Mindfulness vs psychoeducation in adult ADHD: a randomized controlled trial.

BACKGROUND: Mindfulness training is a promising treatment approach in adult ADHD. However, there has not yet been a randomized controlled trial comparing mindfulness to an active control condition. In this study, we assessed the efficacy of a mindfulness training program (MAP) compared to structured psychoeducation (PE). METHODS: After randomization 81 medication-free adult ADHD patients participated either in an 8-week MAP or PE group program. At baseline (T1), after 8 weeks (T2) and after 8 months (T3), severity of ADHD and associated symptoms (depression, general psychopathology, quality of life) were measured with the Conner's ADHD Rating Scales (CAARS), the Beck Depression Inventory (BDI), the Brief Symptom Inventory (BSI) and the SF-36 by self and blind observer ratings. RESULTS: Both groups showed significant pre-post improvements in observer-rated Inattention scale (p < .001, partial η2 = 0.18) and in associated symptomatology, which persisted through 6 months of follow-up. There were no significant differences regarding symptom reduction between the treatment groups. Women benefited more compared to men irrespective of treatment group. Men showed the most pronounced changes under MAP. CONCLUSIONS: In the current study, MAP was not superior to PE regarding symptom reduction in adult ADHD. Both interventions, mindfulness meditation and PE, were efficacious in reducing symptom load in adult ADHD. Furthermore in exploratory post hoc tests the study provides evidence for a potential gender-specific treatment response in adult ADHD.

[Adult attention deficit/hyperactivity disorder, associated symptoms and comorbid psychiatric disorders: diagnosis and pharmacological treatment]. / Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung bei Erwachsenen mit assoziierter Symptomatik und komorbiden psychiatrischen Erkrankungen: Diagnostik und medikamentöse Behandlung.

Adult attention deficit/hyperactivity disorder (ADHD) is characterised by inattention and/or hyperactivity and impulsivity and is a frequent psychiatric disorder with childhood onset. In addition to core symptoms, patients often experience associated symptoms like emotional dysregulation or low self-esteem and suffer from comorbid disorders, particularly depressive episodes, substance abuse, anxiety or sleep disorders. It is recommended to include associated symptoms and comorbid psychiatric disorders in the diagnostic set-up and in the treatment plan. Comorbid psychiatric disorders should be addressed with disorder-specific therapies while associated symptoms also often improve with treatment of the ADHD core symptoms. The most impairing psychiatric disorder should be treated first. This review presents recommendations for differential diagnosis and treatment of adult ADHD with associated symptoms and comorbid psychiatric disorders with respect to internationally published guidelines, clinical trials and expert opinions.

A randomized, waiting list-controlled 12-week trial of atomoxetine in adults with ADHD.

BACKGROUND: With the increasing recognition of adult attention-deficit/hyperactivity disorder (ADHD) there is an emerging need to investigate medication in this population. METHODS: In this waiting list-controlled trial, 64 ADHD-patients (mean age 35.8 ± 8.7 years) were randomly assigned to a daily dosage of up to 80 mg atomoxetine (Atx) or waiting list for 12-weeks. Primary outcome was the change of the observer-rated DSM-IV total ADHD score on the Conners' Adult ADHD Rating Scales (CAARSO: L DSM-IV total ADHD score) from baseline to endpoint. Other efficacy measures included selfrated CAARS-S:L DSM-IV total ADHD score, CAARS-O/S:L problems with self-concept and emotional lability score, Wender-Reimherr Adult Attention Defi cit Disorder Scale Emotional Dysregulation Score, and General Activities Score on the Quality of Life Enjoyment and Satisfaction Questionnaire. Efficacy measures were analysed in the per-protocol population. RESULTS: Mean change in CAARS:O-L DSM-IV total ADHD score was -13.1 ± 7.7 in the Atx vs. -0.4 ± 4.8 in the control group (p < 0.005). Treatment response ( ≥ 30 % reduction) was 60.1 % in the Atx vs. 0 % in the waiting list group. The other efficacy measures also showed significant improvements. The overall incidence of adverse events (AEs) was 70.4 % in the Atx group, the most frequent included fatigue, irritability, nausea and decreased appetite. In Atx-treated patients 18.5 % discontinued early due to AEs. DISCUSSION: Our results suggest that Atx is an effective treatment in adult ADHD. It reduces ADHD core and associated emotional symptoms and increases self-esteem and quality of life. AEs were consistent with those reported in other studies in adult ADHD.

Spinocerebellar ataxia type 17 associated with an expansion of 42 glutamine residues in TATA-box binding protein gene.

BACKGROUND: Spinocerebellar ataxia type 17 (SCA17) is caused by abnormal expansions of CAG/CAA trinucleotides within the TATA-box binding protein gene (TBP). The currently accepted critical threshold of abnormal expansions is ≥43. OBJECTIVE: To investigate the minimal CAG/CAA expansion within the TBP in SCA17. RESULTS: 285 patients with autosomal-dominant ataxia were examined, and abnormal or borderline expansions of CAG/CAA within TBP in eight cases were found. Of those, four patients from three families had exactly 42 CAG/CAA trinucleotides, that is, one codon less than the currently accepted critical threshold of 43. The four patients presented with a relatively benign phenotype. All had dysdiadochokinesia and dysarthria. Mild gait ataxia was observed in three of the four patients. CONCLUSION: The reference definition of at least 43 CAG/CAA codons for pathological SCA17 alleles should be lowered to 42.

[Methylphenidate. Therapy option for adults with ADHD and comorbid substance use disorder?]. / Methylphenidat. Therapieoption bei ADHS und Suchterkrankung im Erwachsenenalter?

Attention-deficit/hyperactivity disorder (ADHD) in adults is often associated with a comorbid substance use disorder (SUD). To date, no treatment algorithms are available. The question of whether the administration of methylphenidate (MPH) is justified in the treatment of adult patients with ADHD and comorbid SUD still remains unclear. While animal studies indicate an addictive potential of intravenous application of the drug, controlled oral treatment with MPH does not seem to carry the potential for abuse in humans. It remains controversial whether MPH treatment of ADHD during childhood protects against the development of SUD during adulthood. Although data remain inconsistent, a small number of studies and our own clinical observations of ADHD patients with SUD treated with MPH support a reduction not only of ADHD-related symptoms, but also of craving and substance abuse. The treatment of the adult ADHD with comorbid SUD with MPH should be conducted after a risk-benefit assessment, taking into consideration the abused substances, the motivation to abstinence and the quality of the physician-patient relationship; it should be evaluated critically, monitored closely and accompanied by treatment of the SUD and specific psychotherapy/psychoeducation.

Interaction between behavioral inhibition and neural alcohol cue-reactivity in ADHD and alcohol use disorder.

RATIONALE: Compared to the general population, adult Attention-Deficit / Hyperactivity Disorder (ADHD) is more prevalent in patients with Alcohol Use Disorder (AUD). Impaired behavioral inhibition is a common characteristic in both ADHD and AUD. Relapse risk is increased in patients with AUD and comorbid, untreated ADHD and in AUD patients with increased neural cue-reactivity. OBJECTIVES: In this study, we examined the interaction between neural correlates of behavioral inhibition and alcohol cue-reactivity with a hybrid imaging task. METHODS: Out of 69 adult study participants, we included n = 49 in our final analyses: Individuals had a diagnosis of either AUD (n = 13), ADHD (n = 14) or both (n = 5), or were healthy controls (HC; n = 17). The functional magnetic resonance imaging paradigm aimed to examine the combined effects of both an interference-inhibition task ("Simon-task") and an alcohol cue-reactivity task. Instead of segregating by diagnostic group, we pursued a dimensional approach in which we compared measures of AUD and ADHD severity, as well as the interaction of both, using multiple regression analyses. RESULTS: The four groups did not differ on the behavioral level on either the inhibition task or the alcohol cue-reactivity task. However, brain activation in frontal control and reward-related regions during completion of the combined tasks were related to ADHD and AUD severity (symptom load). During presentation of both alcohol cues and the inhibition task, participants with higher AUD and ADHD symptom load exhibited greater BOLD (blood oxygen level dependent) responses in subcortical reward-related regions. CONCLUSIONS: Our findings support the hypothesis that ADHD additionally diminishes inhibition ability in individuals with AUD. This may increase relapse risk when confronted with alcohol cues. Further, it is crucial for patients with comorbid AUD and ADHD to take into account not only reduced cognitive control over behavioral inhibition but also simultaneously heightened alcohol cue-reactivity.

Updated European Consensus Statement on diagnosis and treatment of adult ADHD.

Background Attention-deficit/hyperactivity disorder (ADHD) is among the most common psychiatric disorders of childhood that often persists into adulthood and old age. Yet ADHD is currently underdiagnosed and undertreated in many European countries, leading to chronicity of symptoms and impairment, due to lack of, or ineffective treatment, and higher costs of illness. Methods The European Network Adult ADHD and the Section for Neurodevelopmental Disorders Across the Lifespan (NDAL) of the European Psychiatric Association (EPA), aim to increase awareness and knowledge of adult ADHD in and outside Europe. This Updated European Consensus Statement aims to support clinicians with research evidence and clinical experience from 63 experts of European and other countries in which ADHD in adults is recognized and treated. Results Besides reviewing the latest research on prevalence, persistence, genetics and neurobiology of ADHD, three major questions are addressed: (1) What is the clinical picture of ADHD in adults? (2) How should ADHD be properly diagnosed in adults? (3) How should adult ADHDbe effectively treated? Conclusions ADHD often presents as a lifelong impairing condition. The stigma surrounding ADHD, mainly due to lack of knowledge, increases the suffering of patients. Education on the lifespan perspective, diagnostic assessment, and treatment of ADHD must increase for students of general and mental health, and for psychiatry professionals. Instruments for screening and diagnosis of ADHD in adults are available, as are effective evidence-based treatments for ADHD and its negative outcomes. More research is needed on gender differences, and in older adults with ADHD.

Patterns of long-term and short-term responses in adult patients with attention-deficit/hyperactivity disorder in a completer cohort of 12 weeks or more with atomoxetine.

BACKGROUND: Atomoxetine is a well-established pharmacotherapy for adult ADHD. Long-term studies show incremental reductions in symptoms over time. However, clinical experience suggests that patients differ in their response patterns. METHODS: From 13 Eli Lilly-sponsored studies, we pooled and analyzed data for adults with ADHD who completed atomoxetine treatment at long-term (24 weeks; n=1443) and/or short-term (12 weeks; n=2830) time-points, and had CAARS-Inv:SV total and CGI-S data up to or after these time-points and at Week 0 (i.e. at baseline, when patients first received atomoxetine). The goal was to identify and describe distinct trajectories of response to atomoxetine using hierarchical clustering methods and linear mixed modelling. RESULTS: Based on the homogeneity of changes in CAARS-Inv:SV total scores, 5 response clusters were identified for patients who completed long-term (24 weeks) treatment with atomoxetine, and 4 clusters were identified for patients who completed short-term (12 weeks) treatment. Four of the 5 long-term clusters (comprising 95% of completer patients) showed positive trajectories: 2 faster responding clusters (L1 and L2), and 2 more gradually responding clusters (L3 and L4). Responses (i.e.≥30% reduction in CAARS-Inv:SV total score, and CGI-S score≤3) were observed at 8 and 24 weeks in 80% and 95% of completers in Cluster L1, versus 5% and 48% in Cluster L4. CONCLUSIONS: While many adults with ADHD responded relatively rapidly to atomoxetine, others responded more gradually without a clear plateau at 24 weeks. Longer-term treatment may be associated with greater numbers of responders.

Treatment adherence and persistence in adult ADHD: results from a twenty-four week controlled clinical trial with extended release methylphenidate.

PURPOSE: The aim of this analysis is to describe medication adherence, and treatment persistence, in adults with attention deficit/hyperactivity disorder (ADHD) treated for 24 weeks with extended release methylphenidate (MPH-ER). Additionally, patient-, disorder- and treatment-related factors associated with adherence and persistence will be identified. METHOD: Post-hoc analysis of the active treatment group of a placebo-controlled, randomised, 24 week trial with MPH-ER with univariate description and multiple logistic regression models and Hosmer and Lemeshow tests. RESULTS: In the sample of 241 adults with ADHD (mean age of 35.2 ± 10.1 years), 9.4% of the patients were non-adherent, taking less than 80% of the dispensed medication. Factors associated with non-adherence included age<25 years, education level lower than secondary education, lacking family history of ADHD, lower ADHD baseline severity and lower self- and observer-rated medication efficacy. Lacking family history of ADHD, lower education level and lower self-rated medication efficacy, predicted non-adherence with a prediction accuracy of 16%. Seventeen percent of the patients discontinued early with most discontinuing within the first five weeks of the MPH-ER titration phase. Mean persistence in the discontinuing group was 63.4 ± 49.4 days. Factors associated with discontinuation included male gender, lower education level, lacking family history of ADHD and lower self- and observer-rated medication efficacy. Treatment non-response, male gender and lower education level predicted treatment discontinuation with a prediction accuracy of 22.7%. CONCLUSION: Male adults without relatives with ADHD, with lower educational level and lower self- and observer-rated medication efficacy, who are newly treated with MPH-ER, are at increased risk of non-adherence and treatment discontinuation. Patients are at increased risk of treatment discontinuation during the medication titration phase.

Driving performance in adults with ADHD: results from a randomized, waiting list controlled trial with atomoxetine.

PURPOSE: To investigate effects of a 12-week treatment with atomoxetine (ATX) on driving performance in real traffic, driving-related neuropsychological performance tests and self-evaluation of driving in adult patients with ADHD compared to an untreated control group with ADHD. METHODS: Parallel group design with an ATX and a waiting list group. At baseline and endpoint patients were evaluated with a standardized on-road driving test (SDBO), a driving-related neuropsychological test battery (Act and React Test System [ART2020]), and subjective measures of driving performance (one-week driving diary, Driver Coping Questionnaire). RESULTS: Forty-three of the 64 included patients completed the study (n=22 ATX, n=21 controls). Mean intervention period was 11.9±3.0 weeks, mean daily ATX dosage was 71.6±14.9mg. At endpoint, 60.1% of patients treated with ATX and 0% of waiting list group had reduced ADHD symptoms by greater or equal to 30%. In SDBO, ATX group reduced driving errors in three of four driving performance categories (attention, P<0.05; risk-related self-control, P<0.005; driver skills, P<0.001), number of driving errors remained stable in control group. At endpoint, 47.6% of control group and 18.2% of ATX group (P<0.05) did not fulfil the driving fitness criteria according to German Guidelines (percentile rank less or equal to 16 in one or more subtests in ART2020). Total number of self-reported critical traffic situations decreased from 12.0 to 6.8 per week in ATX group (P<0.05) and remained stable in controls by 9.3 and 9.9 at baseline and endpoint (ns). Coping strategies with stressful traffic situations did not change within both groups. CONCLUSION: Our study provides first evidence that treatment with ATX improves driving performance in real traffic in adults with ADHD.

German validation of the Conners Adult ADHD Rating Scales (CAARS) II: reliability, validity, diagnostic sensitivity and specificity.

BACKGROUND: The German version of the Conners Adult ADHD Rating Scales (CAARS) has proven to show very high model fit in confirmative factor analyses with the established factors inattention/memory problems, hyperactivity/restlessness, impulsivity/emotional lability, and problems with self-concept in both large healthy control and ADHD patient samples. This study now presents data on the psychometric properties of the German CAARS-self-report (CAARS-S) and observer-report (CAARS-O) questionnaires. METHODS: CAARS-S/O and questions on sociodemographic variables were filled out by 466 patients with ADHD, 847 healthy control subjects that already participated in two prior studies, and a total of 896 observer data sets were available. Cronbach's-alpha was calculated to obtain internal reliability coefficients. Pearson correlations were performed to assess test-retest reliability, and concurrent, criterion, and discriminant validity. Receiver Operating Characteristics (ROC-analyses) were used to establish sensitivity and specificity for all subscales. RESULTS: Coefficient alphas ranged from .74 to .95, and test-retest reliability from .85 to .92 for the CAARS-S, and from .65 to .85 for the CAARS-O. All CAARS subscales, except problems with self-concept correlated significantly with the Barrett Impulsiveness Scale (BIS), but not with the Wender Utah Rating Scale (WURS). Criterion validity was established with ADHD subtype and diagnosis based on DSM-IV criteria. Sensitivity and specificity were high for all four subscales. CONCLUSION: The reported results confirm our previous study and show that the German CAARS-S/O do indeed represent a reliable and cross-culturally valid measure of current ADHD symptoms in adults.

[Age and gender aspects of attention-deficit hyperactivity disorder]. / Alters- und geschlechtsspezifische Besonderheiten der Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung.

Attention-deficit hyperactivity disorder (ADHD) is a syndrome with onset in childhood which persists at least partially in about 60% of afflicted individuals. Core symptoms include inattention, hyperactivity, and impulsivity. Additional psychopathology with disorganized behavior and emotional dysregulation is common in adulthood. The vast majority of adults affected also present psychiatric comorbidities. There is severe impairment of everyday life and quality of life. Developmental psychopathologic changes, age-related comorbidity, and functional and psychosocial problems associated with ADHD must be taken into account during the diagnostic process. Regarding clinical subtypes of ADHD according to DSM-IV and particularly gender differences, knowledge about these factors in adults with ADHD is limited.

Driving-related risks and impact of methylphenidate treatment on driving in adults with attention-deficit/hyperactivity disorder (ADHD).

This study assesses driving behaviour and history of driving outcomes through a semi-structured interview in 27 clinically referred German adults with ADHD and 27 age-, gender- and education-matched non-ADHD controls. In nineteen of the ADHD-subjects a test battery of driving-related cognitive measures was performed (ART 2020) and re-assessed after at least six weeks of treatment with methylphenidate (n = 9) or after a six-week medication free period (n = 10).ADHD-subjects drove significantly more kilometres per year, were more often registered by traffic authorities and fined more frequently, were involved in more accidents and described their driving style as more insecure and hectic than controls. A high-risk driving group was delineated with 3-6 accidents per ADHD-subject. All results were controlled for intercorrelations with driving experience. Methylphenidate treatment resulted in improved information processing, e.g., better visu-motor coordination under high-stress conditions, improved visual orientation and sustained visual attention compared to baseline and our untreated control group.

[Effect of subtype and psychiatric comorbidities on methylphenidate treatment in adults with attention-deficit hyperactivity disorder]. / Methylphenidatbehandlung bei Erwachsenen mit Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung. Bedeutung von Störungssubtyp und aktueller psychiatrischer Komorbidität.

The present study was intended to examine the efficacy of immediate-release methylphenidate (MPH IR) in the treatment of adults with attention-deficit hyperactivity disorder (ADHD) under consideration of subtype according to DSM-IV criteria and psychiatric comorbidity. After baseline assessment over 3 weeks, 47 patients aged 18-59 years with combined ADHD (ADHD-C) (n=27) and predominantly inattentive ADHD (ADHD-I; n=20) were treated in an open, uncontrolled design with an average dose of 0.5 mg MPH IR per kg over 7 weeks. Thirty-nine patients finished the study. The two groups did not differ in response to treatment with regard to ADHD symptoms (very good to good outcome in ADHD-C 73.9%, in ADHD-I 66.7%) or cognitive measures (sustained attention, information processing speed, divided attention). However, ADHD patients with psychiatric comorbidities had significantly worse outcome: total ADHS scores on the T2 Brown Attention Deficit Disorder Scales (BADDS) were 66.2+/-15.5 with psychiatric comorbidity and 51.7+/-13.7 without (P=0.04), despite significantly higher doses of MPH IR (0.56+/-0.17 mg/kg vs 0.46+/-0.13 mg/kg; P=0.004). This effect was mainly seen in the patients with clinically significant depressive symptoms (Beck Depression Inventory > or =18), who clearly benefited less from treatment (total T2 BADDS scores with depressive symptoms 70.7+/-15.9 and without depressive symptoms 48.1+/-21.2; P=0.001).

[Long-acting methylphenidate. An alternative medical therapy for adult patients with attention deficit hyperactivity disorder]. / Retardiertes Methylphenidat. Eine Alternative in der medikamentösen Therapie bei erwachsenen Patienten mit Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung.

We report a 44-year-old female patient with attention deficit hyperactivity disorder (ADHD), combined subtype (DSM-IV: 314.01), who was treated with 0.5 mg of short-acting immediate-release methylphenidate/kg body weight given t.i.d. (total daily MPH IR dosage 45 mg). Under this medication, the patient reported significant reduction of symptoms. However, several times a day she experienced severe rebound phenomena with pronounced concentration disturbances, unrest, and dysphoric mood. After changing the medication to long-acting methylphenidate once daily (total daily OROS MPH dosage 54 mg), the rebound phenomena stopped, with equivalent beneficial clinical effects.

[Attention deficit hyperactivity disorder in adults. An overview]. / Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) bei Erwachsenen. Ein Uberblick.

Attention deficit hyperactivity disorder (ADHD), which is characterized by the inability to appropriately modulate attention and/or impulse control and hyperactivity, resulting in social, academic and occupational underachievement, is presently the topic of intensive discussion in German psychiatry. With a prevalence of 3-5%, ADHD is one of the most frequently seen disorders in child and adolescent psychiatry. With nearly 50% of childhood patients also affected during adulthood, this disorder is of much higher clinical significance for psychiatry than presumed thus far. The present review discusses current results of epidemiology, etiology, clinical symptoms and comorbidity, diagnostic assessment, pharmacotherapy, and psychological interventions for adults with ADHD.

'Everybody looks at my pubic bone'--a case report of an adolescent patient with body dysmorphic disorder.

OBJECTIVE: Body dysmorphic disorder (BDD) was described for the first time more than 100 years ago, but it is still unknown to many clinicians. Although the onset usually occurs during adolescence, BDD has received little attention in the adolescent psychiatric literature. METHOD: The case and treatment of a 16-year-old female patient is described. RESULTS: The patient, suffering from the overvalued belief of a dislocated pubic bone, a comorbid mild depressive episode, BDD associated rituals and social avoidance, was treated successfully with a combination of exposure and response prevention and 125 mg/day of doxepine. CONCLUSION: If BDD is diagnosed early in the course and treated appropriately, it is possible to obtain a satisfying outcome.

Further evidence for a low body weight in male children and adolescents with Asperger's disorder.

The study explores the common clinical impression and previously reported finding by Hebebrand et al. (7) of reduced body weight in male children and adolescents with Asperger's disorder (AD). Body weight and height of 36 consecutively admitted male patients with AD were retrospectively assessed for the calculation of body mass indices (BMI, kg/m2). The BMIs were transformed to percentile ranks and plotted into BMI-centiles representative for the German population. In addition, comorbid psychopathology was assessed to explore a possible relationship between associated psychopathology and body weight. The mean BMI-centile of all patients was 34.7 +/- 31.8 and, thus, differed significantly from the mean centile of an age- and gender-matched psychiatric control group, which was 52.7 +/- 28.3. Thirteen patients had a BMI below the 10th centile and five even below the third. Three of the latter presented with disturbed eating behaviour. Altogether four patients showed disturbed eating behaviour. They had a significantly lower mean BMI-centile than the rest of the group. The BMI-centiles of patients with other additional psychopathology did not differ significantly from the mean percentile of the whole cohort. The results clearly show an increased risk for underweight and disturbed eating behaviour in patients with Asperger's disorder which should be evaluated in further studies.

Pelvic ultrasound scanning of the ovaries in adolescent anorectic patients at low weight and after weight recovery.

In sixteen adolescent anorectic inpatients with secondary amenorrhea pelvic ultrasound examination of the ovaries was performed at lowest weight and after weight recovery. The outcome was assessed six months later at follow-up, assigning the patients to the categories of good, intermediate and poor outcome according to the modified Morgan and Russell criteria. At lowest weight all patients' ovaries were smaller than expected for age. After weight recovery the good outcome group had mature and fully developed ovaries whereas the ovarian morphology of patients with poor outcome remained prepubertal. The ovarian volume in the good outcome group was significantly higher than in the poor outcome group. From a threshold BMI of 17.8 upwards we observed a positive linear correlation between BMI and ovarian volume. At BMI 18 the probability for recovered ovaries was 53% rising to 82% at BMI 19.8, which was the highest noting in our study. Nevertheless, we could not find a clear cut-off BMI for definite prediction of recovered ovaries. Therefore, in patients with anorexia nervosa pelvic ultrasound is a very suitable method for determining the target weight required for recovery of ovarian function and resumption of menses. Normalized ovaries indicate favourable outcome and physical recovery.