Ahmed M. Alhuwaydi
Department of Psychiatrics, College of Medicine, Jouf University, Sakaka, Saudi Arabia.
For correspondence: [email protected] Abstract
Background: Attention Deficit Hyperactivity Disorder (ADHD) is disorder with many symptoms that overlap with other mental disorders. However, its management is different. Therefore, an accurate diagnosis is necessary. Moreover, other mental disorders that are co morbid with ADHD are common. ADHD diagnostic criteria were changed in DSM-5 compared to DSM-IV, and the symptoms are required to be present before age of 12 years in DSM-5 compared to 7 years in DSM-IV.
Case Description: A 56-year-old male was diagnosed and managed for over 20 years with bipolar disorder (BPD), although the full criteria were not met. Consequently, the disease management was not adequate, and the patient did not reach recovery. He had clear symptoms of ADHD since childhood and ADHD symptoms improved with management with inquiry of unspecified BPD.
Conclusion: ADHD and BPD share similar symptoms. Reviewing the diagnosis and taking a detailed longitudinal history is important especially if the management results are not as expected or the symptoms are not classical.
Key words: Attention Deficit Hyperactivity Disorders, Bipolar disorders, Case report, Saudi Arabia.
Citation: Alhuwaydi AM. Adult Attention Deficit Hyperactivity Disorder: A Case Report. AUMJ, 2018 March 1; 5(1): 35 - 38.
Introduction
Attention Deficit Hyperactivity Disorder (ADHD) affects 2.5% of the adult population(1). In recent years, there is a need for studies about this disorder in adults(2).Otherwise, it leads to lack of awareness, mainly with the many overlapping symptoms between ADHD and hypomania, which renders the diagnosis of late presentation especially difficult in some specific cases(3).
Adult ADHD has a high comorbidity with other disorders; for example, it has a prevalence of 5.1–25% among patients with bipolar disorders (BPD)(4). Additionally, there is a preponderance of males with type I BPD(5). Because BPD is known to be comorbid with ADHD, there is a 40% prevalence of ADHD in adults(6). Additionally, adult ADHD has been found to be more cyclothymic, with patients having irritable temperaments compared
to childhood ADHD, which is independent of the BPD comorbidity(7). This can play a role in misdiagnosis and the negative impact of its course and treatment(6).
There is moderate co-occurrence of ADHD and BPD, and these comorbidities are associated with many negative outcomes, as well as a susceptibility toward hypomania(5). Therefore, it is important to make sure that the precise diagnosis is reached and to determine whether there is comorbidity in managing patient symptoms to prevent misdiagnosis or inefficient treatment.
Case Description
The patient and his family signed an informed consent and approved anonymous de-identified reporting of this case. The patient is a 56-years-old married man with five children. He is a retired Civil Defense Officer. The patient
Alhuwaydi - Adult Attention Deficit Hyperactivity Disorder: A Case Report
Aljouf University Medical Journal (AUMJ), 2018 March 1; 5(1): 35 - 38.
2018 2018
was followed at the Security Forces Hospital (SFH), Riyadh, Saudi Arabia in the period from 2017-2018 as a patient with BPD. He was diagnosed and managed for about 20 years at a private clinic where many medications were tried with the help of his treating psychiatrist, but there was little improvement. While at our clinic, he would stand in front of the door, fidgeting with his hands. When he came to the clinic, he started to talk excessively, answer questions prematurely, and not wait for his turn in the conversation. He was on oral sodium valproate 1000 mg once daily (OD), and quetiapine 300 mg PO before bed, and he still showed little sign of improvement.
When a standard diagnosis of depressive or hypomania episodes was extracted, it was surprising to learn that he did not have any of these, and thus, the diagnosis of BPD appeared to have been made with uncertainty. The physician addressed the primary complaint and current situation during the first session, which lasted about40 minutes, and arranged for a second session for a reassessment and to obtain his collateral history. At this time, the diagnosis of adult ADHD was started.
In the second meeting with the patient and his wife, more details were gathered related to his childhood, and he had a positive history of attention problems, hyperactivity, and impulsivity. This affected him at school, making it more difficult for others to consider him as child with a disorganized behavioral problem. However, he managed his situation and graduated from high school.
During college, he encountered some difficulties, but overall, he graduated with several problems; often expressing negative comments, and disturbing others with his hyperactivity and poor social relationships.
In adolescence and early adulthood, he experienced many impulsive behaviors, which led to some difficult situations. He had a few sexual partnerships and a homosexual experience as well.
According to his history, he had been sexually abused by an older drunk male at one point in his life.
This patient was diagnosed at a private clinic as having BPD, although the
criteria were never a match and as his symptoms were not episodic. This pattern started in childhood, although the patient showed some improvement while on medication, becoming less impulsive and hyperactive. However, he still exhibited the same degree of attention deficit, and could not manage his life without his wife and family’s help and patience. He did not pay attention well while watching TV, and if someone entered the room, he sat next to the TV. The family could not study or sit quietly in his presence. In addition, he was unable to be alerted to details and made many thoughtless mistakes, not seeming to listen to other people, even when they spoke directly to him. Generally, he was disorganized, unable to manage tasks or keep his possessions in order, and also lost things easily.
The patient was always restless, unable to sit quietly, and unable to do any activities quietly. He often talked excessively, interrupted, and intruded on others. All of these symptoms appeared before he was 12 years old. The patient was carefully screened as positive for ADHD, using the Adult ADHD Self-Report Scale symptom checklist (ASRS-v1.1).
Plus normal brain CT, there was no other medical or psychiatric problems, including personality disorders symptoms or traits. Moreover, there were no significant stressors in the family or family history regarding psychiatric disorders. His wife had described him as irritable, poorly-organized, but an outgoing person in general. The patient and his wife desired more treatment to facilitate consistent improvement.
Regarding his symptoms, the patient was diagnosed as having adult ADHD with a comorbid presentation, according to the DSM 5, with a high score on the ASRS- v1.1. Thus, not meeting the BPD criteria, he was started on Concerta 18 mg (methylphenidate) and showed much improvement in terms of hyperactivity and attention, but he also complained of lip tics, which resulted in discontinuation (DC), before decreasing the sodium valproate dose. We started atomoxetine up to 80 mg PO once daily, and the patient showed more improvement,
Alhuwaydi - Adult Attention Deficit Hyperactivity Disorder: A Case Report
Aljouf University Medical Journal (AUMJ), 2018 March 1; 5(1): 35 - 38.
2018 2018
compared to either sodium valproate or quetiapine alone. Since then, the patient has started to decrease the dose of sodium valproate until DC. He then became easily provoked, was stubborn and hyperactive, but did not show full manic or depressive episodes even after 8 months. This suggests that the comorbid Unspecified Bipolar and Related Disorder was questionable. The patient asked to continue quetiapine 300 mg h.s. and atomoxetine 80 mg. However, the family started to complain that he was becoming easily agitated and hot-tempered. The
patient hesitated to go back on sodium valproate because he was feeling better;
he felt calm and able to concentrate.
Discussion
It is not likely that the patient had BPD because he never had manic or depressive episodes, or symptoms of hypomania, and it was not episodic in nature and did not improve with mood stabilizers. He had a positive family history of ADHD. Table 1 shows the most important differences between ADHD and BPD(8,9).
Table 1: Important differences between Attention Deficit Hyperactivity Disorder (ADHD) and Bipolar Disorder (BPD).
Difference ADHD BPD
Onset Before 7 years of age After 12 years of age
Course chronic cyclical
Mood Symptoms absent always present
Psychotic symptoms absent sometimes present
Comorbidity ~20% of adult ADHD patients also BPD 10-20% of BPD patients also have adult ADHD
Inattention Yes Yes
Forgetfulness Yes No
Doesn’t complete tasks
Yes No
hyperactivity All day, worse when prolonged attention or on task behavior is expected
Fluctuation in activity levels day/night
Racing/crowding thought
No Yes
Pressured speech Can be redirected and focused Difficult to stop and to focus
Early insomnia Bed time resistance Decrease need of sleep
Euphoria/elation No Yes
Irritability Not frequent Very frequent
Self-steam Worsens over time Generally inflated
Suicidal ideation/attempts
No Yes
Restlessness Yes Yes
Impulsivity Yes Yes
Finally, he displayed no manic, hypomanic, or depressive episodes, and his symptoms did not wax and wane(1), which made a BPD diagnosis unlikely.
The patient had the criteria for ADHD because he had persistent symptoms of inattention that were not consistent with his developmental level; he had direct negative effects on his social and academic/occupational functions; he can’t pay attention to specifics or made
inconsiderate mistakes; it was usually hard to him to sustaining attention; and, did not appear he is listening when directly spoken to. Organizing tasks and activities was usually difficult for him. He loses necessary things, and, extraneous stimuli were always easily distractive for him. He has unrelated thoughts, and, was often a forgetful person. For hyperactivity and impulsivity, he often fidgeted or tapped his extremities or squirmed in his chair, not able to remain seated quietly
Alhuwaydi - Adult Attention Deficit Hyperactivity Disorder: A Case Report
Aljouf University Medical Journal (AUMJ), 2018 March 1; 5(1): 35 - 38.
2018 2018
when expected to, participating quietly in activities was difficult for him, he was most of the time “on the go,” acted as if
“driven by a motor” talked too much, revealed answers before completing the question, had difficulty waiting his turn, and, often interrupted or intruded on others.
Conclusion
As in our case, some patients may have symptoms that can confuse the physician and could lead to an incorrect diagnosis and treatment. It is important to take a longitudinal, childhood and family history, and, taking a collateral history from a reliable informant is another helpful step in assessment. Physicians should review the diagnoses if the treatment response was not as expected.
Overall, many psychiatric disorders have many common symptoms and differentiation can be difficult. Thus, changing the diagnosis or adding a new diagnosis may be a necessary step.
Funding
This report was self-funded.
Conflict of Interest
The author declared no conflicts of interest.
Acknowledgement
This case was counseled and managed with major help from Dr. Husain A.
AlHumaid, Consultant Psychiatrist and addiction, Security Forces Hospital, Riyadh, Saudi Arabia
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[Accessed: 03-Mar-2019].
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