How to CORRECTLY Diagnose Attention Deficit Hyperactivity Disorder (ADHD) in Adults? - Dr Sanil Rege
Summary
TLDRIn this edition of Hub Bytes, psychiatrist Sunil Rege discusses the comprehensive evaluation of ADHD in adults. He emphasizes that ADHD is a diagnosis of exclusion and should be considered from a longitudinal perspective, taking into account various factors that could contribute to ADHD-like symptoms. Rege highlights the importance of ruling out organic causes, considering inflammation, hormonal aspects, and the impact of substances and trauma on cognition. He also stresses the significance of addressing sleep disturbances and dietary interventions in the management of ADHD, advocating for a thorough and individualized approach to diagnosis and treatment.
Takeaways
- đ ADHD is a diagnosis of exclusion, meaning other potential causes for symptoms must be ruled out first.
- đ The evaluation of ADHD should consider a longitudinal perspective, looking at the individual's history and various contributing factors.
- đ A thorough cognitive examination is crucial, as ADHD symptoms can overlap with other conditions like neurodegenerative disorders.
- đ Sleep apnea and other sleep disturbances can significantly impact daytime cognition and should be considered in ADHD evaluations.
- đ©ž Checking for organic factors such as vascular health, vitamin deficiencies, and hormonal imbalances is important due to their impact on cognitive function.
- đ„ Inflammation, both neural and systemic, can lead to cognitive disturbances and should be evaluated as part of the ADHD assessment.
- đ§ A comprehensive psychiatric evaluation is necessary to rule out conditions like psychotic disorders, affective syndromes, and anxiety that can mimic ADHD symptoms.
- đ« Substance misuse and certain medications can affect cognitive function and must be considered in the diagnosis process.
- đœïž Diet and nutrition play a role in cognitive health, and dietary interventions may be beneficial for individuals with ADHD.
- đ€ Addressing sleep disturbances is essential, as they can affect the effectiveness of ADHD treatments and overall cognitive function.
Q & A
What is the primary focus of the video by Sunil Rege?
-The primary focus of the video is the evaluation of ADHD (Attention Deficit Hyperactivity Disorder) and the importance of considering various factors that might contribute to symptoms similar to ADHD to avoid misdiagnosis.
Why is ADHD considered a diagnosis of exclusion according to the video?
-ADHD is considered a diagnosis of exclusion because it's important to rule out other underlying conditions that might be causing symptoms similar to ADHD before concluding the diagnosis.
What is the significance of evaluating ADHD from a longitudinal perspective as mentioned in the video?
-Evaluating ADHD from a longitudinal perspective is significant because it allows for a better understanding of the patient's history and development, which can help identify any vulnerabilities or other factors contributing to the symptoms.
How does sleep apnea, as discussed in the video, impact cognitive functions related to ADHD?
-Sleep apnea can significantly impact cognitive functions such as attention and concentration during the day due to hypoxia during the night, leading to unrefreshing sleep and fatigue.
What role do vascular factors play in cognitive deficits as discussed in the video?
-Vascular factors like diabetes and hypertension can lead to white matter hyperintensities in the brain, which are associated with cognitive deficits that might be mistaken for ADHD symptoms.
Why is it important to consider vitamin B12, folate, and vitamin D deficiencies in the evaluation of ADHD?
-These deficiencies are important to consider because they are involved in the methylation pathway and are necessary for the production of noradrenaline and dopamine, key neurotransmitters in the neurobiology of ADHD.
What is the inflammatory hypothesis mentioned in the video in relation to ADHD?
-The inflammatory hypothesis suggests that neuroinflammation or systemic inflammation can present with significant cognitive disturbances, which might be mistaken for ADHD symptoms.
How can thyroid function and iron deficiencies present with cognitive issues similar to ADHD?
-Thyroid function abnormalities and iron deficiencies can lead to cognitive issues, including attention and concentration problems, which can mimic ADHD symptoms.
Why is it crucial to evaluate hormonal aspects, particularly in females, when considering ADHD?
-Hormonal aspects, especially estrogen levels, are crucial to evaluate because estrogen plays a significant role in cognition, and abnormalities can lead to symptoms that might be diagnosed as ADHD, particularly in perimenopausal or postmenopausal women.
What is the significance of considering substance misuse and certain medications in the evaluation of ADHD?
-Substance misuse and certain medications can impact the subcortical areas and frontal lobe connections, which are involved in ADHD, and thus their effects on cognition need to be considered to avoid misdiagnosis.
How does the video suggest addressing sleep disturbances in the context of ADHD evaluation?
-The video suggests addressing sleep disturbances by considering good sleep hygiene and, in some cases, using medications like clonidine or guanfacine to treat hyperarousal and improve daytime functioning.
Outlines
đ Evaluating ADHD: Beyond the Symptoms
Dr. Sunil Rege, a consultant psychiatrist, introduces the video by discussing the importance of a comprehensive evaluation for ADHD in adults. He emphasizes that ADHD is a diagnosis of exclusion and should be considered from a longitudinal perspective. The video aims to highlight the need to rule out other underlying factors that might contribute to ADHD-like symptoms to avoid misdiagnosis. Dr. Rege uses the analogy of a bridge to explain how untreated vulnerabilities can lead to the 'breakdown' of a patient's condition, which might be mistakenly attributed to ADHD. He stresses the importance of considering the cumulative effect of all addressed factors for a beneficial outcome, linking this approach to psychiatric formulation and management.
đ§ Organic Factors in ADHD Evaluation
The second paragraph delves into the organic aspects of ADHD evaluation, focusing on medical conditions that can impact cognitive function. Dr. Rege discusses how sleep apnea, vascular factors like diabetes and hypertension, and cognitive examinations are crucial in the diagnostic process. He mentions the potential for neurodegenerative conditions to present ADHD-like symptoms and the importance of ruling these out. The paragraph also covers the role of vitamin deficiencies in ADHD, the inflammatory hypothesis, and the impact of thyroid function and iron levels on cognition. The discussion extends to hormonal aspects, particularly in females, and how conditions like polycystic ovarian syndrome can affect cognitive function.
đ Psychological and Lifestyle Factors in ADHD
In the third paragraph, Dr. Rege explores the psychological and lifestyle factors that can mimic ADHD symptoms. He discusses the impact of substance misuse on cognition and the importance of considering prescribed medications that might affect cognitive function. The paragraph also addresses the psychotic spectrum, emphasizing the need to rule out psychotic disorders before diagnosing ADHD. Affective syndromes, particularly depression, are highlighted for their co-morbidity with ADHD. The discussion includes the effects of trauma on neurodevelopment and cognition, the link between ADHD and anxiety, and the importance of evaluating for hyperarousal. Dr. Rege also touches on the role of sleep disturbances in ADHD, suggesting that addressing sleep issues might improve cognitive function without the need for stimulant medication.
đ Sleep and Diet: Crucial Aspects of ADHD Management
The final paragraph emphasizes the importance of sleep and diet in ADHD management. Dr. Rege discusses how sleep disturbances can affect cognitive function and how addressing these issues might improve ADHD symptoms. He mentions the role of circadian rhythm disturbances and the potential use of medications like clonidine to treat sleep-related issues in ADHD. The paragraph also highlights the importance of a healthy diet in managing ADHD symptoms. Dr. Rege concludes by reiterating the need for a thorough evaluation to rule out other vulnerabilities before diagnosing ADHD, advocating for a deductive reasoning approach to reach the most accurate diagnosis.
Mindmap
Keywords
đĄADHD
đĄCognitive Deficits
đĄSleep Apnea
đĄVascular Factors
đĄNeuroinflammation
đĄThyroid Function
đĄPolycystic Ovarian Syndrome (PCOS)
đĄSubstance Misuse
đĄPsychotic Spectrum
đĄAffective Syndrome
đĄTrauma
Highlights
Introduction to the evaluation of ADHD in adults, emphasizing the importance of considering other underlying factors that might contribute to ADHD symptoms.
ADHD is a diagnosis of exclusion, meaning other potential causes for symptoms must be ruled out first.
The importance of a longitudinal perspective in evaluating ADHD, considering the patient's history and development over time.
The analogy of a bridge to illustrate how underlying vulnerabilities can weaken a person's cognitive functioning, leading to ADHD-like symptoms.
The role of sleep apnea in impacting cognition and its relevance to ADHD symptoms.
The impact of vascular factors like diabetes and hypertension on cognitive deficits and their connection to ADHD.
The necessity of a thorough cognitive examination in individuals with ADHD, beyond just self-report scales.
The significance of vitamin B12, folate, and vitamin D deficiencies in the neurobiology of ADHD.
The inflammatory hypothesis and its link to cognitive disturbances, potentially mimicking ADHD symptoms.
The overlap between fibromyalgia, chronic fatigue syndrome, and cognitive deficits, and their relevance to ADHD evaluation.
The importance of evaluating thyroid function and iron levels in females for cognitive issues related to ADHD.
The consideration of polycystic ovarian syndrome in females due to its impact on estrogen levels and cognition.
The impact of substance misuse on cognitive functioning and its potential to mimic ADHD symptoms.
The evaluation of psychotic spectrum disorders and their potential to present with ADHD-like symptoms.
The importance of ruling out severe forms of depression, especially those with cognitive symptoms, before diagnosing ADHD.
The role of past trauma in neurodevelopment and its potential to result in ADHD-like cognitive and impulse regulation issues.
The significance of current stresses in exacerbating cognitive status and their role in ADHD evaluation.
The potential comorbidity of OCD with ADHD and the implications for treatment with stimulants.
The importance of evaluating anxiety in ADHD, especially the internal agitation that can present as anxiety in adults.
The consideration of sleep disturbances in ADHD, including obstructive sleep apnea and circadian rhythm disorders.
The impact of diet on ADHD symptoms and the importance of a healthy diet in management.
The conclusion emphasizing the thorough evaluation process for ADHD to ensure proper treatment of underlying vulnerabilities.
Transcripts
[Music]
hi welcome to
another edition of hub bytes i'm sunil
rege consultant psychiatrist from
psycsene
today i'll be taking you through the
evaluation of
adhd attention deficit hyperactivity
disorder
to set the scene i received a referral
from a physician
approximately three days ago it was a 42
year old female
it was for an evaluation for adhd
now one of the things we've got to think
about is if i went ahead
and basically carried out an adhd
adult self-report scale or cadre
questionnaire or
diva 2.0 and i identified attention
concentration deficits hyperactivity and
impulsivity
i could basically say this is a this is
adhd
but the question is what if there are
several
other underlying things that might be
contributing to these symptoms it's
possible
that could result in a misdiagnosis so
that's really the aim
of this video is to outline that the
evaluation of adhd
one adhd is a diagnosis of exclusion
two we should think about adhd from a
longitudinal perspective
and to look at several other factors
that might be contributing
to these deficits
and the reason why i think about it that
way is because
let's imagine this was a bridge
and you as an individual crossing the
bridge on a daily
basis and if the individual has adhd
they're doing that they've been
prescribed a stimulant and they're going
okay
but what if there are several underlying
factors that are making this bridge
weaker
that is there are vulnerabilities these
factors act as vulnerabilities and at
some point this bridge
cracks and breaks that's when the
patient comes to you
and says doctor the medication isn't
working
they might present with depression they
might present anxiety they might present
with a range of other disorders
so the really important aspect is to
think about these vulnerabilities and
address these vulnerabilities as well
because every little thing counts and
it's important that the cumulative
effect
of all these things that we've addressed
results in a
beneficial outcome and this is linked to
the basis
of psychiatric formulation and
management i've covered this
in another video on the channel so
please please do have a listen to it as
well
we've also covered it in on the cycling
hub.com
as an article so really we're following
the sherlock holmes way of thinking
deductive reasoning and not succumbing
to
complementary bias so let's get started
with the evaluation
but as always before getting into the
details it's important that this is not
to be construed as medical advice
any personal issues should always be
discussed with your own doctor
so the first thing i think about is the
organic
aspects what does that mean the medical
aspects now this hierarchy has been
covered in more detail on another video
the psychological formulation management
video
on the channel so please do have a
listen to that one as well
so we in the organic section
a few things that i think about firstly
now this particular patient
was diagnosed with moderate sleep apnea
sleep apnea and sleep difficulties can
impact
significantly on cognition during the
day so we know that adhd is
can be considered really a disorder of
cognition as well because it has
attention concentration issues
other cognitive issues as well that one
identifies so sure cognition
is a faculty right at the top that we
think about
but obstructive sleep apnea because of
hypoxia during the night
the individual can wake up really
unrefreshed fatigue
which impacts on concentration and
attention during the day
so obstructive sleep apnea is one of the
factors to take into account
the other aspects are vascular factors
diabetes hypertension
and we know that vascular factors can
result in
white matter hyperintensities of the
brain and white matter hyperintensities
are associated with cognitive deficits
so it's important to be proactive
in treating those as well now of course
in some cases it is important to carry
out an actual
frontal lobe cognitive examination but
other cognitive examinations such as a
clock drawing test
and if there are abnormalities
identified going into more detail
because in some rare cases it is not
uncommon to identify a neurodegenerative
condition
that might present as adhd such as
frontotemporal dementias
because we know that frontal lobe is a
predominant part of the brain that's
involved
in adhd so the point is it is important
to carry out a thorough cognitive
examination
in individuals with adhd not just the
adhd self-report scale of focusing on
attention concentration
hyperactivity and impulsivity then we
also look at
other aspects such as vitamin b12 folate
deficiencies vitamin d
deficiencies why do we look at that
because we know that
these are involved in the methylation
pathway the first two
and are necessary for the production of
noradrenaline dopamine
two key neurotransmitters that are
involved in the
neurobiology of adhd now this particular
patient that was referred to me had
elevated n a elevated
dsdna the anti-ena was normal but their
esr was
elevated as well so that brings in the
inflammatory hypothesis
we know that when neuroinflammation is
present or systemic inflammation is
present
individuals can present with significant
cognitive disturbances
and the other important aspect of
inflammation is there is an
overlap between fibromyalgia chronic
fatigue syndrome
and cognitive deficits as part of these
particular syndromes
so we know that the inflammation neural
inflammation and systemic inflammation
can result
in fibromyalgia type syndromes chronic
fatigue
syndrome myalgic encephalomyelitis and
we know that cognition is a core feature
of these conditions so we often see this
triad
together so it's important to think
about inflammation as well
the other aspect to think about is
thyroid functions
and also iron because these deficiencies
can present with significant
cognitive issues as well
in females and you know this 42 year old
female i would also be thinking about
polycystic ovarian syndrome why because
estrogen and abnormalities in estrogen
we know that estrogen is very very
crucial for
cognition so sometimes in the
perimenopausal postmenopausal group
we can see symptoms that are very very
suggestive
or can be diagnosed as adhd onset
late but much of this can be due to
estrogen deficiency for example
impacting on cognition so it's crucial
that the hormonal aspect
is also evaluated so that's sort of the
the organic evaluation
then we think about substances and here
we think about
substance misuse so for example
excessive alcohol use or cannabis use or
other illicit substances
and the reason why that's important is
because these substances can
impact on the subcortical area the basal
ganglia and the connections to the
frontal lobe the same pathways that can
be involved
in adhd you can have a more detailed
read of the neurobiology of adhd which
we covered in the cycling hub.com
we've also covered the diagnosis and
management of adhd with a focus on adult
adhd
do have a read of that one as well
with substances we've also got to think
about any medications that have been
prescribed
by physicians or psychiatrists because
certain medications can impact
on cognition the next aspect we think
about is psychotic spectrum
and when i think about psychotic
spectrum it's not just about psychosis
in the form of delusions and
hallucinations
but really we're thinking about the
mesolimbic pathway and if the mesolimbic
pathway is activated
it results in hyperarousal symptoms
heightened emotional reactivity racing
thoughts
and we know that these symptoms can
impact impact on
cognition so the functioning during the
day but it can also impact on
sleep resulting in middle insomnia
early insomnia difficulty falling asleep
or early morning awakening
all of which can impact on cognitive
functioning during the day and can look
like adhd
so it is important to address any mixed
features
but the other aspect that's important in
psychotic spectrum is a thorough
evaluation
of ruling out psychotic disorders
by taking a family history looking at
the genetic
aspects because individuals with
prodromal psychosis can have
neurodevelopmental abnormalities
so developmental delay for example or
attention concentration problems
learning difficulty in school etc
and much of this can one can fall in the
trap
of misdiagnosis they can be prescribed a
stimulant and it can result in
a psychotic episode so it's really
really important to rule out
underlying vulnerabilities towards
psychosis to avoid misdiagnosis
and a prescription of a stimulant that
could result in
detrimental sort of consequences the
next one is the affective syndrome and
here really
once focusing on ruling out the severe
forms of depression
for example melancholic type depressions
that
have dopamine and noradrenaline as key
underpinnings in the genesis
so we're looking at you know dopamine
not adrenaline sort of abnormalities
melancholic depression because we know
that
in melancholic depression decision
making attention concentration issues
cognitive issues
are a core feature of course adhd and
depression can be co-morbid
and both need to be treated and the
reason why that can happen particularly
in adulthood is that
they might initially have adhd but
because of difficulty coping through
life
it's resulted in lots of losses
it's resulted in difficulty coping and
it resulted in additional sort of
depressive elements being added on top
of the adhd so that's where the
co-morbidity comes in
moving lower down we think about trauma
now with particular trauma we think
about
past trauma during childhood and why is
this important because trauma
impacts on the neurodevelopment the
development of the brain and can result
in not only cognitive
issues but also impulse just regulation
and impact
on emotional dysregulation so
trauma and looking at those aspects is
important we know that trauma can also
result in
ongoing heightened sympathetic drive so
therefore hyperarousal
can be present so it's linked to mixed
features as well
but we know that trauma is also linked
to fibromyalgia
and chronic fatigue syndrome so we see
this complex picture of
trauma fibromyalgia chronic fatigue
syndrome impacting on cognition
but also many individuals with
fibromyalgia chronic fatigue syndrome
have mixed features
so one's really got to think about
deconstructing the problem and
addressing each one rather than
trying to search for a single diagnosis
so
trauma is really important but of course
we look at current stresses as well
because current stresses
when added on to an underlying
vulnerability can result in worsening of
cognitive status next we look at ocd
they can often be ocd comorbid
i have seen cases of resistant ocd
that actually were treated that had a
diagnosis of adhd
and responded very well well to
stimulants why does that happen it
happens because in ocd one of the
neurotransmitters that's involved
is dopamine so you can have a read of
the neurobiology of ocd as well in
detail in the cycling
hub so in resistant cases one's got to
think about the possibility of adhd and
many individuals with adult adhd
can have severe procrastination as a key
feature the other aspect is anxiety now
this is really crucial because we know
that in childhood hyperactivity is a
symptom but only 30
of individuals sort of move to have
hyperactivity as a symptom
in adulthood so a lot of the
hyperactivity dissipates the external
hyperactivity but sometimes the internal
hyperactivity remains and this can
present
as internal agitation or internal
anxiety
so sometimes in resistant anxiety
disorders it's worth thinking about the
possibility
of adhd but the other aspect with
anxiety is that we know that sometimes
when a stimulant
is prescribed it can actually worsen
anxiety
so a thorough evaluation of the
possibility of hyperarousal
needs to be taken into account in adhd
and hyperarousal is linked to as we saw
mixed features but also
anxiety so if there is significant
hyperarousal
then one can actually combine the
stimulant to treat
the cognitive elements of of
sort of the frontal lobe aspects
noradrenaline dopamine by using a
stimulant
but then treating the hyperarousal
during other periods or the side effects
by
considering clonidine or guanfacine
which is an alpha-2 agonist
but it's important of course any
combination therapy should be a
specialist treatment
as far as possible we try to avoid
combination therapies because we want to
ensure that we prescribe one medication
but again these are things that need to
be discussed
there are individualized treatments but
just to outline that
in some cases reduction of hyperarousal
is absolutely crucial because there are
two elements going on
and i'll come to that in a sec when i
talk about sleep uh of course
it's important to think that individual
eating disorder can also have adhd type
symptomatology
but of course then prescription of
stimulants one's got to be very very
cautious because they drop appetite
we know that uh personality there may be
certain personality traits that can
sort of be associated with adhd but when
there's lots going on here i'm not going
to jump to the diagnosis of a
personality disorder but high levels of
perfectionism
sort of anal casting personality
obsessive compulsive personalities
can sometimes of course add on that
extra stress for an individual with
adhd and one of the important things
that i want to touch on
is sleep a very very large proportion of
individuals
tend to have sleep disturbances
individuals adhd have sleep disturbances
we touched on obstructive sleep apnea
which is important to address
but circadian rhythm disturbance is very
crucial as well
you can have a listen to the
neurobiology of sleep video that i did
on this channel
to really think about what is
hyperarousal and what
are circadian rhythms and how they
impact on
on sleep now when there is significant
hype arousal
at nighttime it can sort of present with
vivid dreams difficulty falling asleep
waking up several times in the middle of
the night
early morning awakening etc now this can
impact significantly on cognition during
the day
because the individual wakes up
unrefreshed and extended periods of hype
arousal and sleep difficulties
impact on cognition so there is good
evidence that
sleep disturbances impact on cognition
therefore it becomes important in some
cases
simply addressing sleep by good sleep
hygiene
may actually improve cognitive function
so that is one of the important things
to take into account as part of
management not just simply prescribing a
stimulant
because if there's ongoing sleep
difficulties the stimulants might stop
working and in many cases to address the
um hyperarousal at nighttime circadian
rhythm disturbances
that's where clonadine and one facing
may be utilized
because they reduce that heightened
sympathetic
overdrive heightened nor adrenaline at
night time
and assist and sleep treat the vivid
dreams of the nightmares and improve
daytime functioning so in some cases a
combination might be required where
treating the hyperarousal at nighttime
but and improving cognition during the
demo be required
but as i mentioned earlier that's really
really individualized
and you know sleep is important and of
course diet is also important
and of course in children and
adolescents the link between
dietary interventions and adhd is
something that is
considered um and it's something to take
into account similarly in adults as well
a healthy diet
becomes very very important so
the purpose of this interview is to
highlight that
it's important to carry out a thorough
evaluation when presented
with an adhd type picture
the reason is because we want to ensure
that these vulnerabilities are
treated before jumping into the
diagnosis of adhd so
adhd is a diagnosis of exclusion it's
important to run through the hierarchy a
proper
thorough deductive reasoning because
when we rule out
the impossible what must remain is as
close to the truth
as possible so i hope that you found
this video useful if you've liked it
please of course click the like button
subscribe to the channel
i look forward to seeing you in another
edition of hub bites take care and stay
[Music]
safe
you
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