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
