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Week 9 Main Post, Case #3, Vol. 2, Case #21, Treating Residual Inattention

Questions I Would Ask the Client

I would ask the client if he felt comfortable taking Cymbalta and if it is helping his anxiety. I would also ask: are you having sexual side effects, are you having trouble sleeping, how long have you noticed the inattention problems, do you have other medical conditions like high blood pressure, and tell me what other symptoms you are having?

I would also question the client’s partner or nearest relative. A partner can provide information about daily activities of the client (Kooij, Bijlenga, Salerno, Jaeschke, Bitter, Balazs, Thome, Dom, Kasper, Filipe, Stes, Mohr, Leppamaki, Casas, Bobes, Mccarthy, Richarte, Philipsen, and Asherson, 2019). I would ask the partner what it is like to be with this person. I would ask: do you notice him having an inability to finish tasks, does he start several projects without completing them? I would ask the client and the partner or family member these questions because the symptomology is what guides the sort of medication that will be prescribed.

Also, some of the side effects of medications are increased heart rate and blood pressure. Sexual side effects can cause the client to discontinue a medication. Sleep problems would incline the clinician to prescribe a more sedating medication at bedtime versus a stimulant. This client likely has ADHD undiagnosed and it is important to get symptoms in order to make a diagnosis.

Tests Needed

I would administer an IQ test since many clients with high IQs can mask their disorder of ADHD (Milioni, Chaim, Cavallet, de Oliveira, Annes, dos Santos, Louza, da Silva, Miguel, Serpa, Zanetti, Husatto, and Cunha, 2017). I would use the Stroop task test which activates the dorsal anterior cingulate cortex of the brain indicating ADHD (Stahl, 2013). I would also administer the n-back test which analyzes the client’s problem solving, sustained attention, and ability to finish tasks (Stahl, 2013). I would have the client fill out the Adult Self Report Rating Scale (ASRS) to get the symptomology in order to diagnose ADHD (Kooij et al., 2019). Finally, I would get a baseline blood pressure and vital signs, since ADHD medications can lower or increase blood pressure and heart rate (Joseph, Ayyagari, Xie, M., Cai, Xie, J., Huss, and Sikirica, 2017).

Differential Diagnoses

According to the DSM-5 I would diagnose this client with these three disorders:

  1. Post-Traumatic Stress Disorder 309.81 (F43.10)
  2. Attention-Deficit/Hyperactivity Disorder: Predominant inattentive presentation 314.01 (F90.0)
  3. Generalized Anxiety Disorder 300.2 (F41.1) (American Psychiatric Association, 2013).

Medications for This Client

I would continue with Cymbalta 60 mg daily for this client if he states it is working for him and we could always increase up to 120 mg per day if his anxiety is not well controlled. Generalized anxiety disorder (GAD) is his main diagnosis and we can also switch him to Zoloft if the side effects are too much, since Zoloft has less side effects (Stahl, 2017).

I would add guanfacine ER (Intuiv), which is an Alpha 2 adrenergic antagonist. I chose this over a stimulant since they can become habit forming (Stahl, 2013). Guanfacine ER has no potential for abuse and works throughout the day with no side effects (Stahl, 2017). I would counsel the patient about possible decreased appetite and sedation, but they generally go away with time (Stahl, 2017).

Since the client has some mood problems, PTSD history, and anxiety, this medication is an NRI and will treat those symptoms as well and is used for treatment-resistant depression (Stahl, 2017). Amoxetine (Strattera) is another non-stimulant medication for ADHD, but in a systematic review of several randomized controlled trials, Intuiv was more efficacious and participant’s ADHD symptoms declined significantly to a probability of 93.91% (Joseph et al., 2017). This is why I chose Intuiv over Strattera, but in 4-8 weeks we could re-evaluate and try Strattera if Intuiv is ineffective.

Lessons Learned

First, many adults go undiagnosed with ADHD because it was missed in childhood and they learned to compensate for the dysfunction as they got older (Stahl, 2013). Too often clinicians focus on the mood disorder and miss the diagnosis of ADHD and this could lead to a substance disorder, low quality of life, or nicotine dependence in adulthood if not treated (Stahl, 2013).

Second, it is important to administer neuropsychology tests in adults in order to diagnose ADHD because many clients with a high IQ mask their ADHD with intelligence and “creative compensation” (Milioni et al., 2017). The executive function dysregulation of ADHD shows up in college and when the client gets a job in the professional world (Milioni et al., 2017). The clients can no longer compensate and the disorganization of ADHD and inability to handle life’s responsibilities shows up (Milioni et al., 2017).

References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: .

Joseph, A., Ayyagari, R., Xie, M., Cai, S., Xie, J., Huss, M., & Sikirica, V. (2017). Comparative efficacy and safety of attention-deficit/hyperactivity disorder pharmacotherapies, including guanfacine extended release: A mixed treatment comparison. European Child & Adolescent Psychiatry26(8), 875-897. https://doi.org/10.1007/s00787-017-0962-6

Kooij, J., Bijlenga, D., Salerno, L., Jaeschke, R., Bitter, I., Balazs, J., … Asherson, P. (2019). Updated European consensus statement on diagnosis and treatment of adult ADHD. European Psychiatry56, 14-34. https://doi.org/10.1016/j.eurpsy.2018.11.001

Milioni, A. L., Chaim, T. M., Cavallet, M., De Oliveira, N. M., Annes, M., Dos Santos, B., … Cunha, P. J. (2017). High IQ may “mask” the diagnosis of ADHD by compensating for deficits in executive functions in treatment-naive adults with ADHD. Journal of Attention Disorders21(6), 455-464. https://doi.org/10.1177/1087054714554933

Stahl, S. M. (2013). Stahl’s essential psychoparmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

Stahl, S. M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide (6th ed.). New York, NY: Cambridge University Press.

 

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