be seen as outpatients. In many cases, a combination of psychotherapy and medication can prevent relapse longer than either treatment type on its own. (Haverkampf, 2018f, 2018e) There is a substantial synergism between the two. Medication can provide the support which facilitates psychotherapy, while psychotherapy can increase the compliance with medication.

Ethics

Most unethical treatments in psychiatry have been a result of neglecting the importance of communication in treatment and seeing properties of interactions as being localized in a particular area of the brain rather than occurring in a network internally and through interactions with the world externally. Much unethical behaviour in psychiatry can be summarised by saying that the physician failed to interact, communicate and understand a patient in any meaningful way. When knowledge about psychiatric conditions is seen separate from the interaction with the patient, it becomes akin to playing the lottery of sorts. Treatment requires a focus on how the patient communicates internally and externally and how the world responds to these messages.

When a psychiatrist is connected on emotional and cognitive levels with himself or herself as well as the patient and has healthy boundaries in place, ethical lapses become less likely. However, this often requires substantial experience and skills in a psychotherapeutic technique that focuses on insight. It requires an interest in and experience with human communication.

Health

To have a definition of illness, one needs a definition of health. Psychiatry is not only concerned with psychiatric illness but largely also with the maintenance of mental health. Insight into the aetiology and pathogenesis of burnout, for example, helps to prevent it, (Haverkampf, 2013a, 2013c, 2017g, 2018b) which is not only good for the individual but society and the economy as a whole. (Haverkampf, 2013c) Knowledge about which work and communication environments are helpful in preventing a relapse of psychosis can help a person arrange life in ways which keep him or her mentally healthy for as long as possible. (Haverkampf, 2017e) Skills in connecting with oneself can help to understand the information contained in emotional signals underlying episodes of anxiety. (Haverkampf, 2012)

Into the Future

The biopsychosocial model reduces to the communication model. Internal communication and external communication are, to some extent, arbitrary distinctions because communication still adheres to the basic rules and laws of communication, whether it unfolds in a person or without. However, this requires an integrated and more universal view of mental health. What makes us all human are the mental processes which give us the ability to observe and reflect on these flows of information. Psychotherapy and medication are the tools to bring about change in these communication patterns, internal and external ones. Other supportive therapies, such as occupational therapy, meditation and various forms of bodywork, can provide crucial additional support towards a satisfied, content and happy life, one in which personal needs, values, wishes, desires and aspirations can be met.


Dr Jonathan Haverkampf, M.D. (Vienna) MLA (Harvard) LL.M. psychoanalytic psychotherapy (Zurich) trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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The Misdiagnosis of ADHD in Adults (1)

The-Misdiagnosis-of-ADHD-in-Adults-1-Christian-Jonathan-Haverkampf-psychiatry-series-1

The Misdiagnosis of ADHD in Adults

Christian Jonathan Haverkampf, M.D.

Adult attention deficit hyperactivity disorder (ADHD) in adults is a childhood-onset, persistent, neurobiological disorder associated with high levels of morbidity and dysfunction estimated to afflict up to 5% of adults worldwide. It includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior, which can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems.

The diagnosis is important to design an effective treatment plan with the patient, which often includes medication and psychotherapy or counselling. There is a wide variety of approaches in the diagnosis of adult ADHD, and this article aims at giving an overview of some of the more common ones. However, there is a high risk of misdiagnosing this condition. The ability to concentrate, for example, can also be affected in depression, PTSD, anxiety, psychosis and other conditions, as can the capacity for organizing and seeing through tasks, various aspects of memory and information retrieval and irritability.

Awareness for the communication patterns in the interaction with the patient, and how the patient communicates internally, are important tools in the diagnostic process and in treatment, improving the individualization of treatment and building and maintaining compliance. While the actual interaction with the patient is of primary diagnostic importance, standardized questionnaires and neuropsychological testing batteries are important to support a diagnosis and to adjust treatment.

Keywords: attention deficit hyperactivity disorder, ADHD, diagnosis, treatment, psychotherapy, psychiatry

Contents

Introduction. 4

Attention. 5

Executive Functioning. 5

Communication. 5

From Childhood to Adulthood: Hyperactivity vs Inattention. 6

Measurement Problems. 6

Misdiagnosis of ADHD.. 6

Autism.. 7

Trauma. 7

OCD.. 7

Bipolar Disorder. 7

Symptoms. 8

Diagnosing ADHD.. 9

Subtypes. 10

Assessment. 10

Communication. 10

The Clinical Interview.. 11

Semi-Structured Interviews. 11

CAADID.. 12

DIVA. 12

Computer-Assisted Diagnosis. 13

Questionnaires. 13

Self-Report Rating Scales. 14

Conners’s Adult ADHD Rating Scales (CAARS) 14

Current Symptoms Scale. 15

Adult ADHD Self-Report Scale–version 1.1 (ASRSv1.1) 15

Retrospective Assessments. 16

Wender Utah Rating Scale (WURS) 16

Non-Self Report Assessments. 16

Brown Attention-Deficit Disorder Rating Scale for Adults (Brown ADD-RS) 16

ADHD Investigator Symptom Rating Scale (AISRS) 17

Neuropsychological Testing. 17

Neurobiological Parameters. 20

Malingering. 20

Differential Diagnosis. 21

Comorbidity. 22

Psychosocial Functioning. 22

Conclusion. 23

References. 25

 

Introduction

Adult attention deficit hyperactivity disorder (ADHD) in adults is a childhood-onset, persistent, neurobiological disorder associated with high levels of morbidity and dysfunction estimated to afflict up to 5% of adults worldwide (Kessler et al., 2006). It includes a combination of persistent problems, such as difficulty paying attention, hyperactivity and impulsive behavior, which can lead to unstable relationships, poor work or school performance, low self-esteem, and other problems. Due concerns about overdiagnosis and overtreatment, many children and youth diagnosed with ADHD still receive no treatment or insufficient treatment (Giuliano & Geyer, 2017).

Using DSM-IV criteria, in a study by Wilens and colleagues, 93% of ADHD adults had either the predominately inattentive or combined subtypes-indicative of prominent behavioral symptoms of inattention in adults. (Wilens et al., 2009) ADHD often presents as an impairing lifelong condition in adults, yet it is currently underdiagnosed and treated in many European countries, leading to ineffective treatment and higher costs of illness. Instruments for screening and diagnosis of ADHD in adults are available and appropriate treatments exist, although more research is needed in this age group. (Kooij et al., 2010)

The diagnosis of ADHD in adults is a complex procedure which should refer to the diagnostic criteria of a diagnostic manual, such as the DSM or ICD. It normally includes the following information:

  • retrospective assessment of childhood ADHD symptoms
  • current adult ADHD psychopathology including symptom severity and pervasiveness,
  • functional impairment
  • quality of life
  • comorbidity

In order to obtain a systematic database for the diagnosis and evaluation of the course ADHD rating scales can be very useful. However, the interaction with the patient in the clinical interview should remain the central part of the diagnosis. (Haverkampf, 2017c, 2017a) Integrating elements of semi-structured questioning into the clinical interview can be helpful, while awareness for the communication patterns the patient uses is crucial. (Haverkampf, 2018c) Still, specific diagnostic criteria that are more sensitive and specific to adult functioning are needed. (Davidson, 2008)

Attention

When focusing on the diagnostic details, one may sometimes run the risk of losing sight of the bigger defining symptoms of ADHD. Attention deficit needs to be present for the diagnosis. Studies of adults with ADHD suggest that the most prominent symptoms of ADHD relate to inattention as opposed to hyperactivity and impulsivity. In a meta-analysis, Schoenlein and Engel integrated 24 empirical studies reporting results of at least one of 50 standard neuropsychological tests comparing adult ADHD patients with controls. Complex attention variables and verbal memory discriminated best between ADHD patients and controls. In contrast to results reported in children, executive functions were not generally reduced in adult ADHD patients. (Schoechlin & Engel, 2005)

Executive Functioning

Attention deficit hyperactivity disorder (ADHD) is associated with deficits in executive functioning. ADHD in adults is also associated with impairments in major life activities, particularly occupational functioning. Executive functioning deficits contribute to the impairments in occupational functioning that occur in conjunction with adult ADHD. Barkley and Murphy concluded in their study that ratings of executive functioning in daily life contribute more to such impairments than do executive functioning tests. The investigators hypothesize that one reason could be that each assesses a different level in the hierarchical organization of EF as a meta-construct. (Barkley & Murphy, 2010)

Communication

The exchange of information, internally and externally, is the process that is generally affected and gives rise to several of the observed symptoms. ADHD interferes with effective and helpful communication internally and externally, which causes several of the observed symptoms. (Haverkampf, 2010b) Internal and external communication patterns should thus be observed in diagnosis and worked with as an important focus later in treatment.

From Childhood to Adulthood: Hyperactivity vs Inattention

Prevalence of ADHD in adults declines with age in the general population, although the unclear validity of DSM–IV diagnostic criteria for this condition may have led to reduced prevalence rates by underestimation of the prevalence of adult ADHD. (Kessler et al., 2006) Symptoms start in early childhood and continue into adulthood. In some cases, ADHD is not recognized or diagnosed until the person is an adult. Adult ADHD symptoms may not be as clear as ADHD symptoms in children. In adults, hyperactivity often decreases, but struggles with impulsiveness, restlessness and difficulty paying attention usually continue. It is mostly these latter symptoms which can interfere significantly with an individual’s daily life.

Hyperactive–impulsive symptoms seem to decline more with increasing age, whereas inattentive symptoms of ADHD tend to persist. In a study by Millstein and colleagues, inattentive symptoms were most frequently endorsed in over 90% of ADHD adults. An assessment of current ADHD symptoms showed that 56% of adults had the combined ADHD subtype, 37% the inattentive only subtype, and 2% the hyperactive/impulsive subtype. Whereas females had fewer childhood hyperactive-impulsive symptoms than males, there were no gender differences in their ADHD presentation as adults. This suggests that the vast majority of adults with ADHD present with prominent symptoms of inattention. (Millstein, Wilens, Biederman, & Spencer, 1997) Decision-making is another important cognitive process which seems impaired in adults with ADHD (Mäntylä, Still, Gullberg, & Del Missier, 2012), and which can lead to impairment in several domains in life.

Measurement Problems

The decrease in ADHD symptoms over time may indicate true remission of symptoms, but it may also indicate that the symptom criteria are less robust in older rage groups. Michielsen and colleagues, for example, concluded in their epidemiological study on ADHD in older persons in the Netherlands that ADHD does not fade or disappear in adulthood. (Michielsen et al., 2012)

Misdiagnosis of ADHD

Rising rates of ADHD have led to the concern that ADHD is often misdiagnosed. The ability to concentrate, for example, can also be affected in depression, PTSD, anxiety, psychosis and other conditions, as can the capacity for organizing and seeing through tasks, various aspects of memory and information retrieval and irritability. There is evidence of medically inappropriate ADHD diagnosis and treatment in school-age children and less so for adults. In a study by Evans and colleagues, for example, age relative to peers directly affected a child’s probability of being diagnosed with ADHD. The relative age effect was present for both ADHD diagnosis and treatment with stimulants (Evans, Morrill, & Parente, 2010).

Autism

Because of the high frequency of ADHD symptoms in autism, children with autism may initially be misdiagnosed with ADHD. The core symptoms of ADHD (attention deficit, impulsivity, and hyperactivity) are part of autism, and autism and ADHD have similar underlying neuropsychological deficits (Mayes, Calhoun, Mayes, & Molitoris, 2012). On the other hand, the rate for children with autism spectrum disorder to be also diagnosed with ADHD is as high as 60% (Stevens, Peng, & Barnard-Brak, 2016).

Trauma

Trauma may also be misinterpreted as ADHD, particularly in children. Hyper-vigilance and dissociation, for example, could be mistaken for inattention. Impulsivity might be brought on by “a stress response in overdrive” (Ruiz, 2014). Cognitive and emotional disruptions that occur in response to trauma, such as difficulty concentrating, dysregulated affect, irritability, and hyperarousal, either overlap with ADHD symptomatology or exasperate it (Szymanski, Sapanski, & Conway, 2011).

OCD

Manifestations of OCD-related inattention may be misdiagnosed as ADHD symptoms, particularly again in children. In OCD only, current ADHD symptoms correlate with obsessive-compulsive symptoms There is a risk of misdiagnosis, especially in children when primarily relying on informants (Abramovitch, Dar, Mittelman, & Schweiger, 2013).

Bipolar Disorder

Bipolar disorder is also a neurodevelopmental disorder with onset in childhood and early adolescence and commonly persists into adulthood. Both disorders are often undiagnosed, misdiagnosed, and sometimes over diagnosed. The differentiation of these conditions is based on their clinical features, comorbidity, psychiatric family history, course of illness, and response to treatment (Marangoni, De Chiara, & Faedda, 2015). Children with bipolar disorder are more likely to present with

  • aggression and lack of remorse, while in ADHD a destructiveness is more likely due to carelessness.
  • severe temper tantrums, often of more than an hour in duration, which are less intense and shorter in ADHD
  • intentional misbehavior, which is in ADHD more likely to be due to inattentiveness
  • underestimating risk, while in ADHD there may be unawareness of risk
  • anger for longer periods of time, holding a grudge and being unforgiving, while in ADHD calm is usually restored within half an hour or considerably more quickly and the reasons for the anger forgotten
  • stimulation seeking due to boredom, while in ADHD the stimulation seeking is more general
  • amnesia for anger outbursts
  • flight of ideas (manic phase), while in ADHD the talkativeness is due to a lack of inhibition and can be influenced and redirected
  • decreased need for sleep
  • sleep inertia and slow awakening (unless in a manic phase)
  • rapidly changing mood shifts
  • suicidal ideation
  • symptoms that routinely improve on lithium, mood stabilizers, antipsychotics
  • symptoms that do not improve on stimulants

If both conditions are present, the mood disorder symptoms and the course of the bipolar condition are usually more severe, and the functional scores lower. Since the symptoms of a separate ADHD are often mistakenly assumed to be part of the bipolar conditions, patients with comorbid ADHD and BD are routinely underdiagnosed and undertreated (Klassen, Katzman, & Chokka, 2010).

Symptoms

Many people with ADHD have fewer symptoms as they age, but some adults continue to have major symptoms that interfere with daily functioning also in later stages of life. In adults, the main features of ADHD may include difficulty paying attention, impulsiveness and restlessness. This can make it more difficult to acquire new information, process it together with existing information and communicate with others.

Adults with ADHD may find it difficult to focus and prioritize, leading to missed deadlines and forgotten meetings or social plans. The inability to control impulses can range from impatience waiting in line or driving in traffic to mood swings and outbursts of anger. The difficulties in persisting with a task is probably a consequence of ineffective information transmission internally.

Adult ADHD symptoms may include:

  • Impulsiveness
  • Disorganization and problems prioritizing
  • Poor time management skills
  • Problems focusing on a task
  • Trouble multitasking
  • Excessive activity or restlessness
  • Poor planning
  • Low frustration tolerance
  • Frequent mood swings
  • Problems following through and completing tasks
  • Hot temper
  • Trouble coping with stress

Diagnosing ADHD

Extensive psychometric studies have provided empirical support for the symptom thresholds used to diagnose ADHD in children, and there is general agreement that ADHD can be reliably diagnosed in children using these formal diagnostic criteria. However, the reliability of the diagnosis of ADHD in adults is less clear. The task would become easier if there were a greater focus on operationalizing internal and external communication patterns, that can be observed, described by the patient or inferred from these observation and descriptions by an experienced therapist. These patterns have been described by the author in for ADHD (Haverkampf, 2017e, 2017a) as well as for several other mental health conditions (Haverkampf, 2010b, 2017d, 2018b). Diagnosis of adult attention-deficit hyperactivity disorder (ADHD) adults is difficult, as neither symptom report nor neuropsychological findings are specific to ADHD. However, the most information can still be gained in the clinical interview if the clinician is receptive to the various levels of information flows and integrates them into the overall assessment.

Subtypes

It is unclear whether the three subtypes recognized in the diagnostic manuals have a different underlying ethology or any other justification to separate them. However, they are frequently used in clinical practice and offer a rough symptom description which can also be useful for many non-medical questions, such as support in school or disability. The subtypes are:

  • ADHD combined type (ADHD-C; both inattentive and hyperactive–impulsive symptoms)
  • ADHD predominantly inattentive type (ADHD-I)
  • ADHD predominantly hyperactive–impulsive type (ADHD-H)

Assessment

The diagnosis of adult ADHD is a clinical decision-making process, where the emphasis lies on the clinical interview and anything that can support the information gained in it. There are no objective, laboratory-based tests that can establish this diagnosis. (Haavik, Halmøy, Lundervold, & Fasmer, 2010) Given the difficulties with the formal diagnostic criteria for ADHD, determining the diagnosis of ADHD in adults presents different challenges than determining the diagnosis in children (Riccio et al., 2005). There is no single neurobiological or neuropsychological test that can determine a diagnosis of ADHD on an individual basis (Rosler et al., 2006).

In most situations, an ADHD assessment should include a comprehensive clinical interview, as rating scales, an assessment of a broader spectrum of psychiatric and somatic conditions and information from third parties if available.

Communication

How patients exchange meaningful information with themselves and others to get their needs and aspirations met or in response to an interaction or a perception or sensation is of very high diagnostic values in most psychiatric conditions, including especially so also ADHD. Unfortunately, there is often a lack of focus on a patients’ internal and external communication, which could be diagnostically helpful in the diagnosis and treatment of ADHD. For example, the effectiveness of ADHD coaching in improving patients’ everyday life has been demonstrated. (Kubik, 2010) Since communication is the basic process by which individuals get their needs and aspirations met in everyday life, increasing their quality of life and integrating them into the community, which in itself can have a protective effect, exploring a patient’s communication patterns should be a primary goal of an assessment for the severity of ADHD. (Haverkampf, 2017f, 2017e, 2017b)

The clinical interview, and thus the interaction with the patient, is at the center of the diagnosis of ADHD. This may make the process more difficult to operationalize for randomized controlled studies if they fail to conceptualize information and communication in a clinical interview. A greater elucidation of communication processes has been described as beneficial by the author and several different techniques and approaches suggested.  (Haverkampf, 2010a)

The Clinical Interview

A comprehensive clinical interview is one of the most effective methods to make a diagnosis of ADHD (Adler, 2004; Jackson & Farrugia, 1997; Murphy & Adler, 2004; Wilens, Faraone, & Biederman, 2004). Open-ended questions about childhood and adult behaviors can be used to elicit information necessary to diagnose ADHD. Interviews also include questions regarding developmental and medical history, school and work history, psychiatric history, and family history of ADHD and other psychiatric disorders (Barkley, 2006).

The clinical interview also gives inside into the communication the patient uses, internally and externally, and how he or she attends to and processes meaningful information. (Haverkampf, 2010a, 2018a) This is important for the diagnosis and treatment of any mental health condition, but particularly also ADHD. (Haverkampf, 2017a)

Semi-Structured Interviews

Although many clinicians use unstructured interviews to assess adult ADHD, semistructured interviews do exist. One does not necessarily have to choose between either one, but it can be helpful to at least integrate semistructured elements into a clinical interview, which still offers the latitude to explore more freely, which can be important in assessing any comorbidities. Research suggests that semistructured clinical interviews can reliably and accurately be used for determining a diagnosis of ADHD in adults (Epstein & Kollins, 2006).

Comprehensive diagnostic interviews not only evaluate diagnostic criteria, but also assess different psychopathological syndrome scores, functional disability measures, indices of pervasiveness and information about comorbid disorders. Comprehensive procedures include the Brown ADD Diagnostic Form and the Adult Interview by Barkley and Murphy. The Wender Reimherr Interview which follows a diagnostic algorithm different from DSM-IV. The interview contains only items delineated from adult psychopathology and not derived from symptoms originally designed for use in children. (Rösler et al., 2006)

From a communication perspective, the etiology of ADHD consists generally of the same maladaptive communication and information handling patterns, whether in a child or an adult. However, given differences in developmental stages and environmental factors the symptoms and impairments can be different. Also, the chronicity and entrenchment of a particular patterns, in connection with developmental progress, can influence the phenomenology of the condition. To consider all these factors a certain flexibility and openness in the clinical interview is of paramount importance.

CAADID

The Conners Adult ADHD Diagnostic Interview for DSM-IV (CAADID), for example, assesses for the presence of the ADHD symptoms listed in the DSM-IV and collects information related to history, developmental course, ADHD risk factors, and comorbid psychopathology. Epstein and Kollines examined the test-retest reliability and concurrent validity of the CAADID for DSM-IV in a sample of thirty patients referred to an outpatient clinic. Kappa statistics for individual symptoms of inattention and hyperactivity-impulsivity were in the fair to good range for current report and retrospective childhood report. Kappa values for overall diagnosis, which included all DSM-IV symptoms, were fair for both current (adult) ADHD diagnosis (kappa = .67) and childhood report (kappa = .69). Concurrent validity was demonstrated for adult hyperactive-impulsive symptoms and child inattentive symptoms. (Epstein & Kollins, 2006)

DIVA

Another semi-structured interview is the Diagnostic Interview for ADHD in adults, which has gone through improvement updates. It has been compared to the CAADID and other ADHD severity scales, following the DSM-IV criteria. Ramos-Quiroga and colleagues carried out a transversal study on 40 out-patients with ADHD to check the criteria and concurrent validity of the DIVA 2.0 compared with the CAADID. The DIVA 2.0 interview showed a diagnostic accuracy of 100% when compared with the diagnoses obtained with the CAADID interview. The concurrent validity demonstrated good correlations with three self-reported rating scales: the Wender Utah Rating Scale (WURS), the ADHD-Rating Scale, and Sheehan’s Dysfunction Inventory. (Ramos-Quiroga et al., 2016) One advantage of the DIVA is that it is free to use.

Computer-Assisted Diagnosis

Supportive methods in diagnosing ADHD are being explored. Using computerized clinical decision support modules can in higher quality of care with respect to ADHD diagnosis including a prospect for higher quality of ADHD management in children. (Bergman et al., 2009) This is different from using computers for neuropsychological testing, where the patient interacts with the computer. Computer-assisted diagnosis tools could, for example, provide decision trees that are based on empirical insights. While this can be a valuable support for the clinician, it is important to keep in mind that the interactions with the patient is probably the most important instrument in the assessment of ADHD.

Questionnaires

Questionnaires may be underutilized in clinical practice. They often are easy to administer, score and interpret, while their reliability and validity can be quite high.

  • The Connors Adult ADHD Rating Scales (CAARS)
  • the Current Symptoms Scales by Barkley and Murphy (CSS)
  • the Adult Self Report Scale (ASRS) by Adler et al. and Kessler et al. and
  • the Attention Deficit Hyperactivity Disorder—Self Report Scale (ADHD-SR by Rösler et al.)

are self-report rating scales focusing mainly on the DSM-IV criteria, although the CAARS and CSS also have other forms.

  • The Wender-Utah Rating Scale (WURS) and

the Childhood Symptoms Scale by Barkley and Murphy aim at making a retrospective assessment of childhood ADHD symptoms.

  • The Brown ADD Rating Scale (Brown ADD-RS) and
  • the Attention Deficit Hyperactivity Disorder-Other Report Scale (ADHD-OR by Rösler et al.)

are instruments for use by clinicians or significant others.

Both self-rating scales and observer report scales quantify the ADHD symptoms by use of a Likert scale mostly ranging from 0 to 3, which makes comparison of follow-up tests easier.

Self-Report Rating Scales

Self-report checklists are commonly used in the assessment of ADHD. In addition to self-report rating scales, rating scales completed by an individual’s spouse or significant other can provide useful information in determining the individual’s overall life functioning. They are easy to administer, and a number of reliable and valid measures exist. Problems may be bias or malingering, which are difficult to control for. Distorted memories probably play a negligible role in rating scales that focus on current symptoms, but could become important in those screening for symptoms in childhood and adolescence.

Research has demonstrated that rating scales can accurately reflect the frequency and intensity of symptoms (Wadsworth & Harper, 2007) and, when used retrospectively, are valid indicators of symptomatology (Murphy & Schachar, 2000). Murphy and Schachar (2000) examined the validity of self-reported ratings of current and childhood ADHD symptoms by adults. In one study, participants’ ratings of their childhood ADHD symptoms were compared to their parents’ ratings of childhood symptoms. In a second study, participants’ ratings of their current ADHD symptoms were compared to a significant other’s rating of current symptoms. All correlations between self-ratings and parent ratings were significant for inattentive, hyperactive–impulsive, and total ADHD symptoms, as were correlations between self-ratings and significant other ratings.

Belendiuk and colleagues examined in 2007 the concordance of diagnostic measures for ADHD, including self-ratings and collateral versions of both rating scales and semistructured interviews. Results supported the findings of Murphy and Schachar, showing high correlations between self-reports and collateral reports of inattentive and hyperactive–impulsive symptoms. Results also demonstrated high correlations between self-report rating scales and diagnostic interviews. (Belendiuk, Clarke, Chronis, & Raggi, 2007)

Conners’s Adult ADHD Rating Scales (CAARS)

The CAARS (Conners, Erhart, & Sparrow, 1999) assesses ADHD symptoms in adults and comprises short, long, and screening self-report and observer rating scale forms. The CAARS produces eight scales, including scales based on DSM-IV criteria and an overall ADHD index. Internal consistency is good, with Cronbach’s alpha across age, scales, and forms ranging from .49 to .92 (Conners et al., 1999; Erhardt, Epstein, Connors, Parker, & Sitarenios, 1999). Test–retest reliability (1 month) estimates are high, ranging from .85 to .95 (Conners et al., 1999; Erhardt et al., 1999). The ADHD index produces an overall correct classification rate of 85%, and the sensitivity of the ADHD index has been estimated at 71% and the specificity at 75% (Conners et al., 1999).

Adler and colleagues compared the reliability, validity, and utility in a sample of adults with ADHD and also as an index of clinical improvement during treatment of self- and investigator ratings of ADHD symptoms via the CAARS. They analyzed data from two double-blind, parallel-design studies of 536 adult ADHD patients, randomized to 10-week treatment with atomoxetine or placebo. The CAARS demonstrated good internal consistency and inter-rater reliability, as well as sensitivity to treatment outcome. (Adler et al., 2008)

Taylor and colleagues retrieved 35 validation studies of adult ADHD rating scales and identified 14 separate scales. The majority of studies were of poor quality and reported insufficient detail. Of the 14 scales, the Conners’ Adult ADHD Rating scale and the Wender Utah Rating Scale (short version) had more robust psychometric statistics and content validity. (Taylor, Deb, & Unwin, 2011)

Current Symptoms Scale

The Current Symptoms Scale (Barkley & Murphy, 1998) is an 18-item selfreport scale with both a patient version and an informant version. It contains the 18 items from the diagnostic criteria in DSM-IV. Validity has been demonstrated through past findings of significant group differences between ADHD and control adults (Barkley, Murphy, DuPaul, & Bush, 2002). An earlier DSM-III version of the scale correlated significantly with the same scale completed by a parent (r = .75) and by a spouse or intimate partner of the ADHD adult (r = .65; Murphy & Barkley, 1996a).

Adult ADHD Self-Report Scale–version 1.1 (ASRSv1.1)

The ASRS-v1.1 (Adler, Kessler, & Spencer, 2003) is an 18-item measure based on the DSM-IV-TR criteria for ADHD that produces three scale scores. Questions are designed to suit an adult rather than a child, and the language provides a context for symptoms that adults can relate to. Internal consistency estimates are high, and the ASRS-v1.1 has been shown to have high concurrent validity (Adler et al., 2006).

Adler et al conducted a study to validate the pilot Adult ADHD Self-Report Scale (pilot ASRS) versus standard clinician ratings on the ADHD Rating Scale (ADHD RS). Sixty adult ADHD patients took the self-administered ADHD RS and then raters administered the standard ADHD RS. Internal consistency was high for both patient and rater-administered versions. The intra-class correlation coefficients (ICCs) between scales for total scores was also high, as were ICCs for subset symptom scores. There was acceptable agreement for individual items and significant kappa coefficients for all items. The pilot Adult ADHD Self-Report Scale symptom checklist was thus a reliable and valid scale for evaluating ADHD for adults and showed a high internal consistency and high concurrent validity with the rater-administered ADHD RS. (Adler et al., 2006)

Retrospective Assessments

Retrospective assessments collect information to help make a retroactive diagnosis of ADHD.

Wender Utah Rating Scale (WURS)

The WURS (Ward, Wender, & Reimherr, 1993) is based on items from the monograph Minimal Brain Dysfunction in Children (Wender, 1971), which is more detailed than the symptoms listed in the DSM or ICD-10. McCann and colleagues examined the factor structure and discriminant validity of the WURS in adults seeking evaluation for attention-deficit/hyperactivity disorder (ADHD). Three factors (Dysthymia, Oppositional/Defiant Behavior, and School Problems) accounted for 59.4% of the variance. In a stepwise discriminant function analysis, age and childhood school problems emerged as significant variables. The classification procedure correctly classified 64.5% of patients. Among those who did not have ADHD, only 57.5% were correctly classified compared with 72.1% among those with ADHD. The WURS thus appears to be sensitive in detecting ADHD, but it misclassified approximately half of those who do not have ADHD. (McCann, Scheele, Ward, & Roy-Byrne, 2000)

Non-Self Report Assessments

Brown Attention-Deficit Disorder Rating Scale for Adults (Brown ADD-RS)

The Brown ADD-RS (Brown, 1996; Brown & Gammon, 1991) assesses symptoms of ADHD in adults. It was developed before the DSM-IV concept of ADHD was published and focuses more on symptoms of inattention rather than hyperactivity and impulsivity. The scale shows high internal consistency (α = .96) and satisfactory validity (M. Weiss, Hechtman, & Weiss, 1999).

ADHD Investigator Symptom Rating Scale (AISRS)

To measure treatment response, the Adult ADHD Investigator Symptom Rating Scale (AISRS) was developed to better capture symptoms of ADHD in adult patients. The AISRS uses a semistructured interview methodology with suggested prompts for each item to improve interrater reliability. (Spencer et al., 2010) The authors analyzed psychometric properties of the AISRS total and AISRS subscales and compared them to the investigator rated version of the CAARS and the Clinical Global Impression-ADHD-Severity Scale using data from a placebo-controlled 6-month clinical trial of once-daily atomoxetine. Results showed that the AISRS and its subscales were robust, valid efficacy measures of ADHD symptoms in adult patients. Its anchored items and semistructured interview are mentioned as advancements over existing scales. (Spencer et al., 2010)

Neuropsychological Testing

Attention-deficit hyperactivity disorder (ADHD) is a behaviorally defined diagnosis. Despite the fact that neuropsychological tests have typically been used successfully to investigate the functional neuroanatomy of ADHD in neuroimaging research paradigms, these tests have been of surprisingly limited utility in the clinical diagnosis of the disorder. (Koziol & Stevens, 2012) Still, if used discriminatingly and with an understanding for their place in an assessment, neuropsychological testing can play a significant role in the assessment of ADHD. However, one needs to keep in mind that there is no single test or battery of tests that has adequate predictive validity or specificity to make a reliable diagnosis of ADHD. Although there seem to be differences between adults with ADHD and control participants on measures of cognitive functioning, these measures probably have limited predictive value in distinguishing ADHD from other psychiatric or neurological conditions that are associated with similar cognitive impairments (Wadsworth & Harper, 2007).

In adult ADHD, neuropsychological testing is most beneficial when the results are used to support conclusions based on history, rating scales, and analysis of current functioning. Cognitive assessments can be useful in that they can improve the validity of an ADHD assessment and be used in assessing the efficacy of pharmacological and/or psychological interventions (Epstein et al., 2003). Also, many researchers agree that a neuropsychological assessment will be most sensitive to ADHD when the assessment incorporates multiple, overlapping procedures measuring a broad array of attentional and executive functions (Alexander & Stuss, 2000; Cohen, Malloy, & Jenkins, 1998; Woods et al., 2002).

Important functional domains of neuropsychological tests are:

  • verbal ability
  • figural problem solving
  • abstract problem solving
  • executive function
  • fluency
  • simple attention
  • sustained attention
  • focused attention
  • verbal memory
  • figural memory

Woods and his colleagues (2002) reviewed the role of neuropsychological evaluation in the diagnosis of adults with ADHD. In their review of 35 studies, the authors found that the majority of the studies demonstrated significant discrepancies between adults with ADHD and normal control participants on at least one measure of executive function (i.e., the ability to assess a task situation, plan a strategy to meet the needs of the situation, implement the plan, make adjustments, and successfully complete the task; Riccio et al., 2005) or attention. Moreover, Woods et al. found that the most prominent and reliable executive function and attention measures that differentiated adults with ADHD were Stroop tasks (Stroop, 1935) and continuous performance tests (CPTs). (The Stroop phenomenon demonstrates that it is difficult to name the ink color of a color word if there is a mismatch between ink color and word. For example, the word GREEN printed in red ink. The CPT measures a person’s sustained and selective attention.)

Neuropsychological tests generally have a poor ability to discriminate between patients diagnosed with ADHD and patients not diagnosed with ADHD. Pettersson and colleagues investigated in their study the discriminative validity of neuropsychological tests and diagnostic assessment instruments in diagnosing adult ADHD in a clinical psychiatric population of 108 patients, 60 were diagnosed with ADHD. The Diagnostic Interview for ADHD in adults (DIVA 2.0) and Adult ADHD Self-Report Scale (ASRS) v.1.1 together with eight neuropsychological tests were investigated. All instruments showed poor discriminative ability except for the DIVA, which showed a relatively good ability to discriminate between the groups (sensitivity = 90.0; specificity = 72.9). A logistic regression analysis model with the DIVA and measures of inattention, impulsivity, and activity from continuous performance tests (CPTs) showed a sensitivity of 90.0 and a specificity of 83.3. This means that while the ability to discriminate between patients with and without ADHD is poor, variables from CPT tests can contribute to increasing the specificity by 10% if used in combination with the DIVA. (Pettersson, Söderström, & Nilsson, 2018)

Schoechlin and colleagues conducted a meta-analysis integrating 24 empirical studies reporting results of at least one of 50 standard neuropsychological tests comparing adult ADHD patients with controls. The 50 tests were categorized into the following 10 functional domains: verbal ability, figural problem solving, abstract problem solving, executive function, fluency, simple attention, sustained attention, focused attention, verbal memory, figural memory. For each domain a pooled effect size d′ was calculated. Complex attention variables and verbal memory discriminated best between ADHD patients and controls. Effect sizes for these domains were homogeneous and of moderate size (d′ between 0.5 and 0.6). In contrast to results reported in children, executive functions were not generally reduced in adult ADHD patients. (Schoechlin & Engel, 2005) Woods et al. (2002), on the other hand, concluded that although a general profile of attentional and executive function impairment is evident in adults with ADHD, expansive impairments in these domains (i.e., impairments on all attention and executive function tasks) is not common. Their review demonstrated inconsistencies in specific instruments across studies, indicating that adults with ADHD may not perform poorly on all attentional measures all the time. This finding is not surprising given the fact that adults with ADHD often demonstrate sporadic or inconsistent attention, which can be difficult to identify given the structure provided by the one-on-one testing environment (Barkley, 1998).

One popular family of measures for the assessment of attention and executive control is the continuous performance test (CPT). A review of the available research on CPTs reveals that they are quite sensitive to CNS dysfunction. This is both a strength and a limitation of CPTs in that multiple disorders can result in impaired performance on a CPT. The high sensitivity of CPTs is further complicated by the multiple variations of CPTs available, some of which may be more sensitive or demonstrate better specificity to ADHD in adults than others. If CPTs are to be used clinically, further research will be needed to answer the questions raised by this review. (Riccio & Reynolds, 2006).

Several theoretical models suggest that the core deficit of ADHD is a deficiency in response inhibition. While neuropsychological deficits in response inhibition are well documented in ADHD children, research on these deficits in adult ADHD populations is minimal. In a study by Epstein and colleagues, twenty-five adult ADHD patients, 15 anxiety-disordered adult patients, and 30 normal adults completed three neuropsychological tests of response inhibition: the Continuous Performance Test, Posner Visual Orienting Test, and the Stop Signal Task. ADHD adults demonstrated response inhibition performance deficits when compared to both normal adults and anxiety disordered adults only on the Continuous Performance Test. A similar pattern of differences was not observed on the other two neuropsychological tests. Differing results between tasks may be due to differences in test reliability, task parameters, or the targeted area of brain functioning assessed by each test. (Epstein, Johnson, Varia, & Conners, 2001)

Neurobiological Parameters

Abibullaev and colleagues proposed a decision support system in diagnosing ADHD through brain electroencephalographic signals. (Abibullaev & An, 2012) Lenartowicz and Loos concluded that while EEG cannot currently be used as a diagnostic tool, vast developments in analytical and technological tools in its domain anticipate future progress in its utility in the clinical setting. (Lenartowicz & Loo, 2014) However, the overall assessment still requires a clinical decision, which may depend on many factors, including the individual attitude towards the diagnosis held by the therapist.

Malingering

Malingering is an important issue in ADHD diagnosis and is defined as the conscious fabrication or exaggeration of physical or psychological symptoms in the pursuit of a recognizable goal. A diagnosis of ADHD can provide an individual with several benefits, including stimulant medication, disability benefits, tax benefits, and academic accommodations, and such benefits may motivate adults undergoing diagnostic evaluations for ADHD to exaggerate symptomatology on self-report measures and tests of neurocognitive functioning. Musso and colleagues identified and summarize nineteen peer-reviewed, empirical studies published between 2002 and 2011 that investigated malingered ADHD in college students. Few of the measures examined proved useful for detecting malingered ADHD. Most self-report questionnaires were not sensitive to malingering. While there is some variability in the usefulness of neuropsychological test failure, profiles between malingerers and individuals with ADHD were too similar to confidently detect malingered ADHD. Failure of three or more symptom validity tests proved most useful at detecting malingered ADHD. The authors concluded that there is substantial need for measures designed specifically for detecting malingered ADHD simulators are able to produce plausible profiles on most tools used to diagnose ADHD. (Musso & Gouvier, 2014)

Detection of faking can prove difficult with adults in particular, as clinicians often do not have access to a parent or sibling who can attest to prior history of ADHD symptoms or the resources to follow up do not exist. Moreover, adults often lack developmental documentation such as report cards, teacher evaluations, or prior psychological testing reports.

Quinn (2003) examined the issue of malingering by comparing the susceptibility of a self-report ADHD rating scale and a CPT to faking in an undergraduate sample of individuals with and without a diagnosis of ADHD. Results indicated that the CPT showed greater sensitivity to malingering than did the self-report scale and that a CPT can successfully discriminate malingerers from those with a valid diagnosis of ADHD. Given the potential benefits associated with an ADHD diagnosis, clinicians should include a symptom validity measure in their assessment battery. At present, however, there is no demonstrated best practice for this.

Suhr and colleagues utilized archival data from young adults referred for concerns about ADHD, divided into three groups: (1) those who failed a measure of noncredible performance (the Word Memory Test; WMT), (2) those who met diagnostic criteria for ADHD, and (3) controls with psychological symptoms but no ADHD. Results showed a 31% failure rate on the WMT. Those who failed the WMT showed clinical levels of self-reported ADHD symptoms and impaired neuropsychological performance. Neither self-report measures nor neuropsychological tests could distinguish ADHD from psychological controls, with the exception of self-reported current hyperactive/impulsive symptoms and Stroop interference. (Suhr, Hammers, Dobbinsbuckland, Zimak, & Hughes, 2008) These results underscore the effect of noncredible performance on both self-report and cognitive measures in ADHD.

It is difficult to tell how much a greater focus on the communication dynamics in a clinical interview can improve the problems around malingering. However, communication in its diverse synchronous forms is probably much more difficult to consciously influence and ‘fake’ than a simple task. However, a greater focus on communication patterns and dynamics also requires the skills and experience in the clinician to work with them.

Differential Diagnosis

Diagnosing ADHD in adults requires careful consideration of differential diagnoses, as it can be difficult to differentiate ADHD from a number of other psychiatric conditions (Pary et al., 2002), including major depression, bipolar disorder, generalized anxiety, obsessive–compulsive disorder (OCD), substance abuse or dependence, personality disorders (borderline and antisocial), and learning disabilities (Searight, Burke, & Rottnek, 2000). For example, differential diagnosis of ADHD from mood and conduct disorders may be difficult because of common features such a mood swings, inability to concentrate, memory impairments, restlessness, and irritability (Adler, 2004). Differential diagnosis of learning disabilities can also prove difficult because of the interrelated functional aspects of the disorders that have the common outcome of poor academic functioning (Adler, 2004; Jackson & Farrugia, 1997).

Comorbidity

High rates of comorbidities are also seen in adults with ADHD, with the majority having at least one additional psychiatric disorder. ADHD is associated with a high percentage of comorbid psychiatric disorders in every lifespan. In adulthood between 65–89% of all patients with ADHD suffer from one or more additional psychiatric disorders, above all mood and anxiety disorders, substance use disorders and personality disorders, which complicates the clinical picture in terms of diagnostics, treatment and outcome issues. (Sobanski, 2006) Outcome studies have demonstrated that individuals diagnosed with ADHD in childhood are at risk for developing comorbid conditions, some of which are likely secondary to ADHD-related frustration and failure.

The most frequent comorbid psychopathologies include mood and anxiety disorders, substance use disorders, and personality disorders. (Katzman, Bilkey, Chokka, Fallu, & Klassen, 2017) Biederman and colleagues (1993) found a relatively high incidence of lifetime diagnoses of anxiety disorders (43% to 52%), major depressive disorder (31%), ODD (29%), CD (20%), antisocial personality disorder (12%), and alcohol and drug dependencies (27% and 18%, respectively) in their sample of clinic-referred adults with ADHD. There are strong familial links and neurobiological similarities between ADHD and the various associated psychiatric comorbidities. Comparable rates of comorbidities have been found in men and women with ADHD, with the exception of men having higher rates of antisocial personality disorder. (Millstein et al., 1997)

With respect to ADHD subtypes in adults, Millstein and colleagues found higher rates of ODD, bipolar disorder, and substance use disorders in patients with the combined type of ADHD than in those with other subtypes and higher rates of ODD, OCD, and PTSD in patients with the hyperactive type than in those with the inattentive type.  In their study, Sprafkin and colleagues found that all three subtypes reported more severe comorbid symptoms than did a control group, with the combined group obtaining the highest ratings of comorbid symptom severity. The authors found that the ADHD symptom subtypes in adults are associated with distinct clinical correlates and conclude that the diversity of self-reported psychopathology in adults who meet symptom criteria for ADHD highlights the importance of conducting broad-based evaluations. (Sprafkin, Gadow, Weiss, Schneider, & Nolan, 2007)

Psychosocial Functioning

In addition to comorbid psychiatric disorders, adults with ADHD often complain of psychosocial difficulties, which can manifest in a significantly higher rate of separation and divorce and lower socioeconomic status, poorer past and current global functioning estimates, and higher occurrence of prior academic problems relative to the control group.

Murphy and Barkley (1996a) documented high rates of educational, employment, and marital problems in adults with ADHD. Multiple marriages were more common in the adult ADHD group, and significantly more adults with ADHD had performed poorly, quit, or been fired from a job and had a history of poorer educational performance and more frequent school disciplinary actions against them than did adults without ADHD. Low self-concept and low self-esteem are common secondary characteristics of adults with ADHD, often resulting from problematic educational experiences and interpersonal difficulties (Jackson & Farrugia, 1997). Adults with ADHD often have strong feelings of incompetence, insecurity, and ineffectiveness, and many of these individuals live with a chronic sense of underachievement and frustration (Murphy, 1995).

Conclusion

Variations in communication processes and patterns, both internally and externally, play an important role in the etiology and the symptomatology of ADHD. Unfortunately, there is not enough focus on them in diagnosis and treatment. The author has proposed a theoretical approach and several practical approaches elsewhere (Haverkampf, 2010b, 2017e, 2017d, 2018b) Since the symptoms of ADHD are consequences of maladaptive internal communication and processing mechanisms of meaningful information, while at the same time there are maladaptive external communication patterns with the world, which lead to the observed difficulties in the personal and professional life of the patient, a greater focus on communication is important.

The use of DSM-IV criteria for ADHD in adults has been criticized. Barkley (1998) suggests that applying current ADHD criteria to adults is not developmentally sensitive. The DSM-IV criteria for ADHD were designed for and selected based on studies with children (Riccio et al., 2005), and validation studies of ADHD criteria in adults have not been conducted (Belendiuk, Clarke, Chronis, & Raggi, 2007). It has thus been suggested that the symptom lists in DSM-IV may be inappropriately worded for adults and that diagnostic thresholds may be too stringent or restrictive when applied to adults (Heiligenstein, Conyers, Berns, & Smith, 1998). The level of impairment caused by ADHD symptoms may also be different between adults and children, and symptoms will likely affect more domains in adults. However, when looked at from a communication perspective, and when focusing on the basic of ADHD, such as the attention deficit, it seems possible to view ADHD as a condition where external and internal communication, including the receptiveness for and decoding of information, is altered in predictable patterns. (Haverkampf, 2017f)


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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Body Work and Exercise for Anxiety Panic Attacks Depression and OCD

Body-Work-and-Exercise-for-Anxiety-Panic-Attacks-Depression-and-OCD-2-Christian-Jonathan-Haverkampf-life-improvement-series

Body Work and Exercise for Anxiety, Panic Attacks, Depression and OCD

Christian Jonathan Haverkampf, M.D.

Working with the body is often neglected in major schools of psychotherapy, such as psychodynamic psychotherapy and CBT. Depression and anxiety disorders are some of the most prevalent psychiatric disorders with close to one in five of adults exhibiting symptoms. Exercise has been shown to reduce symptoms associated with these disorders, has the potential to increase the effectiveness of psychopharmacology and to reduce depenndance on it in specific cases. The balance seems to be important between too little and excessive exercise.

Keywords: body work, exercise, treatment, anxiety, panic attacks, depression, OCD, obsessive-compulsive disorder, Communication-Focused Therapy, CFT, psychotherapy, psychiatry

Contents

Introduction. 4

Reconnection. 4

Communication. 4

Information Processing. 4

Integrative Therapy. 5

Exercise and Mental Health. 5

Depression and Anxiety. 5

Age. 6

Neurophysiology. 6

Hippocampal Volume. 6

Endocannabinoids. 6

Adrenocorticotropic Hormone (ACTH) 6

Serotonin. 7

Depression. 7

Body Image. 7

Body Image as a Problem.. 7

Obesity. 9

Breast Cancer. 9

Exercise as an Adjunct to Medication. 10

Techniques. 10

Basic Body Awareness Therapy (BBAT) 10

Pilates. 11

Body Psychotherapy (BPT) 11

Tai Chi 11

Yoga. 11

Exercise Dose. 12

Exercise and Anxiety. 12

Anxiety Sensitivity. 13

Body Dysmorphic Disorder: OCD.. 13

Hypochondriasis. 14

Risks. 15

Prevention. 15

Conclusion. 15

References. 17

Introduction

Much of the information the brain processes is received from and through the body. Since anxiety, depression and OCD are disturbances in the communication and processing of information, it makes theoretical and practical sense to involve the body in the therapeutic process.

While studies support the use of exercise as a treatment for depression, healthcare professionals irregularly suggest and rarely prescribe it. In their depression treatment guidelines, the American Psychiatric Association (APA) states that exercise may be of value but does not consider it as a first-line treatment. The National Guideline Clearinghouse states in a consensus-based recommendation that exercise is recommended as an adjunctive treatment to antidepressants or psychotherapy.

Chronic major depressive disorder and dysthymia are associated with a high burden and substantial care costs. New and more effective treatments are required. Besides case series and small uncontrolled studies, recent well-controlled studies suggest that exercise training may be clinically effective, at least in major depression and panic disorder. (Ströhle, 2009)

Reconnection

Information comes in through the body. Types of body work and exercise which increase the sense of the body appear to be helpful in various psychiatric conditions. It helps to lessen the focus on a particular bodily function or organ and opens the inflow of information from more points in the body. This can help lower the partial disconnect which is usually present in conditions, such as anxiety, depression, panic attacks, OCD and more.

Communication

The body is a communication device, receiving information from the environment and allowing one to send messages, whether verbal or non-verbal. (Haverkampf, 2018) Communication is also the process which brings about change (Haverkampf, 2010a) and takes a preeminent place in communication-focused therapy (CFT) (Haverkampf, 2017a), which has been developed by the author, and plays a role in all psychotherapies.

Information Processing

The body also uses information that is communicated to it. As the nervous system innervates most parts of the body, there is a fast and ubiquitous connectedness throughout the body. While much information is relayed in the central nervous system (CNS) and then send out again, there are relatively autonomous neural networks distributed throughout the body. From a communication viewpoint one needs to look at them as doing something similar to the brain, though on a simpler level. Information is received, processed and new information is sent out again.

Integrative Therapy

The work with the mind and the work with the body in various shapes and form should be seen as two ways to work on communication systems inside the person. The objective is to make communication work better for the patient. This may require a new perspective on how the mind and the body interact, but communication is how things get done inside the body and with the rest of the world.

Exercise and Mental Health

Early large population studies examined the relationship between exercise behavior and mental health . The relation between self-reported physical activity and depressive symptom was analyzed for 1,900 healthy subjects aged 25–77 years in the Epidemiologic Follow-up Study (1982–1984) to the first National Health and Nutrition Examination Survey (NHANES I) and found that physical inactivity may be a risk factor for depressive symptoms.

Weyer found the odds ratio for depression to be significantly higher (OR 3.15) for the physically inactive compared to regular exercisers in a sample of 1,536 individual 15 years of age and older.

Subsequently, physical activity has been shown to be associated with decreased symptoms of depression and anxiety in numerous studies. For example, in a nationally representative sample of adults ages 15–54 in the United States (n = 8,098), regular physical activity was associated with a significantly decreased prevalence of current major depression and anxiety disorders.

Depression and Anxiety

There is a general belief that physical activity and exercise have positive effects on mood and anxiety and a great number of studies describe an association of physical activity and general well-being, mood and anxiety. (Ströhle, 2009) In a study of 19,288 individuals, De Moor found that regular exercise was associated with lower levels of depression, anxiety, and neuroticism.

Cooney and colleagues conducted a search of the Cochrane Depression, Anxiety and Neurosis Review Group’s Controlled Trials Register up to 2013, www.controlled‐trials.com, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform and any potentially eligible trials not already included are listed as ‘awaiting classification.’ Exercise appeared moderately more effective than a control intervention for reducing symptoms of depression, but analysis of methodologically robust trials only showed a smaller effect in favor of exercise. When compared to psychological or pharmacological therapies, exercise appeared to be no more effective, though this conclusion was based on a few small trials. (Cooney et al., 2013)

Habitual exercise correlates to a heightened level of mental health and wellbeing and reduced feelings of anxiety regardless of the gender of the individual. Relative increases in maximal cardiorespiratory fitness and habitual physical activity appear to be associated with lower depressive symptoms and greater emotional well-being. Ohta noted that 30 minutes or more of walking or cycling while commuting to work might be associated with an increased perception of mental health in men.

Age

The age of the individual may affect the relationship between physical activity and mental health. Exercise has a very small but statistically insignificant effect on reducing anxiety in adolescents. In contrast, Fox found that a population of European adults over the age of 70 had perceived levels of health and quality of life that were positively correlated to higher levels of physical activity.

While regular physical activity appears to be related to mental well-being, physical inactivity appears to be associated with the development of psychological disorders. Some cross-sectional and prospective-longitudinal clinical and epidemiological studies have shown a direct relationship between physical inactivity and symptoms of depression and anxiety.

Neurophysiology

Physical activity and exercise have been shown to induce widespread neurobiological adaptations. Imaging studies have demonstrated structural changes associated with early-onset depression in the hippocampus, amygdala, striatum, and frontal cortex; areas that are all extensively interconnected. Most consistently associated with depression are the findings of volume loss in the hippocampal formation. Increased levels of hippocampal brain-derived neurotrophic factor (BDNF) levels are associated with decreased anxiety. Exercise is associated with the increased synthesis and release of both neurotransmitters and neurotrophic factors, and these increases may be associated with neurogenesis, angiogenesis and neuroplasticity (Portugal et al., 2013).

Hippocampal Volume

As noted above, imaging studies have shown that depressed patients have decreased hippocampal volume. Brain neurogenesis is increased by antidepressant medications. Ernst and colleagues hypothesize that exercise similarly decreases depressive symptoms by increasing brain neurogenesis. They outline four possible molecular mechanisms for this increased neurogenesis, all of which both promote hippocampal neurogenesis and increase with exercise: B-endorphins, vascular endothelial growth factor, brain-derived neurotrophic factor, and serotonin.

Endocannabinoids

Other possible mechanisms for exercise’s ability to improve mood include the association with exercise and increased levels of endocannabinoids, which are associated with analgesia, anxiolysis, and a sense of well-being.

Adrenocorticotropic Hormone (ACTH)

Changes in the hypothalamo-pituitary adrenal axis, including increased adrenocorticotropic hormone (ACTH) and decreased cortisol production, are associated with exercise and thought to be part of the mechanism of its positive effects on mood.

Serotonin

A randmoised prospective study by Wipfli and colleagues showed that the exercise group had lower levels of depression than the stretching‐control group after the intervention. The exercise group also showed a larger percentage decrease in serotonin than the stretching‐control group. This reduction in blood serotonin after exercise is similar to the effects of selective serotonin reuptake inhibitors. Additionally, percent change in serotonin was found to partially mediate the relationship between exercise and depression. (Wipfli, Landers, Nagoshi, & Ringenbach, 2011)

Depression

Multiple studies exist that suggest that exercise is an effective treatment for depression. A Cochrane meta-analysis of 25 randomized controlled trials comparing exercise and placebo or a control intervention found that the exercise groups had a significant improvement in depressive symptoms when compared to the placebo or control group. Only three trials with sufficient allocation concealment, intention to treat analysis, and blinded outcome assessment were found. When these three trials were analyzed together, the effect size was not significant.

There is empirical evidence that exercise compares favourably to antidepressant medications as a first-line treatment for mild to moderate depression. Blumenthal and colleagues conducted a randomized controlled trial in which they assigned 156 adults over age 50 to either aerobic exercise, sertraline, or both. After four months, all three groups had a statistically significant improvement in their depressive symptoms with no statistically significant difference between the groups. The medication group did have a faster response to treatment in the first four weeks, however. However, in a more recent study, the remission rates were also very similar (45-47%), while the rate in the placebo group was moderately, yet not statistically significantly, lower (31%).

Body Image

Exercise improves self-concept in depressed patients, possibly leading to decreased depressive symptoms. Bodywork is related to body image. Bodywork allows us to become more aware of our bodies. It is not necessarily the aim that one builds muscles or achieves a body ideal, which changes as soon as the new magazine ad replaces the old one. But working on and with anything increases our awareness for it. This also applies to the body. By working with the body, we learn about the body. Out of the interaction with the body we get new meaningful information and vice versa. Our bodies are powerful information processing entities, and the information we put into it can bring about significant changes. Exercising is a form of interacting with the body and having the body interact with the world, which leads to a range of changes.

Body Image as a Problem

With a healthy sense of self and a positive body image to go with it, the psyche and the body can work together well and lead to an experience of happiness and contentment. Unfortunately, body image disturbance is an increasing problem in Western societies and is associated with several adverse mental health outcomes, including anorexia, bulimia, body dysmorphia, and depression. (Pimenta, Sánchez-Villegas, Bes-Rastrollo, Lpez, & Martínez-González, 2009)

Body image is, of course, a subjective perception, something that is built from information from the outside (such as a visual image from a mirror) and the inside (perceived needs, values, aspirations, expectations). Body image thus also depends on what we believe is essential and what we think we need, value and should aspire to. It depends on how we communicate and interact with ourselves and other people. (Haverkampf, 2010a, 2017a)

How one sees one’s body affects how one shapes one’s body in the future. It also influences how one feels about the body and, as a consequence, about oneself. Pimenta and colleagues studied the association between body image disturbance and the incidence of depression in 10,286 participants from a dynamic prospective cohort of Spanish university graduates, who were followed-up for four years on average (the SUN study). The difference between BMI and body size perception was considered as a proxy of body image disturbance. Men who underestimated their body size were much more likely to be overweight and obese, whereas women who overestimated their body size were much more likely to be underweight. (Pimenta et al., 2009) However, the authors found no association between body image disturbance and subsequent depression.

Different population may place different emphases on different body attributes. Body fat may, for example, play a greater role in one population than in another, which is probably influenced to a large extent by socialization and communication with others. A study that looked at muscle dissatisfaction, body fat, and height dissatisfaction as predictors of signs of psychological distress, such as depression, eating restraint, eating concerns, and social sensitivity) in a community sample of 228 gay men found that body fat dissatisfaction was predictive of all four distress signs (controlling for muscle dissatisfaction). Conversely, muscle dissatisfaction was only associated with social sensitivity, while height dissatisfaction failed to significantly predict any of the criterion variables for distress. (Blashill, 2010) Another study found that women were more likely to engage in indoor tanning and perceived greater susceptibility to photoaging than men. Body image and depression were found to be associated with tanning behaviors and attitudes. (Gillen & Markey, 2012) Since preferred skin tone, and the behaviors to achieve it, has changed significantly throughout the ages, from very light in past centuries to suntanned in the 1970s and 1980s, social trends must play a significant role. Identifying how one takes in outside preferences and makes them one’s own is an important step in identifying more closely the own needs, values and aspirations, which has a direct effect on quality of life and mental health (Haverkampf, 2010b, 2017a).

Mood plays a large role in how one perceives one’s body. If one sees things more negatively overall, this can also affect one’s view of the own body. Joiner and colleagues examined the relationship between body dissatisfaction, depression, and bulimia in 119 female participants and found that depressed symptoms, but not whether the individual was bulimic, were associated with body dissatisfaction. (Joiner, Wonderlich, Metalsky, & Schmidt, 1995) It is thus important to keep in mind that aside from the effect of variations of the body on mood, the latter does have a significant effect on how we perceive the former. A significant aspect of how depression reduces the activity radius and the quality of life is through a distorted perception of the body.

Obesity

There is a relatively close link between obesity and depression, although it is unclear what is the cause and what the effect. Depression may cause obesity, for example through changing eating patterns or reduced physical activity. But it is also possible that obesity may cause depression through an even more negatively perceived body image, which is a result from an interaction between the obesity and experienced social norms and interactions. The author has discussed possible etiologic factors from a communication perspective elsewhere (Haverkampf, 2017b). In any case, it is easy to see how a vicious cycle can form at the intersection between the psychological and the physical. Breaking that cycle requires awareness for an individual’s internal and external communication.

That internal or external communication dynamics may play a significant role could explain why being ‘overweight’, but not the extremes of being underweight or severely overweight, is most highly correlated with depression. De Wit and colleagues showed in their study a significant U-shaped trend in the association between BMI and depression. (De Wit, Van Straten, Van Herten, Penninx, & Cuijpers, 2009) Externally, the social context seems to play a role. Xie and colleagues investigated in a prospective study the associations between overweight and depressive symptoms in Asian and Hispanic adolescents. Significant mediation effect was found only in Asian girls and girls with high acculturation. Overweight significantly predicted higher body image dissatisfaction, which in turn was significantly related to depressive symptoms. (Xie et al., 2010)

On the other hand, there is data which shows an independence from social factors and current comorbidities. Zhao and colleagues examined the associations of depression and anxiety with BMI after taking into consideration obesity-related comorbidities and other psychosocial or lifestyle factors. They analyzed the data collected from 177 047 adults in the US. Within each gender, the prevalence of the three psychiatric disorders was significantly higher in both men and women who were underweight (BMI<18.5), in women who were overweight (BMI:25–<30) or obese (BMI⩾30), and in men who were severely obese (BMI⩾40) than in those with a normal BMI. Compared with men with a normal BMI, severely obese men were significantly more likely to have current depression or lifetime diagnosed depression and anxiety. Underweight men were also significantly more likely to have lifetime diagnosed depression. Overweight or obese women were significantly more likely than women with a normal BMI to have all three psychiatric disorders. (Zhao et al., 2009)

Breast Cancer

A condition that threatens the body’s integrity also tends to have a psychological effect. If the condition represents a serious threat, fear and anxiety are normal reactions to it. In one study with female survivors of breast cancer of all ages, 56% of the participants had scores that would correlate with potential depression (Begovic-Juhant, Chmielewski, Iwuagwu, & Chapman, 2012). The majority of women felt less attractive and less feminine. Low body image, attractiveness, and femininity positively correlated with depression and negatively with overall quality of life. (Begovic-Juhant et al., 2012) However, this may also provide an approach for ameliorating the depression through work on body image and the self-perception of attractiveness and femininity. Much of this could involve work with communication (Haverkampf, 2017a).

The body and the mind are inseparable. If the integrity of one is in danger, that will reflect of the sense of wholeness of the other. Lasry and colleagues investigated the psychological and social adjustment following total and partial mastectomy. Total mastectomy patients showed higher levels of depression and less satisfaction with body image. Partial mastectomy patients did not display any measurable increase in fear of recurrence. Patients undergoing radiation therapy showed a surprising rise in depressive symptoms, which could be related to an underestimated anxiety they experience. (Lasry et al., 1987)

Exercise as an Adjunct to Medication

Exercise has also been shown to improve depressive symptoms when added to medication. There seems to be an added benefit beyond the direct effect of the antidepressant. In one study, exercise significantly improved symptoms when added to an antidepressant in a group of older patients with depression that had not responded to 6 weeks of antidepressant medication alone. Unlike its benefit as an adjunct to antidepressant medications, exercise in addition to cognitive therapy was found not to be more beneficial than either one by itself. (Ströhle, 2009)

Techniques

Many types of bodywork exist, and several are generally assumed to maintain and improve overall health and raise the quality of life. Important is as already mentioned above, aside from the physical exercise, the greater awareness and the better more meaningful information about the body and how it interacts with the psyche and the outside world. However, there is still far less knowledge of movement-based treatments focusing on body awareness than medication or psychotherapeutic approaches.

While more research is needed on the type of exercise needed for depression treatment, available research indicates that the type of exercise may not be as important as having the physical activity reach a sufficient intensity. For example, both running and weightlifting were found to significantly decrease depressive symptoms with no significant difference found between these two forms of physical activity and the decrease in symptoms.

Basic Body Awareness Therapy (BBAT)

Danielsson and Rosberg explored the experiences of basic body awareness therapy (BBAT) in 15 persons diagnosed with major depression who participated in the treatment in a randomized clinical trial. The participants’ experiences were essentially grasped as a process of

  • (Danielsson & Rosberg, 2015)

Five constituents of this meaning were described (Danielsson & Rosberg, 2015):

The authors conclude that the process of enhanced perceptual openness challenges the numbness experienced in depression, which can provide hope for change, but it is connected to hard work and can be emotionally difficult to bear. (Danielsson & Rosberg, 2015)

Pilates

Mokhtari and colleagues investigated the efficiency of 12-week Pilates exercises on depression and balance associated with falling in thirty elderly participants. The Pilates exercises decreased depression and improved the balance related to falling in participants. (Mokhtari, Nezakatalhossaini, & Esfarjani, 2013)

Body Psychotherapy (BPT)

Body Psychotherapy (BPT) may be an effective treatment option for patients with chronic depression. Rohricht and colleagues studied the effectiveness of BPT in patients with chronic depression. Patients with chronic depressive syndromes and a total score of ≥20 on the Hamilton Rating Scale for Depression (HAMD) were randomly allocated to either immediate BPT or a waiting group which received BPT 12 weeks later. Thirty-one patients were included and twenty-one received the intervention. At the end of treatment patients in the immediate BPT group had significantly lower depressive symptom scores than the waiting group (mean difference 8.7). (Rohricht, Papadopoulos, & Priebe, 2013)

Mindfulness-Based Cognitive Therapy (MBCT) pursues the development of a heightened awareness of one’s body, and its effectiveness has been shown in several empirical studies. Research has focused on the interactions between bodily, cognitive, and emotional processes. Michalak and colleagues argue that considering embodied processes might be a useful perspective for research on the etiology of depression and for mechanisms of action in MBCT. (Michalak, Burg, & Heidenreich, 2012)

Tai Chi

Tai Chi has also been explored in its effectiveness against mental health conditions. It has soft movements, slower speeds, and is relatively easy to learn. The posture of high or low and the amount of exercise can be different according to individual physical fitness. It can meet the needs of different ages and physical fitness. Data from a small study with a single-case design suggests that the intervention had the strongest effect on the participant who presented with hyperactivity and heightened anxiety. (Baron & Faubert, 2005)

Yoga

Field and colleagues compared the effects of yoga (physical activity) versus social support (verbal activity) on prenatal and postpartum depression. Ninety-two prenatally depressed women were randomly assigned to a yoga or a social support control group at 22 weeks gestation. The yoga group participated in a 20-min group session (only physical poses) once per week for 12 weeks. The social support group (a leaderless discussion group) met on the same schedule. At the end of the first and last sessions the yoga group reported less depression, anxiety, anger, back and leg pain as compared to the social support group. At the end of the last session the yoga group and the support group did not differ. They both had lower depression, anxiety, and anger scores and improved relationship scores. In addition, cortisol levels decreased for both groups following each session. Estriol and progesterone levels decreased after the last session. At the postpartum follow-up assessment depression and anxiety levels were lower for both groups. (Field, Diego, Delgado, & Medina, 2013)

Exercise Dose

A dose-response effect with exercise in the treatment for depression has been noted. In one study, high-intensity weight training was more effective than low-intensity weight training in treating depression. Low-intensity weight training and general practitioner care were found to have nearly the same improvement in depression that is consistent with the widely accepted number of the 30% placebo effect in depression treatment. With aerobic exercise, intensity equaling the energy expenditure in public health recommendations was more effective than a program of guided movements of low intensity that had a reduction in depressive symptoms equal to the placebo group.

Aerobic exercise at a dose consistent with public health recommendations is an effective treatment for MDD of mild to moderate severity. Dunn and colleagues studied whether exercise is an efficient treatment for mild to moderate major depressive disorder (MDD), and the dose-response relation of exercise and reduction in depressive symptoms. Participants were randomized to one of four aerobic exercise treatment groups that varied total energy expenditure and frequency or to exercise placebo control. A 17.5-kcal/kg/week dose is consistent with public health recommendations for physical activity. The main effect of energy expenditure in reducing Hamilton Rating Scale for Depression (HRSD17) scores at 12 weeks was significant. Adjusted mean HRSD17 scores at 12 weeks were reduced 47% from baseline for the 17.5-kcal/kg/week dose, compared with 30% for a lower dose and 29% for control. There was no main effect of exercise frequency at 12 weeks. (Dunn, Trivedi, Kampert, Clark, & Chambliss, 2005)

Exercise and Anxiety

Compared to the wide range of research on the positive effects of exercise on depression, anxiety disorders have been less frequently studied. In general, aerobic exercise has been shown to be an effective and cost-efficient treatment alternative for a variety of anxiety disorders. Several studies have indicated that aerobic exercise may be as effective in reducing generalized anxiety as cognitive behavioral therapy.

In general, exercise does appear to be effective in reducing symptoms associated with anxiety. Furthermore, symptoms improve following both an acute episode of physical activity as well as following a program of routine exercise.

In treating anxiety, exercise has been shown to alleviate anxious feelings. While useful in treatment, exercise does not seem to reduce anxiety to the level achieved by psychopharmaceuticals. In a study of patients suffering from moderate to severe panic disorder, both a 10-week protocol of regular aerobic exercise and clomipramine were associated with significant improvement of symptoms compared to placebo. In comparison with exercise, clomipramine improved anxiety symptoms more effectively and significantly earlier.

In another study, the effects of a Feldenkrais® Awareness Through Movement program and relaxation procedures were assessed on a volunteer sample of 54 undergraduate physiotherapy students over a 2-week period. Analysis of variance showed that anxiety scores for all groups varied significantly over time and, specifically, that participants reported lower scores at the completion of the fourth intervention. Further, compared to the control group, females in the Feldenkrais® and relaxation groups reported significantly lower anxiety scores on completion as compared to the beginning of the fourth session, and this reduction was maintained one day later. (Kolt & McConville, 2000)

Anxiety Sensitivity

Exercising at 70%–90% of maximum heart rate for 20 minutes three times a week seems to reduce anxiety sensitivity significantly (Carek, Laibstain, & Carek, 2011). Self-reported fears of anxiety sensations, fears of respiratory and cardiovascular symptoms, publicly observable anxiety symptoms, and cognitive dyscontrol decrease following a prescribed exercise program (Carek et al., 2011). In a study by Cox and colleagues, the most substantial reduction in state anxiety occurred 90 minutes following 20 minutes of aerobic exercise at 80% of maximal oxygen uptake (Cox, Thomas, Hinton, & Donahue, 2004).

Body Dysmorphic Disorder: OCD

The relationship between obsessive–compulsive disorder (OCD) and body dysmorphic disorder (BDD) is unclear. BDD has been proposed to be an OCD‐spectrum disorder or even a type of OCD. There is a growing literature on the concept of an obsessive–compulsive spectrum of disorders. (Lochner & Stein, 2006)

Body dysmorphic disorder (BDD) is a distressing and impairing preoccupation with an imagined or slight defect in appearance, with depression as its most frequent comorbid condition. (Nierenberg et al., 2002)

BDD is frequently comorbid with major depression, is associated with an earlier age of onset of depression and longer duration of depressive episodes, and is found more frequently with atypical than non-atypical depression. Nierenberg and colleagues evaluated the rate of BDD in a cohort of consecutive outpatients with typical and atypical major depressive disorder in 350 outpatient participants. Twenty-eight (8.0%) subjects had a lifetime history of BDD and 23 (6.6%) had current BDD. Those with comorbid lifetime BDD had an earlier age of onset of depression and longer duration of the current episode, but not a greater number of depressive episodes or greater severity of depression. Subjects with and without BDD were similar with respect to age, gender, and marital status. There was a higher rate of lifetime and current BDD in subjects with atypical depression than in those with non-atypical depression. Subjects with BDD also had higher rates of social phobia, any eating disorder, and any somatoform disorder but not OCD. They also had higher rates of avoidant, histrionic, and dependent personality disorders. (Nierenberg et al., 2002)

OCD and BDD do not significantly differ on many variables but did have some clinically important differences. In one study, the comorbid BDD/OCD group evidenced greater morbidity than subjects with OCD or BDD in a number of domains, but differences between the comorbid BDD/OCD group and the BDD group were no longer significant after controlling for BDD severity. However, differences between the comorbid BDD/OCD group and the OCD group remained significant after controlling for OCD severity.

Lochner and Stein conducted a computerized literature search (MEDLINE: 1964–2005) to collect studies addressing different dimensions on which the OCSDs lie. Their cluster analysis found that in OCD there were 3 clusters of OCD spectrum symptoms:

  • “Reward deficiency” (including trichotillomania, pathological gambling, hypersexual disorder and Tourette’s disorder),
  • “Impulsivity” (including compulsive shopping, kleptomania, eating disorders, self-injury and intermittent explosive disorder), and
  • “Somatic” (including body dysmorphic disorder and hypochondriasis).

It is unlikely that OC symptoms and disorders fall on any single phenomenological dimension; instead, multiple different constructs may be required to map this nosological space. Although there is evidence for the validity of some of the relevant dimensions, additional work is required to delineate more fully the endophenotypes that underlie OC symptoms and disorders. (Lochner & Stein, 2006)

It has been argued that body-focused repetitive behavior disorders (e.g., trichotillomania and skin-picking disorder) should be included within the obsessive-compulsive and related disorders category, as this is how most clinicians see these behaviors, and as this may optimize clinical utility. The descriptions of these disorders should largely mirror those in DSM-5, given the evidence from recent field surveys. (Stein & Bouwer, 1997)

Hypochondriasis

The symptoms of HC overlap to an extent with certain anxiety disorders, such as panic disorder and OCD. The results of a study using discriminant function analysis indicated that whereas individuals with hypochondriasis experience panic attacks, obsessions, and compulsions, these symptoms are markedly less pronounced than among those with panic disorder and OCD. Conversely, overlaps were found in terms of cognitive biases, with hypochondriasis patients demonstrating elevated levels of intolerance of uncertainty, body vigilance, and fear of cardiovascular symptoms. (Deacon & Abramowitz, 2008)

Risks

While the Center for Disease Control and Prevention and the American College of Sports Medicine recommend that individuals should engage in 30 minutes or more of moderate-intensity physical activity on most (preferably) all days of the week, physical activity and exercise have risks that need to be considered. The most common risk of physical activity in adults is musculoskeletal injury. The risk of injury increases with obesity, volume of exercise, and participation in vigorous exercise such as competitive sports.

Furthermore, vigorous physical activity acutely increases the risk of sudden cardiac death and myocardial infarction among individuals with both diagnosed and occult heart disease.

Prevention

Reduced incidence rates of depression and (some) anxiety disorders in exercising subjects raise the question whether exercise may be used in the prevention of some mental disorders. A review of studies showed a bidirectional relationship between physical activity, exercise and adolescent mental health (Pascoe & Parker, 2019). The results suggested that physical activity and exercise programs designed to increase the level of activity in young people should be implemented to be attractive and achievable to young people that may have poor psychological health (Pascoe & Parker, 2019). Another study found that participating in diverse leisure activities and longer exercise time decreases older adults’ risk of having depression. Additionally, the results confirmed that depression is positively correlated with chronic diseases (Lee, Yu, Wu, & Pan, 2018). On the other hand, data from the Netherlands Mental Health Survey and Incidence Study did not find evidence for a dose–response relationship between exercise levels and mental health. Among those with mental disorder at baseline, exercise participants were more likely to recover from their illness compared to their counterparts who did not take exercise, but the authors pointed out that it remains uncertain whether this association truly reflects a causal effect of exercise (Ten Have, de Graaf, & Monshouwer, 2011). In a 2010 meta-review, an ssociation between physical activity and mental health in young people was evident, but research designs were described as often weak and effects small to moderate. Evidence showed small but consistent associations between sedentary screen time and poorer mental health (Biddle & Asare, 2011). In another study involving 42 undergraduates, vigorous exercise had mental health benefits beyond moderate physical activity, was associated with less stress, pain, insomnia and depression, more favorable objective sleep patterns, and fewer mental health problems if the individual was exposed to high stress (Gerber et al., 2014).

Conclusion

Depression and anxiety disorders are some of the most prevalent neurological disorders with close to one in five of adults demonstrating symptoms. Exercise has been shown to reduce symptoms associated with these disorders and has the potential to lessen the dependability on psychopharmacology. Physicians should recommend that adults participate in at least 30 minutes of accumulated moderate-intensity physical activity (for example, walking fast) on most days of the week. (Phillips et al., 2007) The balance seems to be important. The term ‘exercise addition’ has been coined for another extreme, in which an individual experiences a need to engage in excessive exercise, has the potential to have adverse effects on both physical and mental health (Berczik et al., 2012).


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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ADHD and Medication (3)

ADHD-and-Medication-3-Christian-Jonathan-Haverkampf-psychiatry-series

ADHD and Medication

Christian Jonathan Haverkampf, M.D.

Attention deficit hyperactivity disorder (ADHD) has become treatable with medication and psychotherapeutic approaches that have become available recently. This article provides a brief overview of some aspects of the medication used for ADHD.

The most widely used group of medication for ADHD comprises the stimulants. Stimulants such as methylphenidate and amphetamine are currently the most common treatment for ADHD. The substance used should fit the particular individual and the particular condition and situation.

Open and transparent communication between clinician and patient is of paramount importance in the case of ADHD for a successful treatment outcome.

Keywords: ADHD, attention deficit hyperactivity disorder, medication, psychiatry

Table of Contents

Keywords: ADHD, attention deficit hyperactivity disorder, medication, psychiatry. 1

Introduction. 5

The Prefrontal Cortex. 5

Substance Abuse. 6

Psychotherapy. 6

Social 6

Diagnosis of ADHD.. 7

Different Types of ADHD.. 7

EEG.. 8

Diagnosis of ADHD in Children. 8

Stability over Time. 9

Adult ADHD.. 10

Baseline assessment. 11

Medication. 11

Long-Term Effect. 12

Anxiety. 12

Tics. 12

Emotional Lability. 13

Smoking. 13

Medication Groups. 13

Methylphenidate. 13

Atomoxetine. 14

Extended Release. 14

Sex. 14

Medication for Children. 14

Consider offering. 15

Medication for Adults. 15

Consider offering. 15

ADHD Type and Medication. 16

Subtype. 16

Sleep. 16

Anxiety. 16

Genotype. 17

Dose Titration. 17

Abuse. 18

Coexisting Conditions. 18

Caution. 18

Psychosis. 19

Bipolar Disorder. 19

Aggression. 20

Seizures. 20

Priapism.. 20

Peripheral Vasculopathy, Including Raynaud’s Phenomenon. 20

Visual Disturbance. 20

Drug Dependence. 20

Pregnancy. 21

Monitoring. 21

Behavior. 21

Height. 21

Weight. 22

Cardiovascular System.. 22

Children and Adolescents. 23

Adults. 23

Tics. 23

Sexual Dysfunction. 23

Seizures. 23

Sleep. 24

Compliance. 24

Psychotherapy. 24

References. 25

Introduction

The use of medications to treat attention deficit hyperactivity disorder (ADHD) has increased. Using a common protocol and data from thirteen countries and one SAR, Raman and colleagues show increases over time but large variations in ADHD medication use in multiple regions across the world. (Raman et al., 2018)

While medication is effective, one needs to keep in mind that most mental health conditions, and particularly ADHD, is caused and maintained not only by neurobiology, but also by psychological, environmental and social patterns. Most patients would thus benefit from a combined approach. Safren and colleagues, for example, studied cognitive-behavioral therapy (CBT) for adults with attention-deficit hyperactivity disorder (ADHD) who have been stabilized on medications but still show clinically significant symptoms. The data showed that CBT for adults with ADHD with residual symptoms can be a feasible, acceptable, and potentially efficacious next-step treatment approach. (Safren et al., 2005)

The most widely used class of medication for ADHD is the group of stimulants, including methylphenidate and other substances. A stimulant is a drug that stimulates the central nervous system, increasing arousal, attention and endurance. For years, it was assumed that stimulants had paradoxical calming effects in ADHD patients, whereas stimulating ‘normal’ individuals and producing locomotor activation in rats. It is now known that low doses of stimulants focus attention and improve executive function in both normal and ADHD subjects. Stimulants are frequently used to treat attention deficit-hyperactivity disorder. Because the medications can be addictive, patients with a history of drug abuse are typically monitored closely or treated with a non-stimulant. It is argued that the risk of addiction in patients diagnosed with ADHD is much lower. On the other hand, well-monitored stimulant treatment may even reduce the risk for alcohol and substance use in adolescent ADHD. (Hammerness, Petty, Faraone, & Biederman, 2017)

The Prefrontal Cortex

At low doses that improve prefrontal cortex-dependent cognitive function and that are devoid of locomotor-activating effects, methylphenidate substantially increases norepinephrine and dopamine efflux within the prefrontal cortex. In contrast, outside the prefrontal cortex these doses of methylphenidate have minimal impact on norepinephrine and dopamine efflux. (Berridge et al., 2006) The prefrontal cortex regulates behavior and attention using representational knowledge, and imaging and neuropsychological studies have shown that the prefrontal cortex is weaker in subjects with ADHD. This cortical area is very sensitive to levels of catecholamines: moderate levels engage postsynaptic α2A-adrenoceptors and D1 receptors and improve prefrontal regulation of behavior and attention, while high levels impair prefrontal function via α1-adrenoceptors and excessive D1 receptor stimulation. Administering low doses of methylphenidate to rats improves the working memory and attentional functions of the prefrontal cortex, while high doses impair working memory and produce a perseverative pattern of errors similar to that seen in patients. The low dose improvement is blocked by either an α2-adrenoceptor or Dl receptor antagonist, suggesting that both norepinephrine and dopamine contribute to the beneficial actions of stimulant medications. (Arnsten, 2006)

Substance Abuse

Chang and colleagues found no indication of increased risks of substance abuse among individuals prescribed stimulant ADHD medication; if anything, the data suggested a long‐term protective effect on substance abuse. (Chang et al., 2014) However, one should still be vigilant towards stimulant misuse and diversion in ADHD patients.

Careful therapeutic monitoring can reduce medical misuse and diversion of controlled medication among adolescents. They appear to be more prevalent among adolescents who misuse their controlled drugs. In a survey study by McCabe and colleagues, misusers were more likely than non-misusers to divert their controlled medications and to abuse other substances. The odds of a positive screening result for drug abuse were substantially higher among medical misusers compared with medical users who used their controlled medications appropriately. The odds of drug abuse did not differ between medical users who used their controlled medications appropriately and nonusers. Most adolescents who used controlled medications took their medications appropriately. (McCabe et al., 2011) In a literature review by Torgersen and colleagues, psychopharmacotherapy did not seem to affect substance use disorder. (Torgersen, Gjervan, & Rasmussen, 2008)

It is is also important to keep in mind the risk of not medicating ADHD. Empirical data indicates that ADHD is a significant risk factor for the development of SUDs and cigarette smoking in both sexes. (Wilens et al., 2011) One would also need to include the risk of self-medication with illegal drugs due to problems that can be caused or maintained by ADHD, such as unemployment or relationship difficulties (Haverkampf, 2017a).

Psychotherapy

Psychotherapy is often very valuable in combination with medication to alleviate the impairments of ADHD. The author has described communication-focused therapy for ADHD elsewhere. (Haverkampf, 2010, 2017d, 2018b) Unfortunately, while the efficacy of stimulants in reducing ADHD symptoms for adults is well documented in meta-analyses, there is a concerning lack of meta-analysis about other treatment interventions (Moriyama, Polanczyk, Terzi, Faria, & Rohde, 2013). Apart from reports using behavioral therapies, there are also several studies on the successful use of psychodynamic techniques

Social

The social and environmental aspects are often underestimated in the case of ADHD. Pfiffner and colleagues evaluated in their study the efficacy of the Child Life and Attention Skills (CLAS) program, a behavioral psychosocial treatment integrated across home and school, for youth with attention-deficit/hyperactivity disorder-inattentive type (ADHD-I). CLAS resulted in greater improvements in teacher-reported inattention, organizational skills, social skills, and global functioning relative to both PFT and TAU at posttreatment. Parents of children in CLAS reported greater improvement in organizational skills than PFT and greater improvements on all outcomes relative to TAU at posttreatment. Differences between CLAS and TAU were maintained at follow-up for most parent-reported measures but were not significant for teacher-reported outcomes. Direct involvement of teachers and children in CLAS appears to amplify effects at school and home and underscores the importance of coordinating parent, teacher, and child treatment components for cross-setting effects on symptoms and impairment associated with ADHD-I. (Pfiffner et al., 2014)

There are also several psychological models that have been helpful in the treatment of adults. Solanto and colleagues assessed the effectiveness of a new manualized group Meta-Cognitive Therapy (MCT) for adults with ADHD that extends the principles and practices of cognitive-behavioral therapy to the development of executive self-management skills in thirty patients. General linear modeling revealed a robust significant posttreatment decline on the CAARS DSM-IV Inattentive symptom scale as well as improvement on the Brown ADD Scales. The findings indicated that participants in the MCT program showed marked improvement with respect to core ADHD symptoms of inattention, as well as executive functioning skills, suggesting that this program has promise as a treatment for meta-cognitive deficits in adults with ADHD. (Solanto, Marks, Mitchell, Wasserstein, & Kofman, 2008)

Charach and colleagues in a review of the literature between 1980 and 2010. The available evidence suggested that underlying prevalence of ADHD varies less than rates of diagnosis and treatment. Patterns of diagnosis and treatment appeared to be associated with such factors as locale, time period, and patient or provider characteristics. The strength of evidence for parent behavior training as the first-line intervention for improved behavior among preschoolers at risk for ADHD was high, while the strength of evidence for methylphenidate for improved behavior among preschoolers was low. Evidence regarding long-term outcomes following interventions for ADHD was sparse among persons of all ages, and therefore inconclusive, with one exception. Primary school–age children, mostly boys with ADHD combined type, showed improvements in symptomatic behavior maintained for 12 to 14 months using pharmacological agents, specifically methylphenidate medication management or atomoxetine. (A Charach et al., 2011)

Diagnosis of ADHD

The clinical interview is the most important pillar in the process of diagnosing ADHD. Reflecting on the interaction with the patients and observing the communication patterns used is very helpful in the diagnosis and in the treatment of ADHD.

There is also the overall problem in the case of ADHD that, while the diagnostic criteria in the diagnostic manuals are quite clear, it may sometimes be diagnosed based on the individual heuristic criteria the therapist has developed over time. Since attention deficit can occur in several disorders and is not as pathognomonic as, for example, feeling depressed or anxious for depression and anxiety, respectively, it takes more complex algorithms to formulate a diagnosis. However, there still seem to be problems, which, however, are not uncommon in psychiatric diagnosis. The accuracy itself even seems to depend on the diagnosis. For some diagnoses, especially psychotic categories, administrative data were generally predictive of true diagnosis. For others, such as anxiety disorders, the data were less satisfactory. (Davis, Sudlow, & Hotopf, 2016)

Different Types of ADHD

ADHD is to a certain degree heterogeneous which can have a n efefct of how well a particular treatment modality or even a specific treatment works. Unfortunately, there are not many clear parameters that can help to optimize treatment. However, in speical circumstances there may be information available that can be helpful in designing a treatment plan.

  1. ADHD, Predominantly Inattentive Presentation (ADHD-I)

Patients have difficulty paying attention. They are easily distracted but do not have significant symptoms of impulsivity or hyperactivity. This is sometimes called attention-deficit disorder (or ADD).

  • ADHD, Predominantly Hyperactive-Impulsive Presentation (ADHD-H)

Patients who have this type of ADHD have symptoms of hyperactivity and feel the need to move constantly. They also struggle with impulse control. Inattention is not a significant issue. This type is seen most often in very young children.

  • ADHD, Combined Presentation (ADHD-C)

Patients with this type of ADHD show significant problems with both hyperactivity/impulsivity and inattention. Children may gradually have less trouble with hyperactivity/impulsivity as they get into their teen years.

In a study by Mullins and colleagues, children with ADHD varied more in the size and direction of their time reproduction errors than control children. Those with ADHD-C demonstrated more intraindividual variability than did those with ADHD-I in the size of their errors. The data provided support for a relationship between sustained attention and time reproduction.(Mullins, Bellgrove, Gill, & Robertson, 2005)

EEG

Arns and colleagues demonstrated in their study that the EEG phenotypes as described by Johnstone, Gunkelman & Lunt are identifiable EEG patterns with good inter-rater reliability. Furthermore, it was also demonstrated that these EEG phenotypes occurred in both ADHD subjects as well as healthy control subjects. The Frontal Slow and Slowed Alpha Peak Frequency and the Low Voltage EEG phenotype discriminated ADHD subjects best from controls (however the difference was not significant). The Frontal Slow group responded to a stimulant with a clinically relevant decreased number of false negative errors on the CPT. The Frontal Slow and Slowed Alpha Peak Frequency phenotypes have different etiologies as evidenced by the treatment response to stimulants. In previous research Slowed Alpha Peak Frequency has most likely erroneously shown up as a frontal theta sub-group. Furthermore, the divergence from normal of the frequency bands pertaining to the various phenotypes is greater in the clinical group than in the controls. Investigating EEG phenotypes provides a promising new way to approach EEG data, explaining much of the variance in EEGs and thereby potentially leading to more specific prospective treatment outcomes. (ARNS, GUNKELMAN, BRETELER, & SPRONK, 2008)

Diagnosis of ADHD in Children

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood and can profoundly affect the academic achievement, well-being, and social interactions of children; the American Academy of Pediatrics first published clinical recommendations for the diagnosis and evaluation of ADHD in children in 2000; recommendations for treatment followed in 2001. (American Academy of Pediatrics, 2000)

Bruchmüller and colleagues sent a case vignette to 1,000 child psychologists, psychiatrists, and social workers and asked them to give a diagnosis. The results were that in the non-ADHD vignettes, 16.7% of therapists diagnosed ADHD. In the boy version of these vignettes, therapists diagnosed ADHD around 2 times more than they did with the girl vignettes. Their study suggested that there may be an overdiagnosis of ADHD and that the patient’s gender influences diagnosis considerably. (Bruchmüller, Margraf, & Schneider, 2012) It is unclear whether the problem is that therapists do not adhere enough to diagnostic manuals and diagnostic criteria, or if there are other factors, such as issues with the diagnostic criteria or diagnostic algorithms. Another explanation could be that a significant amount of information gets lost in the interaction with the patient. Especially, if the time allowed for the meeting is very limited, there is the risk of both over- and underdiagnosis where maybe several other issues are involved, such as trauma, anxiety or depression, for example.

This guideline has been developed to advise on the treatment and management of attention deficit hyperactivity disorder (ADHD). The guideline recommendations have been developed by a multidisciplinary team of healthcare professionals, service users and carers, and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to clinicians and service commissioners in providing and planning high-quality care for people with ADHD while also emphasizing the importance of the experience of care for them and their carers (see Appendix 1 for more details on the scope of the guideline). Although the evidence base is rapidly expanding, there are a number of major gaps; future revisions of this guideline will incorporate new scientific evidence as it develops. The guideline makes a number of research recommendations specifically to address gaps in the evidence base. In the meantime, it is hoped that the guideline will assist clinicians, people with ADHD and their carers by identifying the merits of particular treatment approaches where the evidence from research and clinical experience exists. ((UK, 2018)

While the disorder continues to be viewed as one of inattention and/or hyperactive-impulsive behavior, theories of ADHD are beginning to focus more on poor inhibition and deficient executive functioning (self-regulation) as being central to the disorder. Clinicians should be aware of these problems and the adjustments that need to be made to them when dealing with special populations that were not represented in the field trials used to develop these criteria. (Barkley, 2003)

Kadesjo and Gillberg examined patterns of comorbid/associated diagnoses and associated problems in a population sample of children with and without DSM-III-R attention-deficit hyperactivity disorder (ADHD). Half (N = 409) of a mainstream school population of Swedish 7-year-olds were clinically examined, and parents and teachers were interviewed and completed questionnaires. The children were followed up 2–4 years later. Eighty-seven per cent of children meeting full criteria for ADHD (N = 15) had one or more—and 67% at least two—comorbid diagnoses. The most common comorbidities were oppositional defiant disorder and developmental coordination disorder. Children with subthreshold ADHD (N = 42) also had very high rates of comorbid diagnoses (71% and 36%), whereas those without ADHD (N = 352) had much lower rates (17% and 3%). The rate of associated school adjustment, learning, and behavior problems at follow-up was very high in the ADHD groups. We concluded that pure ADHD is rare even in a general population sample. Thus, studies reporting on ADHD cases without comorbidity probably refer to highly atypical samples. By and large, such studies cannot inform rational clinical decisions. (Kadesjö & Gillberg, 2001)

Stability over Time

Children rarely remain in the HT classification over time; rather, they sometimes desist from ADHD but mostly shift to CT in later years.  In a study on a sample of 118 4- to 6-year-olds who met DSM-IV criteria for ADHD, Lahey and colleagues showed that the number of children who met criteria for ADHD declined over time, but most persisted. Children who met criteria for the combined subtype (CT, n = 83) met criteria for ADHD in more subsequent assessments than children in the predominantly hyperactive-impulsive subtype (HT, n = 23). Thirty-one (37%) of 83 CT children and 6 (50%) of 12 children in the predominantly inattentive subtype (IT) met criteria for a different subtype at least twice in the next 6 assessments. Children of the HT subtype were even more likely to shift to a different subtype over time, with HT children who persisted in ADHD mostly shifting to CT in later assessments. The subtypes exhibited consistently different mean levels of hyperactive-impulsive symptoms during years 2 through 8 that corresponded with their initial subtype classifications, but initial subtype differences in inattention symptoms diminished in later years. Conclusions  In younger children, the CT and IT may be stable enough to segregate groups for research, but they seem too unstable for use in the clinical assessment of individual children. (Lahey, Pelham, Loney, Lee, & Willcutt, 2005) The authors suggested a continuous hyperactivity-impulsivity rating model in the diagnosis.

Adult ADHD

The diagnosis of attention-deficit hyperactivity disorder (ADHD) in adults is a complex procedure which should include retrospective assessment of childhood ADHD symptoms either by patient recall or third party information, diagnostic criteria according to DSM-IV, current adult ADHD psychopathology including symptom severity and pervasiveness, functional impairment, quality of life and comorbidity. The author has discussed the diagnosis of adult ADHD in greater depth elsewhere. (Haverkampf, 2018c)

A valid and reliable assessment should be comprehensive and include the use of symptom rating scales, a clinical interview, neuropsychological testing, and the corroboration of patient reports. Specific diagnostic criteria that are more sensitive and specific to adult functioning are needed. In treatment, pharmacological interventions have the most empirical support, with the stimulants methylphenidate and amphetamine and the antidepressants desipramine and atomoxetine having the highest efficacy rates. Scientific research on psychosocial treatments is lacking, with preliminary evidence supporting the combination of cognitive behavioral therapy and medication. (Davidson, 2008)

The Wender-Utah Rating Scale (WURS) and the Childhood Symptoms Scale by Barkley and Murphy try to make a retrospective assessment of childhood ADHD symptoms. The Connors Adult ADHD Rating Scales (CAARS), the Current Symptoms Scales by Barkley and Murphy (CSS), the Adult Self Report Scale (ASRS) by Adler et al. and Kessler et al. or the Attention Deficit Hyperactivity Disorder—Self Report Scale (ADHD-SR by Rösler et al.) are self-report rating scales focusing mainly on the DSM-IV criteria. The CAARS and the CSS have other report forms too. The Brown ADD Rating Scale (Brown ADD-RS) and the Attention Deficit Hyperactivity Disorder-Other Report Scale (ADHD-OR by Rösler et al.) are instruments for use by clinicians or significant others. Both self-rating scales and observer report scales quantify the ADHD symptoms by use of a Likert scale mostly ranging from 0 to 3. This makes the instruments useful to follow the course of the disease quantitatively. Comprehensive diagnostic interviews not only evaluate diagnostic criteria, but also assess different psychopathological syndrome scores, functional disability measures, indices of pervasiveness and information about comorbid disorders. The most comprehensive procedures are the Brown ADD Diagnostic Form and the Adult Interview (AI) by Barkley and Murphy. An instrument of particular interest is the Wender Reimherr Interview (WRI) which follows a diagnostic algorithm different from DSM-IV. The interview contains only items delineated from adult psychopathology and not derived from symptoms originally designed for use in children. (Rösler et al., 2006)

Baseline assessment

Before starting medication for ADHD, people with ADHD should have a full assessment, possibly through their GP, which should include also:

  • a review to confirm they continue to meet the criteria for ADHD and need treatment
  • a review of mental health and social circumstances, including:
    • presence of coexisting mental health and neurodevelopmental conditions
    • current educational or employment circumstances
    • risk assessment for substance misuse and drug diversion

care needs There should also be a review of physical health, including also:

  • a medical history, taking into account conditions that may be contraindications for specific medicines
  • current medication
  • height and weight (measured and recorded against the normal range for age, height and sex)
  • baseline pulse and blood pressure (measured with an appropriately sized cuff and compared with the normal range for age)
  • a cardiovascular assessment
  • an electrocardiogram (ECG) if the treatment may affect the QT interval.

One should refer for a cardiology opinion before starting medication for ADHD in cases including also:

  • history of congenital heart disease or previous cardiac surgery
  • history of sudden death in a first-degree relative under 40 years suggesting a cardiac disease
  • shortness of breath on exertion compared with peers
  • fainting on exertion or in response to fright or noise
  • palpitations that are rapid, regular and start and stop suddenly (fleeting occasional bumps are usually ectopic and do not need investigation)
  • chest pain suggesting cardiac origin
  • signs of heart failure
  • a murmur heard on cardiac examination
  • blood pressure that is classified as hypertensive for adults

Medication

Stimulants are the classic medication which is used in the treatment of ADHD. If it is used correctly and for the correct indication, it can help patients have a significant improvement in their quality of life.

However, treatment success in the individual and treatment success on average in a large group can diverge significantly. A clinician’s skills in using the medication can play a significant role. In a large Canadian study, Currie and colleagues found little evidence of improvement in either the medium or the long run. Our results are silent on the effects on optimal use of medication for ADHD, but suggest that expanding medication in a community setting had little positive benefit. (Currie, Stabile, & Jones, 2014)

Long-Term Effect

While methylphenidate (MPH) often ameliorates attention-deficit/hyperactivity disorder (ADHD) behavioral dysfunction, it there is little evidence that methylphenidate (MPH) medication leads to long-term-term academic gains in ADHD. In a study by Hale and colleagues, children aged 6 to 16 with ADHD inattentive type (IT; n = 19) and combined type (n = 33)/hyperactive-impulsive type (n = 4) (CT) participated in double-blind placebo-controlled MPH trials with baseline and randomized placebo, low MPH dose, and high MPH dose conditions. Robust cognitive and behavioral MPH response was achieved for children with significant baseline executive working memory (EWM) / self-regulation (SR) impairment, yet response was poor for those with adequate EWM/SR baseline performance. Even for strong MPH responders, the best dose for neuropsychological functioning was typically lower than the best dose for behavior. (Hale et al., 2011)

There is overall little evidence to suggest that the type of treatment in the present affects the severity of ADHD in the future. A study by Molina and colleagues has shown that or intensity of 14 months of treatment for ADHD in childhood (at age 7.0–9.9 years) does not predict functioning 6 to 8 years later. Rather, early ADHD symptom trajectory regardless of treatment type is prognostic. This finding implies that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis. As a group, however, despite initial symptom improvement during treatment that is largely maintained after treatment, children with combined-type ADHD exhibit significant impairment in adolescence. (Molina et al., 2009)

Anxiety

Compared to parent and teacher reports of anxiety, child reported comorbid anxiety shows foremost the largest associations with the neurocognitive dysfunctions observed in children with ADHD. (Bloemsma et al., 2013) In another study, overall rates of individual anxiety disorders, as well as age of onset and severity of illness were not significantly different in the presence of comorbid ADHD. School functioning in children with anxiety disorders was negatively impacted by the presence of comorbid ADHD. Frequency of mental health treatment in children with anxiety disorders was significantly increased in the presence of comorbid ADHD. ADHD had a limited impact on the manifestation of anxiety disorder in children suggesting that ADHD and anxiety disorders are independently expressed. (Hammerness et al., 2010)

Tics

Findings in a study by Gadow and Nolan suggest that the co-occurrence of diagnosed ADHD, chronic multiple tick disorder and anxiety represents a particularly troublesome clinical phenotype, at least in the home setting. Comorbid anxiety disorder was not associated with a less favorable response to immediate release methylphenidate in children with ADHD and chronic multiple disorder, but replication with larger samples is warranted before firm conclusions can be drawn about potential group differences. (Gadow & Nolan, 2011)

Emotional Lability

Emotional lability, or sudden strong shifts in emotion, commonly occurs in youth with attention-deficit/hyperactivity disorder. Although these symptoms are impairing and disruptive, relatively little research has addressed their treatment, likely due to the difficulty of reliable and valid assessment. Promising signals for symptom improvement have come from recent studies using stimulants in adults, children and adolescents. Similarly, neuroimaging studies have begun to identify neurobiological mechanisms underlying stimulants’ impact on emotion regulation capacities. (Posner, Kass, & Hulvershorn, 2014)

Smoking

Individuals suffering from ADHD have a significantly higher risk of cigarette smoking. Stimulant treatment of ADHD may reduce smoking risk. Schoenfelder and colleagues examined the relationship between stimulant treatment of ADHD and cigarette smoking in a meta-analysis. The study revealed a significant association between stimulant treatment and lower smoking rates. the effect was larger in samples with more severe psychopathology. Implications for further research, treatment of ADHD, and smoking prevention are discussed. (Schoenfelder, Faraone, & Kollins, 2014)

Medication Groups

Common stimulants include:

Methylphenidate (Methylphenidate®, Concerta®), a norepinephrine-dopamine reuptake inhibitor

Dextroamphetamine (Dexedrine®), the dextro-enantiomer of amphetamine

Dexmethylphenidate (Focalin®), the active dextro-enantiomer of methylphenidate

Lisdexamfetamine (Vyvanse®), a prodrug containing the dextro-enantiomer of amphetamine

There are also mixed amphetamine salts, such as Adderall®, a 3:1 mix of dextro/levo-enantiomers of amphetamine.

Atomoxetine (Strattera ®) is a norepinephrine (noradrenaline) reuptake inhibitor which is approved for the treatment of attention deficit hyperactivity disorder (ADHD).

There are also some antidepressants that have mild stimulant effects. Further information can be found in the author’s book An Overview of Psychiatric Medication (Haverkampf, 2018a)

Methylphenidate

Methylphenidate is indicated as an integral part of a total treatment program which typically includes other remedial measures (psychological, educational, social) for a stabilizing effect in children with a behavioral syndrome characterized by the following group of developmentally inappropriate symptoms:

  • moderate-to-severe distractibility
  • short attention span
  • hyperactivity
  • emotional lability, an
  • impulsivity.

The diagnosis of this syndrome should not be made with finality when these symptoms are only of comparatively recent origin. Non-localizing neurological signs, learning disability, and abnormal EEG may or may not be present, and a diagnosis of central nervous system dysfunction may or may not be warranted.

Atomoxetine

In pediatric patients with ADHD and comorbid symptoms of depression or anxiety, atomoxetine monotherapy appears to be effective for treating ADHD. (Kratochvil et al., 2005) In the study by Kratochvil and colleagues, anxiety and depressive symptoms also improved, but the absence of a placebo-only arm did not allow the investigators to conclude that these effects are specifically the result of treatment with atomoxetine. Combined atomoxetine and fluoxetine therapy were, however, well tolerated.

Extended Release

When prescribing stimulants for ADHD, one needs to consider modified-release once-daily preparations for the following reasons:

  • convenience
  • improving adherence
  • reducing stigma (because there is no need to take medication at school or in the workplace)
  • reducing problems of storing and administering controlled drugs at school
  • the risk of stimulant misuse and diversion with immediate-release preparations
  • their pharmacokinetic profiles.

Immediate-release preparations may be suitable if more flexible dosing regimens are needed, or during initial titration to determine correct dosing levels.

Sex

ADHD was once thought of as a predominantly male disorder. While this may be true for ADHD in childhood, extant research suggests that the number of women with ADHD may be nearly equal to that of men with the disorder (Faraone et al., 2000). There is accumulating research which clearly indicates subtle but important sex differences exist in the symptom profile, neuropathology and clinical course of ADHD. Compared to males with ADHD, females with ADHD are more prone to have difficulties with inattentive symptoms than hyperactive and impulsive symptoms, and females often receive a diagnosis of ADHD significantly later than do males (Gaub & Carlson, 1997; Gershon, 2002a, 2002b). Emerging evidence suggests differences exist in the neuropathology of ADHD, and there are hormonal factors which may play an important role in understanding ADHD in females. Although research demonstrates females with ADHD differ from males in important ways, little research exists that evaluates differences in treatment response. Given the subtle but important differences in presentation and developmental course of ADHD, it is essential that both clinical practice and research be informed by awareness of these differences in order to better identify and promote improved quality of care to girls and women with ADHD. (Nussbaum, 2012)

Medication for Children

Drug treatment is not indicated for all children with this syndrome. Stimulants are not intended for use in the child who exhibits symptoms secondary to environmental factors and/or primary psychiatric disorders, including psychosis. Appropriate educational placement is essential and psychosocial intervention is generally necessary. When remedial measures alone are insufficient, the decision to prescribe stimulant medication will depend upon the physician’s assessment of the chronicity and severity of the child’s symptoms.

Methylphenidate should not be used in children under 6 years, since safety and efficacy in this age group have not been established.

Consider offering

  1. Methylphenidate as the first line pharmacological treatment,
  2. Lisdexamfetamine for those who have had a 6‑week trial of methylphenidate at an adequate dose and not derived enough benefit in terms of reduced ADHD symptoms and associated impairment,
  3. Dexamfetamine for those whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile,
  4. Atomoxetine or Guanfacine if:
  5. they cannot tolerate methylphenidate or lisdexamfetamine or
  6. their symptoms have not responded to separate 6‑week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.

Medication for Adults

Consider offering

  1. Lisdexamfetamine or Methylphenidate as first-line pharmacological treatment,
  2. Lisdexamfetamine for those who have had a 6‑week trial of methylphenidate at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment,

Methylphenidate for those who have had a 6‑week trial of lisdexamfetamine at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment,

  • Dexamfetamine for those whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile,
  • Atomoxetine if:
  • they cannot tolerate lisdexamfetamine or methylphenidate or
  • their symptoms have not responded to separate 6‑week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.

Do not offer any of the following medication for ADHD without advice from a tertiary ADHD service:

  • guanfacine for adults
  • clonidine for children with ADHD and sleep disturbance, rages or tics
  • atypical antipsychotics in addition to stimulants for people with ADHD and coexisting pervasive aggression, rages or irritability
  • other medication than that listed above.

ADHD Type and Medication

Subtype

In a study by Barbaresi and colleagues, there was no association between DSM-IV subtype and likelihood of a favorable response or of side effects. Dextroamphetamine and methylphenidate were equally likely to be associated with a favorable response, but dextroamphetamine was more likely to be associated with side effects. (Barbaresi et al., 2014)

Sleep

Differences in sleep problems seem to be a function of ADHD subtype, comorbidity, and medication. In a study by Mayes and colleagues, children with ADHD-I alone had the fewest sleep problems and did not differ from controls. Children with ADHD-C had more sleep problems than controls and children with ADHD-I. Comorbid anxiety/depression increased sleep problems, whereas ODD did not. Daytime sleepiness was greatest in ADHD-I and was associated with sleeping more (not less) than normal. Medicated children had greater difficulty falling asleep than unmedicated children. (Mayes et al., 2008) Linear regression analyses by Corkum and colleagues showed that (1) dyssomnias were related to confounding factors (i.e., comorbid oppositional defiant disorder and stimulant medication) rather than ADHD; (2) parasomnias were similar in clinical and nonclinical children; and (3) the DSM-IV combined subtype of ADHD was associated with sleep-related involuntary movements. However, sleep-related involuntary movements were more highly associated with separation anxiety. (CORKUM, MOLDOFSKY, HOGG-JOHNSON, HUMPHRIES, & TANNOCK, 1999)

Anxiety

ADHD co-occurring with internalizing disorders (principally parent-reported anxiety disorders) absent any concurrent disruptive disorder, ADHD co-occurring with ODD/CD (oppositional defiant disorder / conduct disorder) but no anxiety (ADHD + ODD/CD), and ADHD with both anxiety and ODD/CD (ADHD + ANX + ODD/CD) may be sufficiently distinct to warrant classification as ADHD subtypes separate from ADHD without this phenomenology. Jensen and colleagues found evidence of main effects of internalizing and externalizing comorbid disorders. Moderate evidence of interactions of parent-reported anxiety and ODD/CD status were noted on response to treatment, indicating that children with ADHD and anxiety disorders (but no ODD/CD) were likely to respond equally well to behavioral and medication treatments. Children with ADHD-only or ADHD with ODD/CD (but without anxiety disorders) responded best to medication treatments (with or without behavioral treatments), while children with multiple comorbid disorders (anxiety and ODD/CD) responded optimally to combined (medication and behavioral) treatments. (JENSEN et al., 2001)

Genotype

Stein and colleagues studied the relationship between DAT1 3′-untranslated region (3′-UTR) variable number tandem repeats (VNTR) genotypes and dose response to MPH. Children were genotyped for the DAT1 VNTR and evaluated on placebo and three dosage levels of OROS® MPH. Children who were homozygous for the less common, 9-repeat DAT1 3′-UTR genotype displayed a distinct dose–response curve from that of the other genotype groups, with an absence of typical linear improvement when the dose was increased from 18 mg to 36 and 54 mg. (Stein et al., 2005)

In a study by Epstein and colleagues, youths and adults with ADHD showed attenuated activity in fronto‐striatal regions. In addition, adults with ADHD appeared to activate non‐fronto‐striatal regions more than normals. A stimulant medication trial showed that among youths, stimulant medication increased activation in fronto‐striatal and cerebellar regions. In adults with ADHD, increases in activation were observed in the striatum and cerebellum, but not in prefrontal regions. Conclusions: This study extends findings of fronto‐striatal dysfunction to adults with ADHD and highlights the importance of frontostriatal and frontocerebellar circuitry in this disorder, providing evidence of an endophenotype for examining the genetics of ADHD. (Epstein et al., 2007)

Some medication which is licensed for use in childhood may have to be continued off license in adults if there are no better alternatives and the patient has benefitted from it significantly. Psychotherapy may have to be adjusted to external and internal changes that are part of growing up.

Dose Titration

The dose should be titrated against symptoms and adverse effects in line with guidelines until optimized. This means reduced symptoms, positive behavior changes, improvements in education, employment and relationships, with tolerable adverse effects.

During the titration phase, ADHD symptoms, impairment and adverse effects should be recorded at baseline and at each dose change on standard scales, in children also by parents and teachers, and progress reviewed regularly.

Dose titration should be slower and monitoring more frequent if another condition is present, such as

  • neurodevelopmental disorders (for example, autism spectrum disorder, tic disorders, learning disability)
  • mental health conditions (for example, anxiety disorders [including obsessive–compulsive disorder], schizophrenia or bipolar disorder, depression, personality disorder, eating disorder, post-traumatic stress disorder, substance misuse)
  • physical health conditions (for example, cardiac disease, epilepsy or acquired brain injury).
  • Think about using immediate- and modified-release preparations of stimulants to optimize effect (for example, a modified-release preparation of methylphenidate in the morning and an immediate-release preparation of methylphenidate at another time of the day to extend the duration of effect).
  • Addictions

Abuse

One needs to be particularly careful about prescribing stimulants for ADHD if there is a risk of addictions and/or diversion for cognitive enhancement or appetite suppression. One should not offer immediate-release stimulants or modified-release stimulants that can be easily injected or insufflated, if this may be an issue.

Coexisting Conditions

In ADHD the comorbidity for other conditions is quite high, which can play a significant role in treatment. The same medication choices can be offered to people with ADHD and anxiety disorder, tic disorder or autism spectrum disorder as other people with ADHD.

Studies indicate that co-occurrence of clinically significant ADHD and autistic symptoms is common, and that some genes may influence both disorders. However, the DSM basically does not allow for the concurrent diagnosis of ADHD and autism.

Children with the combination of ADHD and motor coordination problems are particularly likely to suffer from an autism spectrum disorder. These co-occurrences of symptoms are important since children with ASD in addition to ADHD symptoms may respond poorly to standard ADHD treatments or have increased side effects. Such children may benefit from additional classes of pharmacologic agents, such as α-agonists, selective serotonin reuptake inhibitors and neuroleptics. They may also benefit from social skills therapy, individual and family psychotherapy, behavioral therapy and other nonpharmacologic interventions. (Reiersen & Todd, 2008)

Caution

Stimulants need to be used with care and caution, and it is important to have as much information about the medical and psychological state of the patient as possible. The following list just gives some examples, but is by no means comprehensive or factually up to date:

  • Some contraindications for methylphenidate are marked anxiety, tension, and agitation are contraindications to Methylphenidate, since the drug may aggravate these symptoms. Methylphenidate is contraindicated also in patients known to be hypersensitive to the drug, in patients with glaucoma, and in patients with motor tics or with a family history or diagnosis of Tourette’s syndrome.
  • Methylphenidate is contraindicated during treatment with monoamine oxidase inhibitors, and within a minimum of 14 days following discontinuation of a monoamine oxidase inhibitor (hypertensive crises may result).
  • Because of possible effects on blood pressure, methylphenidate should be used cautiously with pressor agents.
  • Methylphenidate may decrease the effectiveness of drugs used to treat hypertension. Human pharmacologic studies have shown that racemic methylphenidate may inhibit the metabolism of coumarin anticoagulants, anticonvulsants (e.g., phenobarbital, phenytoin, primidone), and tricyclic drugs (e.g., imipramine, clomipramine, desipramine). Downward dose adjustments of these drugs may be required when given concomitantly with methylphenidate. It may be necessary to adjust the dosage and monitor plasma drug concentration (or, in case of coumarin, coagulation times), when initiating or discontinuing methylphenidate.

Stimulant medications cause a modest increase in average blood pressure (about 2-4 mmHg) and average heart rate (about 3-6 bpm), and individuals may have larger increases. While the mean changes alone would not be expected to have short-term consequences, all patients should be monitored for larger changes in heart rate and blood pressure. Caution is indicated in treating patients whose underlying medical conditions might be compromised by increases in blood pressure or heart rate, such as those with preexisting hypertension, heart failure, recent myocardial infarction, or ventricular arrhythmia.

Psychosis

Psychosis is an important, unpredictable side effect of stimulant medication. In the case of acute psychotic or manic episodes, ADHD medication should be stopped because it can exacerbate or even trigger them under certain conditions. Restarting the ADHD medication after the episode has resolved can be considered, taking into account the individual circumstances, risks and benefits of the ADHD medication. The potential for psychotic side effects are well known, but usually reported as rare. Long acting preparations appear to be a contributory factor to the development of psychotic side effects, while symptoms resolve with discontinuation of treatment. (Shibib & Chalhoub, 2009)

Administration of stimulants may exacerbate symptoms of behavior disturbance and thought disorder in patients with a preexisting psychotic disorder.

Mosholder and colleagues analyzed data from 49 randomized, controlled clinical trials in the pediatric development programs for these products. A total of 11 psychosis/mania adverse events occurred during 743 person-years of double-blind treatment with these drugs, and no comparable adverse events occurred in a total of 420 person-years of placebo exposure in the same trials. The rate per 100 person-years in the pooled active drug group was 1.48. The analysis of spontaneous postmarketing reports yielded >800 reports of adverse events related to psychosis or mania. In about 90% of the cases, there was no reported history of a similar psychiatric condition. Hallucinations involving visual and/or tactile sensations of insects, snakes, or worms were common in cases in children. (Mosholder, Gelperin, Hammad, Phelan, & Johann-Liang, 2009)

Bipolar Disorder

ADHD in combination with bipolar disorder may be associated with more severe symptoms and worse outcomes of both conditions. Prior to initiating treatment with a stimulant, patients with comorbid depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. The frequent coexistence with alcohol and substance abuse may further complicate treatment management. A hierarchical approach is desirable, with mood stabilization preceding the treatment of ADHD symptoms.

Atomoxetine may be effective in the treatment of ADHD symptoms in patients with bipolar disorder, with a modestly increased risk of (hypo)manic switches and destabilization of the mood disorder when utilized in association with mood stabilizers. (Perugi & Vannucchi, 2015)

Aggression

Aggressive behavior or hostility is often observed in children and adolescents with ADHD and has been reported in clinical trials and the post-marketing experience of some medications indicated for the treatment of ADHD. Patients beginning treatment for ADHD should be monitored for the appearance of or worsening of aggressive behavior or hostility.

Seizures

There is some clinical evidence that stimulants may lower the convulsive threshold in patients with prior history of seizures, in patients with prior EEG abnormalities in absence of seizures, and, very rarely, in patients without a history of seizures and no prior EEG evidence of seizures. In the presence of seizures, the drug should be discontinued.

Priapism

Prolonged and painful erections, sometimes requiring surgical intervention, have been reported with methylphenidate products in both pediatric and adult patients. Priapism usually developed after some time on the drug, often subsequent to an increase in dose. Priapism has also appeared during a period of drug withdrawal (drug holidays or during discontinuation). Patients who develop abnormally sustained or frequent and painful erections should seek immediate medical attention.

Peripheral Vasculopathy, Including Raynaud’s Phenomenon

Stimulants are associated with peripheral vasculopathy, including Raynaud’s phenomenon. Signs and symptoms are usually intermittent and mild, although less frequently permanent tissue damage can occur. Signs and symptoms often improve after reduction in dose or discontinuation of the drug. Careful observation for digital changes is necessary during treatment with ADHD stimulants.

Visual Disturbance

Difficulties with accommodation and blurring of vision have been reported with stimulant treatment. However, in a study by Martin and colleagues in children, visual acuity increased significantly in the ADHD group after treatment with a stimulant. Also, more ADHD subjects had subnormal visual field results without stimulants, compared with controls, but with stimulants the difference was no longer significant. (Martin, Aring, Landgren, Hellström, & Andersson Grönlund, 2008)

Drug Dependence

Methylphenidate should be given cautiously to patients with a history of drug dependence or alcoholism. Chronic abusive use can lead to marked tolerance and psychological dependence with varying degrees of abnormal behavior. Psychotic episodes can occur, especially with parenteral abuse. Careful supervision is required during withdrawal from abusive use, since severe depression or another underlying condition may surface.

Pregnancy

The number of pregnancies exposed to ADHD medication has increased similarly to the increase in use of ADHD medication among women of childbearing age. Use of ADHD medication in pregnancy was associated with different indicators of maternal disadvantage and with increased risk of induced abortion and miscarriage.

Haervig and colleagues studied data from the Danish national health registries to identify all recorded pregnancies from 1999 to 2010. From 2003 to the first quarter of 2010, use of ADHD medication during pregnancy increased from 5 to 533 per 100 000 person‐years. Compared with unexposed, women who used ADHD medication during pregnancy were more often younger, single, lower educated, received social security benefits, and used other psychopharmaca. Exposed pregnancies were more likely to result in induced abortions on maternal request, induced abortions on special indication, and miscarriage compared with unexposed pregnancies. (Haervig, Mortensen, Hansen, & Strandberg-Larsen, 2014)

However, ADHD treatment could put both mother and baby at risk. This has to be balanced against the possible risks to the baby of continuing treatment. Although the data remain inadequate, the risk of the latter appears to be quite small overall, at least for methylphenidate, (Besag, 2014) while there is evidence, that the rates of fetal loss both through abortion and through miscarriage are increased with methylphenidate. Discussions about ADHD treatment with women of childbearing age should be balanced, open and honest, acknowledging the lack of information on the possible risks to the offspring of continuing treatment, while also drawing attention to the possible risks to both mother and child of discontinuing treatment. (Besag, 2014)

Monitoring

Medication is an important element of therapeutic strategies for ADHD. While medications for ADHD are generally well‐tolerated, there are common, although less severe, as well as rare but severe adverse events that can occur during treatment with ADHD drugs. Cortese and colleagues reviewed the literature. The review covers monitoring and management strategies of loss of appetite and growth delay, cardiovascular risks, sleep disturbance, tics, substance misuse/abuse, seizures, suicidal thoughts/behaviors and psychotic symptoms. Most AEs during treatment with drugs for ADHD are manageable and most of the times it is not necessary to stop medication, so that patients with ADHD may continue to benefit from the effectiveness of pharmacological treatment. (Cortese et al., 2013)

Behavior

Monitor the behavioral response to medication, and if behavior worsens adjust medication and review the diagnosis.

Height

Growth should be monitored during treatment with stimulants, and patients who are not growing or gaining height or weight as expected may need to have their treatment interrupted.

Research on the issue of growth suppression is lacking, mostly owing to insufficient follow-up on patients’ final heights. However, it has been argued that the rate of height loss seems relatively small and is likely reversible with withdrawal of treatment. (Goldman, 2010)

Weight

Some young adults are misusing prescription stimulants for weight loss. This behavior is associated with other problematic weight loss strategies. Interventions designed to reduce problematic eating behaviors in young adults may wish to assess the misuse of prescription stimulants. (Jeffers, Benotsch, & Koester, 2013) In the study by Jeffers and colleagues, undergraduates who reported using prescription stimulants for weight loss had greater appearance-related motivations for weight loss, greater emotion and stress-related eating, a more compromised appraisal of their ability to cope, lower self-esteem, and were more likely to report engaging in other unhealthy weight loss and eating disordered behaviors.

Weight should be measured at least once at 3 and 6 months after starting treatment in children over 10 years and young people, and at least once every 6 months thereafter. In adults, weight should be measured at least once every 6 months. Monitoring the BMI of adults is in many cases important.

If a child or young person’s height over time is significantly affected by medication (that is, they have not met the height expected for their age), stopping the medication or at least a break in treatment over school holidays to allow ‘catch‑up’ growth may be considered.

Cardiovascular System

Stimulants agents can increase heart rate and blood pressure and cause other cardiovascular symptoms. Since increased BP and HR in general are considered risk factors for cardiovascular morbidity and mortality, heart rate and blood pressure should be monitored closely. Patients who are being considered for treatment with stimulant medications should have a careful history (including assessment for a family history of sudden death or ventricular arrhythmia) and physical exam to assess for the presence of cardiac disease and should receive further cardiac evaluation if findings suggest such disease (e.g., electrocardiogram and echocardiogram).

Statistically significant pre–post increases of SBP, DBP and HR were associated with amphetamine and atomoxetine treatment in children and adolescents with ADHD, while methamphetamine treatment had a statistically significant effect only on SBP in these patients. These increases may be clinically significant for a significant minority of individuals that experience larger increases. (Hennissen et al., 2017)

Among young and middle-aged adults, current or new use of ADHD medications, compared with nonuse or remote use, does not seem associated with an increased risk of serious cardiovascular events. Habel and colleagues examined whether current use of medications prescribed primarily to treat ADHD is associated with increased risk of serious cardiovascular events in young and middle-aged adults. Participants were adults aged 25 through 64 years with dispensed prescriptions for methylphenidate, amphetamine, or atomoxetine at baseline. The sample size was 443 198 users and nonusers. The multivariable-adjusted rate ratio (RR) of serious cardiovascular events for current use vs nonuse of ADHD medications was 0.83. Among new users of ADHD medications, the adjusted RR was 0.77. The adjusted RR for current use vs remote use was 1.03; for new use vs remote use, the adjusted RR was 1.02. (Habel et al., 2011) In the study including data about 1,200,438 children and young adults between the ages of 2 and 24 years and 2,579,104 person-years of follow-up, including 373,667 person-years of current use of ADHD drugs, Habel et al showed no evidence that current use of an ADHD drug was associated with an increased risk of serious cardiovascular events, although the upper limit of the 95% confidence interval indicated that a doubling of the risk could not be ruled out. (Habel et al., 2011)

Children and Adolescents

Sudden death has been reported in association with CNS stimulant treatment at usual doses in children and adolescents with structural cardiac abnormalities or other serious heart problems. Although some serious heart problems alone carry an increased risk of sudden death, stimulant products generally should not be used in children or adolescents with known serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to the sympathomimetic effects of a stimulant drug.

Adults

Sudden death, stroke, and myocardial infarction have been reported in adults taking stimulant drugs at usual doses for ADHD. Although the role of stimulants in these adult cases is also unknown, adults have a greater likelihood than children of having serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other serious cardiac problems. Adults with such abnormalities should also generally not be treated with stimulant drugs.

Tics

If a person taking stimulants develops tics, one should consider whether the tics are related to the stimulant (tics naturally wax and wane) and the impairment associated with the tics outweighs the benefits of ADHD treatment. If tics are stimulant related, one may need to reduce the dose or switch the medication.

Sexual Dysfunction

Erectile and ejaculatory dysfunction are potential adverse effects of atomoxetine.

Seizures

If a person with ADHD develops new seizures or a worsening of existing seizures, their ADHD medication needs to be reviewed and any medication that might be contributing to the seizures stopped.

Patients with ADHD seem to be at a higher risk of seizures. However, ADHD medication was associated with lower risk of seizures within individuals while they were dispensed medication, which is not consistent with the hypothesis that ADHD medication increases risk of seizures. Wiggs and colleagues followed a sample of 801,838 patients with ADHD medication. Patients with ADHD were at higher odds for any seizure compared with non-ADHD controls (odds ratio [OR] = 2.33). In adjusted within-individual comparisons, ADHD medication was associated with lower odds of seizures among patients with (OR = 0.71) and without (OR = 0.71) prior seizures. Long-term within-individual comparisons suggested no evidence of an association between medication use and seizures among individuals with (OR = 0.87) and without (OR = 1.01) a seizure history. (Wiggs et al., 2018) Koneski and colleagues evaluated 24 patients ranging from 7 to 16 years of age who took MPH for 6 months. Inclusion criteria were at least two epileptic seizures in the previous 6 months and a diagnosis of ADHD based on DSM-IV criteria. There was an overall improvement in ADHD symptoms in 70.8% of patients, and there was no increase in frequency of epileptic seizures in 22 patients (91.6%). (Koneski, Casella, Agertt, & Ferreira, 2011)

Sleep

Changes in sleep pattern should always be asked for, the timing and dose of the medication adjusted. Immediate release methamphetamine should usually not be administered after 4pm.

Compliance

Experiences of adverse effects are a frequent explanation for discontinuation among youth. Despite impaired functioning during adolescence, many discontinue medication treatment. Beliefs and attitudes may differ widely. Some families understand that ADHD is a neurobiological condition and accept that medication is indicated, for others, such treatment is unacceptable. Converging evidence describes negative perceptions of the burden associated with medication use as well as concerns about potential short- and long-term adverse effects. Ways to improve shared decision making among practitioners, parents and youth, and to monitor effectiveness, safety and new onset of concurrent difficulties are likely to optimize outcomes. (Alice Charach & Fernandez, 2013).

Psychotherapy

Psychotherapy should always be part of a comprehensive treatment plan for ADHD. Communication-Focused Therapy® (CFT) as it was developed by the author focuses on internal and external communication patterns which has shown to be helpful in ADHD. (Haverkampf, 2017b, 2017d, 2017c)


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

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CBT and Psychodynamic Psychotherapy

CBT-and-Psychodynamic-Psychotherapy-Christian-Jonathan-Haverkampf-2-psychotherapy-series

CBT and Psychodynamic Psychotherapy

Christian Jonathan Haverkampf, M.D.

Cognitive Behavioural Therapy (CBT) and psychodynamic psychotherapy, the less intensive form of psychoanalysis, are arguably the most prominent and well-researched schools of psychotherapy, apart from interpersonal therapy (IPT) models.

Essentially all psychotherapies go back to the revolutionary concept of the ‘talking cure’ in the late nineteenth century, the use of communication as an instrument of healing. CBT and psychodynamic psychotherapy as descendants from the same concept should be viewed as complimentary rather than as substitutes. Technical approaches from both can be helpful in individual situations.

Keywords: CBT, psychodynamic psychotherapy, Communication-Focused Therapy, CFT, communication, psychotherapy, psychiatry

Table of Contents

Introduction. 3

Philosophical Differences. 3

Practical Differences. 4

Example: Obsessive-Compulsive Disorder (OCD) 5

Example: Depression. 6

Into the Future. 7

References. 9

Introduction

Cognitive Behavioural Therapy (CBT) and psychodynamic psychotherapy, the less intensive form of psychoanalysis, are arguably the most prominent and well-researched schools of psychotherapy (see Lambert and Bergin, 1994), apart from interpersonal therapy (IPT) models.

Essentially all psychotherapies go back to the revolutionary concept of the ‘talking cure’ (Breuer et al, 2000)  in the late nineteenth century, the use of communication as an instrument of healing. CBT and psychodynamic psychotherapy as descendants from the same concept should be viewed as complimentary rather than as substitutes. Technical approaches from both can be helpful in individual situations.

Philosophical Differences

The late nineteenth century with new discoveries in biological medicine and neurology and the emergence of Darwinian evolution provided the background for psychoanalysis. Psychoanalysis regards the mind as a complex yet structured system that produces and is affected by communication and meaningful information, not unlike individual cells in an organism. The patient’s free associations  are reflected upon by patient and analyst to explore and resolve intrapsychic conflicts and their defences, which cause ‘neurotic’ symptoms, such as anxiety, OCD, depression. Symptoms contain not only hints of repressed feelings and emotions, but also information about the patient’s authentic wishes and desires for individual growth.

CBT delivers a more action-oriented and problem-focused approach, in which treatment plans and goals are formulated without a prior analysis of the meaning of the symptoms.  CBT goes back to a merger of the behaviourism based on studies on conditioning and learning  and studies into cognitive processes by students of Freud , who believed cognitive processes to be closer to consciousness than their mentor. CBT focuses on an understanding of the mechanisms of present thoughts and behaviours rather than their pathogenesis. Both, however, teach their patients to become experts in their respective skills.

In psychodynamic theory, the development stages in childhood play an important role,  as do other past experiences, which are largely organised around interpersonal relations. In CBT, the focus is on conscious processes and the present. Psychoanalysis assumes that communication phenomena  between therapist and patient allow insight into partly unconscious intrapsychic processes, which are organised in a structured system (such as the tri-partite model of ego, superego and id) .

From a CBT perspective, distorted thought processes and maladaptive behaviours are direct causes of mental health symptoms (Hollon and Beck, 1994),  in psychodynamic theory they are ‘only’ symptoms and not to be confused with the underlying causes.  In CBT, logic, for example in the form of the Socratic dialogue, can be used to identify and discard false beliefs that cause unwanted thoughts and emotions (Beck at al, 1979). Psychodynamic therapy enables reason (the ego) to break down the defences, which protect from underlying conflicts.

In CBT, unhelpful thought patterns are made clear in the beginning (assessment phase), which, however, requires a norm  of ‘helpful thinking’ (Fancher, 1995). In psychodynamic psychotherapy, what is ‘helpful’ depends on the individual and has to be worked out in the exploratory process.

Both therapeutic approaches are growing organically, though unfortunately with less than optimal cross fertilisation. Emotional, motivational and relational aspects have been added to CBT.  Neural networks and neural computation models are used in psychodynamic research (Peled, 2008), as well as in the cognitive sciences which underlie CBT. The neurosciences , infant research , neurobiology , attachment psychology and other fields have contributed significantly to psychodynamic theory.

Practical Differences

Treatment in CBT is usually shorter, often below twenty sessions, and with longer inter-session intervals.   There is an evidence-based short-term psychodynamic psychotherapy (STPP) which, however, has in a meta-analysis shown to be “significantly” less effective than the longer version (LTPP) (Leichsenring and Rabung (2008).

Both therapies transfer skills. In CBT the therapist is “very active” (Hofmann, 2011) and the approach is highly structured (Gatchel, 2008) , often with homework and including an initial assessment, education on the course of therapy (Hofmann, 2011), a reconceptualization of the problem, skills acquisition, skills training, generalisation and maintenance, and another assessment. In psychodynamic psychotherapy, patients learn in the therapist-patient interaction to gain insight into their unconscious dynamics and to become their own analysts.

Since CBT assigns lower priority to the specific thought content and the communication dynamics between patient and therapist and defines problems more narrowly, psychoeducation and ‘manualisation’  are easier to integrate, particularly in clearly defined situations, such as drug addiction (Carroll, 1998) . CBT also lends itself better to conduct therapy over a distance (Weiss et al, 2012; Himle et al., 2006) , including the use of e-mail therapy (Vernmark et al, 2010). Computer programmes (CCBT) can make therapy available to millions of previously underserved populations. 

Both, CBT and psychodynamic psychotherapy have proven their effectiveness in numerous studies and large meta-analyses.  However, direct comparisons of the effectiveness of CBT and psychodynamic psychotherapy can be flawed by design if the two therapies are complementary and conceptually related. Bram and Björgvinsson (2004), for example, have successfully integrated exposure-response prevention into their psychodynamic therapies. Measuring success in completed therapy phases seems equally problematic, but is still often used.

CBT is likely to deliver quicker results in motivated patients with clearly defined symptoms, low resistance levels and relatively intact personality structures (with the exception of borderline personality disorder and DBT). Psychodynamic psychotherapy may have advantages in dealing directly with personality disorders,  which are traditionally derived from psychodynamic models.

Leichsenring and Leibling (2003) demonstrated in a meta-analysis a better long-time effectiveness of psychodynamic psychotherapy than CBT, while CBT on its own has shown to prevent relapses in the long-run (Driessen et al, 2013). Much of the apparent diversity in opinion may depend on the specific diagnosis in question.

CBT may have higher drop-out rates (Cuijpers et al, 2008; Whittal et al, 1999). Motivation seems more external in CBT (see Haddock et al, 2012) than in psychodynamic psychotherapy with its emphasis on the therapeutic relationship  and the integration of the more recent motivational systems research (see Lichtenberg at al, 2016). Adding these psychodynamic elements in CBT therapies may lead to better outcomes.

Example: Obsessive-Compulsive Disorder (OCD)

In psychodynamic theory, the anxiety underlying OCD is a result of conflicting dynamics (including emotions), often with a strong relationship component. A conflict may arise in an unstable relationship to an important other, such as a primary caretaker in early childhood, as the feelings of love for the idealised mental representation of the other (longing for attachment) and the frustration, sadness and/or abandonment about the reality of this person’s unpredictability or unreliability cannot be resolved by the child.  Higher levels of aggression and distrust in other people have indeed been found in OCD (Moritz, 2011), and infant research has demonstrated how the interaction between primary caretaker and child can affect the child’s evolving sense of self and feeling of secure attachment . Obsessive thoughts and compulsive rituals are aimed at temporary relief from the heightened anxiety in present situations which trigger the situational and associated emotional memory systems of previous situations . Awareness of the underlying emotional conflict, which manifests through the symptoms, helps the patient to recognise, identify the ‘free-floating’ anxiety in the past experience, which reduces the anxiety from experienced emotional uncertainty and the OCD symptoms in the present.

                The cognitive-affective schemata of newer developments in psychodynamic theory  have considerable overlap with CBT concepts of the effect of learned cognitive schemata. From a CBT perspective, obsessive thoughts are otherwise ‘normal’  negative thoughts which may be misinterpreted as personally significant (Rachman, 1997) or as a potentially dangerous situation for which the patient feels responsible (Salkovskis, 1985), response patterns which are largely learned (Taylor and Jang, 2011). Compulsive rituals are efforts to control these intrusive thoughts. After performing the rituals, individuals usually report a temporary decrease in their obsessional distress (Rachman and Hodgson, 1980), which negatively reinforces these behaviours, a mechanism similar to CBT models on addiction.

Exposure and Response Prevention (ERP)  tries to break this cycle of negative reinforcement, in which the patient is repeatedly exposed to an anxiety-provoking thought or situation stimulus, but the self-calming ritual is reduced or suppressed. The anxiety may increase in the beginning, but then reach a peak and fade away.  Exposure necessarily leads to an involvement of the patient’s emotional memory and an emotional processing of the anxiety (Foa and Kozak, 1986), which seems a point where CBT and psychodynamic psychotherapy again intersect. Basically, both approaches try to give patients a greater sense of positive control over their lives.

Example: Depression

                Freud considered the internalisation of object loss as a normal part of life, and depression as a reaction formation in the face of a particularly severe super-ego , which holds in check our basic desires and wishes (the ‘id’) with the help of conscious cognitive functions (reason, the ‘ego’). In CBT, the super-ego could be compared to the messages we learn over time and the believes we construct of how we ‘should’ live our lives. And similar to the concept of limited cognitive resources in CBT, the rational ‘ego’ function in psychodynamic theory may get overwhelmed in stressful and traumatic situations and become unable to reconcile the super-ego and the id, leaving an unresolved emotional conflict,  which the ego (reason) needs to defend against. Loss and the emotions associated with this conflict (such as anger, sadness or helplessness) are important themes. Anxiety and avoidance have been shown to be greater in people with more insecure attachment (Bateman & Fonagy, 2012),  who are often more dependent and self-criticising, eliciting responses from others that confirm their fears of rejection and abandonment (see Blatt, 1974; Blatt, 1992). The negative emotions then lead to a ‘withdrawal’ from one’s own emotions (repression), reminiscent of learned helplessness in CBT. Awareness of the underlying dynamics and their origin in the past, helps the patient to understand and integrate them in the present.

                In CBT, thoughts, behaviours and feelings are directly interrelated, which can lead to a circularity that is in psychodynamic theory ‘impossible’. Negative thoughts can lead to depressed feelings, which again lead to negative thoughts and ‘depressed’ behaviour, such as social withdrawal, reinforcing the depression. Maladaptive cognitive patterns, such as negative thinking about oneself and one’s experiences (McGinn, 2000), increase the vulnerability for depression.   In learned helplessness, for example, the sense of low self-efficacy brings about behaviour that just reaffirms the low self-efficacy.

In the cognitive aspect of CBT, a person learns to recognize and turn negative automatic thoughts into realistic  beliefs. More realistic beliefs lead to more adaptive thoughts and less depressed feelings. Patients are taught to deconstruct problems into the actual situation, and the thoughts, feelings and behaviours that occur before, during and after the situation, an external correlate to the internal deconstructive process in psychodynamic psychotherapy. In Mindfulness CBT (MCBT)  the emphasis is on experiencing one’s thoughts as mental events rather than interpreting them as representations of oneself or reality. This detachment from negative thoughts and feelings is also useful in preventing relapse (Teasdale, 1999).

Into the Future

The aim of psychotherapy is not merely to eliminate suffering (WHO, 1946), but to help patients develop as humans. The primary tool is communication, in CBT to provide information that generates change and in psychodynamic psychotherapy to reveal the information that brings about change.  There are synergistic effects from using both. Zipfel et al (2014) showed in a large sample of anorexic patients, that CBT was associated with weight gain, while psychodynamic psychotherapy with lower relapse rates at the 12-month follow-up. McFall and Wollersheim (1979) in an early study successfully used a combination of CBT and psychodynamic psychotherapy in anxiety . Given the widely-perceived need for multimodal approaches , it is difficult to comprehend that this should not apply to the most important therapeutic models we have. In ancient Greece, knowing oneself (γνῶθι σεαυτόν, “know thyself”) and the process of the Socratic dialogue were inextricably linked. Psychodynamic psychotherapy and CBT should be viewed as complementary rather than substitutes.


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

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