6 Challenges in Assessing ADHD in Adult Patients - Psychiatricanswers

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6 Challenges in Assessing ADHD in Adult Patients

By Jennifer A. Reinhold, PharmD, BCPS, BCPP
March 24, 2017


I like the format used to present this article because it is reader-friendly and direct to the point. On the other hand, I believe that the author (as the majority of clinicians do) falls into the trap of endorsing two DSM-supported fallacies:

   “ADHD has a high degree of comorbidities”. The reality that I have found in the past 25 years is that ADHD is frequently considered a Dx of “inclusion” (based of symptoms) instead of one of exclusion. What I mean is that if a person has rapid changes in mood, is irritable or “super happy”, takes 2-3 hours to fall sleep, because of racing thoughts and his parents have spectrum bipolar disorders, OCD or another anxiety disorder, one should consider a Dx different to ADHD.  If the conclusion is, for example, bipolar II disorder then there is no need to add a Dx of ADHD because the lack of attention, restlessness, impulsivity, etc., already have an explanation. Also without logical foundation is to label as “ADHD” a child with Autism Spectrum Disorder.  We all know that Autism comes with obsessions and that those intrusive thoughts distract the person.
   “It is difficult to differentiate bipolar spectrum disorder from ADHD”.  In my entire career I have found one case that let me with doubts about the Dx but I opted for a trial with atomoxetine because that person also was “a nervous wreck” and the stimulants are contraindicated in the presence of anxiety.  The patient responded well and both, the ADHD and the anxiety got better.

Another angle that I want to address is the comment about the potential for “doctor shopping” by pseudo-patients or people addicted to amphetamines. Here in New Mexico (and before in Florida and Arizona) there are doctors and Nurse Practitioners that truly believe that “anybody can benefit from an amphetamine”. Apart from the medical risk that amphetamines pose to the human body, it is the fact that patients with OCD, PTSD and other types of anxiety will get worse if given amphetamines (or even caffeine).  Still, believe it or not, I have found patients with overt psychosis being prescribed psychostimulants.

Finally, I should say that I have a great respect for pharmacist doctors and I welcome their feedback and advice regarding medications but it is true that only physician must diagnose medical conditions.  To rule out medical mimics of psychiatric illnesses you have to be a medical doctor.  Nevertheless, in view of the American Psychiatric Association and the American Academic of Child and Adolescent Psychiatry lack of response to the dangerous practice of allowing teachers and school counselors to “diagnose” AHDH (using a behavioral scale that is not a diagnostic tool) and sending a child to a pediatrician to get a Rx for psychostimulant, I have not quarrel with a pharmacist writing about ADHD.

Dr. Manuel Mota-Castillo
Chief and Residency Program Director
Department of Psychiatry
Burrell College of Osteopathic Medicine
3501 Arrowhead Drive
Las Cruces, NM 88003
Office:  (575) 674-2334
Director of Behavioral Health at Memorial Medical Center
Las Cruces, NM
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