Voksne med ADHD: Et PET studie af den dopaminerge neurobiologi Udredning og diagnostik af voksne med ADHD i klinik og forskning 1
Program ADHD-teamet i Herning Udfordringer ved diagnostik af voksne Diagnostik og udredning i ADHD-teamet Klinisk assessment i andre MR- og PET studier Klinisk assessment i aktuelle PET studie 2
ADHD-teamet i Herning Regionspsykiatrien Herning ADHD-teamet ét af i alt 4 teams Opstart januar 2009 - et led i specialiseringen af psykiatrien i Region Midtjylland Tværfaglig behandlergruppe I 2009 modtaget 232 henvisninger i alt 70 kvinder, 162 mænd 18-63 år Ca. 25-30 % havde ikke ADHD Heraf er ca. 20 sendt retur til egen læge 3
Optageområde: ADHD-teamet i Herning Herning, Ringkøbing-Skjern og Ikast-Brande kommune Befolkningsgrundlag i optageområde pr. 1. januar 2010 1 : 184.299 Prævalens: Børn 3-7%, voksne 2-4 % 2 Op til 2/3 af børnene vil opfylde kriterierne i voksenalderen 3 Mellem 3000 og 7000 voksne må forventes at have ADHD i teamets optageområde. De med sværeste symptomer og funktionsnedsættelse henvises 1 Iflg. tal fra Region Midtjylland Kommunestatistik: http://regionmidtjylland.neozone.com/regionmidtjylland/nzkamap.php?rmpredefined 2 Barkley (1998). Attention-Deficit Hyperactivity Disorder. A Handbook for Diagnosis and Treatment. New York: The Guilford Press. 3 Faraone S. V. et al: The age-dependet decline of attention deficit hyperactivity disorder: a metaanalysis of follow-up studies. Pshycol Med 2006; 36, 159-165 4
Udfordringer ved diagnostik af voksne ADHD-teamet er det første af sin slags i Danmark Begrænset dansk forskning på området To forskellige diagnosesystemer valideret v/ børnestudier 4 Vi har valgt at bruge ICD-10 Ingen formelle danske referenceprogrammer Manglende specificitet Ingen test eller skala kan alene bruges til diagnostik Det kliniske interview er en central del af diagnostikken Underrapportering overrapportering af symptomer 5 4 www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/adhd/nhmrc-draft-adhd-guidelines.pdf 5 Barkley, R.A. ADHD. The latest assessment and treatment strategies. Jones and Bartlett, Massachusetts, 2009
Forløb i aktuelle PET studie Vurdering i ADHD-team: 1. psykopatologiske vurdering Inklusionssamtale Vurdering hos psykolog: 2. psykopatologiske vurdering 1. MR-skanning og 1. PET-skanning Behandling i teamet 2. PET-skanning Follow up samtale 6
Diagnostik og udredning i ADHDteamet 6 Klinisk interview (1-2 timers varighed med pårørende) Indhentning af relevante oplysninger fra eksterne samarbejdspartnere Præ- og perinatale risikofaktorer Disposition til psykiatrisk lidelse Somatisk anamnese Udviklingshistorie, herunder særlig vægt på skolegang Detaljeret social anamnese. Herunder kriminalitet og anden risikoadfærd Misbrugsanamnese 6 jf. Procedureskrivelse udarbejdet af teamet og samarbejdspartnere i forbindelse med teamets opstart januar 2009 7
Diagnostik og udredning i ADHDteamet Klinisk interview fortsat (1-2 timer) ASRS v. 1.1 7 ; ADHD symptomrating PSE til klinisk brug; misbrug, affektive lidelser, angstlidelser, personlighedsforstyrrelser, tic lidelser, gennemgribende udviklingsforstyrrelser, sprog- og indlæringsvanskeligheder, mental retardering GAF scoring; vurdering af symptomer og funktionsnedsættelse Screening for somatiske lidelser: Neuropsykiatriske standardblodprøver, EKG, blodtryk, højde, vægt, evt. supplerende undersøgelser (EEG, neurologisk undersøgelse) 7 Kessler, R.C et al.: The World Health Organization adult ADHD self-report scale (ASRS): a short screening scale for use in the general population, Psychol Med 2005; 35:245-56. 8
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Klinisk assessment i PET- og MR studier 8, 9, 10, 11 Generelt små studiegrupper Erfarne eksperter har stillet diagnosen Struktureret psykopatologisk undersøgelse F.eks. SCID: Structured Clinical Interview for DSM-IV Vurdering af aktuelle ADHD symptomer Iflg. DSM-IV kriterier Flere retrospektiv vurdering af diagnose Interview med forældre, indhentning af information fra skole, forskellige skalaer Screening for somatiske lidelser Flere neuropsykologisk testning 8 Jucaite et al. Reduced Midbrian Dopamine Transporter Binding in Male Adolescents with Attention-Deficit/Hyperactivity Disorder: Association Between Striatal Dopamine Markers and Motor Hyperactivity, Biol Psychiatry 2005; 57:229-238. 9 Rosa-Neto et al. Methylphenidate-evoked changes in striatal dopamine correlate with inattention and impulsivity in adolescents with attention deficit hyperactivity disorder, Neuroimage. 25: 868-876 10 O Gorman et al. Increased perfusion in adult attention deficit hyperactivity disorder is normalised by stimulant treatment: A non-invasive MRI pilot study, Neuroimage 42 (2008) 36-41 11 Seidman et al. Dorsolateral Prefrontal and Anterior Cingulate Cortex Volumetric Abnormalities in Adults with Attention-Deficit/Hyperactivity Disorder Identified by Magnetic Resonance Imaging, Biol Psychiatry 2006; 60:1071-1080 11
Assessment i aktuelle PET studie To trin i den psykopatologiske assessment 1.Vurdering i ADHD-team jf. tidl. procedurer ADHD diagnosen stilles pba. ICD-10 kriterier, F 90.0 ASRS v. 1.1 og GAF Alle patienter vurderes af erfaren overlæge Der screenes for komorbide psykiatriske lidelser 12
Assessment i aktuelle PET studie 2. Vurdering hos psykolog SCAN interview» systematisk vurdering af komorbid psykiatrisk lidelse» Findes kriterier for depression opfyldte, anvendes HDS Conner s Adult ADHD Rating Scale (CAARS) 12» aktuelle ADHD symptomer, patientrating/obs. rating Wender Utah Rating Scale (WURS) 13» retrospektiv vurdering af ADHD symptomer Current Behavior Scale (CBS) 14» grad af funktionsnedsættelse Alcohol Use Disorders Identification Test (AUDIT)» aktuelle alkoholforbrug Edinburgh Handedness Inventory (EHI)» højre/venstrehåndet 12 http://www.neuropsychiatryreviews.com/feb01/npr_feb01_adhd.html 13 Ward, M. F. et al. The Wender Utah Rating Scale: An Aid in the Retrospective Diagnosis of Childhood Attention Deficit Hyperactivity Disorder, Am J Psychiatry 150:6, 1993 14 Biederman, J. et al. Utility of an abbreviated questionnaire to identify individuals with ADHD at risk for functional impairments. Journal of Psychiatric Research 42 (2008) 304-310 13
Assessment i aktuelle PET studie Follow-up samtale: ASRS v. 1.1 Conner s Adult ADHD Rating Scale Current Behavior Scale
Assessment i aktuelle PET studie Current Behavior Scale Items Never or rarely Sometimes Often Very often 1. Have trouble planning ahead or preparing for upcoming events 2. Can t seem to accomplish goals I set for myself 3. Can t seem to hold in mind things I need to remember to do 4. Easily frustrated 5. Have difficulty motivating myself to stick with my work and get it done 6. Have trouble doing what I tell myself to do 7. Lack self-discipline 8. Have trouble organizing my thoughts 15
Assessment i aktuelle PET studie Wender Utah Rating scale Item 1. Concentration problems, easily distracted 2. Anxious, worrying Not at all or very slightly Mildly Moderately Quite a bit Very much 3. Nervous, fidgety 4.Inattentive, daydreaming 5. Hot- or shorttempered 6. Temper outbursts, tantrums 7. Trouble with stickto-it-ness 16
Assessment i aktuelle PET studie Wender Utah Rating Scale (fortsat) Item 8. Stubborn, strongwilled Not at all or very slightly Mildly Moderately Quite a bit Very much 9. Sad or blue, depressed, unhappy 10. Disobedient, rebellious, sassy 11. Low opinion of myself 12. Irritable 13. Moody, ups and downs 14. Angry 17
Assessment i aktuelle PET studie Wender Utah Rating Scale (fortsat) Item 15. Trouble seeing things from someone else s point of view Not at all or very slightly Mildly Moderately Quite a bit Very much 16. Acting without thinking, impulsive 17. Tendency to be immature 18. Guilty feelings, regretful 19. Losing control of myself 20. Tendency to be or act irrational 21. Unpopular with other children 18
Assessment i aktuelle PET studie Wender Utah Rating Scale (fortsat) Item 22. Trouble with authorities, trouble with school, visits to principals office 23. Overall a poor student, slow learner Not at all or very slightly Mildly Moderately Quite a bit Very much 24. Trouble with mathematics or numbers 25. Not achieving up to potentials 19