Discussion: Presentations Of ADHD
Discussion: Presentations Of ADHD
Case 3: Volume 2, Case #21: Hindsight is always 20/20, or attention deficit hyperactivity disorder
- Provide the case number in the subject line of the Discussion. Discussion: Presentations Of ADHD
- List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
- Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
- Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
- List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
- List two pharmacologic agents and their dosing that would be appropriate for the patient’s ADHD therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
- If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
- Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.
Case 3: Volume 2, Case #21: Hindsight is always 20/20, or attention deficit hyperactivity
List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
1. Can you describe to me in your own words how you are feeling today and of late? This is an open-ended question to provide some insight on the patient, such as feelings, attitudes, and thoughts, mood, and how he perceives his well-being expressing his anxiety, any depression, and fatigue which should be taken into consideration.
2. Do you feel your medications all work well for you? This gives an insight to if the client is taking his medications as prescribed. Individuals with attention-deficit/hyperactivity disorder (ADHD) may usually be non-compliant with their medication because of symptoms associated with the disease such as hyperactivity, impulsivity, and inattention (Stahl, 2013).
3. Can you tell me what you mean by “torn in many directions”? This will help understand and assess if the client is pressured form work or from home and how it’s interfering with his social life.
4. Do you have thoughts of hurting yourself or others? Because the client expressed feeling like he is “torn in many direction,” in addition to his increased anxiety and high energy levels, it is important to assess the client for suicide ideation and depression.
Identify people in the patient’s life you would need to speak to or get feedback from to assess the patient’s situation further. Include specific questions you might ask these people and why.
To get feedbacks to further assess my client, I would speak to his wife to provide some history in regards to his moods over the years, any past triggers, his routine sleep/wake cycle, and also any information on how he was in his earlier years. From the information given, the client did show signs of ADHD as a kid. If the mother was present, I would ask about family history of ADHD and any other history of mental health disorder when the client was young. According to Starck, Grünwald, and Schlarb (2016), about 40% of ADHD children have at least one parent with clinical ADHD symptoms.
Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
Diagnosis of ADHD is based on clinical evaluation; therefore, no laboratory-based medical tests are available to confirm the diagnosis; however, basic laboratory studies that may help confirm diagnosis and aid in treatment are as serum CBC count with differential, electrolyte levels, thyroid function tests, and liver function tests before beginning stimulant therapy (Soreff, 2018). Other sources for exams or diagnostics are ADHD symptom checklists and a standardized behavior rating scales (Children and Adults with Attention-Deficit/Hyperactivity Disorder [CHADD], 2019). According to CHADD (2019), ADHD rarely occurs alone, and research has shown that more than two-thirds of people with ADHD have one or more co-existing conditions that include depression, anxiety disorders, learning disabilities and substance use disorders; therefore a comprehensive evaluation includes screening for co-existing conditions.
List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
1) Generalized Anxiety Disorder (GAD): According to American Psychiatric Association (2017), GAD involves persistent and excessive worry that interferes with daily activities accompanied by physical symptoms, such as restlessness, feeling on edge or easily fatigued, difficulty concentrating, muscle tension or problems sleeping and sometimes the worries focus on everyday things such as job responsibilities, family health or minor matters. With this client, he reports having financial worries and also “he worries and is tense most of the time.” He also has been anxious for so many years mostly since college and now graduate school and feels “torn in many directions” working part-time and going to school. He is generally tensed, restless, irritable, and worries about things even outside school and work, and this has caused him to be argumentative and temperamental most of the time; therefore, this most likely would be my primary diagnosis.
2) Attention Deficit Hyperactivity Disorder (ADHD)
3) Other Specified Anxiety Disorder
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
Atomoxetine 40mg daily: Atomoxetine (ATX) boosts neurotransmitter norepinephrine/noradrenaline, increase dopamine in profrontal cortex, blocks norepinephrine reuptake pumps, increases noradrenergic neurotransmission, and can also increase dopamine neurotransmission in frontal cortex of the brain (Stahl, 2014b). Therapeutic actions can be seen as early as the first day of dosing and may continue to improve for 8–12 weeks. It is important to monitor blood pressure (Stahl, 2014b) According to Asherson et al. (2014), the low abuse and diversion potential of ATX, once or twice daily dosing with enduring efficacy, stable effect throughout the day, and demonstrated effectiveness in reducing ADHD symptoms in patients with comorbid social anxiety and alcohol use disorders, make ATX an important medication to consider when treating adult patients with ADHD.
Buspar 15mg BID: It is used in the management of anxiety disorders and depression and in the class of serotonin receptor partial agonist (Stahl, 2014b). According to Rabatin and Keltz (2002), Buspirone has no potential for dependence, withdrawal symptoms, or rebound anxiety after drug withdrawal.
Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations Lesson learned was that instead of using polypharmacy approaches with a limited evidence base it is best to consider using solid approved monotherapies also instead of considering adult ADHD as a diagnosis of exclusion, it is better to evaluate this symptom complex earlier in care by using a rating scale, such as the ASRS. Another important lesson learned was to research typical comorbidities and presentations for adult ADHD patients along with diagnostic rating scales and instruments that may aid in diagnosing ADHD in adults; therefore it is very essential in making sure to get an accurate assessment in diagnosing and treating clients that present with several psychiatric disorders and always discuss the risks and benefits of any new psychoactive medication or dose adjustment and adhering to treatment at the same time monitoring its efficacy.
American Psychiatric Association. (2017). What Are Anxiety Disorders? Retrieved from https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders
Asherson, P., Bushe, C., Saylor, K., Tanaka, Y., Deberdt, W., & Upadhyaya, H. (2014). Efficacy of atomoxetine in adults with attention deficit hyperactivity disorder: an integrated analysis of the complete database of multicenter placebo-controlled trials. Journal of psychopharmacology (Oxford, England), 28(9), 837-46.
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Children and Adults with Attention-Deficit/Hyperactivity Disorder. (2019). Diagnosis of ADHD in Adults. Retrieved from https://chadd.org/for-adults/diagnosis-of-adhd-in-adults/
Rabatin, J., & Keltz, L. B. (2002). Generalized anxiety and panic disorder. The Western journal of medicine, 176(3), 164-8.
Soreff, S. (2018). Attention Deficit Hyperactivity Disorder (ADHD) Workup. Retrieved from https://emedicine.medscape.com/article/289350-workup#showall
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Starck M, Grünwald J, & Schlarb AA. (2016). Occurrence of ADHD in parents of ADHD children in a clinical sample. Neuropsychiatric Disease and Treatment, Vol 2016, Iss Issue 1, Pp 581-588 (2016), (Issue 1), 581. Retrieved from https://ezp.waldenulibrary.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edsdoj&AN=edsdoj.0945878b277f40c58b2346f4c66f35f3&site=eds-live&scope=site