Play PodcastPlay Download PodcastDownload

Transcription:

Announcer: With a relentless focus on excellence in healthcare, Pullman Regional Hospital presents The Health Podcast.

Deborah Howell: All right. You know, people throw the term ADHD around all the time, but do they really know what the condition is truly about? Well, to learn a little bit more about ADHD and its diagnosis and treatment, we're going to talk to someone who knows all about it. Today, we'd like to welcome Dr. Chad Sanders, a clinical neuropsychologist here at Pullman Regional. Hello, Dr. Sanders, and welcome.

Dr. Chad Sanders: Hi. Good morning.

Deborah Howell: So glad you're here. Let's dive right in. What are the signs of having ADHD?

Dr. Chad Sanders: So, there are quite a few. If we go right to the DSM, there are two categories. There's primary inattentiveness and hyperactivity. And this is where colloquially people think of ADD versus ADHD. Technically, it all falls under the banner of ADHD and there are three subtypes. There's predominantly inattentive, predominantly hyperactive and combined, but that stuff doesn't really matter. If you say ADD, that's fine too.

Your primary inattentive symptoms, and for anyone who has ADHD, you don't need to manifest every single one of these. It's about five or more for adults or six or more for kids. But basically for inattention, it's a variety of things, just like it sounds. Problems with focus, problems with following through on tasks, kind of sticktuitiveness; difficulties with organization, structure; problems remembering appointments, obligations, stuff like that. Things that require a lot of sustained attention tend to be avoided. Often people with ADHD just don't do well with tasks that require a long burst of attention, and so you kind of have more of switching between tasks pretty quickly. Carelessness, tendency to make careless or rushing mistakes is another common symptom. Primary problems with sustaining attention in conversation, it can be very difficult for people with ADHD to stay focused just like other contexts. But for others, you can notice that it seems like "Are you listening to me?" or "Did you hear what I just said?" that kind of thing, and it's a more of a recurring problem. And then, losing track of key objects, key things. I'll talk about this probably a bit later as we go into other areas. But people with ADHD over time just kind of learn that they will lose things that are key if they don't do certain strategies to keep track of it. And then, just your filter for distraction is just lower. And so, you hear those stereotypes about like, "Squirrel," all that stuff.

Deborah Howell: I was just going to say, "Squirrel."

Dr. Chad Sanders: Yep. Yeah, it's a real thing. And then, for hyperactivity, it's kind of the outward manifest symptoms and so, fidgeting, squirming, straightforward hyperactivity. But internally, and this is more apparent to the older the person gets, is feeling more driven to do things, driven by a motor, kind of an ongoing tempo. Oftentimes leaving situations when staying seated, staying calm, staying quiet is appropriate. So, kind of moving around or even sometimes standing up in a chair at a movie theater, but difficulties with staying seated or staying kind of still when you're supposed to. Often feeling restless, feeling on edge in terms of needing to do stuff. Difficulty unwinding or slowing down and being quiet. Even for things sometimes that are enjoyable to the person, it can be hard to do it quietly. Talking excessively in social situations and it's not always talking excessively as far as like fast-paced and loud, but it can also be kind of not following the rules, so kind of intruding on boundaries of others, finishing people's sentences, jumping in when you're not supposed to.

And then, difficulties waiting turn is actually one of the specific symptoms in the DSM, but that can look more diverse than that. And so, it can be things like when you're supposed to wait a certain given amount of time for any potential thing, you might just not make it and try to get done earlier. You might give up and you might walk away. And so, people with ADHD are, for example, more likely where if you're at a grocery store and it's really busy and there's a long line, you might be the person that gets out of line to go try to find a shorter one. And then, you end up wasting more time because of problems with the organization and the combination can really manifest. So in a nutshell, those are the kind of key domains, symptom-wise.

Deborah Howell: And as you were talking, I was wondering, does ADHD present differently in children versus adults?

Dr. Chad Sanders: It does. Yeah. Some of the primary things are kind of the same, but the trend from kids to adults is you see kind of through shaping, certain things don't look the same in adulthood. The key neuro kind of chemical etiology is the same, basically deficiencies in norepinephrine and dopamine, that kind of thing, problems with your prefrontal cortex. But for example, hyperactivity looks a certain way in childhood, the stereotypes being bouncy all over the place, et cetera. As people age, that changes and usually it changes through kind of social consequence, private consequence, and you can kind of get shaped to where as a kid, if you are getting out of your seat, bouncing around big picture hyperactivity, that might look the same in adults or not look the same. But in adulthood, that might look like twirling a pen in your hand or twirling a ring on your finger or bouncing your leg versus bouncing your whole body. The inertia, the need for sensation doesn't go away, but the way a person learns to redirect and kind of do it in a more socially acceptable manner, that's what manifests. That's why there's a lot of misconceptions about things like, "Oh, there's a very distinct ADHD in adulthood that's not there in childhood," that's not true. ADHD is there in childhood. If it's not, you don't have ADHD, but it just looks slightly different over time as a person ages.

And then, there's other things. Sexism actually has a pretty big role on this for females. So, children with ADHD, boys in general, regardless of ADHD, are given more latitude because that's kind of the way that our culture works. And so, boys, there's less consequence, there's less immediate repercussions for being outwardly hyperactive and active in that way disrupting others. Girls get consequenced more early and it's not fair, but it's just that is what it is as it stands. And so, females are more likely to internalize that sensation-seeking earlier in life, and that, unfortunately, as a population can leave it slightly less likely to be seen for ADHD as time goes on because of learning to compensate. And the problem with that is that it doesn't go away, it just gets redirected, and that takes effort, that takes compensatory resource. And that's the true trend for adults anyway, is that there's just more resource and effort put into compensate for some of those outward manifest symptoms in comparison to childhood.

Deborah Howell: Fascinating. I'm learning so much. Now, of course, with the internet, it is so easy to self-diagnose anything and everything. How can people figure out if they truly should seek out a professional's opinion?

Dr. Chad Sanders: Yeah. If you go on the internet and you look at the symptoms, you'll think you have ADHD. It's just one of those things where everybody has ADHD. You know, it's kind of a popular trend too, where like, "Oh, I'm so ADHD," or "I have ADHD," and it is a more common disorder and those rates are kind of relatively on the rise, but not everybody has ADHD. And so, the big thing to think about with that is the pervasiveness and the level of functional impact. And I have this kind of dumb phrasing with this where people who don't have ADHD and you ask them about it and can think, "Oh yeah, I can think of times when I couldn't focus," and someone who has ADHD, like, "Oh yeah, I can think of times when I could focus," that there's this much more broad level of inattention on a daily level my whole life.

And so, the common things that bring people in for ADHD when they don't have ADHD, especially like here in Pullman, which is a college town, is you get to college and difficulty has totally ramped up. You're not used to it. College level coursework is a real thing that you're going to be confronted with, not used to to the level of work requirements, et cetera, and then you start to have problems with focus and concentration. So, ADHD is in the ether. People talk about it, especially in college towns. Through diversion, you might even take a friend's stimulant and think, "Oh my, gosh, I could think really sharp. That was wonderful. I must have ADHD." And so, you get seen and you don't. On a side note, like that stimulant example, response to stimulant medication is not diagnostic because anyone who takes a stimulant that day will notice, "Wow, my concentration is really a lot better, and I can focus in." What you will notice if you take a stimulant every day if you don't have ADHD, is it will cause you problems over time if you have cardiovascular issues, anxiety, acute stress, that kind of stuff. Whereas someone with ADHD won't manifest those problems over time with a stimulant. So initial response, and because we see this a lot in college towns where, like it or not, you take a friend's stimulant and like, "Man, that was really helpful during finals," well, that's not exactly diagnostic. That's something that anybody could benefit from in that way, but it's the pervasiveness in the chronic nature.

Deborah Howell: I was wondering if you could give us an example of a stimulant.

Dr. Chad Sanders: Oh, sure. There's quite a variety these days. I mean, the still predominant one is Adderall, dextroamphetamine, and that's an agonist for norepinephrine and dopamine. But there's a lot of other ones too, Ritalin, and these are primary stimulants, but there's quite a few of those. And then, there's non-direct stimulants, so there's SNRIs like atomoxetine or Strattera. There's guanfacine. There's some secondary tier ones too that sometimes people do that can help in multimodal ways, so bupropion or Wellbutrin is one that can be prescribed fairly often, especially if there's any secondary mood issues, things like that. So, there's quite a few options and you'll just want to talk with your primary care provider, whomever is the prescribing person about your full context, because ADHD is often comorbid, and so there's other factors to take into consideration when you go down that road.

Deborah Howell: Okay. And I just wanted to make sure, you know, you're not saying caffeine or anything like that. You're talking about actual...

Dr. Chad Sanders: Yeah. So, caffeine actually is a pretty common self-medicating agent people with ADHD use, and caffeine blocks adenosine. And adenosine is a neurotransmitter that's designed to signal your brain that you're tired. And so when you take caffeine and you block adenosine, that sleep signal goes away. And it kind of indirectly activates your central nervous system because you don't feel as tired, which on a side note is why if people just plug coffee all day, every day, you will crash eventually, because eventually your systems will just shut down even if you're not aware of being tired.

But with ADHD, when you take something that blocks adenosine and it indirectly stimulates your central nervous system, that has a downstream effect on norepinephrine and dopamine, for example. And so, that's why coffee can be something that you can see folks with ADHD will drink and it can be self-medicating where you don't see the traditional effect where a person with ADHD could drink a cup of coffee and then take a nap. Part of that is neurochemistry, is if you're starting deficient with things like norepinephrine and then you take a stimulant and it brings you so to speak up to homeostasis, then it can facilitate things like sleep. So like kids with ADHD who are just bouncing around at night and just boom, boom, boom, and then fall asleep in like five seconds once they hit the pillows, sometimes that's because there's this sensation-seeking that comes with the nature of ADHD that makes it hard to fall asleep. But as soon as you get adequate stimulation, then sleep can kind of happen. Because sleep is one of those things that you need to clear the way for it to happen naturally, you can't force it.

And so with ADHD, weirdly enough, there has to be an adequate degree of stimulation sometimes to fall asleep, which is also why sometimes people with ADHD don't have to follow the rules when it comes to sleep hygiene in certain ways, because things like, you know, the big one, which is really important with sleep hygiene is no screens at bed. But when you have ADHD, sometimes you need a little bit of stimulation to be able to fall asleep. Otherwise, your mind can go off on adventures and wandering and you can find that you're restless in bed, rolling around a lot, that you're still in this deficiency in norepinephrine and dopamine, you're needing that sensation. So, a little bit of stimulation can be good. You still follow the same rules. You don't want to be watching some extremely scary, intense horror movie, but just a little bit of that white noise level of stimulation or activity can sometimes be facilitating. Sorry, I got way off track speaking of ADHD.

Deborah Howell: No, this is just fascinating. How is ADHD medically diagnosed?

Dr. Chad Sanders: Yeah. So, that's a really important question. Like so many things, it often starts at the primary care level. Primary care providers see everything. They don't get near enough credit and ADHD most of the time presents at primary care. So typically there, you'll do a screening. But diagnostically, it's pretty rare these days for you to be diagnosed with ADHD at the primary care level because, unfortunately, they just don't have the time to do it. They have so much demand on their schedule and diagnosing ADHD is a very complex process. So for primary care, it's difficult to go down the road of treating ADHD, which the predominant treatment is a stimulant, if you don't feel like you have enough data to support the diagnosis, because it's a rule out disorder.

So typically, you'll be referred for a specialty evaluation and the textbook evaluation would be a full neuropsych evaluation. It's not always available depending on where you live. Here in Pullman, myself and my colleague here at the hospital, and there's a few other folks in the area, do full neuropsych evaluations, but it's really hard to get in. The whole theme these days is there's a waitlist forever, which can be pretty frustrating. But the best approach is the multimodal approach and neuropsych testing is the best. So, you get a combination of a very thorough review of your clinical history. You want to look at childhood history, knowledgeable informant data, so report data from parents, teachers, if it's available. It's hard for adults sometimes to actually still have that as an adult, but if you have that, it's the holy grail, it goes a long ways. And then, you do standardized screening questionnaires, things about day to day functioning, functioning across domains, those two sets of symptoms, of course, I mentioned in the beginning.

And then, for the neuropsych testing itself, you do kind of ideally a full neurocognitive testing battery, so you establish kind of your core intellectual abilities. And I do want to say that ADHD is not an intellectual disorder. It has nothing to do with that. It's about things that get in the way of a person's ability to apply themself. Although people with ADHD notoriously feel stupid, it has nothing to do with intellect. You can have people who are NSS, which kind of a derogatory term we use for not so smart, or you can have people that are very high IQ. It has nothing to do with that. But again, it can make you feel stupid because it gets in the way of your ability to perform.

Deborah Howell: Right. The social piece.

Dr. Chad Sanders: Yeah. Yep. Across other domains and whatnot, yep. But we do do testing to look at determining if you have an intellectual disability or a specific learning disorder or other neurodevelopmental disorders as a rule out as well. Sometimes attention problems can manifest and, if you're spotting it in, say like a teenager in school, but it can actually be secondary to a specific learning disorder that if they're struggling with all forms of mathematics and then that's creating stress and that's causing concentration problems, you'd want to differentiate those two, and, as an example, that's where the cognitive testing comes in as well.

And then, this is a small piece, but neuropsych testing is good for malingering and feigning. Because these days, especially in college towns, there can be incentives to get stimulant medication. And so, sometimes people can come in faking it. And there are certain tests that I can't go into detail about, but there are veiled tests that are there to determine if people are being genuine. But that's super rare when that comes up. But it is a quick rule out that's built into any standard neuropsych battery. But that's it in a nutshell.

Deborah Howell: Yeah. Good to know.

Dr. Chad Sanders: Yeah.

Deborah Howell: And how is ADHD treated and is ADHD able to be cured?

Dr. Chad Sanders: There is no cure for ADHD. And so, it is a lifelong thing. But the good thing about ADHD is you won't die from it. It's not the kind of disorder that can devolve or cause those kind of things where you'll eventually pass from the disorder. But people certainly have died secondarily because of ADHD for like not packing their parachute correctly, things like that. So, it does increase risk in that sense. But no, ADHD, lots of people live your whole life with ADHD and you never know about it. That's changing nowadays with information being disseminated. So, ADHD is not an emergency disorder, but it is a real disorder. But yeah, unfortunately there's no cure for it as it stands today.

So, your focus is management and trying to compensate. Stimulant medication is the predominant treatment. Some people have some concerns about taking a stimulant, concerns about their kids being zombified, stuff like that. And unfortunately, the truth is that a stimulant is the predominant treatment because it's a neurodevelopmental disorder. When you have a deficiency in norepinephrine and dopamine, you can't think that away. It's like if you have a headache, you can ignore the headache or you can tell yourself positive things like, "Okay, I don't have brain cancer. This hurts, but it'll pass soon." You can do those things or you can take ibuprofen. You can live with ADHD. But if you really want to manage it and you can do those behavioral things, you can do, you know, that kind of stuff, for example, but a stimulant is still the predominant treatment for managing it.

But the combination of everything is the best. So stimulant medication, and that can be a process that you want to work with your-- if you work with a psychiatric provider, a primary care provider, you know, it's still kind of an old school thing where you might start with one thing, start low, go slow, find a good fit. If it's not a good fit, you might move on to trial a different one. Nowadays, more and more genetic testing is being used to determine if a person has any like metabolic issues with certain compounds to try to cut some of that process out because the old school way is you would just trial. If it's bad, you can move on, et cetera, until you find a good fit. And then, once you find a good fit, ideally, you find the right dose and you kind of stay on that. But

stimulants, yeah, that's the predominant treatment. But then on top of that, do the behavioral stuff, the environmental stuff, social support, so setting in things like centralized locations, setting routines. I mentioned earlier about losing track of key objects. A person with ADHD almost always will learn the hard way to use routine. Because if you set your phone down in weird places, you'll just lose it. And then, you have to track it down. And so, there's this natural progression where people will develop these idiosyncratic routines and strategies. One that comes up a lot for people with ADHD are what are called obstruction strategies. So if you put things you just don't want to forget, put them in front of your door where like you don't even have to remember anymore because the door will remind you because you can't open it, so things like that.

Deborah Howell: I do that.

Dr. Chad Sanders: Yeah, me too.

Deborah Howell: As you were doing the list, I was like, "Check, check, check." But you have to have five or more of the symptoms you described, right?

Dr. Chad Sanders: Yup.

Deborah Howell: Okay. I have a final question for you, doctor. Are ADHD and anxiety linked?

Dr. Chad Sanders: Yeah. So, the most comorbid issue with ADHD is anxiety along with depression too. And so, they're so commonly co-occurent that that's usually one of the primary drives for doing a thorough differential, is to differentiate if there is anxiety versus ADHD. And then, it's the chicken and the egg thing.

And so, coming back to like being in a college town, people will often present with ADHD and say it's secondary to college-level coursework. They're struggling. It's dead week, they're kind of drowning and they're having a lot of anxiety because they're not used to the pressure. One of the hallmark symptoms of things like anxiety and depression can be problems with concentration, problems with focus, et cetera. So, it can look and feel like ADHD, but it's not ADHD. And so, the chicken and the egg thing probably can be one of the more difficult things about ADHD, is when you try to look back at the timeline. Because if you have attentional problems, but they don't start until you're in your 20s and you've had anxiety since you were a teenager, 100% you don't have ADHD even if you have symptoms that would reflect six out of the nine of the criteria for inattention. And that's partly more broadly because ADHD is a rule out disorder. You need to rule out everything else before you land at the diagnosis. You don't want to just start with ADHD as a diagnosis because the symptoms can reflect so many other things that you just need to rule those out first, partly because treatment for ADHD is very unique. Well, not totally unique. There's other things like narcolepsy and stuff you use stimulants for. But for the most part, stimulant treatment is a more rare breed. But if you have things like anxiety and you treat that with a stimulant, it's going to get worse in the long run. So, it's just really important to be thorough.

And when it comes to anxiety, yeah, you have to look at the clinical history. And to some extent, this is always the case, there has to be attentional problems in childhood. That can be hard to find sometimes, especially if you're dealing with someone who is very high functioning, high intelligence, lots of compensatory strategies, lots of family support. Sometimes it can be hard to find that, and that's where the mainstream approach is, you look for functional impairment. That's unfortunate for people who have high IQ and are high functioning because you might not see functional impairment. What you might see are things like more subtle things where the person settles for B's in school when they absolutely could get A's, but they can get B's if they just turn stuff in at the last minute, versus they have to study for three hours to get an A and they'd rather go play and so, they're settling for B, stuff like that. Well, that won't look like functional impairment from a broad point of view. But when you go on a case by case basis and you look at baseline things and you do things like, "Well, we've done your neurocog testing and your intellectual capacity is well above average," yeah, those B's start to look more clinically significant, and that's the whole process. So, it takes time and you just have to be thorough.

But yeah, back to the main question, anxiety is the most common comorbid issue. And you certainly can have anxiety or mood issues along with ADHD that can be just a true comorbid thing where you have ADHD and then anxiety and/or depression manifest naturally for whatever reason or you can have untreated ADHD over time and that can lead to anxiety. People with ADHD that goes unmanaged will develop stress because ADHD causes problems. And so, you can get things where hypervigilance, procrastination, things like needing what's called like gun-to-the-head motivation. People with ADHD notoriously need external motivation. Even with things that are really important, you need that gun to the head motivation, and that's where you see these pervasive patterns of getting things done at the last minute. Well, that's because that gives this big jolt to norepinephrine through things like anxiety. When you have two hours to turn something in, you're going to focus on it because you have not really, but you got a gun to the head to motivate yourself.

And it can be really daunting for folks with ADHD because you can schedule yourself out three weeks before a deadline and say, "Two hours a day, no distractions, perfect environment," and you can sit there with your paper and nothing gets done. And part of that can just be because of the neurochemical components that make up ADHD. And then, the night before, boom, you throw everything together. Well, it's not just about the product, that's an anxiety-inducing process, because the whole time, typically the person, it's on their mind, they know they need to get it done, the clock is ticking, and then that midnight oil experience, that's not exactly pleasant. Usually, there's a scramble to it. And then, when you're done, you get it turned in or you get your work task done. Then, there's this like, whew, but you're onto the next thing. So, stress definitely can manifest over time with unmanaged ADHD for sure.

Deborah Howell: Boy, we're lucky to have you on the case, doctor. Dr. Sanders, we so appreciate your time and everything you do to help our wonderful patients. Thanks so much for being with us today,

Dr. Chad Sanders: Oh, absolutely. My pleasure. Thanks for having me.

Deborah Howell: And you can learn more about this subject, providers and services at Pullman Regional Hospital online at pullmanregional.org/palouse-psychiatry-behavioral-health.

This has been The Health Podcast from Pullman Regional. I'm your host, Deborah Howell. Thanks for listening and have yourself a terrific day.