Inside ‘Puter’s Brain
Gentle Readers, ‘Puter has, in true ‘Puter fashion shared with you his recent diagnosis of adult ADHD. Now for those of us who have known ‘Puter for quite some time, our reaction was, “Well, DUH!, That’s why we love ‘Puter!”
But, in all seriousness, Dr. J. wishes his friend and fellow Gormogon well and that he receives benefit from treatment, but not too much, as he has to finish MoDo part 3, and E.J. Dionne still needs his weekly eviserations.
So, what is ADHD?
ADHD is a real condition that is probably overdiagnosed. In the 1970s, about 1.2% of kids carried the diagnosis, while in the 1990s, that rose to 3.4%. Dr. J. is of the opinion that some of that rise is probably due to overdiagnosis rather than new real cases. Dr. J. has worked with kids who have it, so make no mistake, it is not a made up diagnosis.
The DSM-IV use the following criteria to make the diagnosis (which Dr. J. borrowed from the CDC), see how many co-workers you can diagnose:
I. Either A or B:
A. Six or more of the following symptoms of inattention have been present for at least 6 months to a point that is inappropriate for developmental level:
Inattention
1. Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
2. Often has trouble keeping attention on tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions).
5. Often has trouble organizing activities.
6. Often avoids, dislikes, or doesn’t want to do things that take a lot of mental effort for a long period of time (such as schoolwork or homework).
7. Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).
8. Is often easily distracted.
9. Is often forgetful in daily activities.
B. Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level:
Hyperactivity
1. Often fidgets with hands or feet or squirms in seat when sitting still is expected.
2. Often gets up from seat when remaining in seat is expected.
3. Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).
4. Often has trouble playing or doing leisure activities quietly.
5. Is often “on the go” or often acts as if “driven by a motor”.
6. Often talks excessively.
Impulsivity
7. Often blurts out answers before questions have been finished.
8. Often has trouble waiting one’s turn.
9. Often interrupts or intrudes on others (e.g., butts into conversations or games).
II. Some symptoms that cause impairment were present before age 7 years.
III. Some impairment from the symptoms is present in two or more settings (e.g. at school/work and at home).
IV. There must be clear evidence of clinically significant impairment in social, school, or work functioning.
V. The symptoms do not happen only during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder. The symptoms are not better accounted for by another mental disorder (e.g. Mood Disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder).
Based on these criteria, three types of ADHD are identified:
IA. ADHD, Combined Type: if both criteria IA and IB are met for the past 6 months
IB. ADHD, Predominantly Inattentive Type: if criterion IA is met but criterion IB is not met for the past six months
IC. ADHD, Predominantly Hyperactive-Impulsive Type: if Criterion IB is met but Criterion IA is not met for the past six months.
So, how does ADHD happen?
There is a theory, which Dr. J. buys, called the low arousal theory…the brain, especially the frontal lobe, has a low level of norepinephrine and dopamine. As a consequence, the kids (or ‘Puter) stimulate themselves by fidgeting, acting out, or whatever. They do this to boost neurotransmitter levels in the brain. They don’t know that, they just drive you batty. Think of your child when he or she is trying to keep themselves from falling asleep. They do all these things and get on your last nerve, then pass out for the night. The difference is that the child with ADHD acts that way ALL THE TIME.
Actually adults act differently than kids. Wikipedia has a nice table contrasting adult and pediatric ADHD for the layman. As you can see from the table, kids are kids, and adults can turn it into a positive or a a negative by the time they hit adulthood. Some, like ‘Puter, are disinhibited, easily bored, and work long hours or two jobs (a Gormogon and a day job). Dr. J. has a friend who is an orthopedic surgeon and a construction contractor who has ADHD, like ‘Puter, he harnessed the energy of the ADHD and turned it into a positive.
This dovetails nicely with the observation that the dopamine (DA) and norepinephrine (NE) released from the presynaptic nerves in the brain get sucked back up from the synapses by reuptake transporters faster than they can bind and activate receptors on the postsynaptic side, as seen in the figure below.
Here, norepinephrine (NE) is released, and it can bind to alpha and beta adrenergic receptors on both the pre- and post- synaptic sides, or get taken back up via transporters (labeled Neuronal Reuptake).
Genetic studies back this up, as the genes coding many of the components of these systems are different in individuals with ADHD than in individuals without the condition.
This is why stimulants like amphetamines and methylphenidate (Ritalin) work so well. They block NE and DA reuptake into the presynaptic nerve, leaving it to activate receptors on the postsynaptic nerve. While they work great, there is always a risk of dependance. They also can raise blood pressure, which limits their utility in hypertensive individuals.
There are also come alternatives. Atomoxetine is an option. It blocks NE, serotonin and dopamine transporters, but has its own set of side effects. Liver toxicity, depression, and hypertension. Conversely guanfacine and clonidine are antihypertensives that stimulate CNS alpha 2-adrenergic receptors. They have depressive side effects as well. The anti-viral amantadine and antidepressants such as bupropion, and members of the tricyclic and SNRIs such as venlafaxine, may have benefit.
Some of these are off label indications for the respective medications, but the risk-benefit is such that it is not inappropriate to write these scripts in such a manner.
We hope this clarifies the issues related to Puter’s malady, and wish him the best as he takes a few of these meds for a test drive!
