Attention Deficit Hyperactivity Disorder And Patients With Pain
Along with anxiety and depression, attention deficit hyperactivity disorder (ADHD) is a common comorbidity among patients with chronic pain. Although most commonly diagnosed in childhood, ADHD is seen in approximately 4.8% of adults.1
ADHD has become a well-recognized and validated syndrome, known for the havoc it can create in patients’ lives. The public is increasingly aware of ADHD, and more of our patients arrive at the clinic with that diagnosis. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for ADHD will be amended in the upcoming DSM-V; the current criteria relate primarily to children and adolescents and are not entirely applicable to an adult population. Because more patients carry the diagnosis and are on ADHD medications (primarily stimulants), it is important for pain physicians to be aware of the consequences of the disorder. In addition, it is helpful to be aware of interactions between ADHD and pain medications.
Diagnosis of ADHD in Adults
The diagnosis of ADHD includes the patient’s history along with corroborating evidence: educational records and history, input from family or significant other, and so forth. In my experience, most patients who carry the diagnosis of ADHD from childhood have been correctly diagnosed; although there is occasional overdiagnosis of ADHD, underdiagnosis remains more prevalent.
The DSM-IV criteria for the diagnosis of ADHD require that the symptoms have lasted for at least 6 months.2 As noted, the current criteria do not always reflect the adult patient with ADHD. For example, the three primary features of ADHD (attention, hyperactivity, and impulsivity) change over time. Many children and adolescents “lose” the “H” (hyperactive) portion of ADHD as they approach adulthood, and present as the inattentive type. Therefore, using hyperactivity as a measure of ADHD may not be valid in adults.
In addition, ADHD adversely affects adults in their family and work lives; these effects are not addressed by the current criteria. The age of onset, usually listed as before 7 years of age in the DSM-IV, may not be accurate when assessing adults, and adults’ recall of the exact age of onset is often inaccurate. In the DSM-V, it is possible that the age of onset criterion for adult ADHD may either be dropped or amended to state that symptoms must have begun by age 15 or so.
In children, input from parents and teachers is crucial. In adults, we often use patient recall for assessment, in addition to speaking with others who know the person well. There are pitfalls in assessing adults; for example, we must not compare the patient with a high-functioning, high-IQ peer group, but rather with average individuals. In addition, particularly in college students, the desire to excel on examinations or improve scores does not qualify as a diagnosis of ADHD.
Mood disorders may cause an attention/concentration problem in adults, leading to an inappropriate diagnosis of ADHD. However, most patients with ADHD do have associated psychiatric comorbidities, such as anxiety or depression. Many individuals who fit on the bipolar spectrum can have concurrent ADHD. It is important to assess patients for all of these conditions.
One objective test that we have found useful is the Adult Self-Report Scale (ASRS),3 which is an 18-item questionnaire. The first nine questions relate to attention, the remaining nine to hyperactivity. Using the first nine questions gives the clinician an easy screen for ADHD and requires only minutes to administer. The attention portion of the ASRS gives a score of 0 to 36, with 36 being the most severe. This scale or similar ones, along with the clinical and educational histories, helps to determine the diagnosis.
An important question to ask the patient is, “How difficult is it for you to do boring tasks?” People with ADHD have great difficulty with boring material. To aid the diagnosis, I often have the patient read books or other materials on adult ADHD so that they can provide better-informed input into the diagnosis.
ADHD and Impairment
Adult patients with ADHD often are impaired in several categories. They may have done poorly in school, leading to problems with their work and career. Home life is adversely affected, with problems fulfilling daily responsibilities. Relationships are negatively affected by ADHD, and family life often falls apart as a result. The severity of childhood/adolescent ADHD is an accurate predictor of impairment as an adult. Young children who are constantly restless and cannot wait their turn in line, for example, often show more impairment as young adults. ADHD increases the likelihood of driving accidents and also of drug or alcohol abuse. It is probably not true that ADHD allows one to excel in certain areas; the evidence speaks more for impairment than for any positive outcome for those with ADHD, particularly if it is not treated.
The associated psychiatric comorbidities add to impairment, particularly if they are not treated. These include anxiety, depression, bipolar depression, and substance abuse.
The evidence is strong for treating ADHD. Compared with treated patients, those who remain untreated are at greater risk, at age 20 to 25, for drug abuse, accidents, joblessness, and jail. The clinical stakes for underrecognizing and undertreating ADHD are enormous. If impulsivity does not improve by the early 20s, it is a poor prognostic indicator for how the patient will do over time.
ADHD and the Patient With Pain
ADHD complicates the lives of patients with pain. The patient struggles with functional impairment due to pain, and ADHD adds to this dysfunction. Education often suffers because of pain; students take longer to complete their degree, and the addition of the negative impact of ADHD can make completion impossible. Family life is adversely affected, as spouses may tire of the burden of pain complaints, along with the various ADHD symptoms. Chronic pain often leads to performance issues at work or joblessness; ADHD only accentuates this problem. It is not uncommon for patients with chronic pain and ADHD, in combination with anxiety and depression, to be underfunctioning in a number of areas.