Hello, everyone. Welcome to cracking addiction. My name is Dr. Ferghal Armstrong and we have with us today Dr. Manu Bhatnagar. So, Manu, I thought we'd talk today about ADHD and how it presents in adults. So just picking up from the last time we talked about how the prevalence in children was greater than the prevalence in adults, would you care to comment on this issue? Yeah, I think we brought up the statistic last time, that the upper limit of the estimate is that half of adolescents who have
ADHD will no longer retain the traits that meet the full diagnostic criteria once they become adults. And I think that's a very established phenomenon. Something about neuroplasticity, but also the skills that someone acquires through high school and adolescence allow the disorder part of ADHD to be overcome. Right. Are we going to take a stab at numbers here as a percentage of background population? I would hesitate to put a number on it right now. And herein lies the controversy. One of the i
nteresting things about ADHD is that it is so relatable to so many people that adult ADHD. There is some debate, although this is probably not in the mainstream, that there is something called acquired ADHD, so de novo ADHD as a result of things that have happened past the age of 18. Now, from our point of view and regulations and prescribing such a thing is thought to not exist. But people do report that they had a reasonably fine adolescence and childhood bereft of any of these symptoms, and a
ll of a sudden, all of the symptoms that represent the disorder have manifested in their 20s. It's very contentious at the moment, but it is skewing the numbers that we're finding in terms of what is the real rate of those adolescents graduating into a population have ADHD versus those who entirely missed and are getting a diagnosis for the first time. So I'd still say the prevalence is still somewhere in the region of two to 3%. But one of the really important things to think about when we're t
alking about a diagnostic criteria for any mental illness is who is applying the criteria. And I think, in my experience, I've found people in metropolitan areas are attracting these diagnosis disproportionately to people everywhere else in the country. So you've said a lot there, and I don't even know where to start. But just on your last point, why do you think there's a skewing in the prevalence figures favoring the metropolitan? Is it simply the availability of diagnosticians and access to s
ervices, or is there another reason? Definitely that, but I also think, and this is particularly more notable post Covid, people who live in cities have a lot more sedentary jobs, a lot more jobs that require sitting down for 8 hours and doing a lot of work that requires undivided attention. And perhaps that's not conducive to the way the world works now with instant gratification with social media and a phone in your pocket at all times. So these criteria that were formed many, many decades ago
for ADHD and these concepts are really being challenged with our understanding of what is functional attention. And people who live in the city, they have different abilities to focus, to. Be honest, a different, or perhaps, dare we say, a reduced ability to focus. This inability to demonstrate undivided attention or selective attention or vigilance. Yeah, I would say reduced. And attention as a symptom is definitely something that's creeping up. Yeah. You tend not to get the adults who say, wh
o complain of de novo, the acquisition of the hyperkinetic variant, isn't it? It's all about the inattention. And that's tricky because that's also the subtype of ADHD that flies under the radar and doesn't get picked up. You could see it from both sides of the coin. Yeah. And notwithstanding your reticence to put a figure on it, you did actually say two to 3%. And that's pretty much what I've got in my head. I've got in my head a rough prevalence in children of about 5% and a rough prevalence i
n adults of about two and a half, two to 3%. My question then is, is there a cohort of adults who are more likely to have a higher prevalence of ADHD? Yeah, there are many different cohorts of adults who are probably the propensity partly with genetic loading, but also then with psychosocial factors, will have a high degree of impulsivity and inattention, which, if you provide the right frame, meets the criteria for ADHD. And I think that's really difficult to sort of quantify because discrete d
ifferent populations. But something we know is we can see the phenotype at the end for people who have ADHD that goes undiagnosed, like emotional dysregulation, chaos in social relationships, and obviously substance use can not only be the cause of attention, but can also be symptoms of underlying ADHD. Yeah, I suppose we can pause here. We both are passionate about the care of people with substance use disorders. And I don't know about you, but I frequently come across this conundrum that patie
nts give me. They say, look, Doc, I've got undiagnosed ADHD, and we all know that the treatment of ADHD is stimulants. I can't afford an assessment, therefore I'm using methamphetamine or amphetamine illicitly as a stimulant to treat my ADHD. And moreover, I know it works for me because my function improves, because I feel better, I've got more energy, and I'm able to focus and do stuff more. Have you ever come across that presentation? Almost exclusively. Isn'T it? I think it's a valid question
for someone to be asking. And I think one of the benefits of people understanding ADHD, the downside is that everyone thinks they have it, but one of the benefits is that we're talking about it. And as clinicians, we're asking each other questions about our cohort, the people that we look after day to day, whether ADHD could be something that we've missed. And by virtue of having a substance use disorder and being intoxicated or withdrawing constantly, inattention and poor functioning will come
as an adult. But we don't understand intuitively the longitudinal role of those substances. And self medicating is a very common reflection that most people with addictions will report. And self medicating for what? Emotional pain, physical pain. But ADHD is something that a lot of people will say. They've had a diagnosis as a kid that just lost a follow up and they never tried. And once they started using substances, well, no one would give them a prescription for stimulants ever again. And th
ose records, it's a very common story where a disruptive child is diagnosed with ADHD. But the ADHD is so intense that, of course, they don't make the appointments to get repeat prescriptions and have valid rediagnoses as they age. How common that might be? And in my opinion, it's very common in the cohort that we work with. And then think about the people who never got that first diagnosis. Yeah. So I think it's a markedly underrecognized cohort within the mentally unwell population. And moving
further. Right. I don't know if this is actually possible. Is it actually possible in Australia to get a new diagnosis of adult ADHD in the context of methamphetamine use and misuse? Is that even actually possible? And if so, how would you go about teasing it all out? It isn't at the moment, good practice to be able to do that, and in large part is that stimulants are drugs of dependence in and of themselves by their mechanism of action, but also by their classification in Australia. Yeah, I'm
not talking specifically during the period of methamphetamine use. I should have clarified someone with a history of methamphetamine use. So let's say they've been abstinent for three to six months. Would you actually consider that? Consider it theoretically possible, or on a practical level, so practically possible that they could have an ADHD diagnosis given to them? Definitely. And I think addiction specialists are probably more game to do this if you happen to be comfortable managing the sub
stance use disorder and saying, we can make sure you have your drug screens and make sure that you are seen quite regularly for monitoring if you relapse, and we can also provide you reference if we do all of that and make sure your substance use is under control, then a trial of methamphetamines, sorry, stimulant medications, would be very interchangeable in my lexicon as well as others. But it's a common question. Methamphetamines have the unwanted effect, though, for this cohort of causing eu
phoria and psychomotor agitation and not control timeline. But when you can prescribe and you can say you can pick it up from the pharmacy once a week or something, the aim isn't to have that high, it's to be functional so you can really titrate the dose that's happening. And of course, one of the other problems, and I'm sure we'll get into the specific pharmacology of ADHD, but one of the specific problems for people who do misuse or have a history of methamphetamine use disorder in the context
of treating ADHD is that they've literally blown apart the dopamine receptors. And so to get any therapeutic benefit, you really need very high doses. In fact, doses that are higher than those, the maximum doses that are actually funded by PBS, which again, is another issue in itself. But I'm sure we'll do an episode on the pharmacology of treatment later on. One of the common presentations that I hear is that, doc, I've got ADHD. And I know this because anytime I take a sedative, like for inst
ance, a benzo or cannabis, for instance, my focus improves. Everyone else is just munching on the couch, watching tv and drinking beer, know, move, moving away their focus from life into themselves. Whereas when I take this, it unlocks activity and unlocks focus, it unlocks goal directed work. And so there is this idea that for people with ADHD brains they actually respond differently to sedatives and stimulants compared to other people. Have you got any thoughts on that? Yeah, no, I've looked i
nto this and it's not just limited to ADHD. I think there is this idea that all of those people who have a paradoxical reaction to benzodiazepines or antihistamines are some form divergent and be it autistic spectrum disorder or ADHD, there is some evidence that I haven't fully delved into, but there is a common consensus amongst some clinicians that that's somewhat of a pathogenemonic sign of neurodivergence. Paradoxical response. Sorry. Yeah, I don't know. I guess clinically how much weight yo
u can put on that because everyone with ADHD has a paradoxical reaction to sedatives. It definitely is a theory worth considering. Yeah, it's something that makes me think about the question, does this patient in front of me have ADHD? But it's certainly not something you'd rely on. You think about the wandering, not matching up and the typical ward pathways people without ADHD have might not be wired up correctly with others. Another presentation or phenotype, even if you will, is for me is the
treatment resistant adult. And by that I mean the adult with a mental health disorder that's just not getting better. In fact, any mental health disorder. The treatment resistant depression, the treatment resistant anxiety, the treatment resistant borderline personality disorder, the treatment resistant hazardous consumption of substances, the harmful pattern of consumption, all of these things. All of these things. At some point it all says to me, does this patient have ADHD? Is that the reaso
n why they're just not getting better? What would you say to that? I think the difference with ADHD is that medications, stimulant medications are often thought to be first line and then it goes beyond that, where they're thought to be the be all and end all of treatment. And that's a common misconception. And if you could use ADHD as one of many examples within mental health to explain the problems economically with funding treatment for anything, it's a perfect example because a pill is very c
heap for the government to subsidize or for even a patient to pay. But really what the evidence shows us is while you have that optimum dopaminergic environment, while you're on stimulant medication, it's prime time to learn new strategies and engage in ADHD coaching or psychological functioning to then enact neuroplasticity and undo those habits that someone's learned by years of being untreated. So the inattention is temporarily fixed with stimulant medications. But to make lasting changes, yo
u really need to wrap around psychosocial support. And sometimes treatment resistance isn't always about therapeutic nihilism and failure. It's about what other types of treatments can attack onto this before we give up. Yeah, that's a very good point. What you're really saying is, well, look, okay, that's all well and good, but how do you define treatment resistance? And is it simply the failure of response to pharmacotherapy, or is it actually the failure to respond to pharmacotherapy and appr
opriate wraparound services for all of the other mental health conditions before you start moving into ADHD? Very good point. Well said. Yeah, I'm just trying to think about any other presentations of adult ADHD that you might get, especially in an adult that doesn't necessarily have the benefit of hindsight and a diagnosis in childhood. Is there any other type of presentation that you might see? Often? I will find depression and anxiety both being a masquerade and a comorbidity for ADHD. I thin
k in specialist land there are sort of two camps, and people will often present to a psychiatrist who only works with adults who have ADHD and say, I think I have anxiety. I think my mood's been a bit low, and they'll walk out of there with a script for stimulant medications and a retrospective diagnosis. And then another camp where someone will have all of the symptoms of ADHD, but be given antidepressants to treat it. And I think a thorough assessment will often show you that the deficits in f
unctioning that happen with anxiety and depression also happen with ADHD. So the inattention part of all three of those happens in the same part of your brain and the prefrontal cortex, really, it's way more complicated, but that's where that dopaminergic flow is really lacking, and that's where executive function planning needs to come up. So I think the population that most likely is missed is someone who self reports worsening anxiety and worsening depression, but not just for days or weeks,
but bouts of it for a long time, because they're quietly suffering with the functional impacts of having ADHD and not receiving a proper diagnosis because they haven't seen someone wants to give them that diagnosis. But by the same token, those disorders, depression, anxiety, can be treated. And once that's done, you can then consider whether ADHD exists or not. Yeah, I like what you said about the inattention and the prefrontal cortex really being the seat of all acquired inattention syndromes,
not just that associated with ADHD. And I suppose, really, I'm thinking about this in the context of all roads lead to Rome. So really, the inattentive prefrontal cortex is the final common pathway of all. Effectively, the vast majority of mental health disorders, including substance use disorders. And therefore, as we've said previously, really part of the diagnostic art is actually to explore that differential diagnosis. So what's your approach to that differential diagnosis in this acquired
adult inattentive syndrome? What do you look for? I've got, in my mind, diagnosis that I think are really important to exclude. But tell me what your thoughts are. Well, I think, yeah, that's really important, because more common than not, people will come in saying, I think I have ADHD. So there's already a preconceived idea of what ADHD is, and there's a lot of investment emotionally into understanding oneself through that frame. So doing it in a way that's inquisitive and providing psychoeduc
ation is really important, rather than just rattling off a list of diagnoses and symptoms and saying, you don't have this and you don't have that. I think providing education, the way that I approach it, is often doing a thorough assessment and pointing out, as we're doing the assessment, this can also impact your assessment, your diagnosis of ADHD, because they share common signs. For example, one of the most common presentations where people will report inattention is when they have a long sta
nding cannabis use disorder. And that, I find, is becoming increasingly more common. Might not be to the point where it's disorder, but often people have prescribed cannabis and they find that that helps in other parts of their mental health, but it causes them sleep disturbances and inattention. Rather than sort of understanding how cannabis can impact them, they might wonder if they have diagnosis. So substance use disorders are very commonly things to exclude, and I often suggest to people to
have a washout period before we embark upon a conversation about assessment, because that will muddy the picture. Something else I often talk about PTSD and personality disorder, and I think you've. Just hit my list. You've just ticked off all of my list substances, PTSD and borderline. There's a couple of things that I want to say to that. So we do know that actually, cannabis use disorder really will bugger up. It'll bugger up rem sleep, and if you've got no rem sleep, then you've got no slee
p per se. So, again, insomnia will then lead to inattention because you can't focus because you're too tired. And the same thing with alcohol. I'm not sure the effects of other substances, specifically on the sleep hypnogram, but cannabis definitely does that. And as you said, go on. There is some really good evidence, and this is a burgeoning field of people who have ADHD also having a delayed sleep phase disorder. Yes. And the idea of de novo or acquired ADHD, a lot of people are saying that,
well, it's not the same kind of ADHD. This is ADHD that's secondary to a delayed sleep phase disorder in adolescence and taking a good sleep history and fixing that sleep phase. So sleep delayed sleep phase is when more naturally want to go to sleep at 03:00 a.m. And then wake up at 11:00 a.m. Or midday or something like that. So their timeline is skewed, but they have to conform to the norms of society. And, yeah, cannabis can do the exact same thing by depriving you of restful sleep. Yeah. And
of course, it's also important to understand that teenagers and adolescents per se have delayed sleep phase. So they are actually genetically designed to stay up late, watch tv and play on the Playstation, and also get up late for school, much to the chagrin of parents, schools and society. And it is a constant source of wonderment for me to ask, why are schools that are catering for the needs of, say, year ten, 1112 students scheduled for 09:00. It just does not make sense to me. You should sc
hedule them for ten or even eleven. They're old enough to make their own breakfast, so mum and dad can go to work and leave them at home. That was one of my biggest struggles, making it to school for 830 starts. And I went, I thought, oh, thank God, I don't have to do that anymore. But then they scheduled 08:00 a.m., lectures, and I wasn't very much older, so it's definitely no. So for anyone watching when you're young, in your late teens and early 20s, getting up early is actually not part of y
our genetics. So, Manu, what do you think about this idea that I've heard from other esteemed colleagues that borderline personality disorder is actually the manifestation of a combination of an undiagnosed ADHD with an undiagnosed depression or mood disorder? What do you say to that? Yes, it's an interesting concept, and it makes sense intuitively because all three of those disorders share the same neurological underpinnings the difference is in treatment modality. So I would often get a patien
t present to me with a referral saying, I think I have ADHD. But in their past history, they've been given the diagnosis of borderline personality disorder and don't like that label, and it's a very stigmatizing label. So depression and ADHD not only are potentially valid in that the patient will experience symptoms of those diagnoses, they're less stigmatic and there are medications to treat it, whereas with borderline personality there aren't. I think my frame is always to be inquisitive and a
sk why they would prefer those diagnoses over the others. And if they haven't been offered treatment for borderline personality disorder, offer that to them and see if that makes a difference. Because the impulsivity and the emotional dysregulation that can happen with borderline personality disorder can clearly be seen with ADHD as the impulsivity and the lack of focus on a particular thing at a particular time, and the emotional dysregulation of low mood in depression. So it's a very ideal con
cept to understand someone with BPD, but in terms of validity, you really need to be applying the diagnostic criteria of BPD over a long period of time and establish this pattern of behavior from very, very early on in adolescence to be able to then effectively give treatment. One thing that I will mention that completely undoes everything I've just said is that in Scandinavia, they've done a randomized control trial and also a meta analysis of those who have had long standing diagnosis of borde
rline personality disorder. And they've looked at all of the medications, possibly that could have been used on a forest plot that treat BPD. And the number one medication that prevents suicide in people with BPD is dexamphetamine. Where does the truth lie? The fact that stimulants and dopaminergic activity isn't just applied to ADHD. There might be benefits that will come in time, once we stop worrying so much about addiction and overdose, those kind of things, that we can use the right drug fo
r the right medication. Sorry, right diagnosis without having to stick to labels. And the final differential, as you said in your previous comments, trauma, PTSD. How would you describe the role of trauma in this acquired inattention syndrome, as we've discussed? Yeah. Firstly, there's PTSD and then there's complex PTSD, and in the instance, it's an acute, relatively acute. It's over a month, but less than twelve months, where someone has a constellation of symptoms around the particular trauma,
where they had a sense of potentially losing their life or fearing that someone else might lose their life. And in that time frame, people can be very hyper aroused, hyper vigilant about that threat returning. And their rewitnessing of those environments can often preoccupy their mind. So the idea of focus there goes away. But it's quite uncommon for people with the sort of acute kind of PTSD to masquerade or present as potentially having ADHD. More commonly, we're seeing it in people who have
complex PTSD, where you've had many repeated traumas from a very, very long time. And this is similar to borderline personality disorder in phenotype, but also probably in the biological underpinnings, where the trauma is so incessant and accrues so much over time when the brain is developing that it can result in a poorly regulated emotional system, but also misfiring dopaminergic pathways. So commonly for people who have returned back from war in the 1950s, after World War II, they would find
that substance use disorder and a lack of functioning would follow after PTSD because of the inability to hold down a job and pay attention and do the things that good citizens would normally do, so that inattention can develop over time because of a lack of focus onto a particular task. All right, look, Manu, I think we've run out of time. I really want to thank you for your expertise today, and I really do hope we can chat again very soon. Thank you, Manu. Thanks for your time. Ferghal. That's
all for today, folks. My name is Dr. Ferghal Armstrong, and this has been cracking addiction.
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