Recognizing and Managing the Treatment-Disruptive Effects of Adult Attention-Deficit Disorder
Primary Psychiatry. 2003;10(3):59-62
Dr. Schwartz is director of the Adult Attention-Deficit Center, psychiatric consultant to the Clinical Psychology Outpatient Clinic, and research associate at Yale University, all in New Haven, Connecticut.
Disclosure: The author reports no financial, academic or other support of this work.
Please direct all correspondence to: Marc D. Schwartz, MD, 26 Trumbull St, New Haven, CT 06511; Tel: 203-562-9873; Fax: 203-624-2422; E-mail: firstname.lastname@example.org
What treatment-disruptive behaviors suggest that an adult being treated for a disorder such as depression or anxiety may also have attention-deficit disorder (ADD)? How can clinicians manage their clinical contacts with comorbid ADD patients so that these behaviors do not undermine treatment? This article describes certain behaviors that may interfere with the psychological therapy of adults. Once clinicians recognize that these behaviors are symptoms of ADD, they can employ specific strategies to manage them more effectively. In addition, once comorbid ADD is diagnosed, other treatments, including the use of medications for ADD, can be considered. Under these circumstances, treatment is more likely to succeed.
Imagine that you have been seeing a patient with anxiety or depression. The sessions went well at first, but now, a month or two later, you have become concerned about changes in his treatment behavior. The patient has started arriving late for sessions and rather than pursuing important treatment topics, the patient now begins sessions with social chit-chat. While these verbal communications had been fairly well organized at first, they are now often filled with anecdotes and digressions. Shortly before a scheduled session, the patient leaves a phone message canceling because of an unavoidable conflict. The patient asks to be called back but does not leave a telephone number. When he arrives late for the following session, you gently start exploring whether these behaviors might represent resistance to treatment, but this does not seem to be successful. Another month goes by, and the bill has not been paid.
Treatment-disruptive behaviors like these are very common among adults with comorbid ADD. Until around 10 years ago, it was generally thought that ADD was basically a childhood disorder that resolved during adolescence and did not persist into adulthood.1 This belief is reflected in the fact that the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition2 (DSM-IV) makes only one passing reference to adults in its description of the disorder.
Over the past 7 years, a number of studies have demonstrated that, while hyperactivity disappears in most children with ADHD during adolescence, 70% to 80% continue to suffer from attentional and other cognitive deficits into adulthood.3
Adult ADD is frequently comorbid with other disorders that bring people to treatment, including depression, anxiety, bipolar II disorder, substance abuse, and alcoholism.4 Many psychiatrists practicing today were trained during the era in which the disorder was thought not to exist. In part, because “we do not see what we do not look for,”2 the disorder has often been overlooked in patients treated for comorbid disorders. This article presents methods for recognition of comorbid ADD in adults who are in treatment and suggests strategies for making their treatment more successful.
Recognizing Comorbid ADD
There are a number of reasons why comorbid ADD is difficult to recognize in patients being seen in treatment for a comorbid disorder:
(1) Patients with ADD are usually unaware that they have the disorder. Most often, they view their own distracted behavior as frequent interruptions of others, or lack of attention to details merely as bad habits. Under these circumstances they are not likely to mention these ADD symptoms during initial clinical visits. Without this information, the clinician may not consider the diagnosis of ADD.
(2) The cognitive dysfunctions of ADD (such as poor organization, memory difficulties, distractibility, and impulsivity) are not usually evident during diagnostic and early treatment sessions, when patients are generally focused and attentive.
(3) When patients become more comfortable later in therapy, ADD symptoms that emerge are often mistaken for poor motivation, irresponsibility, or resistance to treatment.
When therapy becomes disrupted by certain patient behaviors, clinicians need to be alert to be aware of the possibility that these behaviors may be symptoms of ADD.
DSM-IV Symptoms and Treatment-Resistant Behaviors
Individuals with ADD often have difficulty organizing tasks and activities.2 Most people are able to keep the main idea they are discussing firmly in mind even while they occasionally digress. However, many patients with ADD cannot do this and their narratives during sessions become filled with irrelevant detail. Perhaps after talking for a while, patients may return to their point, but a great deal of time can be wasted. Poorly organized, circumstantial, and tangential speech is as striking in many patients with ADD as in those with schizophrenia.
Individuals with ADD often do not follow through.2 Patients may not follow up on significant topics addressed in prior sessions and may fail to pursue important issues in treatment.
Individuals with ADD often talk excessively.2 Patients may be garrulous or engage in extended social chitchat. Sometimes their speech will meander from one subject to another in a very fluid way, with no apparent boundary between topics. One patient compared his verbal style to channel surfing. Conversely, when their attention is captured by an idea, they may be unable to move on to another and will elaborate long after they have made their point.
They often interrupt and may not attend when spoken to directly.2 Patients with ADD frequently ignore questions, comments, and interpretations made by their treating clinician.
They often dislike tasks that require sustained mental effort.2 Patients with ADD may have difficulty maintaining energy, focus, and motivation in treatment. They may forget their treatment goals or change them with little or no discussion with the treating clinician. Fluctuations in their motivation may contribute to their periodically missing appointments, losing interest in therapy, and even forgetting why they entered treatment to begin with. This can be particularly troublesome to clinicians who invest a great deal of effort in helping these frequently disorganized patients manage their lives. When patients fail to follow through with plans that were carefully worked out with them, the therapist may feel disappointed, even demoralized.
They are often forgetful.2Patients with ADD often forget to bring up significant events in their lives, like major disputes with their spouse or significant setbacks at work. Distracted by their own amusing anecdotes, they may even lose track of issues they have discussed in the current session. They may forget to take their medication or neglect to call for a refill until they run out over the weekend. When leaving phone messages for the therapist, they frequently forget to leave their telephone numbers. They often fail to pay their bills on time and may not submit their bills for insurance reimbursement until it is too late.
There are also other treatment-resistant behaviors as well. For examples, ADD patients exhibit a number of time-related problems. Not infrequently they forget appointments or call to cancel shortly before the scheduled visit time, citing an unavoidable conflict or unanticipated event. If a patient being treated for depression or anxiety manifests this behavior more than once or twice in a period of a month of two, it should alert the clinician to the possibility that the patient has comorbid ADD.
In addition, ADD patients frequently come late for sessions. They may forget or misremember appointment times, and may arrive at the wrong hour or even the wrong day. Reflecting their overall difficulty with time, they often do not “pace” treatment sessions so take longer to get started talking about therapy issues. They frequently have little awareness of the passage of time and do not sense when an office visit is nearing its end. They may not bring up important issues until the clinician states that the session is over. Many, if not interrupted, will talk beyond the scheduled end time, never glancing at their watches or a clock. Even when they are reminded that the time is up, they may continue talking (Table 1).
The disruptive behaviors described are manifestations of disorders in cognitive executive functioning. Whenever such disordered cognitive functions are seen, it is important to determine whether they are caused by ADD or by another disorder. In outpatient treatment, the most common disorders that may present with dysfunctions similar to those seen with ADD include hypomania/mania, mild dementia, depression, and schizophreniform disorders. Resistance to treatment can also be difficult to distinguish from ADD. The main considerations in making the differential diagnosis are as follows:
Patients with mania or hypomania differ from those with ADD by having the following symptoms: an episodic rather than chronic course; increased or fluctuating energy; grandiosity and psychotic features; a family history of bipolar disorder; and decreased need for sleep. It should be noted that ADD and bipolar disorder are sometimes comorbid.
Dementia, including Alzheimer’s
Patients with dementia are more likely than those with ADD to have normal premorbid executive functioning; progressively worsening symptoms; more difficulties finding words and remembering names; and more severe recent memory problems.
Patients with depression may have memory problems and difficulties staying focused, but they differ from those with ADD by being quieter, less chatty, and sad; more likely to exhibit physical symptoms such as loss of appetite, weight loss, and difficulties with sleep; and more likely to have a personal and family history of depression. When a patient is both depressed and has disordered executive functions, it is generally best to treat the depression first to see if executive functions return to normal when the depression clears. If they do not, ADD diagnosis and treatment should be considered.
Schizophrenic or schizophreniform patients differ from those with ADD by being more likely to have positive or negative symptoms of schizophrenia; less likely to interrupt or be forgetful; and less likely to be impulsive.
Resistance to Treatment
ADD symptoms can easily be mistaken for treatment resistance (Table 2). Patients exhibiting treatment resistance are more likely to achieve conscious or unconscious gain by disrupting the treatment and are more likely to modify their behavior once they understand its motivation.
General Principles for Managing Comorbid ADD
Once the diagnosis of ADD is made, patients should be informed that they have the disorder and educated about its causes, symptoms, treatment, and course.5 The use of appropriate medication for ADD should be discussed.6 For most patients, medication, when effective, is the most rapidly acting and least expensive treatment available for the disorder. A positive response to stimulants can reduce or eliminate many treatment-disruptive symptoms. If medication is prescribed, its use and effectiveness should be regularly and carefully monitored. Patients with ADD often do not fully appreciate the nature of their deficits and are not always able to monitor accurately the dysfunctions caused by their deficits. For this reason, feedback about treatment effects should be obtained not only from the patient but, if possible, from an objective observer chosen by the patient.
When treating individuals with comorbid ADD, the clinician should keep in mind that they, like patients with a stroke or other neurological problem, have only a limited ability to overcome the cognitive difficulties that contribute to their interrupting, forgetfulness, lateness, and other ADD symptoms.
Specific Strategies for Managing Comorbid ADD
The clinical literature describing how to recognize and deal with comorbid ADD is sparse. With few exceptions,7 the focus of most articles on the topic is either on the treatment of ADD comorbid with substance use,8 or on strategies designed to modify behavior or thought patterns that disrupt patients’ lives outside of treatment.9
Clinicians can utilize a number of strategies to manage treatment-disruptive ADD behaviors.
Keep Sessions Organized
If the patient is unable to keep his or her presentation organized, the therapist may find it helpful to solicit a list of topics that the patient would like to address at the beginning of sessions, and suggest any important items that the patient omitted toward the end of the session. It is best to write down the items and defer discussion of them until the list has been completed.
The patient and clinician can prioritize and order the topics, scheduling how much time to allocate for each before the session begins. After using this method for a while, many patients get better at keeping the sessions organized and, with some, the structured planning becomes less necessary.
Actively Pursue Important Topics
In view of the frequency with which ADD patients forget, the clinician should feel free to bring up important issues if the patient fails to do so.
Because ADD patients are more likely than others to fail to hear or understand important comments, the clinician should monitor how well their patients understand what he or she said. It may be useful to review the topics discussed at the end of the session and/or at the beginning of the subsequent session.
Limit Circumstantial Talk
When patients with ADD talk excessively or get off the topic, the clinician’s desire to let the patient get to his point at his own speed may result in a great deal of wasted time. In these circumstances it may be more helpful for the therapist to gently shift attention back to the main topic, remind the patient of scheduled agenda, or merely to state the point that the patient was trying to make.
It can be helpful to tactfully let the patient know that talking at length without getting to the point is a common symptom of ADD. If the patient accepts this, he or she may better understand and cooperate with the clinician’s efforts to get the discussion back on track.
Deal With Vacillating Motivation
It is sometimes helpful to write down a statement of the patient’s goals and reasons for being in therapy. This statement can later be used to orient the treatment when the patient shows signs of treatment-disruptive behavior. Sometimes, the best one can do is to wait patiently for motivation to return. If the patient and therapist are aware of the fact that this issue is common among patients with comorbid ADD and not a manifestation of resistance or a moral deficiency, it can help the clinician and patient through fallow periods to a time when more active treatment of the primary disorder can be resumed.
Help the Patient Listen
Interrupting and not listening are classical symptoms of ADD, yet they can come as a challenging surprise to the clinician when they are manifested in therapy, where patients are usually politely attentive. Once the clinician recognizes that a patient’s difficulty shifting from talking to listening is a manifestation of ADD and not resistance to therapy or impoliteness, it becomes easier to deal with the behavior calmly and persistently.
Deal With Lateness and Absences
To avoid excuses for lateness and fruitless discussions about treatment motivation, it is helpful to point out to the patient that these behaviors are common in ADD. At the same time, it is important to have a clear policy about ending sessions on time even when the patient has arrived late. If the patient is consistently late, it is sometimes useful to ask him or her to arrive 10 minutes early to ensure that the patient receives the benefit of a full session.
Reduce the Frequency of Absences
To minimize the number of missed appointments, the clinician can implement any or all of the following strategies: have the patient write down appointment times while still in the office; have an unambiguous agreement about charges for missed sessions; make all appointments for the same time and day of the week, if possible; and offer forgetful patients the option to be phoned with a reminder on the day before the appointment.
To allow time for important issues to be dealt with during the treatment sessions, it is wise to keep to the planned agenda and schedule. Sometimes it is helpful to notify the patient when there are 10 minutes left in the session. Unfortunately, this will not stop some patients from continuing to talk until the clinician firmly ends the session.
Unrecognized comorbid ADD often undermines the treatment of adults being seen for other psychological disorders. If clinicians are familiar with the treatment-disruptive symptoms of ADD, they can employ effective strategies to control them. These strategies require that therapists be more managerial than usual to ensure that patients stay organized, pursue relevant therapy issues, and begin and end sessions when scheduled. Once comorbid ADD is recognized, other treatments, including specific medication for ADD, can also be considered. Under these circumstances, treatment is more likely to succeed. PP
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