The following case report illustrates the diagnostic dilemma for clinicians
when attempting to evaluate and treat a young adult woman who has been academically
successful for many years.
"Sarah" is 23 and a recent college graduate. She was referred for
evaluation because of psychological stress associated with her first year of
law school. During the initial diagnostic interview, rating scales measuring
mood and ADHD symptoms were completed. Sarah’s scores showed elevations
of levels of distractibility, procrastination, and daydreaming.
Vegetative symptoms of depression, such as sleep and appetite disturbances,
were within normal limits, but mild dysthymia, characterized as a feeling of
being chronically "low," frustrated, and demoralized, was reported.
Sarah also revealed that she tended to worry "a great deal" and
at times was anxious and irritable. These latter symptoms seemed to be more
pronounced during the week before her periods, which were irregular.
Psychiatric history revealed that ADHD rather than dysthymia was historically
her problem. Sarah reported that she has always taken longer than other people
to complete academic tasks. During lectures, she often finds her mind wandering,
and she characteristically has difficulty organizing or beginning her work.
These difficulties date back to elementary school, but Sarah worked closely
with her mother during the early years and had a tutor during high school.
Now, Sarah compensates for these problems by working late hours and forgoing
social activities. Sarah confessed that in order to have time to study during
college, she had had only three formal dates during the entire 4 years. Forgetfulness
and feelings of "always being rushed" or "late for everything" were
also acknowledged. High school report cards bore this out with several comments
about Sarah’s disorganization or tardiness. Despite these difficulties,
Sarah was able to maintain good
grades in high school and had a 3.0 grade point average in college. Neuropsychological
testing confirmed superior intelligence, but some difficulties in language
formulation, organization of information, and reading comprehension were noted
on a psychoeducational battery. Sarah gave no previous history of psychological
evaluation or treatment for ADHD or depression. Sarah was currently having
much greater difficulty handling the work load of law school. She now simply
did not have enough hours in the day to complete reading assignments, review
her notes, and attempt other tasks of daily living such as meal preparation
and laundry. She felt more stressed and depressed about her situation, and
led to her decision to seek professional help. Family psychiatric history was
positive for ADHD only. Sarah’s father had been treated for ADHD for
several years, and a maternal uncle had both ADHD (hyperactive subtype) and
learning disabilities. Medical history was negative except for irregular menstrual
periods. No sleep disturbances (other than her wish for more sleep) were reported.
Sarah was diagnosed as having ADHD, inattentive type, using the criteria of
the Diagnostic and Statistical Manual of Mental Disorders, fourth edition.
In addition, it was thought that she had dysthymic disorder and possible
premenstrual syndrome (PMS).
Course of Treatment
Treatment with the long-acting methylphenidate preparation, Concerta 36 mg
each morning, was instituted. Sarah’s mood and academic performance
improved dramatically. Over the first few weeks of dosage adjustment, the
morning dose was increased to 54 mg. In addition, it was determined that
Sarah required coverage of her symptoms for at least 16 hours a day. Thus,
twice-a-day dosage with Concerta 54 mg each morning and an additional dose
of 36 mg at 4:00 pm daily was recommended. Twice-a-day treatment with Concerta
is off-label; however, in cases in which more than 10- to 12-hour coverage
is needed, it can provide extended symptom relief. Sarah reported that she
was feeling more "in control" and more efficient and productive
with this dosage schedule, and, over these first few weeks, her feelings
of depression lifted. Sarah also experienced less anxiety and worry in general.
She also was able to fall asleep more easily and was sleeping better. No
side effects other than mild initial appetite suppression were reported.
Sarah maintained weekly contact for the next 4 weeks. Her progress continued
until immediately before her next menstrual period, when symptoms of irritability
and moodiness and an increase in inattentiveness returned. A 2-month prospective
rating of these symptoms that was undertaken noted that symptoms of ADHD
and PMS worsened consistently before each period. A low dose of fluoxetine
(Prozac 10 mg) was prescribed for the 7 days before her period. Because her
periods were irregular, a consultation with her gynecologist was recommended
to determine whether low-dose sequential oral contraceptive might not also
address some of these issues. Sarah was then followed monthly for the next
few months and then every 6 months for a medication follow-up. Dose remained
stable and Sarah continued to do well without the need for additional psychotherapy.
Outcome and Prognosis
This case demonstrates that emotional distress is not synonymous with depression
among females who have ADHD. It was Sarah’s ADHD symptoms, not depressive
symptoms, that caused the self-doubt, generalized anxiety, and confusion
that Sarah experienced. Treatment for ADHD promoted productivity and afforded
self-awareness and a general feeling of being "in control." Had
ADHD screening not been obtained on initial presentation, it is likely that
Sarah’s treatment would have focused on her depressive symptoms alone,
thus underscoring the importance of routine screening for ADHD in women who
experience anxiety and/or depression. Diagnosis of ADHD has been reported
to be delayed if an individual has protective influences such as a high IQ,
a supportive family, relatively good social skills, and no symptoms of conduct
disorder (Tzelepis, Schubiner, & Warbasse). Indeed, individuals who have
ADHD and a superior IQ may be able to compensate academically for many years,
thus running the risk of late diagnosis (Brown). This certainly was the case
for Sarah, a woman whose academic performance was largely unaffected (she
did have a tutor to help keep her organized in high school) by her long-standing
symptoms until her ability to cope was exceeded by the demands of law school.
An excellent support system and her intellectual ability allowed Sarah to
compensate for ADHD and to excel academically for many years. The influence
of hormonal fluctuations on Sarah’s ADHD symptoms and mood was uncovered
only after the proper diagnosis was made and the appropriate treatment with
stimulant medication was instituted. Once Sarah’s ADHD was under control,
a clearer picture of her premenstrual moodiness and irritability and their
contribution to the total symptom picture emerged. In addition, it was noted
that Sarah’s anxiety and worry were the result of her ADHD, not a true
coexisting generalized anxiety disorder. Concerta, a methylphenidate, was
selected as the stimulant of choice, however, to preclude the possibility
of increasing anxiety with amphetamines. In women who have generalized anxiety
disorder this may be a wise rule to follow. For this population, treatment
with both a stimulant and an antidepressant may also be indicated.
- Quinn, Patricia O.; Treating adolescent girls and women with ADHD: Gender-Specific
Issues; Journal of Clinical Psychology; May 2005, Vol. 61 Issue 5, p579
Reflection Exercise #7
The preceding section contained information
about diagnosing adult ADHD in an academically successful woman. Write
three case study examples regarding how you might use the content of this section
in your practice.
What factors may delay the diagnosis of adult ADHD? Record the letter of the correct answer the .