Chapter 8: Other Disorders and Issues in Primary Care

INTRODUCTION

In this chapter, we consider some other important mental health issues encountered in medical settings. Recognizing the signs and symptoms of these disorders can prevent misdiagnoses and medication errors, as well as help the patient to get started on an effective course of treatment early on, often by timely referral.

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by age-inappropriate levels of motor hyperactivity, impulsivity, and inattention.¹ It is a common disorder of childhood and adolescence and persists into adulthood in about 50% of cases.² The prevalence of ADHD in Americans aged 18 to 44 years is estimated to be 4.4%.³ Like prescribed opioids, the stimulant drugs commonly used to treat ADHD have posed a problem of misuse, so it is important to know how to diagnose these patients so that those with true ADHD can receive the effective treatment you have at your disposal. Also, diagnosis is especially important because persistence of childhood ADHD into adulthood and adult-onset ADHD are associated with increased mental health problems and substance abuse, in addition to the diminished economic and physical health outcomes that characterize remitted childhood ADHD.⁴

Diagnosis and Screening

The differential diagnosis of ADHD in adults includes disorders that are also commonly comorbid with ADHD such as mood disorders, anxiety disorders, substance use disorders, learning disabilities, and impulse control disorders.^3,5 Medical disorders that can mimic ADHD include endocrine and metabolic disorders (thyroid disorders), neurologic disorders (including traumatic brain injury), sleep disorders (obstructive sleep apnea), and side effects of medications.¹

The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) diagnostic criteria for ADHD (Table 8-1), originally developed to diagnose ADHD in children, need slight modifications for use with adults. Adults with ADHD present primarily with deficits in executive functioning such as memory deficits, problems with initiating and shifting tasks, and difficulty with inhibiting or monitoring themselves. This leads to problems with organizing, prioritizing, remaining focused, and following through with tasks and assignments.⁵ While these manifestations of inattention are prominent, symptoms of hyperactivity or impulsivity are less or overt in adults.