ADHD & Addictions -What We Know Dr. David Teplin, Psy.D., C.Psych. 4th CADDAC Annual Conference, Toronto October 14, 2012 1
Introduction Adult ADHD commonly co-exists with several other disorders, including Mood Disorders, Anxiety Disorders, Learning Disorders, Impulse Control Disorders, Sleep Disorders, Eating Disorders, Substance Use Disorders, Personality Disorders. Adult ADHD overlaps with various addictions, including alcohol, drugs, gambling, sex, food, spending, Internet. 2
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Introduction Addiction is not a diagnostic term. It refers to tolerance, withdrawal (physical and psychological), preoccupation, compulsive use, continued use despite emotional or physical problems, and strong cravings and urges to use. The overlap between Adult ADHD and addictions can have profound social, psychological, economic, and legal consequences. 4
Introduction In a nutshell, the overlap between Adult ADHD & addictions has to do with genetics, dopamine spike, boredom, self-medication, self-soothing, impulsivity (thoughts and behaviour), excitement or novelty-seeking, the rush, recklessness. A person can have more than one addiction at a time, or substitute one addiction for another along the way. 5
What We Know The high heritability of ADHD and Substance Use Disorders (SUD s) seen in both twin and adoption studies suggests that there is considerable overlap in the genetic influences between them. The high co-morbidity between such disorders also suggests some shared underlying neurobiological mechanisms may be at play. 6
What We Know Brain-imaging studies show similarities have been found between those persons with ADHD and those with addictionrelated craving. A possible explanation is that those with addiction show more craving when having ADHD, and that adequate treatment of ADHD actually reduces craving and relapse into substance use. Impulsivity is a risk factor for substance use, and poor inhibitory control is also a feature of ADHD. 7
What We Know The thinking has been that there is a common brain network that underlies such impulsivity in both disorders. Recent brain-imaging research suggests that the brain networks underlying both disorders are actually distinct, and that impulsive behaviour can have several underlying brain networks. 8
What We Know While ADHD and SUD s are distinct independent disorders, they often share an under-function of the neurotransmitter, dopamine, in the brain. Also, all addictive drugs strongly stimulate dopamine through which they stimulate the reward system, as well as learning, memory, and behaviour. 9
What We Know Under-function of dopamine is associated with reduced perception of reward, worsening cognition, and difficulty inhibiting behaviour. This makes life boring, worsens the ability to recognise future negative consequences, and reduces the ability to not respond to an inviting distraction. We see this in both ADHD and SUD s. 10
What We Know Also, the cognitive dysfunction associated with ADHD may decrease the person's ability to estimate the negative consequences of substance abuse and to delay immediate. gratification from drug or alcohol use. Those with ADHD also experience earlier onset and higher rates of tobacco smoking by mid-adolescence. 11
What We Know Biological mechanisms may underlie both ADHD and nicotine dependence. Children of mothers who smoked during pregnancy are at a much greater risk of ADHD. Nicotine improves attentiveness and performance deficits amongst those with ADHD, which provides a self-medicating rationale that nicotine increases dopamine release in the brain. 12
What We Know Early nicotine use among those adolescents with ADHD may also be due to factors such as acting out behaviour, impulsivity and peer rejection ( birds of a feather ). Knowing that ADHD actually increases the risk of more serious nicotine addiction, stresses the importance of prevention efforts aimed at adolescents and their families. 13
What We Know Those with ADHD have an over 6 times higher risk of developing an SUD, compared to those without ADHD. Up to 45% of adults with ADHD have a history of alcohol abuse or dependence, and about a third have a history of drug abuse or dependence. Marijuana, nicotine, alcohol, and cocaine appear to be most commonly used substances in those with ADHD. 14
What We Know Those with ADHD are more vulnerable to SUD s if they also have co-existing Oppositional Defiant Disorder, Bipolar Disorder, or Conduct Disorder. Those with ADHD and co-existing Conduct Disorder are estimated to be almost 9 times more likely to develop an SUD before age 18, compared with those with ADHD alone. 15
What We Know Impaired executive functioning, behavioural dyscontrol, impulsivity and peer rejection are common in both ADHD and Conduct disorder, and therefore, may increase the risk of developing SUD's in individuals who have both conditions. 16
What We Know Of Note: Approximately 25% of those persons with problem gambling also have a history of ADHD. Those with ADHD have more severe gambling problems. Of Note: Approximately 25-30% of those persons with sex addiction or hypersexuality also have adult ADHD. 17
Treatment ADHD and SUD s can mimic one another, and thus detection can be very challenging. Detecting evidence of childhood onset of ADHD symptoms before the person began using substances, and/or that persisted through periods of prolonged abstinence from substances, can be helpful in conducting a proper differential diagnosis. 18
Treatment When assessing for SUD risk, it is also important to consider the person's clinical condition, history of co-existing conditions that suggest SUD's, overall functional status, as well as collateral information from family members about the person's behaviour, substance use history, and patterns of use. 19
Treatment Treatment for those with co-existing ADHD and active addictions should occur together. If possible, the addictions should be initially treated to try and ensure stabilization. Combined treatment approaches may be best, including medication, CBT, motivational interviewing, family therapy, and mutual support groups. 20
Treatment There has been some concern that exposure to stimulant medication early on in childhood can increase the risk of later substance abuse by "priming" the brain. Recent studies show that stimulant medication use does not increase susceptibility to substance use problems, and may actually protect against such problems. 21
Treatment This protective factor seems to decrease into adulthood. Perhaps, use of stimulant medication may delay, but not prevent SUD's. Perhaps by adulthood, loss of parental supervision may lead to poor medication compliance, and therefore, increased susceptibility to SUD's. 22
In Conclusion... As ADHD is a risk factor for addictions, and because there is great overlap between them, it is imperative that persons being evaluated for adult ADHD also be assessed for the possible presence and/or history of the various addictions. Failure to do so, not only affects diagnosis, but can hugely impact both treatment and outcome. 23
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