Professor Edward Ogden PSM

MA MBBS BMedSc DipCrim GradCertMgt(TechMgt) FRAGP FAChAM(RCPA) FFCFM(RCPA)

Addiction Medicine Specialist

Do you recognise Laura!

ADHD in childhood, drug induced psychosis. What’s her story?

Objectives

• Meet Laura

• Learn the problem is common

• Understand a little about ADHD and the treatment

• Think about what to do when you meet Laura

Laura’s story

• Laura is 24

• Grew up in a little country town

• Went to a 2 teacher primary school

• Described herself as

– Chatterbox - ‘Laura stop talking’

– Daydreamer - ‘Laura pay attention’

Laura at high school

• Went to high school in rural city

• Really enjoyed athletics and basketball

• Increasingly tension over school work

– Stressed

– Could not concentrate

• Started smoking dope to relax

Laura drops out

• School becomes more difficult

• Brain racing with too many thoughts

• Only daydreaming and cannabis help

• Starts hanging around with the pot smokers

• Drops out

• Starts having weird thoughts

Laura needs help!

• Several episodes of psychosis

• Diagnosed with

– Drug induced psychosis

– Borderline Personality Disorder

– Bipolar Disorder

– ? Schizophrenia

• Have you met Laura?

Selina lee “aDHD WHiSperer on Facebook”

Dysregulation of Attention

• Laura’s brain is so busy

– Easily distracted,

– Can’t pay attention

– Can’t listen or remember

– Disorganised and overwhelmed

• Laura can hyper-focus

– When the topic is exciting, frightening, urgent or emotional

• Sometimes Laura seems super bright other times lazy and stupid

Dysregulation of Movement”

• Laura always feels restless

– Fidgety

– Can’t easily sit still

– Driven by a motor

– Always talking

• And this irritates others

– but she can’t stop it

• She only feels really normal when she is moving

Dysregulation of Impulses”

• Can’t wait her turn

• Often interrupts

• Blurts out things

• Makes impulsive decisions

• Accident-prone

Dysregulation of emotions• Laura’s emotions are

• Out of proportion to the triggers

• Hard to manage

• Laura experiences extreme

• Anger, impatience, rage

• Rejection Sensitivity

• Dysphoria

• Social anxiety, panic

Laura binge eats

• She won’t volunteer it but

– She binges

– Has bulimia

– Suffers anorexia

Laura is suffering

• So she uses cannabis

– Relieves the tension

– Helps her sleep

• BUT it

– Increases her sense of shame and failure

– Affects her mental health

First Admission

• Drug induced psychosis

– Prescribed olanzapine

• Sedated

• Confused

• Very upset by weight gain

• Goes back to cannabis

Second admission

• Referred to you for AOD counselling

Back to Laura

• Nuclear family• Dad is an electrician, mother receptionist in real estate

• Older brother builder & captain of the football team

• Younger brother doing well at university

• Laura• The challenging child

• Chatterbox

• Loved sport

• Popular

Laura dropped out

• School too difficult

– Brain racing with too many thoughts

– Only daydreaming and cannabis helpped

– Started hanging around with the pot smokers

– Weird thoughts

• Dropped out

Is this Laura’s brain?

Could this be ADHD?

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Laura

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Fast Facts

• 7 % of kids have ADHD– 40 % adjust

– 60% don’t

• 2- 4% of Adult Population– <20% diagnosed

– < 5% are treated.

• 3.8% adults have untreated ADHD– Burden of problems and emotional pain

– Drug use

– Workaholism

There are many positives?

Common ADHD traits:

• Creative talent

• Intuitive

• Out-of-the-box thinking

• Entrepreneur

• Funny

• Try hard

• Hyperfocus(sometimes)

• Warm-hearted

• Generous

• Passionate

• Quick-thinking

• Good in a Crisis

• Athletic

• Novelty-seeking

ADHD -> a busy brain• Imagine that while you are trying to

listen to me you have 5 children yanking at your arm, calling your name. Someone is brewing coffee through a loudspeaker aimed at your ear. You want to draw this Chinese dragon. A song comes on the radio. A childhood friend you haven’t seen for 15 years pops into your head and your start to reminisce and then two of the kids start pulling each others hair and one kid vomits.

• Now ignore all that and listen to me focus on what I am saying.

• Imagine that while you are trying to listen to me you have 5 children yanking at your arm, calling your name. Someone is brewing coffee through a loudspeaker aimed at your ear. You want to draw this Chinese dragon. A song comes on the radio. A childhood friend you haven’t seen for 15 years pops into your head and your start to reminisce and then two of the kids start pulling each others hair and one kid vomits.

• Now ignore all that and listen to me focus on what I am saying.

Neurones and Synapses

Neurons and Synapses – what usually happens

Neuron sends an electrical signal

to communicate with next neuron

Axon carries the electrical impulse

to the synapse

Dopamine vesicle sprays

dopamine into the synapse

Dopamine

crosses and

passes the signal

to the dopamine

receptors

Reuptake pumps take

away excess dopamine

If you have the genetic marker

associated with DAT you will have

more reuptake pumps

Too much dopamine is

reabsorbed and not enough gets

to the receptor sites

= weak signal

Neurons and Synapses – what happens with ADHD

ADHD medication works by

blocking some of these extra

reuptake pumps

= better signal

Neurons and Synapses – what happens with medication

ADHD Brain is like a radio that is not tuned to the station, so you hear

song and static noises

Cannabinoids and Serotonin act like a mute button, so you do not feel as

much and do not care

Dopamine is like the tuning knob:The song is heard clearly

How common is it?

• 7 % of kids have ADHD

– 60 % are troubled by ADHD as Adults

• 2 - 4% of Adult Population has ADHD

– <20% are diagnosed

– Most are not treated

• 3.8% of adults have untreated ADHD

AOD and prison populations

• 30 – 40% have ADHD

– Self medicating with

• Sedatives to slow the busy brain– Cannabis

– Alcohol

– Opioids

• Stimulants for self-medication– Amphetamine

– Methamphetamine

– Illicit medication

Laura comes to you with

• Recently discharged from hospital after admission for psychosis

• The GP referral lists

– Drug induced psychosis

– Borderline Personality Disorder

– Bipolar Disorder

– ? Schizophrenia

What did I do with Laura?

• Explored the evidence for ADHD– Screening test 16/18 on ASRS (inattentive)

– Supporting evidence• School reports

• Family or friends

• Started treatment

• Referred for ADHD coaching

Outcome?

• Laura became a mature age student– Finished Cert IV in Community Service

– Working part-time

– Doing an on-line course in AOD

– Planning enrolment in degree course

• Other indicators of success– Relationships improved

– Watched first movie EVER

Barriers?

• Lack of diagnostic skills

– Most of us were not taught about ADHD

– Most practitioners were not taught

• Lack of community resources

– Prescription requires a psychiatric opinion

– Who will treat patients who use drugs?

– ADHD coaching is not covered by Medicare

Resources

• ADHD Australia – consumer organisation

• Join

• www.totallyadd.com

• ADHD Coaches

Questions?