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PSY10 ADHD
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1Epidemiology of ADHD
• Historically viewed as a childhood disorder only but that’s changed with [blank_start]3-7%[blank_end] of school age children diagnosed globally, in adults ~ half that
• Increased incidence of [blank_start]depression[blank_end], ~14% of those who are 6-17 years old, some studies demonstrated in up to 50% of adolescents
• Adults with ADHD also show early onset of depression, increased [blank_start]morbidity[blank_end] and severity plus a higher [blank_start]suicide[blank_end] rate compared to adults without ADHD
• Treatment of depression with comorbid ADHD generally more [blank_start]difficult[blank_end], treatment-resistance is more common
• Childhood ADHD is sometimes the early expression of an emergent [blank_start]bipolar disorder[blank_end]
• 10 - 20% of adults with bipolar disorder have comorbid [blank_start]ADHD[blank_end]- A3-7%
- Bdepression
- Cmorbidity
- Dsuicide
- Edifficult
- Fbipolar disorder
- GADHD
2Children and adolescents: Easy to diagnose, [blank_start]High[blank_end] levels of identification, and Tx > 50%, stimulants used [blank_start]first and second[blank_end] line
Adults: Hard to diagnose (inaccurate retrospective recall of [blank_start]onset[blank_end]). Late onset, same [blank_start]genetics, comorbidity and impairments[blank_end]. [blank_start]Low[blank_end] levels of identification, and Tx < 20%. Stimulants [blank_start]not[blank_end] first line.- Ahigh
- Bfirst and second
- Conset
- Dgenetics, comorbidity and impairments
- ELow
- Fnot
3DSM-V Diagnosis
Noted trio of symptoms i.e. inattention (selective and sustained), hyperactivity and impulsivity.
- Inattention:
-- Sustained attention: Hypothetically modulated by connections between the [blank_start]dorsolateral prefrontal cortex (DLPFC)[blank_end] projecting to the striatal complex, the thalamus and back. Inefficient activation leads to difficulty following through/[blank_start]finishing[blank_end] tasks, dis[blank_start]organization[blank_end] and trouble sustaining mental [blank_start]effort[blank_end].
-- Selective attention: Hypothetically modulated by connections between the [blank_start]dorsal anterior cingulate cortex (dACC)[blank_end] which projects to the striatal complex, then thalamus and back to the dACC. Inefficient activation of the [blank_start]dACC[blank_end] results in
symptoms such as decreased attention to [blank_start]detail[blank_end], careless mistakes, not listening, [blank_start]losing[blank_end]things, being [blank_start]distracted[blank_end] and forgetting.
- Hyperactivity and impulsivity
Often fidgets, squirm, is restless, can't stay [blank_start]seated[blank_end], difficulty playing [blank_start]quietly[blank_end], [blank_start]interrupts[blank_end] or intrudes on others; may take over what others are doing
• [blank_start]Six[blank_end] or more symptoms must be present for at least 6 [blank_start]months[blank_end]; [blank_start]five[blank_end] symptoms required in older adolescents and
adults (> 17 years of age)
• Significant impairment must be seen in two or more settings (e.g. home and school); symptoms must be documented by parent, teacher, and clinician.- Adorsolateral prefrontal cortex (DLPFC)
- Bfinishing
- Corganization
- Deffort
- Edorsal anterior cingulate cortex (dACC)
- FdACC
- Gdetail
- Hlosing
- Idistracted
- Jseated
- Kquietly
- Linterrupts
- MSix
- Nmonths
- Ofive
4Match the symptoms to the regions:
Dorsal ACC - [blank_start]selective attention[blank_end]
Prefrontal cortex (PFC) - [blank_start]hyperactivity[blank_end]
Dorsolateral prefrontal cortex (DLPFC) - [blank_start]sustained attention[blank_end]
Orbitofrontal cortex - [blank_start]impulsivity[blank_end]- Aselective attention
- Bsustained attention
- Chyperactivity
- Dimpulsivity
5Causes?
• Familial and [blank_start]genetic[blank_end] association
• Synaptogenesis in [blank_start]PFC[blank_end] might be responsible...
-At 6-7 years, [blank_start]sustained[blank_end] attention and planning begin to develop. This age is characterized by “[blank_start]synaptic pruning,[blank_end]” i.e. overproduced or “weak” synapses are “weeded out,” which allows [blank_start]cognitive intelligence[blank_end] to mature.
Errors in this [blank_start]process[blank_end] could hypothetically affect further development of executive function and could be a cause of ADHD.
ADHD symptoms in children often appear around [blank_start]6[blank_end] years of age.- Agenetic
- BPFC
- Csustained
- Dsynaptic pruning
- Ecognitive intelligence
- Fprocess
- G6
6Hyperactivity and impulsivity are key symptoms in childhood, while inattention becomes prevalent with age.
- AVerdadeiro
- BFalso
7Impulsivity
• Associated with reciprocal connections between the [blank_start]orbitofrontal cortex (OFC)[blank_end], the striatal complex, and the thalamus.
Hyperactivity and psychomotor agitation/retardation
• Modulated by cortico-striato-thalamo-cortical ([blank_start]CSTC[blank_end]) loop from the [blank_start]PFC[blank_end] to the [blank_start]lateral[blank_end] striatum, to the thalamus and back to the PFC.- Aorbitofrontal cortex (OFC)
- BCSTC
- CPFC
- Dlateral
8Choose the correct statement.
- AAlterations within the prefrontal cortex (PFC) hypothesized to lead to problems with impulsivity or hyperactivity
- BInadequate ‘tuning’ of the DLPFC or the dACC can respectively lead to deficits in sustained or selective attention
9Comorbidities
• Result of [blank_start]similar or additional[blank_end] deficits within the ventromedial prefrontal cortex – [blank_start]limbic[blank_end] system
• Many [blank_start]mood[blank_end] disorders comorbid with ADHD in children and adults
• Symptoms in adults more disabling if comorbidities were already present in the [blank_start]child[blank_end]. Reinforces the
importance of treating all symptoms in young patients to maximize their chances of a “regular” adult life
• Oppositional defiant or [blank_start]Conduct[blank_end] disorder occur in 30-[blank_start]60[blank_end]% of youth diagnosed with ADHD
• Childhood comorbidities include depression, [blank_start]Autism[blank_end] spectrum disorders, childhood [blank_start]bipolar[blank_end] disorder- Asimilar or additional
- Blimbic
- Cmood
- Dchild
- EConduct
- F60
- GAutism
- Hbipolar
10As deficient [blank_start]arousal in the PRC[blank_end] is the main problem in ADHD, drugs to treat it either:
1. increase the [blank_start]release of DA and NA[blank_end]
or
2. increase tonic [blank_start]firing of the neurons[blank_end] increases prefrontal activity to an optimal level
Hypothetically, if DA and NA levels are to low, low [blank_start]NA[blank_end] causes reduced '[blank_start]signal[blank_end]' and low [blank_start]DA[blank_end] causes increased '[blank_start]noise[blank_end]'. Inability to sit still and focus are manifestations of the imbalanced signal-to-noise ratio.
Treatment increases [blank_start]signal strength output[blank_end] by increasing the [blank_start]concentration[blank_end] of both DA and NA until they reach the optimal dose.- Aarousal in the PRC
- Brelease of DA and NA
- Cfiring of the neurons
- DNA
- Esignal
- FDA
- Gnoise
- Hsignal strength output
- Iconcentration
11Methylphenidate(stimulant) / Vitamin R:
- increase release of DA in the [blank_start]NAc[blank_end] (nucleus accumbens)
and
- increase release of NA and DA in the [blank_start]PFC[blank_end]
by [blank_start]blocking blocking[blank_end] reuptake pumps (NAT and DAT).
Unlike amphetamine, [blank_start]methylphenidate[blank_end] is not taken up into the [blank_start]DA terminal[blank_end] via the transporter and is not a [blank_start]competitive[blank_end] inhibitor.- ANAc
- BPFC
- Cblocking
- Dmethylphenidate
- EDA terminal
- Fcompetitive
12Amphetamine:
Competitive inhibitor-
1) at [blank_start]DAT[blank_end] which competes with DA
2) at [blank_start]NAT[blank_end] which competes with NA
Also competitive inhibitor of the [blank_start]VMAT[blank_end] (methylphenidate is [blank_start]not[blank_end]) = taken into the [blank_start]DA terminal[blank_end] via the DAT, where it's packaged into [blank_start]vesicles[blank_end].
At [blank_start]high[blank_end] levels, it also [blank_start]displaces[blank_end] DA from the vesicles into the terminal.
Once a critical [blank_start]threshold[blank_end] of DA is reached, DA is expelled from terminaml by opening [blank_start]channels[blank_end] to allow [blank_start]large[blank_end] scale release into the [blank_start]synapse[blank_end] and reversal of the [blank_start]DAT[blank_end]! This rapid release of DA leads to the [blank_start]euphoria[blank_end] experienced by amphetamine users.- ADAT
- BNAT
- CVMAT
- Dnot
- EDA terminal
- Fvesicles
- Gdisplaces
- Hhigh
- Ithreshold
- Jchannels
- Klarge
- Lsynapse
- MDA transporter (DAT)
- Neuphoria
13Dexamphetamine
• Competitive inhibitor at [blank_start]DAT, NET,[blank_end] and the [blank_start]Vesicular Monoamine Transporter[blank_end] (VMAT) - competes with Da and NA
• Unlike methylphenidate, which is not taken [blank_start]into the cell[blank_end]
• [blank_start]d-isomer[blank_end] more effective than [blank_start]l-isomer[blank_end] for DAT binding
• d- and l-isomers are equipotent for [blank_start]NAT[blank_end] binding- ADAT, NAT,
- BVesicular Monoamine Transporter
- Cinto the cell
- Dd-isomer
- El-isomer
- FNAT
14Common Stimulant Adverse effects:
1. [blank_start]Reduced appetite, weight loss[blank_end]
Have a high-calorie meal when stimulant effects are low (at breakfast or at bedtime), or consider cyproheptadine (antihistamine) at bedtime
2. [blank_start]Stomach-ache[blank_end]
Give on a full stomach; lower dose if possible
3. [blank_start]Insomnia[blank_end]
Give earlier in the day; decrease last dose of the day, consider a hypnotic at bedtime e.g. clonidine, melatonin, or cyproheptadine.
4. [blank_start]Headache[blank_end]
Divide dose, give with food, or give analgesic
5. [blank_start]Rebound symptoms[blank_end]
Consider longer-acting stimulant trial, atomoxetine, or antidepressant
6. [blank_start]Irritability/jitteriness[blank_end]
Assess for comorbid condition e.g. bipolar disorder; reduce dose; consider mood stabilizer or atypical antipsychotic- AReduced appetite, weight loss
- BStomach-ache
- CInsomnia
- DHeadache
- ERebound symptoms
- FIrritability/jitteriness
15Atomoxetine
• Selective [blank_start]NA reuptake inhibitor (NRI)[blank_end], also an antidepressant
• Since the PFC lacks [blank_start]high[blank_end] concentrations of the DAT, [blank_start]DA[blank_end] is inactivated there by the [blank_start]NAT[blank_end] (promiscuous). So, blocking NAT will increase [blank_start]both DA and NA[blank_end] levels in the PFC
• The relative [blank_start]lack[blank_end] of NAT in the [blank_start]NAc[blank_end] prevents atomoxetine from [blank_start]increasing[blank_end] NA or DA levels in that region → reduced risk of [blank_start]abuse[blank_end]
Bupropion
- Not selective, is a [blank_start]noradrenaline - dopamine[blank_end] reuptake inhibitor or [blank_start]NDRI[blank_end]
- Effective for the treatment of ADHD and depression
- Preferred for [blank_start]older[blank_end] patients due to comorbid substance abuse or depression- ANA reuptake inhibitor (NRI)
- BNDRI
- Cnoradrenaline - dopamine
- Dhigh
- EDA
- FNAT
- Gboth DA and NA
- Hlack
- INAc
- Jincreasing
- Kabuse
- Lolder
16Relative effects
• [blank_start]Atomoxetine[blank_end] - slower onset than stimulants - 2–4 weeks v’s 1–2 hours, full benefit might take [blank_start]6-12 weeks[blank_end]
• Gender - males having increased [blank_start]methylphenidate bioavailability[blank_end] compared to females
• Dose [blank_start]variability[blank_end] for all of mentioned meds, can be due to inter-individual variability in plasma concentration.
• All metabolized by CYP2D6 so [blank_start]bupropion, fluoxetine, or paroxetine[blank_end] can increase biavailability by [blank_start]4-8[blank_end] times
• Atomoxetine - [blank_start]CYP2D6 poor metabolizers[blank_end] may experience more insomnia, weight loss, increased HR and BP constipation and depression compared to extensive metabolizers BUT might also have [blank_start]better[blank_end] therapeutic benefit
• Small increase in [blank_start]HR and BP[blank_end] on 1-2% of children
• No effect on liability for substance abuse with increasing age, possibly [blank_start]protective[blank_end] if started < [blank_start]8[blank_end] years of age- A6-12 weeks
- BAtomoxetine
- Cmethylphenidate bioavailability
- Dvariability
- Ebupropion, fluoxetine, or paroxetine
- F4-8
- GCYP2D6 poor metabolizers
- Hbetter
- IHR and BP
- Jprotective
- K8
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- O usuário eliminou as informações de disciplina Quiz sobre PSY10 ADHD, criado por Usuário eliminado em 14-10-2019.
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- Criado em 14 out 2019 · atualizado em 14 out 2019
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