Diagnostik av vuxna patienter med ADHD

Diagnostik av vuxna patienter med ADHD
Vetenskaplig kommitté: Prof Philip Asherson; Prof Jan Buitelaar; Prof Kai Kahl; Maria Nilsson Markhed MD; Josep Antoni Ramos-Quiroga MD, PhD; Esther Sobanski MD, PhD SE SESTR00494a

Disclosure

Innehåll Avsnitt 1: Bakgrund till vuxen-ADHD
Epidemiologiska data Neurobiologi, genetik, kognitiva data Funktionsnedsättning Avsnitt 2: Klinisk presentation Kliniska symptom och diagnostiska kriterier Klassificering av ADHD Ärftlighetsfaktorer och barndomsanamnes Screeningfrågor och -formulär Avsnitt 3: Komorbiditeter och differentialdiagnoser Komorbiditeter ADHD och substansmissbruk Hur man skiljer ADHD från andra vanliga psykiska sjukdomar Slutsatser

Avsnitt 1: Bakgrund till ADHD

Avsnitt 1: Bakgrund till ADHD
1.1 Epidemiologiska data

Vad är ADHD? ADHD är ett neurobiologiskt funktionshinder, kännetecknat av ihållande mönster av uppmärksamhetsproblem och/eller hyperaktivitet och impulsivitet, som kan leda till allvarligt utagerande beteende1 Trots att den ursprungligen antogs vara ett tillstånd som enbart förekommer hos barn, indikerar studier att drabbade barn även har symptom och betydande beteendemässiga och psykiska problem upp i vuxen ålder2-3 KEYPOINTS The essential feature of attention-deficit/hyperactivity disorder (ADHD) is a persistent pattern of inattention and/or hyperactivity-impulsivity that is more frequently displayed and more severe than is typically observed in individuals at a comparable level of development.1 BACKGROUND Some symptoms must have been present before 7 years of age, although many individuals are diagnosed at a later age, even as late as adulthood.1 The impairment from symptoms must be present in at least 2 settings (e.g. work, school, home).1 There must be clear evidence of interference with social, academic, and/or occupational functioning.1 The symptoms are not better explained by another mental disorder.1 REFERENCES American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders - Text Revision, Fourth Edition. Washington, DC: American Psychiatric Association; 2000: Asherson P. Clinical assessment and treatment of attention deficit hyperactivity disorder in adults. Expert Rev Neurother 2005;5(4): Elia J, Ambrosini PJ, Rapoport JL. Treatment of attention-deficit-hyperactivity disorder. N Engl J Med 1999;340(10):780-8. APA. Diagnostic and Statistical Manual of Mental Disorders – Text Revision. 4th Edn. Washington DC: APA; 2000;85–93. Asherson. Expert Rev Neurother 2005;5:525–39. Elia et al. N Engl J Med 1999;340:780–8.

ADHD – prevalens och persistens
ADHD-prevalensen hos vuxna är 2–5 %, alltså jämförbar med den för klinisk depression1 I vuxen ålder föreligger en könskvot M:K på 1,5:1, och man tror att kvinnor sannolikt är underdiagnostiserade2 En vanlig orsak till att patienter söker är att deras barn dessförinnan fått en ADHD- diagnos3 Persistensen upp i vuxen ålder är uppskattningsvis 40–60 %; det kan dock röra sig om restsymptom snarare än en fullständig diagnos, vilket dock inte innebär remission3 Kooij et al. BMC Psychiatry 2010;10:67. Faraone et al. Psych Med. 2006;36:159–165. Fayyad et al. Br J Psychiatry 2007;190:402–9.

Global prevalens av ADHD hos vuxna
Enligt WHO-WMH:s undersökning 2007 är den beräknade globala prevalensen av vuxen-ADHD 3,4 %. Land Prevalens, % (SE) n Belgien 4,1 (1,5) 486 Colombia 1,9 (0,5)a 1 731 Frankrike 7,3 (1,8)b 727 Tyskland 3,1 (0,8) 621 Italien 2,8 (0,6) 853 Libanon 1,8 (0,7)a 595 Mexiko 1,9 (0,4)a 1 736 Nederländerna 5,0 (1,6) 516 Spanien 1,2 (0,6)a 960 USA 5,2 (0,6) 3 197 Totalt 3,4 (0,4) 11 422 ABSTRACT BACKGROUND: Little is known about the epidemiology of adult attention-deficit hyperactivity disorder (ADHD). AIMS: To estimate the prevalence and correlates of DSM-IV adult ADHD in the World Health Organization World Mental Health Survey Initiative. METHOD: An ADHD screen was administered to respondents aged years in ten countries in the Americas, Europe and the Middle East (n=11422). Masked clinical reappraisal interviews were administered to 154 US respondents to calibrate the screen. Multiple imputation was used to estimate prevalence and correlates based on the assumption of cross-national calibration comparability. RESULTS: Estimates of ADHD prevalence averaged 3.4% (range %), with lower prevalence in lower-income countries (1.9%) compared with higher-income countries (4.2%). Adult ADHD often co-occurs with other DSM-IV disorders and is associated with considerable role disability. Few cases are treated for ADHD, but in many cases treatment is given for comorbid disorders. CONCLUSIONS: Adult ADHD should be considered more seriously in future epidemiological and clinical studies than is currently the case. ABBREVIATIONS ADHD: attention-deficit/hyperactivity disorder, WHO: World Heath Organization, WMH: World Mental Health, SE: standard error, CI: confidence interval KEYPOINT ADHD is a prevalent disease both in the United States and worldwide. BACKGROUND According to the 2007 WHO-WMH survey initiative, the estimated worldwide prevalence of adult ADHD is 3.4%. Estimates indicate lower prevalence in lower-income countries (1.9%) compared with higher-income countries (4.2%). REFERENCE Fayyad J, De Graaf R, Kessler R, Alonso J, Angermeyer M, Demyttenaere K, De Girolamo G, Haro JM, Karam EG, Lara C, Lépine JP, Ormel J, Posada-Villa J, Zaslavsky AM, Jin R. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry 2007;190:402-9. aÖvre gränsen för 95 % CI ligger under prevalensestimatet för hela urvalet bUndre gränsen för 95 % CI ligger över prevalensestimatet för hela urvalet Fayyad et al. Br J Psychiatry 2007;190:402–9. Atom

Förekomst av vuxna med ADHD i en patientgrupp från Ungern
Individer i åldern år från sammanlagt 17 allmänläkarmottagningar (n = 3529) 161 bedömdes som positiva och genomgick klinisk intervju Prevalensen varierade mellan 1,35 till 5 beroende på de kriterier som användes Grov justerad beräkning av intervjudata avsende specificitet och känslighet, % (95% CL) Diagnosgrupp Rådata, n (%) Grov uppskattninge % (95% CI) Beräkning utifrån förväntat värde Beräkning utifrån övre CI av förväntat värde Beräkning utifrån lägre CI av förväntat värde DSM-IVa 29 (18.01) 1.4 (1.0‒1.81) 1.35 (0.4‒2.86) 2.14 (1.0‒3.89) 0.7 (0.15‒2.0) Exkl. kriterier vid debutb 33 (20.50) 1.62 (1.2‒2.0) 1.64 (0.63‒3.24) 2.46 (1.3‒4.3) 0.95 (0.07‒2.34) Inkl.Sx kriterierc 61 (37.89) 3.0 (2.43‒3.56) 3.65 (2.27‒5.84) 4.58 (3.03‒7.04) 2.78 (1.56‒4.72) Sx reduceraded 68 (42.24) 3.34 (2.75‒3.93) 4.16 (2.69‒6.5) 5.09 (3.44‒7.7) 3.26 (1.95‒5.34) 10. Bitter I, Simon V, Balint S, Meszaros A, Czobor P (2010) How do different diagnostic criteria, age and gender affect the prevalence of attention deficit hyperactivity disorder in adults? An epidemiological study in a Hungarian community sample. Eur Arch Psychiatry Clin Neurosci 260 (4):287‐296. The goal of the study was twofold: (1) to investigate the effect of different diagnostic criteria on prevalence estimates of adult attention deficit hyperactivity disorder (ADHD), and (2) to provide prevalence estimates of adult ADHD for the first time in a Hungarian sample. Subjects between 18 and 60 years were included in the screening phase of the study (N = 3,529), conducted in 17 GP practices in Budapest. Adult self‐report scale 6‐item version was used for screening. Out of 279 positively screened subjects 161 subjects participated in a clinical interview and filled out a selfreport questionnaire to confirm the diagnosis. Beside DSM‐IV diagnostic criteria, we applied four alternative diagnostic criteria: 'No‐onset' (DSM‐IV criteria without the specific requirement for onset); full/Sx (DSM‐IV "symptoms only" criteria); and reduced/Sx (DSM‐IV "symptoms only" criteria with a reduced threshold for symptom count). Crude prevalence estimates adjusted for the specificity and sensitivity data of the screener were 1.35% in the 'DSM‐IV' group, 1.64% in the 'Noonset' group, 3.65% in the 'Sx/full' group and 4.16% in the 'Sx/reduced' group. Logistic regression analysis showed that ADHD was significantly more prevalent with younger age and male gender [chi(2) = 14.46; P = ]. Prevalence estimates corrected for the 'not‐interviewed' subsample and adjusted for specificity and sensitivity data of the screener was 2.3% in males, 0.91% in females; 2.02% in the < or =40 years age group and 0.70% in the >40 years age group, based on DSM‐IV diagnostic criteria. Prevalence rates found in this study are somewhat lower, but still are in line with those reported in the literature. aDSM-IV kriterier avsende både barn och vuxen ADHD inklusive bakgrundsinformation från klinisk intervju. bDSM-IV kriterier avseende både barn och vuxen ADHD, exklusive kriterier vid debut. cDSM-IV symtomkriterier endast (6 av 9 symtom för antingen ouppmärksamhet eller hyperaktivitet/impulsivitet avseende både barn och vuxen ADHD. dReducerat antal förekommande symtom från DSM-IV symtomens (4 av 9 symtoms av antingen ouppmärksamhet eller hyperaktivitet/impulsivitet) som vuxen, och där ursprungliga symtom enligt DSM-IV kriterierna mäste finnas närvarande. eBaserade på observerade data från intervjuad subgrupp. Bitter et al. Eur Arch Psychiatry Clin Neurosci 2010;260:287‒96.

Vilken är förekomsten av ADHD vid en öppenvårdsklinik för vuxna med ADHD i UK?
194 patiententer undersökta 59 avböjt att medverka 11 exkluderade 124 återstående patienter i åldrar 20‒70 år 57 män 67 kvinnor ASRS and Wender Utah Rating Scale Diagnosen ADHD ställdes hos 22% (n = 27: 12 män, 15 kvinnor) Klinisk diagnos före utvärdering Antal (n = 124) Depression 59 Bipolär/schizoaffektiv/psykos 48 Neuros och stress 12 Personlighetstörning 5 Rao, Place. Prog Neuro Psyc 2010;15(5):7‒11.

Läkemedelskonsumtion mot ADHD i Sverige 2006–2009
Populationskohortanalyser 2006–2009 på 5 miljoner patienter inkluderade 41 700 expedierade ADHD-läkemedel Genomsnittlig årlig ökning av förskrivningar på 34 %. Prevalenskvot ökning 2,38 (CI 2,34–2,43) Patienter i åldern 15–21 år är mest benägna att avbryta behandlingen. 27 % i behandling efter nästan 4 år 30 2006 2007 2008 2009 Män och kvinnor Prevalens* Prevalens* 2009 Prevalenskvot (95 % CI) Alla åldrar 2,93 6,98 2,38 (2,34–2,43) 8–14 år 6,63 12,61 1,90 (1,84–1,96) 15–21 år 5,16 12,47 2,41 (2,33–2,50) 22–45 år 1,05 3,59 3,40 (3,27–3,54) 25 20 Behandlade* personer per 1000 invånare 15 10 The data on the use of medication for ADHD in Sweden shows an important decline during the transition from adolescense into adulthood, which is not in line with the much smaller decline in ADHD prevalence. Therefore these data illustrate the under-treatment of ADHD in adults. Since non-drug treatment usually goes in parallel with drug treatment the problem of undertreatment is likely not only true for drug treatment but also for treatment of ADHD in general. 5 Ålder Zetterqvist et al. Acta Psychiatr Scand. 2012:1-8.

Användningen av ADHD-läkemedel i UK, 1999-2006
Prevalensen för förskrivning via allmänläkare till patienter med ADHD minskar kraftigt i åldersgruppen 15 till 21 år Denna minskning är större än den redovisade åldersrelaterade minskningen av symtom Behandlingen kan ha avbrutits för tidigt hos en del unga vuxna med kvarstående symtom Prevalens för förskrivning av metylfenidat, dexamfetamin och atomoxetin till manliga patienter i åldrarna år, 2006 2005 2004 2003 2002 1999 2001 2000 Prevalens per patienter Ålder (år) 12.77 9.08 5.64 3.18 1.92 1.07 0.64 General research practice database maintained by the MHRA . Results of 1636 patients taking these treatments. After 6m since their last prescription this was counted as cessation of treatment. Duration may have included periods of no treatment within timeframes year olds have the greatest drop in prescription rates Reasons for discontinuation: Greater autonomy Less parental/teacher expectation of need for treatment Coping strategies Low level of services Br J Psychiatry Mar;194(3): doi: /bjp.bp Attention-deficit hyperactivity disorder: treatment discontinuation in adolescents and young adults. McCarthy S1, Asherson P, Coghill D, Hollis C, Murray M, Potts L, Sayal K, de Soysa R, Taylor E, Williams T, Wong IC. Author information 1Centre for Paediatric Pharmacy Research, School of Pharmacy, University of London and Institute of Child Health, University College London, UK. Abstract BACKGROUND: Symptoms of attention-deficit hyperactivity disorder (ADHD) are known to persist into adulthood in the majority of cases. AIMS: To determine the prevalence of methylphenidate, dexamfetamine and atomoxetine prescribing and treatment discontinuation in adolescents and young adults. METHOD: A descriptive cohort study using the UK General Practice Research Database included patients aged years from 1999 to 2006 with a prescription for a study drug. RESULTS: Prevalence of prescribing averaged across all ages increased 6.23-fold over the study period. Overall, prevalence decreased with age: in 2006, prevalence in males dropped 95% from per 1000 in 15-year-olds to 0.64 per 1000 in 21-year-olds. A longitudinal analysis of a cohort of 44 patients aged 15 years in 1999 demonstrated that no patient received treatment after the age of 21 years. CONCLUSIONS: The prevalence of prescribing by general practitioners to patients with ADHD drops significantly from age 15 to age 21 years. The fall in prescribing is greater than the reported age-related decrease in symptoms, raising the possibility that treatment is prematurely discontinued in some young adults in whom symptoms persist McCarthy et al. Br J Psych 2009;194:273‒77.

Förhållandet mellan könsfördelning och prevalens av vuxna med ADHD
Förekomsten av ADHD hos vuxna i den allmänna befolkningen avtar med åldern. Delvis är detta relaterat till den åldersrelaterade minskningen av symtom och funktionsnedsättning vid ADHD. Men vissa patienter, barn med ADHD vilka uppfyller färre kriterier än de gör som vuxna, har kvarstående symtom som leder till fortsatt funktionsnedsättning. Denna grupp definieras i DSM5 som ADHD i partiell remission. Hos barn är ADHD 3-5 gånger vanligare hos pojkar än hos flickor och förekommer i ett förhållande så högt som 3:1. Men hos vuxna, är könsfördelningen närmast lika. Med högre ålder ökar andelen kvinnor med ADHD och minskar gällande män. ABBREVIATION ADHD: attention-deficit/hyperactivity disorder KEYPOINT This slide shows the relationship between gender composition and the prevalence of adult ADHD BACKGROUND A meta-regression analysis (Simon et al 2009) indicated that gender and mean age, interacting with each other, were statistically significantly related to the prevalence of ADHD in the sample. Relationship between gender composition and prevalence at ages 20, 30 and 40 years. Relationship between age and prevalence as a function of gender composition (a third, a half, two-thirds males). The association between the proportion of participants with ADHD and gender composition and mean age is shown in this figure, by Simon et al Owing to the statistically significant interaction reported above, for illustrative purposes the association of prevalence with gender composition is displayed at various ages (20, 30 and 40 years; Fig. 2; for younger age groups the prevalence increases, whereas for the older age group prevalence decreases with higher proportion of males in the sample. In children, ADHD is 3-5 times more common in boys than in girls with an incidence ratio of as high as 3:1. However, in adults, the sex ratio is closer to even. REFERENCE Br J Psychiatry Mar;194(3): doi: /bjp.bp Prevalence and correlates of adult attention-deficit hyperactivity disorder: meta-analysis. Simon V1, Czobor P, Bálint S, Mészáros A, Bitter I. Author information 1Semmelweis University Budapest, Department of Psychiatry and Psychotherapy, Balassa u. 6, Budapest H-1083, Hungary. Abstract BACKGROUND: In spite of the growing literature about adult attention-deficit hyperactivity disorder (ADHD), relatively little is known about the prevalence and correlates of this disorder. AIMS: To estimate the prevalence of adult ADHD and to identify its demographic correlates using meta-regression analysis. METHOD: We used the MEDLINE, PsycLit and EMBASE databases as well as hand-searching to find relevant publications. RESULTS: The pooled prevalence of adult ADHD was 2.5% (95% CI ). Gender and mean age, interacting with each other, were significantly related to prevalence of ADHD. Meta-regression analysis indicated that the proportion of participants with ADHD decreased with age when men and women were equally represented in the sample. CONCLUSIONS: Prevalence of ADHD in adults declines with age in the general population. We think, however, that the unclear validity of DSM-IV diagnostic criteria for this condition can lead to reduced prevalence rates by underestimation of the prevalence of adult ADHD. Kooij et al. BMC Psychiatry 2010;10:67. European consensus statement on diagnosis and treatment of adult ADHD: The European Network Adult ADHD. Kooij SJ1, Bejerot S, Blackwell A, Caci H, Casas-Brugué M, Carpentier PJ, Edvinsson D, Fayyad J, Foeken K, Fitzgerald M, Gaillac V, Ginsberg Y, Henry C, Krause J, Lensing MB, Manor I, Niederhofer H, Nunes-Filipe C, Ohlmeier MD, Oswald P, Pallanti S, Pehlivanidis A, Ramos-Quiroga JA, Rastam M, Ryffel-Rawak D, Stes S, Asherson P. 1PsyQ, psycho medische programma's, Department Adult ADHD, Carel Reinierszkade 197, Den Haag, The Netherlands. Attention deficit hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that persists into adulthood in the majority of cases. The evidence on persistence poses several difficulties for adult psychiatry considering the lack of expertise for diagnostic assessment, limited treatment options and patient facilities across Europe. METHODS: The European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated. Besides information on the genetics and neurobiology of ADHD, three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated? 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. Expertise in diagnostic assessment and treatment of ADHD in adults must increase in psychiatry. 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. BMC Psychiatry 2010;10:67. Simon et al. Br J Psychiatry 2009;194(3):204-11 Atom

1.2 Neurobiologi, genetik och kognitiva data
Avsnitt 1: Bakgrund till ADHD 1.2 Neurobiologi, genetik och kognitiva data

Potentiella etiologiska faktorer associerade med ADHD
ADHD har förmodligen en multifaktoriell etiologi, som inkluderar en kombination av genetiska och miljömässiga riskfaktorer: Cirka 80 % av ADHD:s etiologi är kopplad till genetiska faktorer Olika miljöfaktorer kan också bidra som sekundära orsaker Potentiella etiologiska faktorer associerade med ADHD Grupp Tid Etiologiska faktorer Genetiska Mutationer i generna för dopaminreceptorer och dopamintransportörer Miljömässiga Prenatalt Avvikande utveckling av hjärnan, kromosomanomali, virus, anemi, hypotyreos, jodbrist, exponering för missbruksdroger (t.ex. nikotin) Perinatalt Prematuritet, låg födelsevikt, anoxisk-ischemisk encefalopati, meningit, encefalit Postnatalt Virusmeningit, encefalit, hjärntrauma, sköldkörteldysfunktion Millichap. Pediatrics 2008;121:e358–65. Atom

Hjärnregioner involverade vid ADHD
Liston C et al. Biol Psychiatry 2011;69:1168–1177. A network of structures, each with projections to and from prefrontal cortical areas, mediate the cognitive control of attention and behaviour, and dysfunction in this network has been implicated in ADHD, particularly in the core symptoms of the inattention subtype. The anterior cingulate cortex (ACC) and posterior parietal cortex (PPC) detect conflicts in information processing, recruiting the prefrontal cortex (PFC) to provide top-down bias signals, resolving conflicts and enhancing control. Cortico-subcortical signals originating in the basal ganglia and cerebellum convey critical information about violations in the expected frequency and timing of events, respectively. REFERENCE Liston C, Malter Cohen M, Teslovich T et al. Atypical prefrontal connectivity in attention-deficit/hyperactivity disorder: pathway to disease or pathological end point? Biol Psychiatry. 2011;69: Liston et al. Biol Psychiatry 2011;69:1168–77. Atom

ADHD och nedsättning av exekutiva funktioner
Ny forskning visar att utvecklingshämning av exekutiva funktioner också är en integrerad del av ADHD1-2 Exekutiva funktioner är neurokognitiva processer som gör det möjligt för en person att hantera multipla uppgifter i vardagslivet1-2 ADHD påverkar starkt mätningar av hämning, vaksamhet, arbetsminne, och planering1 Brown Attention-Deficit Disorder Scales: Sex kluster för exekutiva funktioner2 Aktivering Organisera, prioritera och komma igång med arbete Uppmärksamhet Fokusera, upprätthålla och skifta uppmärksamhet Energi Aktivitetsnivå, energi och bearbetningshastighet Emotion/Affekt Frustrationstolerans och reglering av känslor Minne Arbetsminne och återgivning Agerande Kontroll och självreglering Brown. Curr Psychiatry Rep 2008;10(5): The BADDS is organised in 6 clusters, and queries the degree to which daily executive function is impaired: Activation: organising tasks and materials, estimating time, prioritising tasks, and getting started on work tasks. Patients with ADHD describe chronic difficulty with excessive procrastination. Often they will put off getting started on a task until the very last minute. It is as though they cannot get themselves started until the point at which they perceive the task to be an acute emergency. Attention: focusing, sustaining focus and shifting focus to tasks. Patients with ADHD say they are easily distracted not only by activites going on around them, but also by thoughts in their own minds. In addition, the ability to focus on reading is difficult for many. Words are generally understood as they are read, but often have to be read over and over again in order for the meaning to be fully grasped and remembered. Effort: regulating alertness, sustaining effort, and processing speed. Many patients with ADHD report they can perform short-term projects well, but have much more difficulty with sustained effort over longer periods of time. Many also experience chronic difficulty regulating sleep and alertness. Often they stay up too late at night because they can’t quiet their thoughts. Once asleep, they often sleep heavily and have difficulty getting up in the morning. Emotion: managing frustration and modulating emotions. Many patients describe chronic difficulties managing frustration, anger, worry, disappointment, desire, and other emotions. They describe these emotions as ‘taking over’ their thinking, making it impossible for them to give attention to anything else. They find it very difficult to put the emotion into perspective and get on with what they need to do. Memory: utilising working memory and accessing recall. Very often people with ADHD will report that they have adequate or even exceptional memory of events that happened long ago, but great difficulty in being able to remember where they just put something, what someone just said to them, or what they were about to say. In addition, people with ADHD often complain that they cannot retrieve learned information from memory when they need it. Action: monitoring and regulating self-action. Many individuals with ADHD, even those without problems of hyperactive behaviour, report chronic problems in regulating their actions. They are often too impulsive in what they say or do and in the way they think, jumping too quickly to inaccurate conclusions. People with ADHD also report problems in monitoring the context in which they are interacting. They fail to notice when other people are puzzled, hurt, or annoyed by what they have just said or done and thus fail to modify their behaviour in response to specific circumstances. They also often report chronic difficulty in regulating the pace of their actions, in slowing self and/or speeding up as needed for specific tasks. Willcutt et al. Biol Psychiatry 2005;57:1336–46. Brown. Curr Psychiatry Rep 2008;10:407–11. Atom

Etablerade samband med ADHD
Genetisk påverkan: Familje- och tvillingstudier – genomsnittlig ärftlighet: 76 %1 Specifika gener: DRD4, DRD52 Hjärnstruktur: De största minskningarna av hjärnvolym ses i vermis cerebelli, corpus callosum, totalcerebral volym och högersidig cerebral volym, och höger hjärnvolym, höger nucleus caudatus, flera frontalregioner1 fMRI: Lägre hjärnaktivitet under uppmärksamhetskrävande uppgifter (temporala och parietala regioner) och under motoriska uppgifter (frontala regioner)3 Mest konsistenta fynd: minskad aktivering av striatum3 Biederman J. Biol Psychiatry. 2005;57(11): ABSTRACT Attention-deficit/hyperactivity disorder (ADHD) is a multifactorial and clinically heterogeneous disorder that is associated with tremendous financial burden, stress to families, and adverse academic and vocational outcomes. Attention-deficit/hyperactivity disorder is highly prevalent in children worldwide, and the prevalence of this disorder in adults is increasingly recognised. Studies of adults with a diagnosis of childhood-onset ADHD indicate that clinical correlates – demographic, psychosocial, psychiatric, and cognitive features – mirror findings among children with ADHD. Predictors of persistence of ADHD include family history of the disorder, psychiatric comorbidity, and psychosocial adversity. Family studies of ADHD have consistently supported its strong familial nature. Psychiatric disorders comorbid with childhood ADHD include oppositional defiant and conduct disorders, whereas mood and anxiety disorders are comorbid with ADHD in both children and adults. Pregnancy and delivery complications, maternal smoking during pregnancy, and adverse family environment variables are considered important risk factors for ADHD. The aetiology of ADHD has not been clearly identified, although evidence supports neurobiological and genetic origins. Structural and functional imaging studies suggest that dysfunction in the frontal-subcortical pathways, as well as imbalances in the dopaminergic and noradrenergic systems, contribute to the pathophysiology of ADHD. Medication with dopaminergic and noradrenergic activity seems to reduce ADHD symptoms by blocking dopamine and noradrenaline reuptake. Such alterations in dopaminergic and noradrenergic function are apparently necessary for the clinical efficacy of pharmacological treatments of ADHD. Cortese S. Eur J Paediatr Neurol. 2012;16(5): This review, addressed mainly to clinicians, considers commonly asked questions related to the neuroimaging, neurophysiology, neurochemistry and genetics of Attention-Deficit/Hyperactivity Disorder (ADHD). It provides answers based on the most recent meta-analyses and systematic reviews, as well as additional relevant original studies. Empirical findings from neurobiological research into ADHD reflect a shift in the conceptualisation of this disorder from simple theoretical views of a few isolated dysfunctions to more complex models integrating the heterogeneity of the clinical manifestations of ADHD. Thus, findings from structural and functional neuroimaging suggest the involvement of developmentally abnormal brain networks related to cognition, attention, emotion and sensorimotor functions. Brain functioning alterations are confirmed by neurophysiological findings, showing that individuals with ADHD have elevated theta/beta power ratios, and less pronounced responses and longer latencies of event-related potentials, compared with controls. At a molecular level, alterations in any single neurotransmitter system are unlikely to explain the complexity of ADHD; rather, the disorder has been linked to dysfunctions in several systems, including the dopaminergic, adrenergic, serotonergic and cholinergic pathways. Genetic studies showing a heritability of ∼60–75% suggest that a plethora of genes, each one with a small but significant effect, interact with environmental factors to increase the susceptibility to ADHD. Currently, findings from neurobiological research do not have a direct application in daily clinical practice, but it is hoped that in the near future they will complement the diagnostic process and contribute to the long-term effective treatment of this impairing condition. Bush G. Biol Psychiatry. 2011;69(12): Functional and structural neuroimaging have identified abnormalities of the brain that are likely to contribute to the neuropathophysiology of attention-deficit/hyperactivity disorder (ADHD). In particular, hypofunction of the brain regions comprising the cingulo-frontal-parietal cognitive-attention network have been consistently observed across studies. These are major components of neural systems that are relevant to ADHD, including cognitive/attention networks, motor systems, and reward/feedback-based processing systems. Moreover, these areas interact with other brain circuits that have been implicated in ADHD, such as the "default mode" resting-state network. The ADHD imaging data related to cingulo-frontal-parietal network dysfunction will be selectively highlighted here to help facilitate its integration with the other information. Cortese. Eur J Paediatr Neurol. 2012;16:422–33. Bush. Biol Psychiatry. 2011;69:1160–7. Franke. Mol Psychiatry. 2012;17:960–87.

Ärftlighet i samma storleksordning som schizofreni och kroppslängd
0,2 0,4 0,6 0,8 1 Willerman 19732 Goodman 19892 Gillis 19922 Edelbrock 19922 Schmitz 19952 Thapar 19952 Gjone 19962 Silberg 19962 Sherman 19972 Levy 19972 Nadder 19982 Hudziak 20001 Kroppslängd Schizofreni Tvillingstudier av ADHD KEY POINTS This graph shows the heritability for ADHD from 12 twin studies as compared to two other things – schizophrenia and height. These twin studies estimate the heritability of ADHD to be on average 0.80, indicating that genes play an important role in the aetiology of this disorder. The fact that heritability is less than 1.0 shows that features of the environment are involved in the aetiology of ADHD. We can conclude that genes play more of a role in height than ADHD and less of a role in schizophrenia than ADHD. References: Hudziak JJ, Rudiger LP, Rudiger LP, Neale MC, Heath AC, Todd RD. A twin study of inattentive, aggressive, and anxious depressed behaviors. Am Acad of Child and Adolesc Psychiatry 2000;39(4): Faraone SV, Biederman J. Neurobiology of attention-deficit hyperactivity disorder. Biol Psychiatry 1998;44: Ärftlighet Hudziak et al. Am Acad Child Adolesc Psychiatry 2000;39:469–76. Faraone et al. Biol Psychiatry 1998;44:951–8.

Etablerade samband med ADHD
Kognitiv förmåga Måttlig korrelation med ”exekutiv funktion” (styrning och reglering av beteende)1 Funktionsnedsättningar inom ett brett spektrum av kognitiva processer (som kännetecknas av lång och varierande reaktionstid – vakenhet; ökat antal fel – kortikal kontroll)2 Interaktion med motiverande processer (belöning/stimuluspresentation)3 “Event-related potentials” (ERP) – ger konsistent evidens för tidiga problem med uppmärksamhet (mot sensoriska stimuli) och bristande motorisk respons4 Prenatal utveckling: Låg födelsevikt5, maternell stress6 Social miljö: Tidig svår deprivation, samband med skattningar av social utsatthet7 REFERENCES: Willcutt et al. Biol Psychiatry 2005;57(11): Loo et al. Neuropsychologia. 2009;47(10): 2114–2119. Arnsten AF, Rubia K. J. Am Acad Child Adolesc Psychiatry. 2012;51(4):356 –367. Mueller et al. Nonlinear Biomed Phys. 2010;4(Suppl 1): S1-S9. Mick et al. J Dev Behav Pediatr. 2002;23(1):16-22. Grizenko et al. J Can Acad Child Adolesc Psychiatry. 2012;21(1): 9–15. McLaughlin et al. Biol Psychiatry 2010;68:329–36. One of the most prominent neuropsychological theories of attention-deficit/hyperactivity disorder (ADHD) suggests that its symptoms arise from a primary deficit in executive functions (EF), defined as neurocognitive processes that maintain an appropriate problem-solving set to attain a later goal. To examine the validity of the EF theory, we conducted a meta-analysis of 83 studies that administered EF measures to groups with ADHD (total N = 3734) and without ADHD (N = 2969). Groups with ADHD exhibited significant impairment on all EF tasks. Effect sizes for all measures fell in the medium range ( ), but the strongest and most consistent effects were obtained on measures of response inhibition, vigilance, working memory, and planning. Weaknesses in EF were significant in both clinic-referred and community samples and were not explained by group differences in intelligence, academic achievement, or symptoms of other disorders. ADHD is associated with significant weaknesses in several key EF domains. However, moderate effect sizes and lack of universality of EF deficits among individuals with ADHD suggest that EF weaknesses are neither necessary nor sufficient to cause all cases of ADHD. Difficulties with EF appear to be one important component of the complex neuropsychology of ADHD. OBJECTIVE: This article aims to review basic and clinical studies outlining the roles of prefrontal cortical (PFC) networks in the behaviour and cognitive functions that are compromised in childhood neurodevelopmental disorders and how these map into the neuroimaging evidence of circuit abnormalities in these disorders. METHOD: Studies of animals, normally developing children, and patients with neurodevelopmental disorders were reviewed, with focus on neuroimaging studies. RESULTS: The PFC provides "top-down" regulation of attention, inhibition/cognitive control, motivation, and emotion through connections with posterior cortical and subcortical structures. Dorsolateral and inferior PFC regulate attention and cognitive/inhibitory control, whereas orbital and ventromedial structures regulate motivation and affect. PFC circuitries are very sensitive to their neurochemical environment, and small changes in the underlying neurotransmitter systems, e.g. by medications, can produce large effects on mediated function. Neuroimaging studies of children with neurodevelopmental disorders show altered brain structure and function in distinctive circuits respecting this organisation. Children with attention-deficit/hyperactivity disorder show prominent abnormalities in the inferior PFC and its connections to striatal, cerebellar, and parietal regions, whereas children with conduct disorder show alterations in the paralimbic system, comprising ventromedial, lateral orbitofrontal, and superior temporal cortices together with specific underlying limbic regions, regulating motivation and emotion control. Children with major depressive disorder show alterations in ventral orbital and limbic activity, particularly in the left hemisphere, mediating emotions. Finally, children with obsessive-compulsive disorder appear to have a dysregulation in orbito-fronto-striatal inhibitory control pathways, but also deficits in dorsolateral fronto-parietal systems of attention. CONCLUSIONS: Altogether, there is a good correspondence between anatomical circuitry mediating compromised functions and patterns of brain structure and function changes in children with neuropsychiatric disorders. Medications may optimise the neurochemical environment in PFC and associated circuitries, and improve structure and function. McLaughlin KA, et al. Biol Psychiatry. 2010;68(4): BACKGROUND: Children raised in institutional settings are exposed to social and environmental circumstances that may deprive them of expected environmental inputs during sensitive periods of brain development that are necessary to foster healthy development. This deprivation is thought to underlie the abnormalities in neurodevelopment that have been found in previously institutionalised children. It is unknown whether deviations in neurodevelopment explain the high rates of developmental problems evident in previously institutionalised children, including psychiatric disorders. METHODS: We present data from a sample of children raised in institutions in Bucharest, Romania (n=117) and an age- and sex-matched sample of community control subjects (n=49). Electroencephalogram data were acquired following entry into the study at age 6 to 30 months, and a structured diagnostic interview of psychiatric disorders was completed at age 54 months. RESULTS: Children reared in institutions evidenced greater symptoms of attention-deficit/hyperactivity disorder, anxiety, depression, and disruptive behaviour disorders than community controls. Electroencephalogram revealed significant reductions in alpha relative power and increases in theta relative power among children reared in institutions in frontal, temporal, and occipital regions, suggesting a delay in cortical maturation. This pattern of brain activity predicted symptoms of hyperactivity and impulsivity at age 54 months, and significantly mediated the association between institutionalisation and attention-deficit/hyperactivity disorder symptoms. Electroencephalogram power was unrelated to depression, anxiety, or disruptive behaviours. CONCLUSIONS: These findings document a potential neurodevelopmental mechanism underlying the association between institutionalisation and psychiatric morbidity. Deprivation in social and environmental conditions may perturb early patterns of neurodevelopment and manifest as psychiatric problems later in life. McLaughlin Willcutt et al Mueller et al Loo et al Mick et al Arnsten & Rubia Grizenko et al

1.3 Funktionsnedsättning
Avsnitt 1: Bakgrund till ADHD 1.3 Funktionsnedsättning

Effekter av ADHD bortom kärnsymptomen
Patient Sjukvårdssystem 33 % fler akutbesök1 10 x fler öppenvårdsbesök2 5 x fler önskemål om öppenvårds- recept2 3 x fler inläggningar i slutenvård2 2–4 x fler olyckor med motorfordon3,4 Familj Benägenhet för känsloutbrott5-6 Känner sig missmodig p.g.a. ständiga misslyckanden5 Låg självkänsla5-6 Mer kaotiska personliga rutiner och familjerutiner6 Högre frekvens av skilsmässa/separation mellan föräldrar7 Utbildning och arbete Lägre yrkesställning8 Ökad frånvaro9 och kostnad för arbetsbortfall9-10 Låga betyg i förhållande till kapacitet6 Missar deadlines och tappar ofta bort saker5-6 Ofta sen till jobbet/möten5-6 Socialt Svårigheter att skapa/upprätthålla vänskapsrelationer5 Dålig lyssnare och otillräcklig social kompetens5 Snar till ilska och att uttrycka sig kränkande när han/hon blir arg5 Svårt att hantera ekonomi6 Missbrukssjukdomar: 2 x högre risk11 och tidigare debut12 Mindre benägna att sluta röka13 Familj Benägenhet för känsloutbrott6,11 Känner sig missmodig p.g.a. ständiga misslyckanden6,11 Låg självkänsla6,11 Mer kaotiska personliga rutiner och familjerutiner11 Högre frekvens av skilsmässa/separation mellan föräldrar12,13 2–4 x  syskonbråk14 §§[taggarna efter ”x” står för en uppåtriktad pil] §§[ändra i Powerpoint till ”2–4 x fler. Även i nedanstående” ABBREVIATION ADHD: attention-deficit/hyperactivity disorder KEYPOINTS Untreated and undertreated ADHD has a significant social and economic impact. The increased rate of accidents has economic impacts on the healthcare system, as well as economic and social effects within the family (reduced income, missing education). Individuals are more likely to be expelled from school or play truant, may have lower grades than expected, and may also disrupt others’ education. Inadequate schooling may impact on the individuals future economic status. Family life may be disrupted by behavioural issues as well as comorbid conditions such as substance use or abuse, depression, and anxiety. Societal impact of substance use, increased STD and pregnancy rate. Employment history of individuals may include multiple job changes, increased absenteeism and reduced productivity, resulting in a negative economic impact on the employer and the employee and his/her family. REFERENCES Leibson CL, Katusic SK, Barbaresi WJ, Ransom J, O’Brien PC. Use and cost of medical care for children and adolescents with and without attention- deficit/hyperactivity disorder. JAMA. 2001;285:60-6. Hodgkins P, Montejano L, Sasané R, Huse D. Cost of illness and comorbidities in adults diagnosed with attention-deficit/hyperactivity disorder: a retrospective analysis. Prim Care Companion CNS Disord. 2011;13(2). Sobanski E, Sabljic D, Alm B, Dittmann RW, Wehmeier PM, Skopp G, Strohbeck-Kuhner P. Driving performance in adults with ADHD: Results from a randomized, waiting list controlled trial with atomoxetine. Eur Psychiatry. 2012. [Epub ahead of print] Barkley RA, Murphy KR, Kwasnik D. Motor vehicle driving competencies and risks in teens and young adults with attention deficit hyperactivity disorder. Pediatrics. 1996;98(6 Pt 1): Searight HR, Burke JM, Rottnek F. Adult ADHD: evaluation and treatment in family medicine. Am Fam Physician. 2000;62(9): , Weiss M, Hechtman LT, Weiss G. ADHD in Adulthood: a guide to current theory, diagnosis and treatment. John Hopkins University Press 1999. Brown RT, Pacini JN. Perceived family functioning, marital status, and depression in parents of boys with attention deficit disorder. J Learn Disabil. 1989;22(9):581-7. Manuzza S, Klein RG, Bessler A, Malloy P, Hynes ME. Educational and Occupational Outcome of Hyperactive Boys Grown Up. Am Acad Child Adolesc Psychiatry. 1997;36(9): Secnik K, Swensen A, Lage MJ. Comorbidities and costs of adult patients diagnosed with attention-deficit hyperactivity disorder. Pharmacoeconomics. 2005;23(1): Birnbaum HG, Kessler RC, Lowe SW, Secnik K, Greenberg PE, Leong SA and Swensen AR. Costs of attention deficit–hyperactivity disorder (ADHD) in the US: excess costs of persons with ADHD and their family members in Current Medical Research and Opinion. 2005;21:195–205. Biederman J, Wilens TE, Mick E, Faraone SV, Spencer T. Does attention-deficit hyperactivity disorder impact the developmental course of drug and alcohol abuse and dependence? Biol Psychiatry. 1998;44(4): Milberger S, Biederman J, Faraone SV, Wilens T, Chu MP. Associations between ADHD and psychoactive substance use disorders. Findings from a longitudinal study of high-risk siblings of ADHD children. Am J Addict. 1997;6(4): Pomerleau, OF, Downey KK, Stelson FW, CS Pomerleau. Cigarette Smoking in Adult Patients Diagnosed with Attention Deficit Hyperactivity Disorder. Journal of Substance Abuse. 1995;7: Leibson et al Hodgkins et al Sobanski et al Barkley et al Searight et al Weiss et al Brown and Pacini Manuzza et al.1997. Secnik et al Birnbaum et al Biederman et al Milberger et al.1997. Pomerleau et al.1995. Atom

ADHD och mängd kriminalitet vid ”på- och av-behandling”
Antal brott under 4 år hos svenska individer med ADHD i åldrar> 15 år (n = 25,656) Manliga patienter som begått brott Kvinnliga patienter som begått brott ADHD 36.6% 15.4% Allmänna populationen 8.9% 2.2% Riskkvot (hazard ratio) för fällande dom för något brott under ADHD-medicinering ( ) Behandling Män (n = 16,087), hazard ratio (95% CI) Kvinnor (n = 9,569), Alla medicineringar 0.68 (0.63–0.73) 0.59 (0.50–0.70) Stimulantia 0.66 (0.61–0.71) N/A Atomoxetin 0.76 (0.63–0.91) Background Attention deficit–hyperactivity disorder (ADHD) is a common disorder that has been associated with criminal behaviour in some studies. Pharmacological treatment is available for ADHD and may reduce the risk of criminality. Methods Using Swedish national registers, we gathered information on 25,656 patients with a diagnosis of ADHD, their pharmacological treatment, and subsequent criminal convictions in Sweden from 2006 through We used stratified Cox regression analyses to compare the rate of criminality while the patients were receiving ADHD medication, as compared with the rate for the same patients while not receiving medication. Results As compared with non-medication periods, among patients receiving ADHD medication, there was a significant reduction of 32% in the criminality rate for men (adjusted hazard ratio, 0.68; 95% confidence interval [CI], 0.63 to 0.73) and 41% for women (hazard ratio, 0.59; 95% CI, 0.50 to 0.70). The rate reduction remained between 17% and 46% in sensitivity analyses among men, with factors that included different types of drugs (e.g., stimulant vs non-stimulant) and outcomes (e.g., type of crime). Conclusions Among patients with ADHD, rates of criminality were lower during periods when they were receiving ADHD medication. These findings raise the possibility that the use of medication reduces the risk of criminality among patients with ADHD. N Engl J Med Nov 22;367(21): doi: /NEJMoa Medication for attention deficit-hyperactivity disorder and criminality. Lichtenstein P1, Halldner L, Zetterqvist J, Sjölander A, Serlachius E, Fazel S, Långström N, Larsson H. Author information 1Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden. Abstract BACKGROUND: Attention deficit-hyperactivity disorder (ADHD) is a common disorder that has been associated with criminal behavior in some studies. Pharmacologic treatment is available for ADHD and may reduce the risk of criminality. METHODS: Using Swedish national registers, we gathered information on 25,656 patients with a diagnosis of ADHD, their pharmacologic treatment, and subsequent criminal convictions in Sweden from 2006 through We used stratified Cox regression analyses to compare the rate of criminality while the patients were receiving ADHD medication, as compared with the rate for the same patients while not receiving medication. RESULTS: As compared with nonmedication periods, among patients receiving ADHD medication, there was a significant reduction of 32% in the criminality rate for men (adjusted hazard ratio, 0.68; 95% confidence interval [CI], 0.63 to 0.73) and 41% for women (hazard ratio, 0.59; 95% CI, 0.50 to 0.70). The rate reduction remained between 17% and 46% in sensitivity analyses among men, with factors that included different types of drugs (e.g., stimulant vs. nonstimulant) and outcomes (e.g., type of crime). CONCLUSIONS: Among patients with ADHD, rates of criminality were lower during periods when they were receiving ADHD medication. These findings raise the possibility that the use of medication reduces the risk of criminality among patients with ADHD. (Funded by the Swedish Research Council and others.). Brott förekom mindre ofta under perioder då ADHD-patienter tog medicin (män 32% minskning, kvinnor 41% minskning); Men uppgifter av observationstyp kan inte bekräfta ett orsakssamband med ADHD- medicinering och andra faktorer med samtidigt förekommande medicinering kan spela en roll Lichtenstein et al. N Engl J Med 2012;367:2006–14.

Dödlighet och utfall hos vuxna som fått diagnosen ADHD som barn
Bland de 367 fallen med ADHD i barndomen: 7 dödsfall (1.9%), av vilka 5 tidigare haft en historik av substansmissbruk och ≥1 annan samtidig psykiatrisk sjukdom 10 inspärrade (2,7%) Bland de 232 barnfallen som deltog i uppföljning: 56.9% hade ≥1 samtidig psykiatrisk sjukdom (jmf med 34.9% i kontrollgruppen; OR 2.6, 95% CI 1.8‒3.8) Övriga frågor: Alkoholberoende ‒ 26.3% Antisocial personlighetsstörning ‒ 16.8% Substansberoende/missbruk ‒ 16.4% Närvarande/tidigare hypoman episod ‒ 15.1% Generell ångestsjukdom ‒ 14.2% Egentlig depressiv episod ‒ 12.9% Ihållande ADHD var associerat med ≥1 komorbid psykiatrisk sjukdom jmf med icke-ihållande (80,9% vs 47%, OR 4,8 (95% konfidensintervall 2,4-9,5, p <0,001) Pediatrics Apr;131(4): doi: /peds Epub 2013 Mar 4. Mortality, ADHD, and psychosocial adversity in adults with childhood ADHD: a prospective study. Barbaresi WJ1, Colligan RC, Weaver AL, Voigt RG, Killian JM, Katusic SK. Author information 1Division of Developmental Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA. Abstract OBJECTIVE: We examined long-term outcomes of attention-deficit/hyperactivity disorder (ADHD) in a population-based sample of childhood ADHD cases and controls, prospectively assessed as adults. METHODS: Adults with childhood ADHD and non-ADHD controls from the same birth cohort (N = 5718) were invited to participate in a prospective outcome study. Vital status was determined for birth cohort members. Standardized mortality ratios (SMRs) were constructed to compare overall and cause-specific mortality between childhood ADHD cases and controls. Incarceration status was determined for childhood ADHD cases. A standardized neuropsychiatric interview was administered. RESULTS: Vital status for 367 childhood ADHD cases was determined: 7 (1.9%) were deceased, and 10 (2.7%) were currently incarcerated. The SMR for overall survival of childhood ADHD cases versus controls was 1.88 (95% confidence interval [CI], ; P = .13) and for accidents only was 1.70 (95% CI, ; P = .41). However, the cause-specific mortality for suicide only was significantly higher among ADHD cases (SMR, 4.83; 95% CI, ; P = .032). Among the childhood ADHD cases participating in the prospective assessment (N = 232; mean age, 27.0 years), ADHD persisted into adulthood for 29.3% (95% CI, ). Participating childhood ADHD cases were more likely than controls (N = 335; mean age, 28.6 years) to have ≥1 other psychiatric disorder (56.9% vs 34.9%; odds ratio, 2.6; 95% CI, ; P < .01). CONCLUSIONS: Childhood ADHD is a chronic health problem, with significant risk for mortality, persistence of ADHD, and long-term morbidity in adulthood. Barbaresi et al. Pediatrics 2013;131:637–44.

Dödlighet och utfall hos vuxna som fått diagnosen ADHD som barn
Resultat av de 232 barndomsfall som deltog i den prospektiva uppföljningen (medelålder vid diagnos, 10 år; medelålder vid uppföljning, 27 år): 23.7% (n=55) ihållande ADHD med ≥1 samtidig psykiatrisk sjukdom 5.6% (n=13) ihållande ADHD utan samtidig psykiatrisk sjukdom 33.2% (n=77) ingen ADHD men med ≥1 annan psykiatrisk sjukdom 37.5% (n=87) inga negativa utfall ADHD-fall (n = 367) Resten av åldersgruppen (n = 4,946) Total antal dödsfalla 7 37 Medinskt relaterade 1 13 Självmordb 3 5 Mord 2 Olyckac 15 Okänt Medlålder vid död (år) 21.9 19.9 Pediatrics Apr;131(4): doi: /peds Epub 2013 Mar 4. Mortality, ADHD, and psychosocial adversity in adults with childhood ADHD: a prospective study. Barbaresi WJ1, Colligan RC, Weaver AL, Voigt RG, Killian JM, Katusic SK. Author information 1Division of Developmental Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA. Abstract OBJECTIVE: We examined long-term outcomes of attention-deficit/hyperactivity disorder (ADHD) in a population-based sample of childhood ADHD cases and controls, prospectively assessed as adults. METHODS: Adults with childhood ADHD and non-ADHD controls from the same birth cohort (N = 5718) were invited to participate in a prospective outcome study. Vital status was determined for birth cohort members. Standardized mortality ratios (SMRs) were constructed to compare overall and cause-specific mortality between childhood ADHD cases and controls. Incarceration status was determined for childhood ADHD cases. A standardized neuropsychiatric interview was administered. RESULTS: Vital status for 367 childhood ADHD cases was determined: 7 (1.9%) were deceased, and 10 (2.7%) were currently incarcerated. The SMR for overall survival of childhood ADHD cases versus controls was 1.88 (95% confidence interval [CI], ; P = .13) and for accidents only was 1.70 (95% CI, ; P = .41). However, the cause-specific mortality for suicide only was significantly higher among ADHD cases (SMR, 4.83; 95% CI, ; P = .032). Among the childhood ADHD cases participating in the prospective assessment (N = 232; mean age, 27.0 years), ADHD persisted into adulthood for 29.3% (95% CI, ). Participating childhood ADHD cases were more likely than controls (N = 335; mean age, 28.6 years) to have ≥1 other psychiatric disorder (56.9% vs 34.9%; odds ratio, 2.6; 95% CI, ; P < .01). CONCLUSIONS: Childhood ADHD is a chronic health problem, with significant risk for mortality, persistence of ADHD, and long-term morbidity in adulthood. a Övergripande SMR, 1.88 (95% CI 0.83‒4.26; p = 0.13); bSMR för endast självmord, 4.83 (95% CI 1.14‒20.46; p = 0.032); cSMR för enbart olyckor, 1.70 (95% CI 0.49‒5.97; p = 0.41) Barbaresi et al. Pediatrics 2013;131:637–44.

Förhöjd livstidsincidens av substansmissbruk
Livstidsnamnes på missbruk av psykoaktiva substanser *** 60 55 % Livstidsincidens (%) av substansmissbruk hos de vuxna som studerats 50 ***p=0,001 40 30 27 % 20 10 Biederman et al. Biol Psychiatry. 1998;44(4): BACKGROUND: The co-occurrence of attention-deficit hyperactivity disorder (ADHD) and psychoactive substance use disorder (PSUD) in adults has been the focus of much clinical and scientific inquiry. In this study, we examine the effects of ADHD on the transitions from substance abuse to dependence and between different classes of agents of abuse. METHODS: An ADHD sample of 239 consecutively referred adults of both genders with a clinical diagnosis of childhood-onset and persistent DSM-III-R ADHD confirmed by structured interview were compared with 268 non-ADHD healthy adults. RESULTS: ADHD was associated with a two-fold increased risk for PSUD. ADHD subjects were significantly more likely than comparisons to make the transition from an alcohol use disorder to a drug use disorder (hazard ratio = 3.8) and were significantly more likely to continue to abuse substances following a period of dependence (hazard ratio = 4.9). CONCLUSIONS: ADHD is associated with a sequence of PSUD in which early alcohol use disorder increases the risk for subsequent drug use disorder, and early substance dependence increases the risk for subsequent substance abuse. If confirmed such developmental pathways might lead to preventive and early intervention strategies aimed at reducing the risk for PSUD in ADHD subjects. ABBREVIATION ADHD: attention-deficit/hyperactivity disorder KEY POINTS In adolescents and adults, ADHD often contributes to addictive vulnerability. ADHD is a significant risk factor that is independent of co-morbid conditions.1 The use of specific treatment for ADHD, such as psychostimulant medication, may significantly diminish the risk of substance abuse.1 Impaired behavioural learning may be involved in the pathogenesis of substance use disorder.1 The inability to delay gratification increases the relative value of immediate gratification.1 The presence of co-morbid conditions may induce defiant behaviour that is conducive to developing substance use disorder. Onset of substance abuse in ADHD subjects averaged 3 years earlier than controls in late adolescence and early adulthood studies. In the presence of conduct disorder, the risk is heightened. Substance abuse itself may further aggravate attentional deficits and behavioural dysregulation.1 As depicted in this slide, ADHD may be associated with a two-fold increased risk for psychoactive substance abuse (27% for controls and 55% for ADHD adults).1 BACKGROUND An ADHD sample of 239 consecutively referred adults of both genders with a clinical diagnosis of childhood-onset and persistent DSM-III-R ADHD, confirmed by structured interview and compared with 268 non-ADHD healthy adults from a preexisting sample who had been evaluated in an ongoing family study of ADHD. Alcohol or drug abuse or dependence was diagnosed based on DSM-III-R criteria using the Structured Clinical Interview for DSM-III-R (SCID). Average age for the ADHD group was 37.4 years; average age for the control group was 39.8 years.1 REFERENCE Biederman J, Wilens TE, Mick E, Faraone SV, Spencer T. Does attention-deficit hyperactivity disorder impact the developmental course of drug and alcohol abuse and dependence? Biol Psychiatry. 1998;44(4): Kontroll (n=268) ADHD (n=239) Biederman et al. Biol Psychiatry 1998;44:269–73. Atom

Prevalens av ADHD inom missbruk: metaanalys och metaregressionsanalys
Rapporterad prevalens av ADHD och missbruk har varierat kraftigt (2-83%) Behandling med metylfenidat / atomoxetin är mindre effektivt hos ADHD-patienter med missbruksproblem jämfört med de som inte missbrukar Att samtidigt ha ADHD utgör en negativ inverkan på missbruksproblem Patienter med ADHD och missbruksproblem uppvisar en högre grad av andra psykiatriska sjukdomar Metoder Litteratursökning (MEDLINE, PsycINFO, EMBASE) 29 utvalda studier (studier med nikotin som primärt substansmissbruk exkluderade) Metaanalys utförd på relevanta data Metaregressionsanalyser utförda för att utvärdera effekten av ålder, primärt substansmissbruk, inställning, och metoder för bedömning om förekomsten av ADHD i en mängd olika populationer med missbruk Drug Alcohol Depend Apr 1;122(1-2):11-9. doi: /j.drugalcdep Epub 2011 Dec 30. Prevalence of attention-deficit hyperactivity disorder in substance use disorder patients: a meta-analysis and meta-regression analysis. van Emmerik-van Oortmerssen K1, van de Glind G, van den Brink W, Smit F, Crunelle CL, Swets M, Schoevers RA. Author information 1Arkin Mental Health and Addiction Treatment Centre, Amsterdam, The Netherlands. Abstract CONTEXT: Substance use disorders (SUD) are a major public health problem. Attention deficit hyperactivity disorder (ADHD) is a comorbid condition associated with both onset and prognosis of SUD. Prevalence estimates of ADHD in SUD vary significantly. OBJECTIVE: To obtain a best estimate of the prevalence of ADHD in SUD populations. DATA SOURCES: A literature search was conducted using MEDLINE, PsycINFO and EMBASE. Search terms were ADHD, substance-related disorders, addiction, drug abuse, drug dependence, alcohol abuse, alcoholism, comorbidity, and prevalence. Results were limited to the English language. STUDY SELECTION: After assessing the quality of the retrieved studies, 29 studies were selected. Studies in which nicotine was the primary drug of abuse were not included. DATA EXTRACTION: All relevant data were extracted and analysed in a meta-analysis. A series of meta-regression analyses was performed to evaluate the effect of age, primary substance of abuse, setting and assessment procedure on the prevalence of ADHD in a variety of SUD populations. DATA SYNTHESIS: Overall, 23.1% (CI: %) of all SUD subjects met DSM-criteria for comorbid ADHD. Cocaine dependence was associated with lower ADHD prevalence than alcohol dependence, opioid dependence and other addictions. Studies using the DICA or the SADS-L for the diagnosis of ADHD showed significantly higher comorbidity rates than studies using the KSADS, DISC, DIS or other assessment instruments. CONCLUSIONS: ADHD is present in almost one out of every four patients with SUD. The prevalence estimate is dependent on substance of abuse and assessment instrument. SUD: substance use disorder (missbruksproblem) van Emmerik-van Oortmerssen et al. Drug Alcohol Depend 2012;122:11–9.

Prevalens av ADHD inom missbruk: metaanalys och metaregressionsanalys
Resultat Totalt, 23.1% (95% CI 19.4–27.2%) av alla personer med missbruksproblem uppfyller samtidigt DSM-kriterierna för ADHD 25.3% hos ungdomar (95% CI 20.0–31.4%; I2 = 93.2%) 21.2% hos vuxna(95% CI 15.9–27.2%; I2 = 91.3%) Relevanta fynd Kokainberoende var mindre associerat till förekomst av ADHD än alkoholberoende, opiatberoende och andra beroenden Uppskattningen av prevalensen beror på innehållet i missbruket och de bedömningsinstrument som använts Drug Alcohol Depend Apr 1;122(1-2):11-9. doi: /j.drugalcdep Epub 2011 Dec 30. Prevalence of attention-deficit hyperactivity disorder in substance use disorder patients: a meta-analysis and meta-regression analysis. van Emmerik-van Oortmerssen K1, van de Glind G, van den Brink W, Smit F, Crunelle CL, Swets M, Schoevers RA. Author information 1Arkin Mental Health and Addiction Treatment Centre, Amsterdam, The Netherlands. Abstract CONTEXT: Substance use disorders (SUD) are a major public health problem. Attention deficit hyperactivity disorder (ADHD) is a comorbid condition associated with both onset and prognosis of SUD. Prevalence estimates of ADHD in SUD vary significantly. OBJECTIVE: To obtain a best estimate of the prevalence of ADHD in SUD populations. DATA SOURCES: A literature search was conducted using MEDLINE, PsycINFO and EMBASE. Search terms were ADHD, substance-related disorders, addiction, drug abuse, drug dependence, alcohol abuse, alcoholism, comorbidity, and prevalence. Results were limited to the English language. STUDY SELECTION: After assessing the quality of the retrieved studies, 29 studies were selected. Studies in which nicotine was the primary drug of abuse were not included. DATA EXTRACTION: All relevant data were extracted and analysed in a meta-analysis. A series of meta-regression analyses was performed to evaluate the effect of age, primary substance of abuse, setting and assessment procedure on the prevalence of ADHD in a variety of SUD populations. DATA SYNTHESIS: Overall, 23.1% (CI: %) of all SUD subjects met DSM-criteria for comorbid ADHD. Cocaine dependence was associated with lower ADHD prevalence than alcohol dependence, opioid dependence and other addictions. Studies using the DICA or the SADS-L for the diagnosis of ADHD showed significantly higher comorbidity rates than studies using the KSADS, DISC, DIS or other assessment instruments. CONCLUSIONS: ADHD is present in almost one out of every four patients with SUD. The prevalence estimate is dependent on substance of abuse and assessment instrument. van Emmerik-van Oortmerssen et al. Drug Alcohol Depend 2012;122:11–9.

Prevalens av ADHD hos vuxna som söker behandling för missbruksproblem
Den internationella ”ADHD Substance Use Disorders Prevalence Study (IASP)” är den första tvärnationella studien av ADHD bland behandlingssökande patienter med missbruksproblem 10 länder, tvärsnittsstudie 3558 vuxna patienter som sökt behandling för missbruksproblem undersöktes avseende ADHD med hjälp av ASRS (v1.1) 1276 patienter, varav 511 bedömdes som positiva, 765 negativa, deltog i Conners 'Adult ADHD Diagnostic Interview for DSM-IV ADHD (CAADID) Missbruksproblem utvärderades via självskattningsformulär Drug Alcohol Depend Jan 1;134: doi: /j.drugalcdep Epub 2013 Oct 5. Variability in the prevalence of adult ADHD in treatment seeking substance use disorder patients: results from an international multi-center study exploring DSM-IV and DSM-5 criteria. van de Glind G1, Konstenius M2, Koeter MW3, van Emmerik-van Oortmerssen K4, Carpentier PJ5, Kaye S6, Degenhardt L7, Skutle A8, Franck J2, Bu ET8, Moggi F9, Dom G10, Verspreet S10, Demetrovics Z11, Kapitány-Fövény M12, Fatséas M13, Auriacombe M13, Schillinger A14, Møller M14, Johnson B15, Faraone SV15, Ramos-Quiroga JA16, Casas M16, Allsop S17, Carruthers S17, Schoevers RA18, Wallhed S19, Barta C20, Alleman P21, Levin FR22, van den Brink W3; IASP Research Group. Collaborators (14) Løvaas EK, Lossius K, van Wamel A, Bosma G, Hay D, Malivert M, Debrabant R, Dahl T, Stevens L, Roncero C, Daigre C, van der Gaag RJ, Cassar J, Young J. Author information 1Trimbos-instituut and ICASA Foundation, Utrecht, The Netherlands; Amsterdam Institute for Addiction Research, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. Electronic address: 2Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden. 3Amsterdam Institute for Addiction Research, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. 4Amsterdam Institute for Addiction Research, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Arkin Mental Health and Addiction Treatment Center, Amsterdam, The Netherlands; Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. 5Reinier van Arkel groep, 's-Hertogenbosch, The Netherlands. 6National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia. 7National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia; Melbourne School of Population and Global Health, University of Melbourne, Australia. 8Bergen Clinics Foundation, Bergen, Norway. 9University Hospital of Psychiatry Bern and Department of Psychology, University of Fribourg, Fribourg, Switzerland. 10Collaborative Antwerp Psychiatry Research Institute (CAPRI, UA), PC Alexian Brothers, Boechout, Belgium. 11Institute of Psychology, Eötvös Loránd University, Budapest, Hungary. 12Institute of Psychology, Eötvös Loránd University, Budapest, Hungary; Nyírő Gyula Hospital Drug Outpatient and Prevention Center, Budapest, Hungary. 13Laboratoire de psychiatrie, Sanpsy CNRS USR 3413, Université de Bordeaux, and Département d'addictologie, CH Ch. Perrens/CHU de Bordeaux, Bordeaux, France. 14Østfold Hospital Trust, Department for Substance Abuse Treatment, Norway. 15Departments of Psychiatry and of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, NY, USA. 16Servei de Psiquiatria, Hospital Universitari Vall d'Hebron, CIBERSAM, Department of Psychiatry and Legal Medicine, Universitat Autònoma de Barcelona, Spain. 17National Drug Research Institute/Curtin University of Technology, Perth, Australia. 18Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. 19Stockholm Centre for Dependency Disorders, Sweden. 20Institute of Medical Chemistry, Molecular Biology and Pathobiochemistry, Semmelweis University, Budapest, Hungary. 21Alcohol Treatment Research, Kirchlindach and Ellikon, Switzerland. 22Columbia University/New York State Psychiatric Institute, New York City, NY, USA. Abstract BACKGROUND: Available studies vary in their estimated prevalence of attention deficit/hyperactivity disorder (ADHD) in substance use disorder (SUD) patients, ranging from 2 to 83%. A better understanding of the possible reasons for this variability and the effect of the change from DSM-IV to DSM-5 is needed. METHODS: A two stage international multi-center, cross-sectional study in 10 countries, among patients form inpatient and outpatient addiction treatment centers for alcohol and/or drug use disorder patients. A total of 3558 treatment seeking SUD patients were screened for adult ADHD. A subsample of 1276 subjects, both screen positive and screen negative patients, participated in a structured diagnostic interview. RESULTS: Prevalence of DSM-IV and DSM-5 adult ADHD varied for DSM-IV from 5.4% (CI 95%: ) for Hungary to 31.3% (CI 95%: ) for Norway and for DSM-5 from 7.6% (CI 95%: ) for Hungary to 32.6% (CI 95%: ) for Norway. Using the same assessment procedures in all countries and centers resulted in substantial reduction of the variability in the prevalence of adult ADHD reported in previous studies among SUD patients (2-83%→ %). The remaining variability was partly explained by primary substance of abuse and by country (Nordic versus non-Nordic countries). Prevalence estimates for DSM-5 were slightly higher than for DSM-IV. CONCLUSIONS: Given the generally high prevalence of adult ADHD, all treatment seeking SUD patients should be screened and, after a confirmed diagnosis, treated for ADHD since the literature indicates poor prognoses of SUD in treatment seeking SUD patients with ADHD. van de Glind et al. Drug Alcohol Depend. 2014;134:158–66.

Prevalens av ADHD hos vuxna som söker behandling för missbruksproblem
Demografi Medeltal åldersgrupp, 37 (Frankrike) till 43 år (Ungern) 26.7% kvinnor, 31% anställda, 8.6% hemlösa, 25.9% gifta/partner Prevalens vuxna med ADHD ASRS 40% totalt bedömdes positiva Resultat varierade från 20.8% (Ungern) till 65.9% (Norge) DSM-IV 5.4% (95% CI 2.4–8.3) Ungern, 31.3% (95% CI 25.2–37.5) Norge DSM-5 7.6% (95% CI 4.1–11.1) Ungern, 32.6% (95% CI 26.4–38.8) Norge Drug Alcohol Depend Jan 1;134: doi: /j.drugalcdep Epub 2013 Oct 5. Variability in the prevalence of adult ADHD in treatment seeking substance use disorder patients: results from an international multi-center study exploring DSM-IV and DSM-5 criteria. van de Glind G1, Konstenius M2, Koeter MW3, van Emmerik-van Oortmerssen K4, Carpentier PJ5, Kaye S6, Degenhardt L7, Skutle A8, Franck J2, Bu ET8, Moggi F9, Dom G10, Verspreet S10, Demetrovics Z11, Kapitány-Fövény M12, Fatséas M13, Auriacombe M13, Schillinger A14, Møller M14, Johnson B15, Faraone SV15, Ramos-Quiroga JA16, Casas M16, Allsop S17, Carruthers S17, Schoevers RA18, Wallhed S19, Barta C20, Alleman P21, Levin FR22, van den Brink W3; IASP Research Group. Collaborators (14) Løvaas EK, Lossius K, van Wamel A, Bosma G, Hay D, Malivert M, Debrabant R, Dahl T, Stevens L, Roncero C, Daigre C, van der Gaag RJ, Cassar J, Young J. Author information 1Trimbos-instituut and ICASA Foundation, Utrecht, The Netherlands; Amsterdam Institute for Addiction Research, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. Electronic address: 2Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden. 3Amsterdam Institute for Addiction Research, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. 4Amsterdam Institute for Addiction Research, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Arkin Mental Health and Addiction Treatment Center, Amsterdam, The Netherlands; Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. 5Reinier van Arkel groep, 's-Hertogenbosch, The Netherlands. 6National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia. 7National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia; Melbourne School of Population and Global Health, University of Melbourne, Australia. 8Bergen Clinics Foundation, Bergen, Norway. 9University Hospital of Psychiatry Bern and Department of Psychology, University of Fribourg, Fribourg, Switzerland. 10Collaborative Antwerp Psychiatry Research Institute (CAPRI, UA), PC Alexian Brothers, Boechout, Belgium. 11Institute of Psychology, Eötvös Loránd University, Budapest, Hungary. 12Institute of Psychology, Eötvös Loránd University, Budapest, Hungary; Nyírő Gyula Hospital Drug Outpatient and Prevention Center, Budapest, Hungary. 13Laboratoire de psychiatrie, Sanpsy CNRS USR 3413, Université de Bordeaux, and Département d'addictologie, CH Ch. Perrens/CHU de Bordeaux, Bordeaux, France. 14Østfold Hospital Trust, Department for Substance Abuse Treatment, Norway. 15Departments of Psychiatry and of Neuroscience and Physiology, SUNY Upstate Medical University, Syracuse, NY, USA. 16Servei de Psiquiatria, Hospital Universitari Vall d'Hebron, CIBERSAM, Department of Psychiatry and Legal Medicine, Universitat Autònoma de Barcelona, Spain. 17National Drug Research Institute/Curtin University of Technology, Perth, Australia. 18Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands. 19Stockholm Centre for Dependency Disorders, Sweden. 20Institute of Medical Chemistry, Molecular Biology and Pathobiochemistry, Semmelweis University, Budapest, Hungary. 21Alcohol Treatment Research, Kirchlindach and Ellikon, Switzerland. 22Columbia University/New York State Psychiatric Institute, New York City, NY, USA. Abstract BACKGROUND: Available studies vary in their estimated prevalence of attention deficit/hyperactivity disorder (ADHD) in substance use disorder (SUD) patients, ranging from 2 to 83%. A better understanding of the possible reasons for this variability and the effect of the change from DSM-IV to DSM-5 is needed. METHODS: A two stage international multi-center, cross-sectional study in 10 countries, among patients form inpatient and outpatient addiction treatment centers for alcohol and/or drug use disorder patients. A total of 3558 treatment seeking SUD patients were screened for adult ADHD. A subsample of 1276 subjects, both screen positive and screen negative patients, participated in a structured diagnostic interview. RESULTS: Prevalence of DSM-IV and DSM-5 adult ADHD varied for DSM-IV from 5.4% (CI 95%: ) for Hungary to 31.3% (CI 95%: ) for Norway and for DSM-5 from 7.6% (CI 95%: ) for Hungary to 32.6% (CI 95%: ) for Norway. Using the same assessment procedures in all countries and centers resulted in substantial reduction of the variability in the prevalence of adult ADHD reported in previous studies among SUD patients (2-83%→ %). The remaining variability was partly explained by primary substance of abuse and by country (Nordic versus non-Nordic countries). Prevalence estimates for DSM-5 were slightly higher than for DSM-IV. CONCLUSIONS: Given the generally high prevalence of adult ADHD, all treatment seeking SUD patients should be screened and, after a confirmed diagnosis, treated for ADHD since the literature indicates poor prognoses of SUD in treatment seeking SUD patients with ADHD. van de Glind et al. Drug Alcohol Depend 2014;134:158–66.

Giltigheten av ASRS som screeninginstrument för vuxna patienter med ADHD som söker behandling för missbruk Giltigheten av ASRS undersöktes jämfört med CAADID och andelen ställda diagnoser hos 1138 personer som sökt behandling för missbruk Total prevalens för vuxna med ADHD var 13.9% Ett stabilt resultat uppvisades hos 84% av patienterna och en förändring av resultat hos 16% av patienterna Resultat Positivt prediktivt värde (PPV) 0.26 (95% CI 0.22–0.30) Negativt prediktivt värde (NPV) 0.97 (95% CI 0.96–0.98) Slutsatser ASRS är ett känsligt instrument för att identifiera möjliga fall av ADHD och med mycket lågt antal fall bland de som bedömts negativa i denna population Drug Alcohol Depend Oct 1;132(3): doi: /j.drugalcdep Epub 2013 May 6. Validity of the Adult ADHD Self-Report Scale (ASRS) as a screener for adult ADHD in treatment seeking substance use disorder patients. van de Glind G1, van den Brink W, Koeter MW, Carpentier PJ, van Emmerik-van Oortmerssen K, Kaye S, Skutle A, Bu ET, Franck J, Konstenius M, Moggi F, Dom G, Verspreet S, Demetrovics Z, Kapitány-Fövény M, Fatséas M, Auriacombe M, Schillinger A, Seitz A, Johnson B, Faraone SV, Ramos-Quiroga JA, Casas M, Allsop S, Carruthers S, Barta C, Schoevers RA; IASP Research Group, Levin FR. Author information 1Trimbos-instituut and ICASA Foundation, Utrecht, The Netherlands; Amsterdam Institute for Addiction Research, Amsterdam, The Netherlands. Electronic address: Abstract BACKGROUND: To detect attention deficit hyperactivity disorder (ADHD) in treatment seeking substance use disorders (SUD) patients, a valid screening instrument is needed. OBJECTIVES: To test the performance of the Adult ADHD Self-Report Scale V 1.1(ASRS) for adult ADHD in an international sample of treatment seeking SUD patients for DSM-IV-TR; for the proposed DSM-5 criteria; in different subpopulations, at intake and 1-2 weeks after intake; using different scoring algorithms; and different externalizing disorders as external criterion (including adult ADHD, bipolar disorder, antisocial and borderline personality disorder). METHODS: In 1138 treatment seeking SUD subjects, ASRS performance was determined using diagnoses based on Conner's Adult ADHD Diagnostic Interview for DSM-IV (CAADID) as gold standard. RESULTS: The prevalence of adult ADHD was 13.0% (95% CI: %). The overall positive predictive value (PPV) of the ASRS was 0.26 (95% CI: ), the negative predictive value (NPV) was 0.97 (95% CI: ). The sensitivity (0.84, 95% CI: ) and specificity (0.66, 95% CI: ) measured at admission were similar to the sensitivity (0.88, 95% CI: ) and specificity (0.67, 95% CI: ) measured 2 weeks after admission. Sensitivity was similar, but specificity was significantly better in patients with alcohol compared to (illicit) drugs as the primary substance of abuse (0.76 vs. 0.56). ASRS was not a good screener for externalizing disorders other than ADHD. CONCLUSIONS: The ASRS is a sensitive screener for identifying possible ADHD cases with very few missed cases among those screening negative in this population. van de Glind et al. Drug Alcohol Depend 2013;132:587‒96.

Ingen samsjuklighet, n (%) En samtidig sjukdom, n (%)
Förekomst av samsjuklighet hos patienter som sökerbehandling för missbruk, med och utan ADHD Samsjuk-lighet Ingen samsjuklighet, n (%) En samtidig sjukdom, n (%) 2 samtidiga sjukdomar, n (%) 3 samtidiga sjukdomar, 4 samtidiga sjukdomar, Ingen ADHD (n = 1,037) 653 (63.0) 272 (26.2) 82 (7.9) 26 (2.5) 4 (0.4) ADHD (n = 168) 42 (25.0) 68 (40.5) 39 (23.2) 10 (6.0) 9 (5.4) Addiction Feb;109(2): doi: /add Epub 2013 Nov 20. Psychiatric comorbidity in treatment-seeking substance use disorder patients with and without attention deficit hyperactivity disorder: results of the IASP study. van Emmerik-van Oortmerssen K1, van de Glind G, Koeter MW, Allsop S, Auriacombe M, Barta C, Bu ET, Burren Y, Carpentier PJ, Carruthers S, Casas M, Demetrovics Z, Dom G, Faraone SV, Fatseas M, Franck J, Johnson B, Kapitány-Fövény M, Kaye S, Konstenius M, Levin FR, Moggi F, Møller M, Ramos-Quiroga JA, Schillinger A, Skutle A, Verspreet S; IASP research group, van den Brink W, Schoevers RA. Collaborators (18) Beniwal A, Bosma G, Cassar J, Dahl T, Daigre C, Debrabant R, Degenhardt L, van der Gaag RJ, Hay D, Lossius K, Løvaas EK, Malivert M, Möller M, Roncero C, Stevens L, Wallhed S, van Wamel A, Young J. Author information 1Arkin Mental Health and Addiction Treatment Center, Amsterdam, the Netherlands; Amsterdam Institute for Addiction Research, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands. Abstract AIMS: To determine comorbidity patterns in treatment-seeking substance use disorder (SUD) patients with and without adult attention deficit hyperactivity disorder (ADHD), with an emphasis on subgroups defined by ADHD subtype, taking into account differences related to gender and primary substance of abuse. DESIGN: Data were obtained from the cross-sectional International ADHD in Substance use disorder Prevalence (IASP) study. SETTING: Forty-seven centres of SUD treatment in 10 countries. PARTICIPANTS: A total of 1205 treatment-seeking SUD patients. MEASUREMENTS: Structured diagnostic assessments were used for all disorders: presence of ADHD was assessed with the Conners' Adult ADHD Diagnostic Interview for DSM-IV (CAADID), the presence of antisocial personality disorder (ASPD), major depression (MD) and (hypo)manic episode (HME) was assessed with the Mini International Neuropsychiatric Interview-Plus (MINI Plus), and the presence of borderline personality disorder (BPD) was assessed with the Structured Clinical Interview for DSM-IV Axis II (SCID II). FINDINGS: The prevalence of DSM-IV adult ADHD in this SUD sample was 13.9%. ASPD [odds ratio (OR) = 2.8, 95% confidence interval (CI) = ], BPD (OR = 7.0, 95% CI = for alcohol; OR = 3.4, 95% CI = for drugs), MD in patients with alcohol as primary substance of abuse (OR = 4.1, 95% CI = ) and HME (OR = 4.3, 95% CI = ) were all more prevalent in ADHD(+) compared with ADHD(-) patients (P < 0.001). These results also indicate increased levels of BPD and MD for alcohol compared with drugs as primary substance of abuse. Comorbidity patterns differed between ADHD subtypes with increased MD in the inattentive and combined subtype (P < 0.01), increased HME and ASPD in the hyperactive/impulsive (P < 0.01) and combined subtypes (P < 0.001) and increased BPD in all subtypes (P < 0.001) compared with SUD patients without ADHD. Seventy-five per cent of ADHD patients had at least one additional comorbid disorder compared with 37% of SUD patients without ADHD. CONCLUSIONS: Treatment-seeking substance use disorder patients with attention deficit hyperactivity disorder are at a very high risk for additional externalizing disorders. van Emmerik-van Oortmerssen et al. Addiction 2014;109:262‒72.

Psykiatrisk samsjuklighet hos patienter som söker behandling för missbruk, med eller utan ADHD
Samtidig sjukdoma ADHD‒ ADHD+ ORbcd 95% CI σ2u (SE)e Pågående depression (%)f Primär substans alkohola 15.3 39.7 4.1* 2.1‒7.8 0.63 (0.33) Primär substans drogera 22.8 24.3 1.2 0.7‒2.2 0.44 (0.28) Pågående (hypo)mani (%) 4.1 14.9 4.3* 2.1‒8.7 3.17 (1.58) Antisocial personlighetsstörning (%) 17.0 51.8 2.8* 1.8‒4.2 0.40 (0.21) Borderline personlighetsstörning (%)f Primär substans alkohola 8.2 34.5 7.0* 3.1‒15.6 1.55 (0.85) 16.7 29.0 3.4* 1.8‒6.4 0.58 (0.37) aNumber of patients with/without ADHD; bmulti-level logistic regression analysis with random intercept, independent variable ADHD (yes/no), comorbid condition as dependent variable and site as level two, σ2u = level two variance of the intercept; cpresented is the odds ratio (OR) adjusted for age, gender, marital status, housing, employment status and primary substance of abuse (alcohol/drugs); dreference category no ADHD; ein logit scale; fbecause the relation with ADHD is modified by primary substance of abuse, the results are presented separately for alcohol and drug use disorder patients; *p<0.001. Addiction Feb;109(2): doi: /add Epub 2013 Nov 20. Psychiatric comorbidity in treatment-seeking substance use disorder patients with and without attention deficit hyperactivity disorder: results of the IASP study. van Emmerik-van Oortmerssen K1, van de Glind G, Koeter MW, Allsop S, Auriacombe M, Barta C, Bu ET, Burren Y, Carpentier PJ, Carruthers S, Casas M, Demetrovics Z, Dom G, Faraone SV, Fatseas M, Franck J, Johnson B, Kapitány-Fövény M, Kaye S, Konstenius M, Levin FR, Moggi F, Møller M, Ramos-Quiroga JA, Schillinger A, Skutle A, Verspreet S; IASP research group, van den Brink W, Schoevers RA. Collaborators (18) Beniwal A, Bosma G, Cassar J, Dahl T, Daigre C, Debrabant R, Degenhardt L, van der Gaag RJ, Hay D, Lossius K, Løvaas EK, Malivert M, Möller M, Roncero C, Stevens L, Wallhed S, van Wamel A, Young J. Author information 1Arkin Mental Health and Addiction Treatment Center, Amsterdam, the Netherlands; Amsterdam Institute for Addiction Research, Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands. Abstract AIMS: To determine comorbidity patterns in treatment-seeking substance use disorder (SUD) patients with and without adult attention deficit hyperactivity disorder (ADHD), with an emphasis on subgroups defined by ADHD subtype, taking into account differences related to gender and primary substance of abuse. DESIGN: Data were obtained from the cross-sectional International ADHD in Substance use disorder Prevalence (IASP) study. SETTING: Forty-seven centres of SUD treatment in 10 countries. PARTICIPANTS: A total of 1205 treatment-seeking SUD patients. MEASUREMENTS: Structured diagnostic assessments were used for all disorders: presence of ADHD was assessed with the Conners' Adult ADHD Diagnostic Interview for DSM-IV (CAADID), the presence of antisocial personality disorder (ASPD), major depression (MD) and (hypo)manic episode (HME) was assessed with the Mini International Neuropsychiatric Interview-Plus (MINI Plus), and the presence of borderline personality disorder (BPD) was assessed with the Structured Clinical Interview for DSM-IV Axis II (SCID II). FINDINGS: The prevalence of DSM-IV adult ADHD in this SUD sample was 13.9%. ASPD [odds ratio (OR) = 2.8, 95% confidence interval (CI) = ], BPD (OR = 7.0, 95% CI = for alcohol; OR = 3.4, 95% CI = for drugs), MD in patients with alcohol as primary substance of abuse (OR = 4.1, 95% CI = ) and HME (OR = 4.3, 95% CI = ) were all more prevalent in ADHD(+) compared with ADHD(-) patients (P < 0.001). These results also indicate increased levels of BPD and MD for alcohol compared with drugs as primary substance of abuse. Comorbidity patterns differed between ADHD subtypes with increased MD in the inattentive and combined subtype (P < 0.01), increased HME and ASPD in the hyperactive/impulsive (P < 0.01) and combined subtypes (P < 0.001) and increased BPD in all subtypes (P < 0.001) compared with SUD patients without ADHD. Seventy-five per cent of ADHD patients had at least one additional comorbid disorder compared with 37% of SUD patients without ADHD. CONCLUSIONS: Treatment-seeking substance use disorder patients with attention deficit hyperactivity disorder are at a very high risk for additional externalizing disorders van Emmerik-van Oortmerssen et al. Addiction 2014;109:262‒72.

Ökad risk för trafikförseelser och -olyckor
Data från trafikregister som erhållits från statliga myndigheter **p ≤0,01 Personer som fått böter/anmärkning för något trafikbrott (%) Fortkörning Ratt- fylleri Körkorts- indragning olyckor Förar- orsakade ADHD (n=25) Kontroll (n=23) 10 20 30 40 50 60 70 80 90 Trafik- förseelser ** ** Barkley et al. Pediatrics. 1996;98(6 pt 1): PURPOSE: To evaluate the motor vehicle driving knowledge, skills, and negative driving outcomes of older teens and young adults with attention deficit hyperactivity disorder (ADHD). LOCATION: A university medical centre clinic for adult ADHD. SUBJECTS: A total of 25 young adults with ADHD and 23 young adults without ADHD 17 to 30 years old drawn from the community and equated for age, gender, and educational level. MEASURES: Structured interview, behaviour ratings by self- and others, video test of driving knowledge, computer simulated driving test, and official motor vehicle records. RESULTS: ADHD young adults were cited more often for speeding, were more likely to have had their licenses suspended, were involved in more crashes, were more likely to have had crashes causing bodily injury, and were rated by themselves and others as using poorer driving habits. Official driving records corroborated these negative outcomes. Although no group differences in driving knowledge were evident, young adults with ADHD had more crashes, scrapes, and erratic steering during the computer-stimulated driving test than did the control subjects. CONCLUSIONS: Findings supported previous research suggesting that greater driving risks are associated with ADHD and suggested that ADHD does not interfere with driving knowledge so much as with actual performance (motor control) during vehicle operation. ABBREVIATION ADHD: attention-deficit/hyperactivity disorder KEY POINTS Previous studies have suggested that adolescents and young adults with ADHD are more likely to be cited for speeding and to be cited more often for this and other traffic violations than are control subjects. The results of this study provide further corroboration of these driving risks. Young adult drivers with ADHD were found to be nearly twice as likely to be cited for unlawful speeding and to be cited more than three times as often as young adult subjects in the control group. These results, based on self-reports, were validated by the official driving records of these subjects (shown in the slide). Drivers with ADHD had more than 5 times as many traffic citations on their records than did controls. The totality of findings to date clearly indicates that young adults with ADHD are more likely to be apprehended for violations of traffic laws and to be cited more often for such violations. BACKGROUND A total of 25 young adults, 17 to 30 years old, with ADHD (mean age = 22.5 years ± 4) and 23 young adults without ADHD (mean age = 22.0 years ± 4) were recruited from the local community. ADHD subjects were referred from a university medical centre clinic for adult ADHD and diagnosed based on DSM-IV criteria. ADHD subjects receiving treatment were required to refrain from taking their medication at least 24 hours before undergoing testing procedures because the purpose of the study was to evaluate the impact of ADHD on driving performance. The control group was volunteers recruited from advertisements placed throughout the medical centre. The control group consisted of young adults without ADHD who were not currently receiving any psychotropic medication. Efforts were made to recruit control subjects into the study who were of similar gender, education, and ethnic background as the young adults with ADHD. REFERENCE Barkley RA, Murphy KR, Kwasnik D. Motor vehicle driving competencies and risks in teens and young adults with attention deficit hyperactivity disorder. Pediatrics.1996;98: Barkley et al. Pediatrics 1996;98:1089–95. Atom

Medicinering för ADHD hos vuxna och allvarliga trafikolyckor: Analys av observationell svensk databas Andel allvarliga trafikolyckor under 4 år hos svenska individer med ADHD i ålder> 18 år Manliga individer involverade i olyckor Kvinnliga individer involverade i olyckor ADHD 6.5% 3.9% Allmänna populationen 2.6% 1.8% Riskkvot (hazard ratio) för allvarliga trafikolyckor under medicinering för ADHD (2006‒2009), jämfört med perioder utan medicinering Behandling Män (n = 10,528), hazard ratio (95% CI) Kvinnor (n = 6,880), Alla medicineringar 0.71 (0.57–0.89) 0.92 (0.78–1.23) JAMA Psychiatry Mar;71(3): doi: /jamapsychiatry Serious transport accidents in adults with attention-deficit/hyperactivity disorder and the effect of medication: a population-based study. Chang Z1, Lichtenstein P1, D'Onofrio BM2, Sjölander A1, Larsson H1. Author information 1Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden. 2Department of Psychological and Brain Sciences, Indiana University, Bloomington. Abstract IMPORTANCE: Studies have shown that attention-deficit/hyperactivity disorder (ADHD) is associated with transport accidents, but the magnitude of the association remains unclear. Most important, it is also unclear whether ADHD medication reduces this risk. OBJECTIVES: To estimate the association between ADHD and the risk of serious transport accidents and to explore the extent to which ADHD medication influences this risk among patients with ADHD. DESIGN, SETTING, AND PARTICIPANTS: In total, 17,408 patients with a diagnosis of ADHD were observed from January 1, 2006, through December 31, 2009, for serious transport accidents documented in Swedish national registers. The association between ADHD and accidents was estimated with Cox proportional hazards regression. To study the effect of ADHD medication, we used stratified Cox regression to compare the risk of accidents during the medication period with the risk during the nonmedication period within the same patients. MAIN OUTCOMES AND MEASURES: Serious transport accident, identified as an emergency hospital visit or death due to transport accident. RESULTS: Compared with individuals without ADHD, male patients with ADHD (adjusted hazard ratio, 1.47; 95% CI, ) and female patients with ADHD (1.45; ) had an increased risk of serious transport accidents. In male patients with ADHD, medication was associated with a 58% risk reduction (hazard ratio, 0.42; 95% CI, ), but there was no statistically significant association in female patients. Estimates of the population-attributable fractions suggested that 41% to 49% of the accidents in male patients with ADHD could have been avoided if they had been receiving treatment during the entire follow-up. CONCLUSIONS AND RELEVANCE: Attention-deficit/hyperactivity disorder is associated with an increased risk of serious transport accidents, and this risk seems to be possibly reduced by ADHD medication, at least among male patients. This should lead to increased awareness among clinicians and patients of the association between serious transport accidents and ADHD medication. Allvarliga trafikolyckor inträffade mindre ofta under perioder med medicinering endast hos män (29% minskning); Men uppgifter av observationstyp kan inte bekräfta ett orsakssamband med ADHD medicinering och andra faktorer som samtidigt förekommer under medicinering kan spela en roll. Allvarliga trafikolyckor definierades som antingen de som kräver akut sjukhusbesök eller orsakat dödsfall på grund av transportrelaterade trauma. Chang et al. JAMA Psychiatry 2014;71:319‒25.

Ökad risk för problem i arbetslivet
Personer med ADHD löper 3 gånger högre risk att förlora arbetet än personer utan ADHD ADHD-patienter byter jobb i en takt av 2–3 gånger inom en 10-årsperiod ADHD-patienter har lägre poäng avseende arbetsförmåga (Work Performance Rating) än anställda utan ADHD Barkley. J Clin Psychiatry. 2002;63(Suppl 12):10-15. ABSTRACT People with ADHD are affected by the disorder throughout their lifetimes. Children with ADHD often have comorbid oppositional defiant disorder and conduct disorder in addition to having developmental and social problems. The persistence of ADHD into adolescence and young adulthood varies according to who is being interviewed and the criteria used to define the disorder. For those adolescents and adults in whom ADHD does persist, educational difficulties continue, and problems in the areas of employment, driving, and sexual relationships emerge. ADHD is also associated with increased healthcare costs even when controlled for psychiatric treatment. Because most ADHD research has been conducted with male children and adolescents with ADHD, combined type, most outcomes for ADHD should be thought of as male outcomes for this subtype. In the future, ADHD researchers should study outcomes for girls and women and for people with ADHD, predominantly inattentive type. ABBREVIATION ADHD: attention-deficit/hyperactivity disorder REFERENCE Barkley RA. Major life activity and health outcomes associated with attention-deficit/hyperactivity disorder. J Clin Psychiatry. 2002;63(Suppl 12):10-15. Barkley. J Clin Psychiatry 2002;63:10–15. Atom

Funktionsnedsättning och yrkessysselsättning hos norska vuxna med ADHD
Tvärsnittsstudie 149 individer, 78 kvinnor, 71 män Åldrar 18‒63 år (medelålder 33.7 år) 8.9% utbildning högskola/universitet (jmf med 20.8% i den allmänna populationen) 22.2% hade anställning som inkomstkälla (jmf med 72% i den allmänna populationen) 44% ej studerande/arbetslösa under föregående 12 månader Samsjuklighet % Depression (livslång diagnos) 37.8 Drogmissbruk 28.1 Alkoholmissbruk 23.3 Borderline personlighetsstörning (manlig och kvinnlig) 19.0 Borderline personlighetsstörning hos kvinnor 10.5 J Atten Disord Oct;16(7): doi: / Epub 2011 Jul 1. Functional impairment and occupational outcome in adults with ADHD. Gjervan B1, Torgersen T, Nordahl HM, Rasmussen K. Author information 1Levanger Hospital, Levanger, Norway. Abstract OBJECTIVE: ADHD is associated with poor functional outcomes. The objectives were to investigate the prevalence of functional impairment and occupational status in a clinically referred sample of adults with ADHD and explore factors predicting occupational outcome. METHOD: A sample of 149 adults with a confirmed diagnosis of ADHD participated in the present study. Cross-sectional data were collected from the participant's medical records and from self-report questionnaires. A multiple regression model was applied to identify possible predictors of occupational outcome. RESULTS: Only 22.2% had ordinary work as their source of income, compared with 72% in the general population. The most prevalent comorbid disorders were lifetime depression (37.8%), substance abuse (28.1%), and alcohol abuse (23.3%). Age at first treatment with central stimulants and inattentiveness negatively predicted occupational outcome. CONCLUSION: Adult ADHD was associated with lower educational attainment and lower level of employment. Later age of first central stimulant treatment and higher inattentiveness ratings were associated with lower level of employment. Gjervan et al. J Atten Disord 2012;16:544–52.

Andra konsekvenser av ADHD
Effekt av ADHD på viktigare livsaktiviteter *** *** ***p<0,001 **p<0,01 *** Patienter (%) ** Barkley et al. J Am Acad Child Adolesc Psych. 2006;45(2): OBJECTIVE: The authors report the adaptive functioning of hyperactive and control children in southeastern Wisconsin (Milwaukee) followed to young adulthood. METHOD: Interviews with participants concerning major life activities were collected between 1992 and 1996 and used along with employer ratings and high school records at the young adult follow-up (mean = 20 years, range 19-25) for this large sample of hyperactive (H; n = 149) and community control (CC; n = 72) children initially seen in and studied for at least 13 years. Age, duration of follow-up, and IQ were statistically controlled as needed. RESULTS: The H group had significantly lower educational performance and attainment, with 32% failing to complete high school. H group members had been fired from more jobs and manifested greater employer-rated attention-deficit/hyperactivity disorder and oppositional defiant disorder symptoms and lower job performance than the CC group. Socially, the H group had fewer close friends, more trouble keeping friends, and more social problems as rated by parents. Far more H than CC group members had become parents (38% versus 4%) and had been treated for sexually transmitted disease (16% versus 4%). Severity of lifetime conduct disorder was predictive of several of the most salient outcomes (failure to graduate, earlier sexual intercourse, early parenthood) whereas attention-deficit/hyperactivity disorder and oppositional defiant disorder at work were predictive of job performance and risk of being fired. CONCLUSIONS: These findings corroborate prior research and go further in identifying sexual activity and early parenthood as additional problematic domains of adaptive functioning at adulthood. ABBREVIATION ADHD: attention-deficit/hyperactivity disorder KEY POINTS ADHD may have significant consequences on many aspects of a patient’s life. The consequences of ADHD impairment can be seen in the differential rates between children with ADHD and those without in the rates of high school suspension, high school graduation, involvement in a pregnancy as a mother or father, and rates of contracting sexually transmitted diseases. BACKGROUND Study compared adaptive outcomes of a group rigorously diagnosed as hyperactive (H) in childhood (n = 158) with a community control (CC) group (n = 81) followed concurrently for ≥13 years. The (H) group (mean = 21.1 years, SD = 1.3) was significantly older at follow-up than the (CC) group. REFERENCE Barkley, RA, Fischer M, Smallish L, Fletcher K. Young adult outcome of hyperactive children: adaptive functioning in major life activities. J Am Acad Child Adolesc Psych. 2006;45(2): Barkley et al. J Am Acad Child Adolesc Psych 2006;45:192at–202. Atom

Sjukdomsbörda Uppmärksamhetsproblemen, impulsiviteten och hyperaktiviteten till följd av ADHD kan påverka en rad olika livsfunktioner, vilket inverkar på social och funktionell förmåga och har en negativ påverkan på patientens: Studieresultat – 75 % Familjerelationer – 58 % Sociala relationer – 24 % Yrkesliv – 83 % Psykiska hälsa – 38 % Brod et al. Qual Life Res. 2012;21(5):795-9. PURPOSE: To explore the burden of illness and impact on patients' quality of life (QoL) experiences in older ADHD adults. METHODS: Telephone interviews were conducted with older adult participants diagnosed with ADHD later in life. Transcripts were analysed following a grounded theory approach. RESULTS: Mean age of participants (N=24) was 66 years, and mean age at diagnosis was 57 years; 68% were men and 63% reported other comorbid mental health conditions. ADHD symptoms reported were inattention (71%), impulsivity (58%), hyperactivity (54%), and disorganisation (54%). The majority of participants (63%) experienced an accumulated lifetime burden of illness and reported being financially less-well-off, had lower educational achievement, job performance, and greater social isolation due to their ADHD. Older adults reported significantly greater impairments in productivity (P ≤ 0.02) and a better life outlook (P ≤ 0.05) than younger ADHD adults. CONCLUSIONS: Older adults' QoL suffers from the accumulative negative impact of ADHD symptoms/impairments on their professional, economic, social, and emotional well-being. ABBREVIATION ADHD: attention-deficit/hyperactivity disorder KEYPOINTS ADHD can negatively impact a patient’s quality of life and can contribute to impairments in social and functional performance. The majority of participants (63%) experienced an accumulated lifetime burden of illness and reported being financially less-well-off, had lower educational achievement, job performance, and greater social isolation due to their ADHD. Impairment can cause an increased risk of Academic outcomes (75%) Family relationships (58%) Social relationships (24%) Professional life (83%) Psychological health (38%) BACKGROUND A study of ADHD in older adults (n=24, age 66 years), the mean age at diagnosis was 57 years; 68% were men and 63% reported other comorbid mental health conditions. ADHD symptoms reported were inattention (71%), impulsivity (58%), hyperactivity (54%), and disorganisation (54%). Older adults reported significantly greater impairments in productivity (p≤.02) and a better life outlook (p≤0.05) than younger ADHD adults. Brod et al. Qual Life Res 2012;21:795–9. Atom

Sjukdomsbörda (data från USA)
Årliga sjukvårdskostnader (direkta, indirekta och totala) kopplade till ADHD- och jämförelsegrupper Årliga sjukvårdskostnader ($) 12 074 *** *** 8 709 8 836 ***p<0,001 6 627 6 383 5 691 4 306 4 403 4 209 4 422 4 414 2 418 ABBREVIATIONS ADHD: attention-deficit/hyperactivity disorder KEYPOINTS ADHD patients incurred higher total health care expenditures than non-ADHD controls; mean total expenditures were $4,306 and $2,418 (p<0.001), with median values of $2,270 and $606, respectively. In comparisons between ADHD and depression groups, however, the reverse was observed; the ADHD group incurred significantly lower direct costs (mean of $4,422 [median of $902] vs. $6,383 [median of $1,219]; p<0.001). BACKGROUND This retrospective study assessed the cost of illness and medical and psychiatric co-morbidities in adults with ADHD compared with adults without ADHD (matched 1:3) and adults with depression (1:1). Individuals with depression were included as a benchmark against which the burden of ADHD could be measured. Individuals with ADHD (n=31,752) were matched with non-ADHD controls (n=95,256). The majority of individuals with ADHD (n=29,965) were also matched with an equal number of individuals with a depression diagnosis (using ICD-9-CM codes). REFERENCE Hodgkins P, Montejano L, Sasané R, Huse D. Cost of illness and comorbidities in adults diagnosed with attention-deficit/hyperactivity disorder: a retrospective analysis. Prim Care Companion CNS Disord. 2011;13(2): e1-e12. a b aPatienter matchade 1:3 med en icke-ADHD-grupp bPatienter matchade 1:1 med en depressionsgrupp Hodgkins et al. Prim Care Companion CNS Disord 2011;13:e1–e12. Atom

Avsnitt 2: Klinisk presentation

2.1 Kliniska symptom och diagnostiska kriterier
Avsnitt 2: Klinisk presentation 2.1 Kliniska symptom och diagnostiska kriterier

Problem vid diagnostik av vuxen-ADHD
När barn med ADHD når vuxen ålder manifesterar sig symptomen ofta annorlunda Svårigheterna att ställa diagnos kan bero på: hur symptomförändringar i vuxen-ADHD tolkas av läkaren att de aktuella DSM-IV-kriterierna inte speglar symptomutvecklingen att vuxna med ADHD misstolkar eller negligerar sina symptom och funktionsnedsättningar komorbiditeter symptomheterogenitet KEYPOINTS This slide focuses on the diagnostic concerns with ADHD, and how evolving symptoms and remission can impact quality diagnoses. As children with ADHD mature into adulthood, symptoms often manifest differently. BACKGROUND Difficulty in diagnosis may be a result of Symptom changes in adult ADHD being interpreted by clinicians The current DSM-IV criteria not reflecting the evolution of symptoms Adults with ADHD mistaking or overlooking their symptoms and impairments Comorbidities Symptom heterogeneity REFERENCE Adler LA. Epidemiology, impairments, and differential diagnosis in adult ADHD: introduction. CNS Spectr. 2008;13(8 Suppl 12):4-5. . Adler. CNS Spectr 2008;13:4–5. Atom

ADHD kräver en klinisk diagnos
För att förstå och känna igen ADHD krävs en god förståelse av debut, förlopp och de specifika symptom som kännetecknar sjukdomen Det är viktigt att göra en koppling mellan de underliggande förändringarna i mentalt tillstånd och de beteendemässiga symptom som dessa leder till, eftersom det är dessa ”beteenden” som definierar sjukdomen Det finns en karakteristisk psykopatologi (ett subjektivt mentalt tillstånd) som ligger bakom de beteendemässiga symptomen på ADHD Kooij et al. BMC Psychiatry 2010;10:67.

Klinisk presentation hos vuxna
Disorganisation (”planerar inte i förväg”) Glömska (”missar möten, tappar bort saker”) Uppskjutandebeteende (”påbörjar projekt men kan inte slutföra dem”) Problem med tidshantering (”alltid sen”) Övergår i förtid till andra aktiviteter (”påbörjar någonting men blir sedan snabbt distraherad av något annat”) Impulsiva beslut (särskilt vad gäller utgifter, att ta på sig projekt, resor, jobb eller social planering) Brottslighet (fortkörning, illegala droger) Instabilitet i yrkesliv och relationer Kooij et al. BMC Psychiatry 2010;10:67.

Vanliga symptom Uppmärksamhetsproblem Överaktivitet DSM-IV-kriterierna
Impulsivitet Oavbruten mental aktivitet (distraherade tankar) Labil sinnesstämning/emotionell dysreglering Låg tolerans för frustration Låg självkänsla Varierande prestationsförmåga DSM-IV-kriterierna (kärnsymptom) Associerade symptom Asherson. 1st European Network Adult ADHD Conference. London, 2011.

Hyperaktivitetsrelaterade problem
Oförmåga att koppla av Orolig sömn Överdrivet aktiv livsstil Rör konstant på extremiteterna utan något uppenbart syfte Stimulussökande eller antisociala beteenden Asherson. 1st European Network Adult ADHD Conference. London, 2011.

Impulsivitetsrelaterade problem1,2
Ohämmat beteende Missbruk av alkohol, cannabis, kokain, tobak, koffein Familjevåld Talar rätt ut eller fattar beslut utan att tänka sig för Asherson et al. Br J Psychiatry 2007;190:4–5. Kooij et al. BMC Psychiatry 2010;10:67.

Uppmärksamhetsrelaterade problem1,2
Oorganiserat och ineffektivt beteende Uppskjutandebeteende Oförmåga att planera framåt Glömska Svårigheter med att utföra olika uppgifter på samma gång Missbedömer hur lång tid det tar att utföra uppgifter Oförmåga att fullfölja uppgifter Distraherbarhet Bristande förmåga att ta till sig långa förklaringar Asherson et al. Br J Psychiatry 2007;190:4–5. Asherson. 1st European Network Adult ADHD Conference. London, 2011

Andra symptom1,2 Humörrelaterade:
Snabbt övergående humörväxlingar eller överretbarhet (dysreglering) Hett temperament eller vredesutbrott Låg självkänsla eller känslor av otillräcklighet Låg tolerans mot stress eller en känsla av att vara kroniskt överhopad Envishet Trafikolyckor (och andra olyckor) Svårigheter att behålla jobb Instabila relationer Oförmåga att utnyttja hela sin potential (särskilt yrkesmässigt) Asherson et al. Br J Psychiatry 2007;190:4–5. Kooij et al. BMC Psychiatry 2010;10:67.

Varför ska vuxenpsykiatrin intressera sig för ADHD?
ADHD är en vanlig beteendestörning associerad med betydande psykopatologi hos vuxna, sociala och utbildningsmässiga funktionsnedsättningar och risk för negativa långsiktiga utfall1,2 ADHD-symptom kvarstår upp i vuxen ålder och orsakar betydande kliniska funktionsnedsättningar1 Det viktigaste kliniska problemet är att känna igen sjukdomen hos vuxna och kvantifiera belastningen på den vuxna psykopatologin1 ADHD är en behandlingsbar sjukdom1 Asherson et al. Br J Psychiatry 2007;190:4–5. Antshel et al. BMC Med 2011;9:72.

2.2 Klassifikation av ADHD
Avsnitt 2: Klinisk presentation 2.2 Klassifikation av ADHD

Huvudprinciper ADHD hos vuxna är inte svårare att diagnostisera och behandla än andra vanliga psykiska tillstånd1 ADHD hos vuxna är ett symptomgivande tillstånd (det handlar inte bara om beteende)1,2 ADHD hos vuxna feldiagnostiseras ofta som andra vanliga vuxenpsykiatriska sjukdomar1,2 ADHD hos vuxna är i de flesta fall behandlingsbar1 Asherson. 1st European Network Adult ADHD Conference. London, 2011. Kooij et al. BMC Psychiatry 2010;10:67.

Klassifikation av vuxna (>17 år) med ADHD: DSM-5 kriterierna1
Ouppmärksamhet (åtminstone 5 symtom före 12 års ålder) Hyperaktivitet-impulsivitet (åtminstone 5 symtom före 12 års ålder) Undertyper: Kombinerad typ Huvudsakligen ouppmärksamhet Huvudsakligen hyperaktivitet-impulsivitet ADHD i “partiell remission” Svårighetsgrad: Lätt, Måttlig, eller Svår beroende på få, måttliga eller många symtom i förhållande till kriteriekrav Funktionsnedsättning: Lätt, Måttlig, eller Svår Combined type: criteria for both inattention and hyperactivity-impulsivity are met Predominantly inattentive type: criteria are met for inattention but not for hyperactivity-impulsivity (at least 6 criteria for each category) Predominantly hyperactive-impulsive type: criteria are met for hyperactivity-impulsivity but not for inattention ADHD in 'partial remission’: for individuals, especially adolescents and adults who currently have symptoms that no longer meet full criteria APA. Diagnostic and Statistical Manual of Mental Disorders 5th Edn. Washington DC: APA; 2013;59–60

DSM-V: ADHD-symptom på uppmärksamhetsproblem1
>17 år: måste ha ≥ 5 symptom på ouppmärksamhet som har förelegat i ≥6 månader till en grad som är maladaptiv och oförenlig med utvecklingsnivån Bristande uppmärksamhet på detaljer Undviker arbetsuppgifter som kräver mental uthållighet Svårighet att bibehålla uppmärksamheten Tappar ofta bort saker som är nödvändiga för olika aktiviteter Lyssnar inte på direkt tilltal Lättdistraherad av yttre stimuli Bristande förmåga att fullfölja arbetsuppgifter Glömsk i det dagliga livet Svårigheter att organisera sina arbetsuppgifter och aktiviteter Text from Asherson P. Expert Rev Neurotherapeutics 2005;5(4): Inattention: Often fails to give close attention to detail: difficulty remembering where they put things. In work this may lead to costly errors. Tasks that require detail and are tedious (e.g., income tax returns) become very stressful. This may include overly perfectionistic and rigid behaviour, needing too much time for tasks involving details in order to prevent forgetting any of them. Often has difficulty sustaining attention: inability to complete tasks such as tidying a room or mowing the lawn without forgetting the objective and starting something else. Inability to persist with boring jobs. Inability to sustain sufficient attention to read a book that is not of special interest, although there is no reading disorder. Inability to keep accounts, write letters or pay bills. Attention, however, can often be sustained during exciting, new or interesting activities (e.g. using the internet, chatting and computer games). This does not exclude the criterion when boring activities are not completed. Often does not appear to listen when spoken to: adults receive complaints that they do not listen, and that it is difficult to gain their attention. Even where they appear to have heard, they forget what was said and follow through. These complaints reflect a sense that they are ‘not always in the room’, ‘not all there’ or ‘not tuned in’. Fails to follow through on instructions and complete tasks: adults may observe difficulty in following other people’s instructions. Inability to read or follow instructions in a manual for appliances. Failure to keep commitments undertaken (e.g., work around the house). Difficulty organizing tasks or activities: adults note recurrent errors (e.g., lateness, missed appointments or missing critical deadlines). Sometimes a deficit in this area is seen in the amount of delegation to others such as secretary at work or spouse at home. Avoids or dislikes sustained mental effort: putting off tasks such as responding to letters, completing tax returns, organising old papers, paying bills or establishing a will. One can enquire about specifics then ask why particular tasks were not attended to. These adults often complain of procrastination. Often loses things needed for tasks: misplacing purse, wallet, keys and assignments from work, where car is parked, tools and even children! Easily distracted by extraneous stimuli: subjectively experience distractibility and describe ways in which they try to overcome this. This may include listening to white noise, multitasking, requiring absolute quiet or creating an emergency to achieve adequate states or arousal to complete tasks, many projects going simultaneously and trouble with completion of tasks Forgetful in daily activities: may complain of memory problems. They head out to the supermarket with a list of things, but end up coming home having failed to complete their tasks or having purchased something else ABBREVIATIONS ADHD: attention-deficit/hyperactivity disorder KEYPOINTS According to DSM-IV criteria, diagnosing ADHD requires a persistent pattern of inattention/hyperactivity that is more frequently displayed and grows more severe than is typically displayed in individuals of comparable development. If a patient is predominantly inattentive, he/she must have 6 or more symptoms of inattention for at least 6 months that is inconsistent with individuals of comparable development.1 BACKGROUND1 Some symptoms are present before age 7 years. Impairment must be present in at least 2 settings (e.g., home, work, school). Interference with social, occupational and/or academic functioning. Symptoms not due to another mental disorder. These criteria, specifically avoiding tasks requiring sustained mental effort, must be because of the individual’s difficulties with attention and not a primary oppositional attitude. REFERENCE American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders - Text Revision, Fourth Edition. Washington, DC: American Psychiatric Association; 2000: APA. Diagnostic and Statistical Manual of Mental Disorders 5th Edn. Washington DC: APA; 2013;59 Atom

DSM-V: ADHD-symptom på hyperaktivitet/impulsivitet
>17 år: måste ha ≥ 5 symptom på hyperaktivitet/impulsivitet som har förelegat i ≥6 månadertill en grad som är maladaptiv och oförenlig med utvecklingsnivån Symptom på hyperaktivitet Symptom på impulsivitet Rör på händer/fötter eller vrider sig Kastar ur sig svar Har ofta svårt att vänta på sin tur Kan inte sitta stilla där man förväntas sitta stilla Avbryter ofta andra eller lägger sig i Springer och/eller klättrar överdrivet mycket Svårt att leka lugnt och stilla Ständigt ”på språng” Pratar överdrivet mycket Text from Asherson P. Expert Rev Neurotherapeutics 2005;5(4) Hyperactivity Fidgets with hands or feet: this item may be observed, but it is also useful to ask about this. Fidgeting may include picking their fingers, shaking their knees, tapping their hands or feet and changing position. Fidgeting is most likely to be observed while waiting in the waiting area of the clinic. Leaves seat in situations in which remaining seated is usual: adults may be restless. For example, they experience frustration with dinners out in restaurants and are unable to sit during conversations, meetings and conferences. This may also manifest as a strong internal feeling of restlessness when waiting. Wanders or runs about excessively or frequently experiences subjective feelings of restlessness: adults may describe their subjective sense of always needing to be ‘on the go’, or feeling more comfortable with stimulating activities (e.g., skiing) than with more sedentary types of recreation. They may pace during the interview. Difficulty engaging in leisure activities quietly: adults may describe an unwillingness/dislike to ever just stay home or engage in quiet activities. They may complain that they are workaholics, in which case detailed examples should be given. Often ‘on the go’ or acts as if driven by a motor: significant others may have a sense of the exhausting and frenetic pace of these adults. Attention deficit hyperactivity disorder adults will often appear to expect the same frenetic pace of others. Holidays may be described as draining since there is no opportunity for rest. Talks excessively: excessive talking makes dialogue difficult. This may interfere with a spouse’s sense of ‘being heard’ or achieving intimacy. This chatter may be experienced as nagging and may interfere with normal social interactions. Clowning, repartee or other means of dominating conversations may mask an inability to engage in give-and-take conversation. Impulsivity Blurts out answers before questions have been completed: this will usually be observed during the interview. This may also be experienced by probands as a subjective sense of other people talking too slowly and of finding it difficult to wait for them to finish. Tendency to say what comes to mind considering timing or appropriateness. Difficulty waiting in turn: adults find it difficult to wait for others to finish tasks at their own pace, such as children. They may feel irritated waiting in line at bank machines or in a restaurant. They may be aware of their own intense efforts to force themselves to wait. Some adults compensate for this by carrying something to do at all times. Interrupts or intrudes on others: most often experienced by adults as social ineptness at social gatherings or even with close friends. An example might be the inability to watch others struggle with a task (e.g., opening a door with a key) without jumping in to try for themselves. ABBREVIATIONS ADHD: attention-deficit/hyperactivity disorder KEYPOINTS According to DSM-IV criteria, diagnosing ADHD requires a persistent pattern of inattention/hyperactivity that is more frequently displayed and grows more severe than is typically displayed in individuals of comparable development. If a patient is predominantly hyperactive-impulsive, he/she must have 6 or more symptoms of hyperactivity-impulsiveness for at least 6 months that is inconsistent with individuals of comparable development.1 BACKGROUND1 Some symptoms are present before age 7 years. Impairment must be present in at least 2 settings (eg, home, work, school). Interference with social, occupational and/or academic functioning. Symptoms not due to another mental disorder. REFERENCE American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders - Text Revision, Fourth Edition. Washington, DC: American Psychiatric Association; 2000: APA. Diagnostic and Statistical Manual of Mental Disorders ‒ Text Revision. 4th Edn. Washington DC: APA; 2000;85–93. Atom

Diagnostik av ADHD: DSM-IV-kriterierna
Det utmärkande för ADHD* är ett ihållande mönster av ouppmärksamhet och/eller hyperaktivitet-impulsivitet som visar sig oftare och är svårare än vad som i normalfallet ses hos individer på en jämförbar utvecklingsnivå Vissa symptom förekommer före 7 års ålder Funktionsnedsättningen måste visa sig i minst två miljöer (t.ex. hemma, på arbetet, i skolan) Symptomen ger en funktionsnedsättning socialt eller i arbete eller studier Symptomen beror inte på annan psykisk sjukdom ABBREVIATIONS ADHD: attention-deficit/hyperactivity disorder, DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, 4th edition KEYPOINT According to DSM-IV criteria, diagnosing ADHD requires a persistent pattern of inattention/hyperactivity that is more frequently displayed and grows more severe than is typically displayed in individuals of comparable development. BACKGROUND Some hyperactive-impulsive or inattentive symptoms must have been present before 7 years of age, but many individuals may be diagnosed after the symptoms have been present for a number of years. It is very unusual for an individual to display the same level of impairment in all settings (eg, home, work, school) or within the same setting at all times. ADHD is classified as a mental disorder (eg, mood disorder, anxiety disorder) and with the presence of pervasive developmental disorder, schizophrenia, or other psychotic disorders. REFERENCE American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders - Text Revision, Fourth Edition. Washington, DC: American Psychiatric Association; 2000: *Kategoriseras av DSM-IV såsom sjukdomar som vanligtvis först diagnostiseras under spädbarnstiden, barndomen eller ungdomen APA. Diagnostic and Statistical Manual of Mental Disorders ‒Text Revision. 4th Edn. Washington DC: APA; 2000;85–93.

DSM-IV: ADHD-symptom på uppmärksamhetsproblem1
Måste ha ≥6 symptom på ouppmärksamhet som har förelegat i ≥6 månader till en grad som är maladaptiv och oförenlig med utvecklingsnivån Bristande uppmärksamhet på detaljer Undviker arbetsuppgifter som kräver mental uthållighet Svårighet att bibehålla uppmärksamheten Tappar ofta bort saker som är nödvändiga för olika aktiviteter Lyssnar inte på direkt tilltal Lättdistraherad av yttre stimuli Bristande förmåga att fullfölja arbetsuppgifter Glömsk i det dagliga livet Svårigheter att organisera sina arbetsuppgifter och aktiviteter Text from Asherson P. Expert Rev Neurotherapeutics 2005;5(4): Inattention: Often fails to give close attention to detail: difficulty remembering where they put things. In work this may lead to costly errors. Tasks that require detail and are tedious (e.g., income tax returns) become very stressful. This may include overly perfectionistic and rigid behaviour, needing too much time for tasks involving details in order to prevent forgetting any of them. Often has difficulty sustaining attention: inability to complete tasks such as tidying a room or mowing the lawn without forgetting the objective and starting something else. Inability to persist with boring jobs. Inability to sustain sufficient attention to read a book that is not of special interest, although there is no reading disorder. Inability to keep accounts, write letters or pay bills. Attention, however, can often be sustained during exciting, new or interesting activities (e.g. using the internet, chatting and computer games). This does not exclude the criterion when boring activities are not completed. Often does not appear to listen when spoken to: adults receive complaints that they do not listen, and that it is difficult to gain their attention. Even where they appear to have heard, they forget what was said and follow through. These complaints reflect a sense that they are ‘not always in the room’, ‘not all there’ or ‘not tuned in’. Fails to follow through on instructions and complete tasks: adults may observe difficulty in following other people’s instructions. Inability to read or follow instructions in a manual for appliances. Failure to keep commitments undertaken (e.g., work around the house). Difficulty organizing tasks or activities: adults note recurrent errors (e.g., lateness, missed appointments or missing critical deadlines). Sometimes a deficit in this area is seen in the amount of delegation to others such as secretary at work or spouse at home. Avoids or dislikes sustained mental effort: putting off tasks such as responding to letters, completing tax returns, organising old papers, paying bills or establishing a will. One can enquire about specifics then ask why particular tasks were not attended to. These adults often complain of procrastination. Often loses things needed for tasks: misplacing purse, wallet, keys and assignments from work, where car is parked, tools and even children! Easily distracted by extraneous stimuli: subjectively experience distractibility and describe ways in which they try to overcome this. This may include listening to white noise, multitasking, requiring absolute quiet or creating an emergency to achieve adequate states or arousal to complete tasks, many projects going simultaneously and trouble with completion of tasks Forgetful in daily activities: may complain of memory problems. They head out to the supermarket with a list of things, but end up coming home having failed to complete their tasks or having purchased something else ABBREVIATIONS ADHD: attention-deficit/hyperactivity disorder KEYPOINTS According to DSM-IV criteria, diagnosing ADHD requires a persistent pattern of inattention/hyperactivity that is more frequently displayed and grows more severe than is typically displayed in individuals of comparable development. If a patient is predominantly inattentive, he/she must have 6 or more symptoms of inattention for at least 6 months that is inconsistent with individuals of comparable development.1 BACKGROUND1 Some symptoms are present before age 7 years. Impairment must be present in at least 2 settings (e.g., home, work, school). Interference with social, occupational and/or academic functioning. Symptoms not due to another mental disorder. These criteria, specifically avoiding tasks requiring sustained mental effort, must be because of the individual’s difficulties with attention and not a primary oppositional attitude. REFERENCE American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders - Text Revision, Fourth Edition. Washington, DC: American Psychiatric Association; 2000: APA. Diagnostic and Statistical Manual of Mental Disorders ‒ Text Revision. 4th Edn. Washington DC: APA; 2000;85–93. Atom

DSM-IV: ADHD-symptom på hyperaktivitet/impulsivitet
Måste ha ≥6 symptom på hyperaktivitet/impulsivitet som har förelegat i ≥6 månader till en grad som är maladaptiv och oförenlig med utvecklingsnivån Symptom på hyperaktivitet Symptom på impulsivitet Rör på händer/fötter eller vrider sig Kastar ur sig svar Har ofta svårt att vänta på sin tur Kan inte sitta stilla där man förväntas sitta stilla Avbryter ofta andra eller lägger sig i Springer och/eller klättrar överdrivet mycket Svårt att leka lugnt och stilla Ständigt ”på språng” Pratar överdrivet mycket Text from Asherson P. Expert Rev Neurotherapeutics 2005;5(4) Hyperactivity Fidgets with hands or feet: this item may be observed, but it is also useful to ask about this. Fidgeting may include picking their fingers, shaking their knees, tapping their hands or feet and changing position. Fidgeting is most likely to be observed while waiting in the waiting area of the clinic. Leaves seat in situations in which remaining seated is usual: adults may be restless. For example, they experience frustration with dinners out in restaurants and are unable to sit during conversations, meetings and conferences. This may also manifest as a strong internal feeling of restlessness when waiting. Wanders or runs about excessively or frequently experiences subjective feelings of restlessness: adults may describe their subjective sense of always needing to be ‘on the go’, or feeling more comfortable with stimulating activities (e.g., skiing) than with more sedentary types of recreation. They may pace during the interview. Difficulty engaging in leisure activities quietly: adults may describe an unwillingness/dislike to ever just stay home or engage in quiet activities. They may complain that they are workaholics, in which case detailed examples should be given. Often ‘on the go’ or acts as if driven by a motor: significant others may have a sense of the exhausting and frenetic pace of these adults. Attention deficit hyperactivity disorder adults will often appear to expect the same frenetic pace of others. Holidays may be described as draining since there is no opportunity for rest. Talks excessively: excessive talking makes dialogue difficult. This may interfere with a spouse’s sense of ‘being heard’ or achieving intimacy. This chatter may be experienced as nagging and may interfere with normal social interactions. Clowning, repartee or other means of dominating conversations may mask an inability to engage in give-and-take conversation. Impulsivity Blurts out answers before questions have been completed: this will usually be observed during the interview. This may also be experienced by probands as a subjective sense of other people talking too slowly and of finding it difficult to wait for them to finish. Tendency to say what comes to mind considering timing or appropriateness. Difficulty waiting in turn: adults find it difficult to wait for others to finish tasks at their own pace, such as children. They may feel irritated waiting in line at bank machines or in a restaurant. They may be aware of their own intense efforts to force themselves to wait. Some adults compensate for this by carrying something to do at all times. Interrupts or intrudes on others: most often experienced by adults as social ineptness at social gatherings or even with close friends. An example might be the inability to watch others struggle with a task (e.g., opening a door with a key) without jumping in to try for themselves. ABBREVIATIONS ADHD: attention-deficit/hyperactivity disorder KEYPOINTS According to DSM-IV criteria, diagnosing ADHD requires a persistent pattern of inattention/hyperactivity that is more frequently displayed and grows more severe than is typically displayed in individuals of comparable development. If a patient is predominantly hyperactive-impulsive, he/she must have 6 or more symptoms of hyperactivity-impulsiveness for at least 6 months that is inconsistent with individuals of comparable development.1 BACKGROUND1 Some symptoms are present before age 7 years. Impairment must be present in at least 2 settings (eg, home, work, school). Interference with social, occupational and/or academic functioning. Symptoms not due to another mental disorder. REFERENCE American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders - Text Revision, Fourth Edition. Washington, DC: American Psychiatric Association; 2000: APA. Diagnostic and Statistical Manual of Mental Disorders ‒ Text Revision. 4th Edn. Washington DC: APA; 2000;85–93. Atom

Klassifikation av ADHD: DSM-IV-kriterierna1,2
Ouppmärksamhet (minst 6 symptom) Hyperaktivitet-impulsivitet (minst 6 symptom) Undertyper: Kombinerad typ Huvudsakligen ouppmärksamhet Huvudsakligen hyperaktivitet-impulsivitet ADHD i ”partiell remission” (de flesta uppfyller kriterierna enligt DSM-5) Combined type: criteria for both inattention and hyperactivity-impulsivity are met Predominantly inattentive type: criteria are met for inattention but not for hyperactivity-impulsivity (at least 6 criteria for each category) Predominantly hyperactive-impulsive type: criteria are met for hyperactivity-impulsivity but not for inattention ADHD in 'partial remission’: for individuals, especially adolescents and adults who currently have symptoms that no longer meet full criteria APA. Diagnostic and Statistical Manual of Mental Disorders –Text Revision. 4th Edn. Washington DC: APA; 2000;85–93. APA. DSM-5 development Finns tillgänglig på:

Definiera funktionsnedsättningarna vid ADHD
NICE 2008: Funktionsnedsättningen vid ADHD ska ha följande kännetecken:1 Vara genomgripande och av minst måttlig svårighetsgrad Orsakar problem inom minst två domäner: Personligt lidande till följd av ADHD-symptom Sänkt självkänsla Problem med sociala interaktioner och relationer Nedsatt funktion inom utbildning, arbetsliv och vardagsaktiviteter Trafikolyckor och risktagande beteende Komorbida psykiatriska syndrom och beteendeproblem Effekter av ADHD-symptomen begränsar sig inte till enbart skolresultat UKAAN permission needed. National Institute for Health and Clinical Excellence. Attention Deficit Hyperactivity Disorder. London: NICE; 2008.

2.3 Ärftlighetsfaktorer och barndomsanamnes
Avsnitt 2: Klinisk presentation 2.3 Ärftlighetsfaktorer och barndomsanamnes

Ärftlighetsfaktorer är relevanta
Hereditetsanamnesen är mycket viktig: Prevalensen bland första gradens släktingar ligger i intervallet 20–50 %1 4–10 gånger högre familjär risk än i allmänpopulationen1 Viktigt att inkludera patientens familjeanamnes1 Faraone et al. Genetic Epidem. 2000;18(1):1-16 Converging evidence from family, twin, and adoption studies points to a substantial genetic component of the etiology of attention deficit hyperactivity disorder (ADHD). These data about ADHD have motivated molecular genetic studies of the disorder, which have produced intriguing but somewhat conflicting results. Some studies have reported associations with candidate genes and others not. Our review of the literature shows that one problem facing molecular genetic studies of ADHD is that its recurrence risk to first-degree relatives is only about five times higher than the population prevalence. This suggests that, to produce consistently replicated results, molecular genetic studies should either use much larger samples or should select those families in which genes exert the largest effect. Risch [(1990a) Am J Hum Genet 46: ;(1990b) Am J Hum Genet 46: ] proved that the statistical power of a linkage study increases with the magnitude of risk ratios (lambda's) computed by dividing the affection rate among each relative type to the rate of affection in the population. Our prior work suggests two dimensions of genetic heterogeneity that might be useful for selecting ADHD subjects for molecular genetic studies: co-morbidity with conduct disorder and persistence of ADHD into adolescence. This paper shows that these sub-phenotypes are useful for molecular genetic studies because (1) they have much higher empirical lambda values and (2) they affect a substantial minority of ADHD patients. Kooij et al. BMC Psychiatry. 2010;10:67 BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that persists into adulthood in the majority of cases. The evidence on persistence poses several difficulties for adult psychiatry considering the lack of expertise for diagnostic assessment, limited treatment options and patient facilities across Europe. METHODS: The European Network Adult ADHD, founded in 2003, aims to increase awareness of this disorder and improve knowledge and patient care for adults with ADHD across Europe. This Consensus Statement is one of the actions taken by the European Network Adult ADHD in order to support the clinician with research evidence and clinical experience from 18 European countries in which ADHD in adults is recognised and treated. RESULTS: Besides information on the genetics and neurobiology of ADHD, three major questions are addressed in this statement: (1) What is the clinical picture of ADHD in adults? (2) How can ADHD in adults be properly diagnosed? (3) How should ADHD in adults be effectively treated? CONCLUSIONS: 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. Expertise in diagnostic assessment and treatment of ADHD in adults must increase in psychiatry. 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. BMC Psychiatry 2010;10:67.

En kritisk komponent i ADHD-utredningen
Ta reda på barndomssymptomen Gå tillbaka till tidigaste minnen – använd associationer: Beskriv ditt hus, människor, händelser etc. Fastslå kronologin: När började du få de här symptomen? Anamnes på betydande trauma: Har du någonsin utsatts för misshandel eller sexuella övergrepp? En kritisk komponent i ADHD-utredningen Young. ADHD Grown Up: A Guide to Adolescent and Adult ADHD. London: WW Norton; 2007.

Ta reda på barndomssymptomen
Skolstarten och patientens uppfattning om skolresultaten: Hur var du som barn, både i skolan och hemma? Var symptomen konstanta över tid eller kom de i perioder? Har du tidigare varit med om några psykologiska tester och/eller andra undersökningar? Kände du någon separationsångest? The DIVA Foundation. DIVA Tillgänglig på:

Tidslinje för symptomen – hur ska man fråga?
Ta reda på barndomssymptomen När började du få de här symptomen? Hur var du som barn, både i skolan och hemma? Skolbetyg kan vara till hjälp här Var symptomen kroniska eller kom de i perioder? Hur har symptomen påverkat din funktionsförmåga? Tidslinje för symptomen – hur ska man fråga? The DIVA Foundation. DIVA Tillgänglig på:

2.4 Screeningfrågor och -formulär
Avsnitt 2: Klinisk presentation 2.4 Screeningfrågor och -formulär

Diagnostiska metoder 1: Klinisk diagnostisk intervju:
Utvärdera var och en av de 18 punkterna (DSM/ICD) både med avseende på nutid och retrospektivt, och screena för komorbida sjukdomar 2: Utvärdering av funktionsnedsättningar/behov: Att matcha symptomen till funktionsnedsättningar är nyckeln till diagnosen (utvecklingshistorien är viktigt) 3: Screeninginstrument Används för att screena för ADHD och kontrollera behandlingssvaret 4: Psykometriska tester: Inte tillräckligt prediktiva, men ett bra komplement till bedömningen (inkluderar: IQ-specifika lässvårigheter/matematiska svårigheter, lång och varierande reaktionstid, responsinhibition, arbetsminne, impulsivitet i valsituationer) Asherson. 1st European Network Adult ADHD Conference. London, 2011.

Diagnostiska instrument
Kommentarer Conners’ Adult ADHD1 (CAADID) Diagnostisk intervju enligt DSM-IV - Del I: Utvecklingshistoria - Del II: Diagnostiska kriterier - Obs! Det tas ut en avgift varje gång CAADID används Diagnostisk intervju enligt DSM-IV (DIVA)2 Vuxen-ADHD Endast diagnostiska kriterier - Utvecklad i Europa - Multipla exempel på enskilda faktorer - Fem områden av funktionsnedsättningar - Gratis att använda Conners et al. J Attention Disord 1999;3:141. Kooij & Francken. DIVA Foundation 2010.

Screeninginstrument Instrument Kommentarer
Vuxen-Självrapportskala för ADHD (ASRS)1 Fritt tillgänglig från WHO Huvudversion – 18 frågor Kort screeningversion – 6 frågor Symptomchecklistor enligt DSM-IV2 (versioner för aktuella symptom, retrospektiva symptom och informant) Alternativ: - Barkleys ”workbook” - Conners’ Adult ADHD Rating Scale4 Weiss Functional Impairment Scale5 Detaljerad förteckning av olika typer av funktionsnedsättningar hos vuxna med ADHD Gratis att använda Barkleys ”Impairment Items”3 10 screeningfrågor för olika områden av funktionsnedsättning associerade med ADHD hos vuxna REFERENCES: ASRS: Kessler RC. Psychol Med. 2005 Feb;35(2): Kessler RC. Int J Methods Psychiatr Res. 2007;16(2):52-65. DSM-IV Symptom Checklists: Amador-Campos JA et al. J Atten Disord Jul 6. [Epub ahead of print]. Christiansen H, et al. Eur Psychiatry Jul;27(5): Christiansen H, et al. Eur Psychiatry Mar;26(2): Conners CK. Journal of Attention Disorders. 1999;3(3):141. Epstein JN and Kollins SH. J Atten Disord Feb;9(3): Ramos-Quiroga JA et al. Rev Neurol. 2009;48(9): BARKLEY IMPAIRMENT ITEMS: Weiss M, Hechtman LT, Weiss G. ADHD in Adulthood: a guide to current theory, diagnosis and treatment. John Hopkins University Press 1999. Kessler et al. Int J Methods Psychiatr Res. 2007;16:52‒65. Conners et al. North Tonawanda, NY: Multi-Health Systems Inc.; 1999. Amador-Campos et al. J Atten Disord [Epub ahead of print]. Barkley MA, Murphy RA. New York: Guildford Press; 2006. Weiss. John Hopkins University Press 1999.

Verktyg för diagnostik och screening av ADHD hos vuxna
Verktygets namn Typ av verktyg Tillgängliga språk /pågående översättning Referens Vuxen-Självrapportskala för ADHD (ASRS) Självrapporterat frågeformulär Engelska, kinesiska, holländska, finska, franska, tyska, hebreiska, japanska, norska, portugisiska, ryska, spanska, svenska Kessler et al, 2005; Kessler et al, 2007. Conners’ Adult ADHD Rating Scale (CAARS) Självrapporterat (CAARS-S) och observatörsrapporterat (CAARS-O) frågeformulär Engelska, tyska, spanska, katalanska Amador-Campos et al, 2012; Christiansen et al, 2011a; Christiansen et al, 2011b; Conners et al, 1999. Conners’ Adult ADHD Diagnostic Interview for DSM‑IV (CAADID) Strukturerad intervju Engelska, spanska Epstein and Kollins, 2006; Ramos Quiroga et al, 2009. Diagnostic Interview for ADHD in Adults, 2nd Edn (DIVA 2.0) Danska, nederländska, engelska, finska, franska, tyska, grekiska, hebreiska, japanska, norska, portugisiska, brasiliansk portugisiska, spanska, svenska, turkiska DIVA; Kooij, 2010. Wender Utah Rating Scale (WURS) Engelska, spanska, tyska och franska Ward et al, 1993; Rodríguez-Jiménez et al, 2001; Retz-Junginger et al, 2002; Caci et al, 2010. Brown Attention-Deficit Disorder Rating Scale (BADDS) Engelska Brown, 1996. Current Symptoms Scale (CSS) Engelska, kinesiska, turkiska Barkley and Murphy, 2006; Aycicegi et al, 2003; Norvilitis et al, 2008. ADHD Rating Scale IV (ADHD-RS-IV) Frågeformulär Engelska och många andra språk DuPaul et al, 1998, Döpfner et al, 2006. ADHD Self-Report (ADHD-SR) Tyska, spanska Rösler et al, 2004; Rösler et al, 2008; Bosch et al, 2009. ADHD Diagnostic Checklist (ADHD‑DC) Diagnostisk checklista Tyska Rösler et al, 2004.

Övrig relevant anamnes
Födelse och spädbarnstid: Födelsekomplikationer Milstolpar i utvecklingen Tidigt temperament Graviditet Barn- och ungdomstid: Framsteg i skolan, avstängningar/relegeringar, beteende i skolan Relationer i kamratgruppen, antisocialt beteende, personliga relationer Vuxenliv: Anställningshistorik Socialt liv och privatliv Asherson. 1st European Network Adult ADHD Conference. London, 2011.

Övrig relevant anamnes
Anamnes för tidigare psykiatriska diagnoser och behandlingar Anamnes för tidigare medicinska diagnoser och behandlingar Screening av vanliga komorbida sjukdomar Screening av specifika och generella inlärningssvårigheter Hereditet Drog- och alkoholbruk Brottshistorik Asherson. 1st European Network Adult ADHD Conference. London, 2011.

För den oerfarna ADHD-diagnostikern
Potentiella fällor ADHD-symptom: Kanske inte är uppenbara i den kliniska miljön (känslighet för nyheter och stimuli) Särskiljer ADHD: Symptomen ger intryck av att vara en del av personligheten och är icke- episodiska Affektiv instabilitet är ytterst vanligt Debutålder: Tydlig anamnes på funktionsnedsättningar För den oerfarna ADHD-diagnostikern Asherson. 1st European Network Adult ADHD Conference. London, 2011.

Avfärda inte ADHD …1,2 om läkaren inte observerar hyperaktivitet
om det inte finns någon anamnes om patienten avfärdar de symptom som familjen rapporterar om patienten är välutbildad eller har ett prestigefyllt arbete om patienten lyckades bra i grundskolan om ADHD-symptom i barndomen har avtagit i vuxen ålder om patienten inte kommer ihåg barndomssymptomen eller förnekar dem KEYPOINTS Hyperactivity often decreases with age. Adult ADHD patients may not be hyperactive, especially when attending the doctor office and being there for a few minutes. Adult ADHD patients often attend the doctor’s office not because of ADHD symptoms, but due to the complications like job problems, spouse conflicts, drug or alcohol abuse, irritability, mood or anxiety disorders, etc. It is very common for adolescent or adult ADHD patients to perceive symptoms as less severe than perceived by relatives. An adult ADHD patient, with good IQ, family support and no clear or severe co-morbid condition, may have a good job and income. This does not rule out ADHD. An ADHD adult patient frequently faces difficulties remembering things, his/her own history included, so symptoms and consequences may not be clear in patient’s memory. Hence, obtaining history from someone else who knows the patient is helpful if available. REFERENCE Weiss M, Murray C, Weiss G. Adults with attention-deficit/hyperactivity disorder: current concepts. J Psychiatr Pract. 2002;8(2): The DIVA Foundation. DIVA Tillgänglig på: Weiss et al. J Psychiatr Pract 2002;8:99–111. Atom

Avsnitt 3: Komorbiditeter och differentialdiagnoser

Komorbiditet Symptom, syndrom eller sjukdomar? 1 Symptom på ADHD
2. Överlappande neuropsykiatriska sjukdomar 3. ADHD som en riskfaktor för utveckling av komorbida sjukdomar senare i livet

1. Symptom på ADHD Ångest:1 Malande tankar, undvikande beteende
Depression:1 Instabil sinnesstämning, otålighet, irritabilitet, insomningssvårigheter, låg självkänsla Personlighetsstörning:1 Antisocial, borderline, emotionellt instabil, dåliga sociala interaktioner, impulsivitet, instabilitet i vuxen ålder som ger intryck av att vara en del av personligheten Hypomani, bipolär II-sjukdom, cyklotymi:2 Särskiljer sig genom grandiositet, tydligt fokus på tankar, episodisk karaktär, nedsatt sömnbehov, psykos Some symptoms of ADHD may occur also in other disorders (like avoidance behavior or low self esteem), but may have some aspects that are more characteristic for ADHD (like ceaseless thoughts and unstable mood) or lack some characteristics of the other disorder (like lack of grandiosity, clear focus of thoughts, etc for hypomanic bipolar episode). Asherson. 1st European Network Adult ADHD Conference. London, 2011. Babcock and Ornstein. Postgraduate Medicine. 2009;121(3):73-82.

2. Överlappande neuropsykiatriska sjukdomar
Dyslexi (överlappande genetiska riskfaktorer)1 Specifika och generella inlärningssvårigheter (överlappande genetiska riskfaktorer, uppmärksamhetsproblem1 Genomgripande störning i utvecklingen1 Dyspraxi1 Ticsstöming/Tourettes syndrom1 Talproblem2 Autismspektrumstörning1 Kooij et al. BMC Psychiatry 2010;10:67. Tannock et al J Abnl Child Psychol, 2000; 28(3):237–252

Miljömässiga och genetiska risker: (misshandel/COMT*-genotyp)
3. ADHD som en riskfaktor för utveckling av komorbida sjukdomar senare i livet Riskmodell Antisocialt beteende Missbruk Depression/låg självkänsla Ångest Vuxen med ADHD Miljömässiga och genetiska risker: (misshandel/COMT*-genotyp) *Katekol-O-metyltransferas Asherson. 1st European Network Adult ADHD Conference. London, 2011.

Komorbiditet vid ADHD Villkorliga prevalensskattningar, % (SE)1
OR (95 % CI) ADHD vid annan sjukdoma Annan sjukdom vid ADHDb Klasser av komorbiditet Affektiv sjukdom 11 (1,2) 25 (2,6) 3,9 (3,0–5,1) Ångest 10 (1,0) 38 (3,1) 4,0 (3,0–5,2) Substansmissbruk 12,5 (2,3) 11 (2,0) 4,0 (2,8–5,8) Fayyad et al. Br J Psychiatry. 2007;190:402-9. BACKGROUND: Little is known about the epidemiology of adult attention-deficit hyperactivity disorder (ADHD). AIMS: To estimate the prevalence and correlates of DSM-IV adult ADHD in the World Health Organization World Mental Health Survey Initiative. METHOD: An ADHD screen was administered to respondents aged years in ten countries in the Americas, Europe and the Middle East (n=11422). Masked clinical reappraisal interviews were administered to 154 US respondents to calibrate the screen. Multiple imputation was used to estimate prevalence and correlates based on the assumption of cross-national calibration comparability. RESULTS: Estimates of ADHD prevalence averaged 3.4% (range %), with lower prevalence in lower-income countries (1.9%) compared with higher-income countries (4.2%). Adult ADHD often co-occurs with other DSM-IV disorders and is associated with considerable role disability. Few cases are treated for ADHD, but in many cases treatment is given for comorbid disorders. CONCLUSIONS: Adult ADHD should be considered more seriously in future epidemiological and clinical studies than is currently the case. ABBREVIATIONS ADHD: attention-deficit/hyperactivity disorder, SE: standard error, OR: odds ratio, CI: confidence interval, DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. KEYPOINTS ADHD is highly comorbid with many other DSM-IV disorders including anxiety, mood, substance use, and intermittent explosive disorder. A 10-country screen (Belgium, Colombia, France, Germany, Italy, Lebanon, Mexico, The Netherlands, Spain, and the USA) indicated that adult ADHD is significantly associated with numerous DSM-IV disorders, with many patients experiencing more than one co-occurring disorder. The strength of these associations in terms of odds ratios (95% CI) was extremely consistent across classes of disorder Mood disorders = 3.9 (3.0–5.1) Anxiety disorders = 4.0 (3.0–5.2) Substance use disorders = 4.0 (2.8–5.8) Among those with comorbidities, approximately 10–20% had more than one comorbidity. A dose-response relationship exists between ADHD and a number of other disorders, with the highest odds ratio (OR = 7.2, 95% CI 5.1–10.2) associated with having three or more other disorders. BACKGROUND An ADHD screen was administered in 10 countries in Europe, the Americas and the Middle East (n=11,422). The two-part, face-to-face surveys assessed respondents who met the requirements for diagnosis of ADHD. The screen included adults 18–44 years of age. Other DSM-IV disorders were assessed using the surveys and the World Health Organization (WHO) Composite International Diagnostic Interview. Core disorders assessed included anxiety disorders, mood disorders, and substance use disorders. REFERENCE Fayyad J, De Graaf R, Kessler R, Alonso J, Angermeyer M, Demyttenaere K, De Girolamo G, Haro JM, Karam EG, Lara C, Lépine JP, Ormel J, Posada-Villa J, Zaslavsky AM, Jin R. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry. 2007;190:402-9. aPrevalensskattningar av ADHD i delurvalet med komorbida sjukdomar bPrevalensskattningar av komorbida sjukdomar i delurvalet med ADHD Fayyad et al. Br J Psychiatry 2007;190:402–9. Atom

3.2 ADHD och substansmissbruk
Avsnitt 3: Komorbiditet och differentialdiagnoser 3.2 ADHD och substansmissbruk

ADHD och substansmissbruk
Anledningar till sambandet: Stimulussökande beteende: Inneboende komponent av ADHD (t.ex. nyhetssökande) Gemensamma genetiska riskfaktorer Nedsatt funktionsförmåga socialt/inom studier/inom yrkesliv: Sekundär konsekvens av psykosociala funktionsnedsättningar Symptomlindring: Egenbehandling av symptom (t.ex. cannabis, alkohol, kokain) Arias et al. Addictive Behaviors 2008;33(9):1199–207. Asherson. 1st European Network Adult ADHD Conference. London, 2011.

3.3 Hur man skiljer ADHD från andra vanliga psykiska sjukdomar
Avsnitt 3: Komorbiditet och differentialdiagnoser 3.3 Hur man skiljer ADHD från andra vanliga psykiska sjukdomar

ADHD och depressionssymptom
Affektiv störning Kronisk affektiv instabilitet Affektiv instabilitet endast under episod Ingen anhedoni, inga aptitstörningar Neurovegetativa symptom föreligger Svarar vanligtvis på symptomkontroll och förbättring av funktionsnivån Episoder av depression, som kräver separat depressionsbehandling Skirrow C, Hosang GM, Farmer AE, Asherson P. An update on the debated association between ADHD and bipolar disorder across the lifespan. Journal of Affective Disorders 2012; 141:143–159. An irritable or unstable mood is frequently seen in adults with ADHD and is not usually the consequence of comorbid depression or bipolar disorder. In this case, treatment should be targeted at ADHD. Mood instability may also arise as part of a major affective disorder and care must therefore be taken to ensure that mood lability does not occur solely within the context of a depressive or manic/hypomanic episode. This is determined predominantly by attending to the time course of the symptoms (i.e., early onset, chronic trait-like course, frequency of mood swings), and the detailed psychopathology (i.e., whether the mood swings are extreme, sustained for longer periods, or are associated with other features of major affective disorder). Where there is a clear cyclical mood disorder, treatment with mood stabilizers or antidepressants usually takes priority over other treatments. Some individuals previously diagnosed with atypical depression, cyclothymia, or emotionally unstable personality disorder (who may or may not also fulfill criteria for these diagnoses) will have a primary diagnosis of ADHD with good response to stimulants. A previous history of such diagnoses should therefore not exclude the possibility of ADHD as the primary diagnosis. Individuals with ADHD may present with an episode of depression that requires treatment. In this case, treatment of depression would usually be the priority because of the risks of untreated depression. Moreover, persistence of major depression may interfere with the efficacy of treatments for ADHD. Amons. J Affective Disord 2006;91:251–5. Kooij et al. J Attention Disord 2012;16:3S–19S.

Utvärdering och behandling av patienter med affektiv instabilitet
Affektiv instabilitet kan vara en central komponent i ADHD-syndromet1 Vid (kroniskt) affektiv instabilitet eller depression2: Ställ frågor för ADHD-screening Utvärdera om det föreligger affektiv störning (egentlig depression, hypoman eller blandad episod) Hantering: Affektiv instabilitet som en del av ADHD svarar bra på ADHD-behandling3-4 Om ADHD och den affektiva störningen är komorbida bör båda behandlas, men ordningen kan bero på svårighetsgraden och typen av komorbiditet.5Till exempel: Behandla först den svåra affektiva episoden, ompröva sedan diagnosen och behovet av behandling av ADHD Vid mildare depressiva symptom eller personlighetsstörningar – behandla ADHD först Kooij SJ, et al. BMC Psychiatry Sep 3;10:67. Treatment should follow careful diagnostic assessment of ADHD and associated comorbid disorders. In the case of comorbidity, the integrated treatment plan should address both ADHD and the comorbid condition, the order of pharmacological treatment depending on the type and severity of comorbidity. Generally, severe mental health disorders should be treated first, such as in-patients with psychosis, major depression, mania or drug addiction; following which the diagnosis of ADHD and need for treatment can be reviewed. However, treatment of milder depressive and anxiety disorders may be deferred until after treatment of ADHD and often needs no further treatment as the comorbid symptoms may resolve following effective treatment of ADHD. Symptoms such as demoralisation and low self-esteem following a life with ADHD, and mood instability, improve with stimulant treatment alone. It is up to the clinician to decide on what is the most important need for every patient with specialist advice being sort for more complex cases. Skirrow et al. Expert Rev Neurother 2009;9:489―503. McIntosh et al. Neuropsych Dis Treat 2009;5:137―50. Reimherr et al. Biol Psych 2005;58:125―31. Rösler et al. World J Biol Psychiatry 2010;11:709–18. Kooij et al. BMC Psychiatry. 2010;10:67.

ADHD och ångest ADHD Ångestsjukdom Oavbruten mental aktivitet1
Ångestfylld oro (kan te sig som tvångstankar [OCD])2 Motorisk rastlöshet1 Nervösa spänningar2 Hereditet för ADHD2 Hereditet för ångest–depression2 Undviker frustrerande situationer: Shopping, sociala situationer, köer, resor Fobiskt undvikande2 Blir lätt överväldigad av stimuli3 Blir lätt ångestfylld2 Glömska2 Hypervigilans Inga somatiska symptom1 Somatiska symptom1 Förbättras av centralstimulerande medel4 Förvärras av centralstimulerande medel4 Kooij JJS, et al. J Att Dis. 2012;16(5S):3S-19S. Anxiety is another frequent comorbidity with ADHD: lifetime prevalence of anxiety disorder among patients with ADHD is 60%, and about 10% of adults with anxiety disorders also have ADHD. Anxiety disorders share symptoms with ADHD such as attention and concentration deficits. However, with anxiety disorders, there usually are symptoms of psychic and somatic anxiety present, whereas for ADHD these symptoms are not typical. Besides GAD other anxiety disorders that are more prevalent among ADHD patients include panic disorder, agoraphobia, post-traumatic stress disorder, social phobia, and specific phobia. Kooij et al. J Att Dis 2012;16:3S–19S. Wender PH. Oxford University Press 1995. APA. DSM-IV-TR. APA 2000 Produktresumé för Ritalin

ADHD och bipolär sjukdom
Debut i tidig barndom1 Debut i ungdomen eller vuxen ålder1 Ger intryck av att vara en del av personligheten, ingen förändring från tillståndet före sjukdomen1 Episodiskt förlopp, förändring från tillståndet före sjukdomen1 Livlig, men inte grandios/upprymd Grandios/upprymd2 Beskriver svårigheter att fungera1 Beskriver hög funktionsnivå1 Kroniskt låg självkänsla2 Episoder av depression1 Har vanligen sjukdomsinsikt, klagar över växlande sinnesstämning Tenderar att sakna sjukdomsinsikt1 Sömnsvårigheter2 Minskat sömnbehov2 Klagar över att inte kunna koncentrera sig/fokusera1 Subjektiv känsla av skärpt mental förmåga1 Rastlös (motorisk oro, svårt att vara stilla)1 Överaktivitet, ofta kopplad till orealistiska idéer/planer1 Kooij JJS, et al. J of Att Dis 2012; 16(5S) 3S-19S. Bipolar disorder and ADHD are two distinct disorders that may coexist together, especially bipolar II disorder. Both disorders are associated with hyperactivity, racing thoughts, distractibility, impulsivity, and talkativiness, although these symptoms are limited to the (hypo)manic episodes in bipolar patients, and they are chronically persistent in ADHD. However, bipolar disorder can be differentiated by the prominence of episodic mood symptoms. Grandiosity, decreased need for sleep, hypersexuality, and racing thoughts are more specific to bipolar disorder. Conversely, adults with ADHD show a chronic pattern of high energy, difficult sleeping, and often cannot slow down their racing thoughts to attain cognitive relaxation. In addition, patients with ADHD may also have episodic-like deterioration in functioning because ADHD is characterised by variable performance, reactivity, and developmental hurdles. APA. DSM-IV-TR. APA 2000. Kooij et al. J Att Dis 2012;16:3S–19S.

ADHD och personlighetsstörning
Borderline-personlighetsstörning Debut i barndom/ungdom1 Definieras av funktionsnedsättningar2 Kronisk personlighetsliknande egenskap1 Visar sig i alla typer av situationer1 Visar sig i alla typer av situationer2 Affektiv labilitet (kan vara svår)4 Affektiv labilitet3 Impulsiv3 Uppmärksamhetsproblem3 Fanatiska ansträngningar för att undvika verkligt eller inbillat övergivande4 Återkommande självmordsbeteende4 Kooij JJS, et al. J of Att Dis. 2012;16(5S) 3S-19S. Impulse-control disorders include disorders such as antisocial and borderline personality disorder (BPD), oppositional defiant disorder (ODD), conduct disorder, and intermittent explosive disorder. Data from the NCS-R study found that 20% of ADHD patients had impulse-control disorders, with a lifetime prevalence rate of 70% (Adler, Spencer et al 2008; Kessler 2006). Among the adults with impulse-control disorders, 12% had ADHD. Longitudinal studies suggest that the prevalence of comorbid antisocial and BPD in adults with ADHD is 10- to 13-fold compared with adults without ADHD (Miller 2008). Antisocial and BPD share symptoms such as impulsivity and affective lability with ADHD; however antisocial personality disorder is also characterised by an arrest history and lack of insight and remorse regarding behaviours, and BPD by chronic instability in interpersonal relationships and self-esteem. To differentiate ADHD from BPD it is important to know that BPD is not charcterised by lifetime inattention and hyperactivity but by abondonment fears, self-injurious behaviour, and dichotomous thinking: behaviours not typical for ADHD. APA. DSM-IV-TR. APA 2000. Distel et al. Am J Med Genet 2011;156:817–25. Miller et al. J Clin Psychiatr 2008;69:1477–84. Kooij et al. J Att Dis 2012:16(5S):3S–19S.

Prevalensen av ADHD som barn / vuxen hos kvinnor med borderline personlighetsstörning (BPD)
Förekomsten av ADHD som barn / vuxen utvärderades i en grupp av 118 kvinnor som sökt behandling för BPD 41.5% uppfyllde kriterierna för barn ADHD (genom retrospektiv diagnos, Wender Utah Rating Scale) 16.1% diagnostiserades med vuxen-ADHD ADHD som barn var förknippat med känslomässiga övergrepp i barndomen och en ökad svårighetsgrad av borderline symptom som vuxen Bipolar disorder and ADHD are two distinct disorders that may coexist together, especially bipolar II disorder. Both disorders are associated with hyperactivity, racing thoughts, distractibility, impulsivity, and talkativiness, although these symptoms are limited to the (hypo)manic episodes in bipolar patients, and they are chronically persistent in ADHD. However, bipolar disorder can be differentiated by the prominence of episodic mood symptoms. Grandiosity, decreased need for sleep, hypersexuality, and racing thoughts are more specific to bipolar disorder. Conversely, adults with ADHD show a chronic pattern of high energy, difficult sleeping, and often cannot slow down their racing thoughts to attain cognitive relaxation. In addition, patients with ADHD may also have episodic-like deterioration in functioning because ADHD is characterised by variable performance, rea ctivity, and developmental hurdles. Br J Psychiatry Feb;192(2): doi: /bjp.bp Attention-deficit hyperactivity disorder as a potentially aggravating factor in borderline personality disorder. Philipsen A1, Limberger MF, Lieb K, Feige B, Kleindienst N, Ebner-Priemer U, Barth J, Schmahl C, Bohus M. Author information 1Department of Psychiatry and Psychotherapy, University Medical Center, Freiburg, Germany. Abstract BACKGROUND: Clinical experience suggests that people with borderline personality disorder often meet criteria for attention-deficit hyperactivity disorder (ADHD). However, empirical data are sparse. AIMS: To establish the prevalence of childhood and adult ADHD in a group of women with borderline personality disorder and to investigate the psychopathology and childhood experiences of those with and without ADHD. METHOD: We assessed women seeking treatment for borderline personality disorder (n=118) for childhood and adult ADHD, co-occurring Axis I and Axis II disorders, severity of borderline symptomatology and traumatic childhood experiences. RESULTS: Childhood (41.5%) and adult (16.1%) ADHD prevalence was high. Childhood ADHD was associated with emotional abuse in childhood and greater severity of adult borderline symptoms. Adult ADHD was associated with greater risk for co-occurring Axis I and II disorders. CONCLUSIONS: Adults with severe borderline personality disorder frequently show a history of childhood ADHD symptomatology. Persisting ADHD correlates with frequency of co-occurring Axis I and II disorders. Severity of borderline symptomatology in adulthood is associated with emotional abuse in childhood. Further studies are needed to differentiate any potential causal relationship between ADHD and borderline personality disorder. Philipsen et al. Br J Psych 2008;192:118–123.

ADHD och somatiska sjukdomar
Tyreoidearubbningar: Hypotyreos: kan uppvisa symptom på ouppmärksamhet Hypertyreos: kan uppvisa hyperaktivitet och ouppmärksamhet, handla impulsivt Järnbristanemi: Uppmärksamhetsproblem Förlångsammade kognitiva processer Young. ADHD Grown Up: A Guide to Adolescent and Adult ADHD. London: WW Norton; 2007.

ADHD och somatiska sjukdomar
Epilepsi: Högre incidens av symptom på ADHD hos barn med epilepsi Högre incidens av epilepsi hos barn med ADHD Förefaller vara allvarligare än hos dem utan ADHD Hjärnskada: Risk för fysiska skador på grund av ADHD-symptom Hjärnskador (särskilt på frontalloberna) kan ge sekundär ADHD Barn/ungdomar med en måttlig/svår hjärnskada har 20 % risk att utveckla sekundär ADHD Övrigt: Fetma CADDRA: Canadian ADHD Practice Guidelines, Third Edition, Toronto ON; CADDRA, 2011 ADHD and Epilepsy Some studies have suggested a higher incidence of symptoms of ADHD in children with epilepsy. Other research noted a strong trend toward a higher incidence of epilepsy among children with ADHD than among children without ADHD. Epilepsy in children with ADHD appears to be more severe than in those without. ADHD and Brain Injury (any aetiology) Individuals with ADHD of all ages are at risk for physical injuries because they are impulsive, hyperactive and inattentive. Any injury to the brain, particularly to the frontal lobes, can produce a syndrome known as Secondary-ADHD (S-ADHD). Trauma to the brain can also worsen the symptoms of pre-existing ADHD. Children and teens with ADHD are three times as likely to experience a moderate or severe brain injury than their peers without ADHD. Children and adolescents with a moderate or severe brain injury have a 20% chance of developing S-ADHD. The literature on adults is less clear. Given that concussion and brain injury are relatively common experiences, it is recommended that all patients being assessed for ADHD be questioned as to whether they have ever had a concussion or brain injury in the past. It is generally accepted that the more severe the brain injury, the greater the likelihood of developing or worsening ADHD. This is the one instance in which a patient may present with de novo ADHD symptoms, having no past history of these types of symptoms before the injury. CADDRA. Canadian ADHD Practice Guidelines. 3rd Edn. CADDRA: Toronto ON; 2011.

Slutsatser ADHD är en neurobiologisk sjukdom, kännetecknad av ihållande mönster av uppmärksamhetsproblem och/eller hyperaktivitet, impulsivitet och nedsättning av exekutiv funktion ADHD-symptomen kvarstår upp i vuxen ålder och orsakar betydande kliniska, sociala, ekonomiska, psykologiska och funktionella problem ADHD hos vuxna är ofta förenad med ett antal komorbida tillstånd Diagnostik av ADHD hos vuxna är en mångfacetterad process Läkaren bör noga överväga komorbiditet och somatiska ”rule-outs” ADHD hos vuxna är ett behandlingsbart tillstånd Atom

Förskrivarinformation Strattera
Strattera® 10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg och 100 mg kapslar, hårda (atomoxetin) ATC-kod: N06BA09 Indikationer: Behandling av ADHD (Attention Deficit Hyperactivity Disorder) hos barn (6 år och äldre), ungdomar och vuxna som en del i ett komplett behandlingsprogram. Behandling skall påbörjas av en läkare som är specialiserad på behandling av ADHD, så som barnläkare, barn/ungdomspsykiater eller psykiater. Diagnos skall ställas enligt gällande DSM- kriterier eller riktlinjerna i ICD. Kontraindikationer: Samtidig behandling med monoaminoxidashämmare eller glaukom med trång kammarvinkel. Atomoxetin bör inte användas till patienter med allvarlig kardiovaskulär eller cerebrovaskulär sjukdom. Atomoxetin skall inte användas till patienter som har, eller som tidigare haft, feokromocytom. Varningar: Självmordsrelaterat beteende (självmordsförsök och självmordstankar) har rapporterats hos patienter som behandlas med atomoxetin. Skall inte användas till barn yngre än 6 år. Datum för översyn av produktresumén: Läs bipacksedeln före användning. För ytterligare information och priser se Rx, F Subventioneras när svar på tidigare behandling med metylfenidat bedöms vara kliniskt otillräckligt, eller när behandling med centralstimulerande medel är olämpligt. Eli Lilly Sweden AB, Box 721, Solna

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