Mark Williams
Main Post – Case 3: Volume 2, Case #21
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Main Post– Case 3: Volume 2, Case #21: Hindsight is always 20/20, or attention deficit hyperactivity disorder
This case study presents a 31-year-old man with a chief complaint of anxiety of “different types”, stating he “has been successful in graduate school, has financial worries, but states he worries and is tense most of the time”. The client also states he has been anxious for many years, mostly since college, and that now he is “torn in many directions”. He reports symptoms including feeling tense, restless, irritable, argumentative, temperamental, and worries about things other than work or school. He also states his anxiety lingers without the presence of stressors. He denies drug or alcohol use. He is married without children. He is gainfully employed and also in graduate school. He has no significant medical history. Psychological history includes chronic GAD symptoms. His father has AUD, and distant family members have probable bipolar disorder. Current medications on initial visit were Vistaril, Paxil-CR, and Gabitril (Stahl, 2013).
Questions for client:
1.) Did you experience stressful or scary events as a child? Were you physically, sexually, or emotionally abused in the past, or did you witness such abuse? Screening for PTSD could provide a link to the client’s ADHD symptoms. The prevalence of PTSD is significantly higher among adults with ADHD compared to [controls]. Moreover, those with PTSD and ADHD had higher rates of comorbidity than those with ADHD alone (including higher rates of MDD, social phobia, oppositional defiant disorder, and GAD) (Antchel et al., 2013).
2.) Were you ever diagnosed with ADHD as a child, or do you remember having ADHD symptoms in your early life? The classic form of ADHD has an onset by age seven, relating to abnormalities developed in the prefrontal cortex before age seven but last a lifetime. However, later onset ADHD is often diagnosed as well, although not as prevalent.
3.) In what ways do you try to cope with your symptoms? How do you cope with your anxiety? How do you attempt to cope with your inattention? What are your personality characteristics in response to your daily environment? According to Young (2005), adults with ADHD have maladaptive coping strategies stemming from cognitive factors, rather than from personality factors. Their ability, however, to positively reappraise stressful situations is an important protective factor (Young, 2005).
Questions for client’s family:
Since the client is married without children, I would attempt to speak with his wife to gain insight into his condition. I would ask her questions such as: Does he have difficulty with organization? Does he have difficulty remembering appointments or obligations? Does he have trouble finishing the final details of a project? Is he squirmy or fidgety when he is required to sit for a long time? Does he put difficult tasks off or avoid them altogether? Does he seem overactive or driven by a motor at times? These are all core questions included in the ASRS-v 1.1., the adult ADHD self-report scale symptom checklist, which is a valid and reliable screening instrument for ADHD among adults (Green et al., 2019).
Physical Exams and Diagnostic Tests:
I would perform the ASRS v1.1 test with the client, which is the predictive screening tool to assess adults for ADHD. I would also like to utilize the GAD-7 assessment tool as a measure of anxiety symptom severity (Beard, 2014). I would also want to rule out any neurological or medical symptom that could be contributing to the client’s symptoms, so a complete neurological assessment may be indicated. If positive findings are seen, then a CT or MRI of the brain may be indicated.
Differential Diagnoses:
1.) Attention Deficit Hyperactivity Disorder – This is the most likely diagnosis for the client’s chief compliant. The client has experienced ADHD symptoms for a period of longer than six months and meets six or more of the symptom criteria in the ASRS v1.1 screening tool.
2.) Generalized Anxiety Disorder – This is an existing diagnosis for this client. Severity and symptom management should be assessed.
3.) Post-Traumatic Stress Disorder – May be a contributing factor in the prevalence of comorbidities in this client.
Pharmacologic Agents:
1.) Duloxetine (Cymbalta) 60 mg daily. Duloxetine is an SNRI that blocks both serotonin and norepinephrine reuptake pumps, increasing neurotransmission of both. It also will increase dopamine transmission in the frontal cortex. Cymbalta has full ability as an NRI, which is the preferred treatment for patients with both ADHD and anxiety symptoms. The use of stimulants would worsen anxiety symptoms in these patients, and therefore are contraindicated (Stahl, 2013)
2.) Guanfacine-ER (Intuniv) 2 mg daily. Guanfacine is a selective a2A receptor agonist that treats ADHD by enhancing prefrontal cortical function. It works much like clonidine without the sedative and antihypertensive properties. As an augmentation to Cymbalta, guanfacine should work to improve inattention and anxiety symptoms (Stahl, 2013).
Lessons Learned:
In this case study the client presented with chronic GAD and chief complaints of anxiety of different types, which included feeling tense, restless, irritable, argumentative, temperamental, worries about things other than work or school, and feeling “torn in many directions”. It is easy for providers to overlook the presence of ADHD in clients presenting with other comorbidities like GAD. However, assessing for ADHD early on could help identify its presence and more effectively formulate a synchronous treatment plan.
Resources
Antchel, K., Kaul, P., Biederman, J., Spencer, T., Hier, B., Hendricks, K., Faraone, S. (2013).
Postraumatic Stress Disorder in Adult Attention-Deficit/Hyperactivity Disorder: Clinical Features and Familial Transmission. J Clin Psychiatry, 74(3)197-204. Doi:10.4088/JCP.12m07698.
Beard, C, Bjorgvinsson, T. (2014). Beyond Generalized Anxiety Disorder: Psychometric
Properties of the GAD-7 in a Heterogeneous Psychiatric Sample. Journal of Anxiety Disorders, 28(6), 547-552. https://doi.org/10.1016/j.janxdis.2014.06.002
Green, J., DeYoung, G., Wogan, M., Wolf, E., Lane, K., Adler, L. (2019). Evidence for the
Reliability and Preliminary Validity of the Adult ADHD Self-Report Scale V1.1 (ASRS V1.1) Screener in an Adolescent Community Sample. Int J Methods Psychiatr Res, 28(1), 1751. Doi:10.1002/mpr.1751.
