Agenda. Types of Remission. ADHS im Erwachsenenalter: Was gibt s Neues? Syndromal Remission. Subthreshold Remission (~ Residual) Functional Remission

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1 SUCHTSYMPOSIUM PDGR ADHS im Erwachsenenalter: Was gibt s Neues? Dominique Eich-Höchli i O O O SUCHT UND ADHS Beverin,, 23. Juni 2011 ADHS: Was gibt s Neues? Agenda Langzeitverlauf von ADHS Mögliche Verlaufsparameter: Syndromale Verbesserung Symptomatische Verbesserung Verbesserung der Funktionsfähigkeit Normalisierung / Erreichen des prämorbiden Niveaus Diagnostische Aspekte Komorbiditäten von ADHS Behandlung: NICE, DGPPN Neuer Faktor aus alter Skala: SCL-ADHD Types of Remission Syndromal Remission of full diagnostic status ( -1 symptom) Subthreshold Remission (~ Residual) of most of the ADHD-symptoms Functional Remission Less than subthreshold status and functional recovery Keck et al, Am. J. Psychiatry,

2 Ramos-Quiroga JA and Casas M, 2011 Impact of Development on ADHD inattention impulsivity hyperactivity comorbidity treatment? preschool behavioral disturbances school age - behavioral disturbances - academic problems - difficulty with social interactions - self-esteem adolescence - academic problems - difficulty with social interactions - self-esteem issues - legal issues, smoking and injury college age -academic failure - occupational difficulties - self-esteem issues - Substance abuse - Injury / accidents adulthood - Occupatonal failure - self-esteem issues - Relationship problems - Injury / accidents - Substance abuse Stahl s Illustrated by St.M.Stahl and L.Mignon Levels of Remission Syndromatic of full diagnostic status ( -1 symptom) Symptomatic of partial diagnostic status Functional of partial diagnostic status + functional recovery (full recovery) Biedermann J.,

3 ADHS: Was gibt s Neues? Agenda Langzeitverlauf von ADHS Mögliche Verlaufsparameter: Syndromale Verbesserung Symptomatische Verbesserung Verbesserung der Funktionsfähigkeit Normalisierung / Erreichen des prämorbiden Niveaus Diagnostische Aspekte Komorbiditäten von ADHS Behandlung: NICE, DGPPN Neuer Faktor aus alter Skala: SCL-ADHD DSM-IV-TR / II DSM-IV-TR: In Partial Remission (314.00, ) Adults who met criteria for ADHD (some that caused impairment before age 7 years) and continue to have significant symptoms and impairment that falls below threshold for full diagnoses. ADHD NOS (314.9) Adults who met criteria for ADHD after the age of 7 years. Adults who have impairment from symptoms of inattention or hyperactivity/impulsivity impulsivity but fail to meet all criteria difficulty to start any activity, day dreaming and being hypoactiv. Biederman, Mick, Faraone, Am J Psychiatry, 2000 ADHD in Adults with Variations Full Late-Onset ADHD: full DSM-IV criteria for ADHD onset of some symptoms < 7y ADHD: full DSM-IV criteria for ADHD no age-at at-onset criterion (7 12y) Subthreshold ADHD: never DSM-IV criteria for ADHD chronic history of 3 hyperactive-impulsive impulsive symptoms / 3 inattentive symptoms Faraone SV et al., 2006, Am J Psychiatry; 163:

4 ADHS: Was gibt s Neues? Agenda Langzeitverlauf von ADHS Mögliche Verlaufsparameter: Syndromale Verbesserung Symptomatische Verbesserung Verbesserung der Funktionsfähigkeit Normalisierung / Erreichen des prämorbiden Niveaus Diagnostische Aspekte Komorbiditäten von ADHS Behandlung: NICE, DGPPN Neuer Faktor aus alter Skala: SCL-ADHD 0 Auftreten von Störungen Komorbidität Schizophrenien Angststörungen Differentialdiagnose Alkohol- + Drogenmissbrauch / -abhängigkeit Tourette / Tics Störungen des Sozialverhaltens Lernstörungen Persönlichkeitsstörungen Entwicklungsstörungen Affektive Störungen ADHS Soziale Anpassungsstörungen / Delinquenz / Verhaftungen Schul- und Ausbildungsschwierigkeiten Probleme bei der Organisation von Alltagspflichten Soziale Auswirkungen Probleme am Arbeitsplatz 18 Instabile Beziehungen Erziehungsprobleme D. Eich, 2010 Proportion of (adult) subjects at risk of comorbid psychiatric disorders in each proband Schizophrenia: none (Oral communication Prof. Biedermann, ) Faraone SV et al., Am J Psychiatry 2006; 163:

5 Substance use among ADHD adults: implications of late onset and subthreshold diagnoses /I Faraone, S. V., Wilens, T. E., Petty, C., Antshel, K., Spencer, T., & Biederman, J. (2007). Substance use among ADHD adults: implications of late onset and subthreshold diagnoses. Am J Addict, 16 Suppl 1, 24-32; quiz Substance use among ADHD adults: implications of late onset and subthreshold diagnoses /II Faraone, S. V., Wilens, T. E., Petty, C., Antshel,, K., Spencer, T., & Biederman, J.(2007). Am J Addict,16 Suppl 1, 24-32; quiz Continuation /VI Faraone SV, et al.,

6 Substance Use among ADHD adults: implications for late onset and subthreshold diagnoses /VIII all ADHD groups: Full -, late onset ADHD: Full -, late onset ADHD: Nikotin THC * each drug (ex. alcohol) * Nikotin, THC, Alcohol * trouble resisting use of drugs / alc. * getting high (1st and continued use) * * = sign., compared to Not ADHD Faraone SV, et al., 2007 Bi-Directional Overlap between ADHD and SUD Adolescents Adults ADHD: primary disorder SUD ADHD SUD ADHD SUD: primary disorder ADHD SUD SUD ADHD Stahl s Illustrated by St.M.Stahl and L.Mignon 2009 Agenda ADHS: Was gibt s Neues? Langzeitverlauf von ADHS Mögliche Verlaufsparameter: Syndromale Verbesserung Symptomatische Verbesserung Verbesserung der Funktionsfähigkeit Normalisierung / Erreichen des prämorbiden Niveaus Diagnostische Aspekte Komorbiditäten von ADHS Behandlung: NICE, DGPPN Neuer Faktor aus alter Skala: SCL-ADHD 6

7 ADHD in adults Care pathway Adults with suspected ADHD Adults previously diagnosed with ADHD in childhood and with symptoms suggestive of continuing ADHD Secondary care assessment (see identification and referral to secondary care, below) Diagnosis of ADHD (see page 10) Treatment (see section below) Choice of drug (see page 16) Psychological treatment (see page 16) NICE clinical guideline 72; Sept Developed by the National Collaborating Centre for Mental Health Choice of drug Methylphenidate should normally be tried first. Consider atomoxetine or dexamfetamine if symptoms do not respond to methylphenidate or the person is intolerant to it after an adequate ate trial (usually about 6 weeks). Exercise caution if prescribing dexamfetamine to people at risk of stimulant misuse or diversion. Consider atomoxetine as first-line treatment if there are concerns about drug misuse and diversion (for example, in prison). Drug treatment for people who misuse substances should only be prescribed by healthcare professionals with expertise in managing g both ADHD and substance misuse. For adults with ADHD and drug or alcohol addiction disorders,, there should be close liaison between the professional treating the ADHD and an addiction specialist. Do not use antipsychotics for ADHD in adults. NICE clinical guideline 72; Sept Developed by the National Collaborating Centre for Mental Health Summary of recommendations Duration, discontinuation and continuitiy of treatment of adults Drug treatment for ADHD should be continued for as long as it is clinically effective (following an adequate response): to be reviewed annually comprehensive assessment of clinical need, benefits and side effects Take into account: Effect of missed doses Planned dose reductions Brief periods of no treatment Coexisting conditions Assessment of psychological, social and occupational support NICE clinical guideline 72; Sept Developed by the National Collaborating Centre for Mental Health 7

8 ADHS-Therapie bei Erwachsenen nach den deutschsprachigen Leitlinien ( erwachsenen) III Aus Diagnose allein leitet sich keine Behandlungsnotwendigkeit aba Behandlung erst dann, wenn eindeutig durch ADHS - in einem Lebensbereich ausgeprägte gte Störungen oder - in mehreren Lebensbereichen leichte Störungen oder - krankheitswertige Symptome Therapie = multimodal: : Medikation + Psychotherapie Monotherapien sollen begründet werden Komorbide Störungen sind die Regel und müssen m berücksichtigt werden. Aus: Therapie psych. Erkrankungen, 4.Auflage 2008/2009 Psychological treatment Consider group or individual CBT for adults who: are stabilised on medication but have persisting functional impairment associated with ADHD have partial or no response to drug treatment or who are intolerant to it have made an informed choice not to have drug treatment have difficulty accepting the diagnosis of ADHD and accepting and adhering to drug treatment have remitting symptoms and psychological treatment is considered sufficient to treat mild to moderate residual functional impairment. Offer group therapy first because it is the most cost effective. NICE clinical guideline 72; Sept Developed by the National Collaborating Centre for Mental Health Psychotherapie Keine kontrollierten Studien bei Erwachsenen, Evidenzstufe: III, Empfehlungsgrad D (aus D. Ebert et al, Nervenarzt 10, 2003) Störungsspez.. Verfahren, Bramham et al., J Atten Disord in press Evidenzstufe IIa,, Empfehlungsgrad B Structured group psychotherapy..multicentre Study,, Philipsen A. et al., J Nerv Ment Dis, 2007 Cognitive-behavioral therapy..,.., S.A. Safren et al., Behav Res Ther, 2005 C.P. Jacob et al., Multimodale Therapie der Aufmerksamkeitsdefizit it-/ Hyperaktivitätsstörung im Erwachsenenalter, Nervenarzt 7,