Diagnostic Controversies in Adult Attention Deficit Hyperactivity Disorder

Department of Psychiastry and Biobehavioral Sciences, University of California-Los Angeles, Suite 1414, 300 UCLA Medical Plaza, Los Angeles, CA 90095, USA.
American Journal of Psychiatry (Impact Factor: 12.3). 11/2004; 161(11):1948-56. DOI: 10.1176/appi.ajp.161.11.1948
Source: PubMed


While it is increasingly recognized that attention deficit hyperactivity disorder (ADHD) persists into adulthood, there is no consensus on diagnostic criteria for adult ADHD. In this article the authors describe and contrast competing approaches for diagnosis of adult ADHD used in clinical and research practice.
The authors review the Wender Utah criteria, DSM criteria, and laboratory assessment strategies for adult ADHD. Advantages and disadvantages of each approach are described, and recommendations are made as a basis for clinical assessment and future research.
Both the Wender Utah criteria and DSM-based approaches identify significantly impaired ADHD adults with neurocognitive, biological, and treatment response patterns similar to pediatric ADHD patients. The Wender Utah criteria established the need for retrospective childhood diagnosis and recognize developmental differences in adult symptom expression. The Wender Utah criteria fail to identify patients with predominantly inattentive symptoms, exclude some patients with significant comorbid psychopathology, and diverge significantly from the DSM conception of ADHD. The DSM criteria have never been validated in adults, do not include developmentally appropriate symptoms and thresholds for adults, and fail to identify some significantly impaired adults who are likely to benefit from treatment. There are insufficient scientific data to justify use of laboratory assessment measures, including neuropsychological tests and brain imaging, in diagnosing adult ADHD.
Adult ADHD remains a clinical diagnosis. Clinicians should be flexible in application of the current ADHD criteria to adults. Additional research is required to validate adult diagnostic criteria.

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    • "ADHD is a neurodevelopmental disorder characterized by excessive inattention, hyperactivity, and impulsivity[14]. Although it has a childhood onset, it can persist into adulthood[15]and approximately 60 to 70% of children diagnosed with this disorder grow into adulthood retaining at least some, if not all the specific manifestations of ADHD[16]. A large percent of adults with ADHD (75%) are associated with at least one psychiatric condition[17]. "
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    ABSTRACT: Background and aims: To evaluate the effects of paroxetine on the pharmacokinetics of atomoxetine and its main metabolite, 4-hydroxyatomoxetine-O-glucuronide, after coadministration of atomoxetine and paroxetine in healthy volunteers. Methods: 22 healthy volunteers, extensive metabolizers, took part in this open-label, non-randomized, clinical trial. The study consisted of two periods: Reference, when a single oral dose of 25 mg atomoxetine was administrated to each subject and Test, when 25 mg atomoxetine and 20 mg paroxetine were coadministered. Between the two periods, the volunteers received an oral daily dose of 20-40 mg paroxetine, for 6 days. Atomoxetine and 4-hydroxyatomoxetine-O-glucuronide plasma concentrations were determined within the first 48 hours following drug administration. The pharmacokinetic parameters of both compounds were assessed using a non-compartmental method and the analysis of variance aimed at identifying any statistical significant differences between the pharmacokinetic parameters of atomoxetine and its main metabolite, corresponding to each study period. Results: Paroxetine modified the pharmacokinetic parameters of atomoxetine. Cmax increased from 221.26±94.93 to 372.53±128.28 ng/mL, while AUC0-t and AUC0-∞ also increased from 1151.19±686.52 to 6452.37±3388.76 ng*h/mL, and from 1229.15±751.04 to 7111.74±4195.17 ng*h/mL respectively. The main metabolite pharmacokinetics was also influenced by paroxetine intake, namely Cmax, AUC0-t and AUC0-∞ decreased from 688.76±270.27 to 131.01±100.43 ng*h/mL, and from 4810.93±845.06 to 2606.04±923.88 and from 4928.55±853.25 to 3029.82 ±941.84 respectively. Conclusions: Multiple-dose paroxetine intake significantly influenced atomoxetine and its active metabolite pharmacokinetics, causing a 5.8-fold increased exposure to atomoxetine and 1.6-fold reduced exposure to 4-hydroxyatomoxetine-O-glucuronide.
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    • "When comorbidities are present in adults with ADHD, ADHD becomes more difficult to diagnose, as the symptom expression varies. Consequently, ADHD is not treated properly, despite deteriorating QOL.28 When adults with ADHD had low self-esteem, depression, oversensitivity, impulsivity, affective instability and uncontrolled anger, these symptoms could be misdiagnosed as borderline personality disorder or bipolar disorder. "
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