Sunday, July 17, 2016

‘Adult-Onset ADHD’: Is It A Real Thing, Or Must It Have Started In Childhood?

June 10, 2016

Zoe Kessler, a Canadian writer and performer, was diagnosed with attention deficit hyperactivity disorder at age 46. At the time, she says, her life was "falling apart" and she was desperate to figure out why.
"I was struggling financially, I'd had any number of romantic relationships gonebad, I felt socially awkward, and, working as a freelance writer, I couldn't concentrate or focus," she said in an interview. "I was so scattered. I'd stand in the middle of a room in my apartment and literally not know what I was supposed to be doing."
Kessler sought help from "psychologists, social workers, psychiatrists, previous life regression therapists and rebirthers." None of them raised the possibility of ADHD, she said.
But when a friend suggested she might have the brain disorder that is most typically associated with "little boys bouncing off the walls," she went to see her doctor.
"Not long after, I left with a prescription for stimulant medication in my hand," she said. That diagnosis and treatment radically changed her life.
And only then did it dawn on Kessler, who wrote a book about her experience, that she'd likely suffered with the condition for decades, beginning in elementary school.

Controversial Findings
ADHD, the thinking goes, generally begins in childhood. In fact, to get diagnosed with ADHD as an adult, a patient needs to demonstrate they've had traits of the condition by age 12. But new research is fueling questions about the origins and trajectory of the brain disorder.
Several reports — two population studies from the U.K. and Brazil, and an earlier study from New Zealand — suggest not only that ADHD can begin in adulthood, but also that there may exist two distinct syndromes: adult-onset ADHD and childhood ADHD.
But as it is with many issues surrounding the disorder, it's controversial and complicated.
In one of the new papers, published last month in the journal JAMA Psychiatry, researchers from King's College, London, assessed a cohort of more than of 2,000 twins born in England and Wales in the mid 1990s. They found that among those over 18 with ADHD, more than two-thirds were not diagnosed during childhood assessments.  Based on that, the researchers said, two different groups emerged: "a large, late-onset ADHD group with no childhood diagnosis, and a smaller group with persistent ADHD" from childhood into late adolescence or adulthood.
They conclude that "adult ADHD is more complex than a straightforward continuation of the childhood disorder," and suggest the possibility that "childhood-onset and late-onset adult ADHD may reflect different causes."
One of the study authors, Dr. Jessica Agnew-Blais from King’s College, offers several theories on what might be driving this "late-onset" ADHD. In a statement, she said:
• The disorder could have been masked in childhood due to protective factors, such as a supportive family environment;
• It could be entirely explained by other mental health problems;
• Late-onset ADHD could be a distinct disorder altogether.

A second report  similarly concludes that adult ADHD may not necessarily be a continuation of childhood ADHD. Rather, researchers say, their results "suggest the existence of 2 syndromes that have distinct developmental trajectories."
"The key message here is that … ADHD [does] not always begin in childhood," said Luis Augusto Rohde, a professor in the department of psychiatry at the Federal University of Rio Grande do Sul in Brazil, and one of the study authors, in an email.
Why does this matter?
Rohde said that for patients, it can be a crucial distinction.  "The majority of clinicians worldwide are trained to only diagnose ADHD in adults when a clear history of ADHD symptoms would be detected during childhood," he said. "According to the data from the two studies, a substantial proportion of adults in the population with clear ADHD symptoms and impairments during adulthood are not receiving diagnosis and treatment."
The researchers say more study is needed to determine the nuances of the disorder. But the findings also raise provocative questions, for instance, are there treatments that might work better for adult patients, and how should clinicians evaluate adults who report no childhood history?

Premature Conclusions?

An editorial in JAMA Psychiatry accompanying the papers cautions about potential flaws in the studies, among them, underestimating the persistence of ADHD into adulthood and overestimating the prevalence of adult-onset ADHD.  In general, the editorial authors suggest, the conclusions of the new research "seem premature."
ADHD, with its telltale traits, including inattentiveness, a need for constant movement and rash, impulsive, sometimes scattered behavior, used to be considered an illness solely of childhood. And while an understanding of ADHD has evolved to include adult sufferers, there remains controversy around the diagnosis.  Some have suggested that the broader definition of ADHD was fueled, at least in part,  to broaden the market for medication manufacturers; and as the criteria for the condition loosened, reports emerged about clinicians involved in diagnosing ADHD also receiving money from drug makers.
These days, much attention has focused on the very young children who are now being diagnosed with ADHD — 4-year-olds and younger — and treated with powerful medications. Earlier this year, for instance, there was public outcry when a new chewable, fruit-flavored ADHD medication hit the market.
And, of course, numerous reports have documented how the medication,  aka "the good grade pill" can be abused by students and others seeking to improve test scores, focus and academic performance.

Pinpointing The Onset of ADHD

Despite all that, the conventional wisdom remains that adults with ADHD also had it as children.  (If you’re wondering if you might have ADHD, the full criteria for diagnosis is on the CDC website.)
Ron Kessler -- a psychiatric epidemiologist and professor of health care policy at Harvard Medical School, and no relation to Zoe Kessler -- says much of the recent literature on adult ADHD  "is just trying to figure out the nature of the beast" since it's a relatively new diagnosis.
"Nobody stands on their desks and jumps up and down as an adult like a fourth grader might," Kessler said, so it's clear the condition can look very different at different ages. Still, says Kessler: "I'd be very cautious jumping to a conclusion that says there are adults who have it who didn't have it as kids."
Based on his own research, which includes a broader view of adult ADHD that involves so-called "executive function" problems, Kessler said "it seems unlikely that out of the clear blue sky, there are all these adults who didn't have symptoms when they were young."
The lead author of the ADHD editorial, Stephen V. Faraone, with the department of psychiatry and behavioral sciences at the State University of New York Upstate Medical University, said in an interview that he's not convinced adult-onset ADHD is a distinct condition but rather that signs of the disorder were there much earlier, but missed.
"My interpretation," he said, is that the researchers involved in the recent studies, "found a group of people with sub-threshold ADHD [patients who have some characteristics of ADHD but don't meet the official criteria for a diagnosis] in their youth. There may have been signs that things weren't going too well, but they weren't bad enough to go to a doctor."
Perhaps these were smart kids with particularly supportive parents or teachers who provided the "scaffolding" needed to help the children cope with their attention problems, he says, but then, "later in life something happen[ed] to trigger full blown ADHD."

'I Don't Care What We Call It'
More than a decade after her diagnosis, Kessler now uses her own ADHD as material for stand-up comedy (An example: "They say people with ADHD think outside the box. That's ridiculous. I lost the box...years ago.")
For Kessler, the question of whether there's really a separate condition known as adult-onset ADHD is more an intellectual pursuit, rather than a pragmatic one.
"Is there adult-onset ADHD? Who knows," she said. "The bottom line is I don't care what we call it — I care that we get help and support and strategies for everyone who suffered from the things I suffered from."

Wednesday, July 6, 2016

Deep TMS Promising for OCD, ADHD, Other Mental Illnesses

Pauline Anderson

May 17, 2016

ATLANTA ― Deep transcranial magnetic stimulation (dTMS), already approved for treatment-resistant depression, is proving beneficial for obsessive compulsive disorder (OCD), adult attention- deficit/hyperactivity disorder (ADHD), and other psychiatric conditions, according to new research.
The success of the technology depends on targeting the most appropriate brain regions, the research suggests.
Results from some of these new studies were presented here at American Psychiatric Association (APA) 2016 Annual Meeting.

Immediate Treatment
A number of psychiatric disorders are associated with abnormal neuronal activity patterns in deep brain regions. Such abnormal activity is the target of TMS.
The noninvasive technology involves applying brief magnetic pulses to the brain. The pulses are administered by passing high currents through an electromagnetic coil placed adjacent to the patient's scalp. The pulses induce an electric field in the underlying brain tissue.
Conventional TMS was approved in 2008 for the treatment of major depressive disorder, which affects an estimated 15 million Americans a year. But this approach misses the target about 30% of the time, according to Aron Tendler, MD, chief medical officer, Brainsway Ltd.
By contrast, the company's Deep TMS System has a "wider, broader, and significantly deeper field," said Dr Tendler.
The Brainsway device, which is encased in a helmet that holds a large magnet, was approved for use in depression in 2013. The company is now investigating different coils and stimulation targets to treat other conditions, including OCD, ADHD, and smoking cessation.
In one study, deep TMS was used in 12 patients who had failed not only drug therapy but also at least one course of electric convulsive therapy, which is considered "the most aggressive treatment for depression," said Dr Tendler.
Ten of these patients underwent an adequate dTMS treatment trial. When the daily pulse intensity, but not the number of sessions, was increased, depression improved.
"We got them to remit," said Dr Tendler. "Seven out of those 10 patients had remission from their depression."
An advantage of this deep TMS approach, he said, is that a physician can treat a suicidal or depressed patient who comes into the office right away; there is no need for laboratory work or x- rays.

In addition, he said, the treatment takes only 20 minutes per session. "The patient sits down, you put a helmet on their head, and you do the stimulation."
A typical round of treatment consists of 22 to 44 sessions 5 days a week. The treatment, he said, is covered by most insurance plans, typically under certain conditions ― for example, in patients in whom medications have failed medications.
OCD, ADHD, Schizophrenia
The device also appears promising for OCD. It is believed that this condition involves dysfunctional cortico-striato-thalamo-cortical circuits. 

Whereas conventional TMS coils cannot directly target these circuits, dTMS apparently can.
To test this, researchers first provoked 40 patients to "obsess" and then treated them with dTMS (high [20-Hz] or low [1-Hz)] frequency) or a sham coil 5 days a week for 5 weeks in a double- blind, controlled setting. They targeted the current to the medial prefrontal cortex and the anterior cingulate cortex beneath.

For the group that received high-frequency active treatment, scores on the Yale-Brown Obsessive Compulsive Scale improved significantly in comparison with the groups that received low-frequency treatment and placebo (P = .0243)
A multicenter, randomized controlled trial is now underway and has enrolled about 60 of the target 96 patients with OCD, said Dr Tendler. The study will again compare active stimulation to sham treatment. Results are expected later this year.
Dr Tendler also presented promising results of another randomized, sham-controlled study of the device ― this time in 42 adult patients with ADHD. Here, the target of the stimulation was the right prefrontal cortex.

Although stimulants are an effective treatment for ADHD, some patients cannot tolerate them, said Dr Tendler. "Taking stimulants for a long time is not necessarily the best thing for everybody," he said.
Another area of research is schizophrenia. The investigators conducted a study of the use of stimulation of the prefrontal cortex in four patients with schizoaffective disorder and one with schizophrenia, all of whom had comorbid depression. In all five patients, depression improved ― two patients responded, and three patients went into remission.
"This is probably the only treatment that we know of that works for the negative symptoms of schizophrenia," said Dr Tendler.

He believes that when it comes to dTMS, location of the stimulation is the key to success. Sometimes it takes trial and error or attempts at several different target sites to achieve success.
Yet another study showed that the medial prefrontal, medial orbitofrontal, and anterior cingulate cortices could be alternative targets of stimulation for the treatment of severe depression. Combining treatment targets in patients whose conditions fail to respond might improve the remission rate, said Dr Tendler.
The Brainsway device costs about $200,000 but can be leased for $72,000 per year. The cost includes maintenance.

It is not difficult to learn to use the technology, although there is still a risk, albeit slim, of seizures, said Dr Tendler.
"Exciting, Positive"
Commenting on the findings for Medscape Medical News, David Feifel, MD, PhD, professor, Departments of Psychiatry and Neurosciences, University of California, San Diego, and founding director, UCSD Center for Advanced Treatment of Mood and Anxiety Disorders, estimates that in the past 2 years, he has used the Brainsway device on more than 100 patients with treatment-resistant major depressive disorder.

Although deep TMS is currently approved only for major depression, the preliminary results of studies of the device in OCD, PTSD, nicotine addiction, and for the negative symptoms of schizophrenia are "exciting" and "positive," said Dr Feifel.
Dr Tendler is an employee of Brainsway. Dr Feifel is participating in Brainsway multisite studies in OCD, PTSD, and smoking cessation, for which he receives research funding.
American Psychiatric Association (APA) 2016 Annual Meeting: Abstract 131, presented May 16, 2015.