Sunday, November 9, 2008

Inappropriate Stimulant Use for Misdiagnosed A.D.H.D. Can Contribute to Psychosis

A very bright young man whose evaluation I recently completed sent me information that he'd found, on psychiatryonline, that he thought might be useful for others, so I'm posting it here.  (His encouragement to write a blog contributed to my beginning this one.)  He had suffered a psychotic episode in college after using stimulants for A.D.H.D.; though stimulants were not the only factor contributing to the psychotic episode in his case.  My evaluation indicated that his attention problems were part of his cognitive learning style, a kind of nonverbal learning disorder, and not really due to A.D.H.D.  The stimulants had only helped him as they would help anyone who took them, and his dependence on them contributed toward tipping him into a psychotic episode that he is still working his way out of.  Here's what he sent:   

"This case has some similarities to my situation."

"Stimulant use to treat attention deficit disorder and stimulant misuse to aid studying has dramatically increased in recent years among college students.  A phenomenon we have observed is the use of stimulants during the schizophreniaprodrome for presumed attention deficit disorder or attentional difficulties in the absence of any childhood attention deficit disorder.  The following case typifies this presentation, which we have seen several times over the past 2 years in our First Episode and Early Psychosis Program.

"Mr. A," a 20 year old man, with normal childhood development and no behavioral or academic problems, graduated high school with honors despite regular marijuana use.  During his sophomore year, he suddenly found it difficult to concentrate and demonstrated difficulty keeping up with his course work.  these difficulties prompted him to try a friend's prescription stimulant Adderall, which he found effective and continued to use it intermittently without a prescription for "cramming."  Several months after starting Adderall, he became acutely psychotic after smoking phencyclidine-laced cannabis at a party.  He required a lengthy hospitalization but was eventually stabilized and treated with aripiprazole 10mg/daily.  His request for stimulants "to concentrate better" was resisted, and after 6 months of treatment with aripiprazole, he made a full symptomatic and functional recovery without any objective or subjective residual psychotic or cognitive symptoms.  His provisional diagnosis of schizophrenia was confirmed when he had a psychotic relapse 3 months after discontinuing his maintenance antipsychotic aripiprazole following 1 year of treatment. (italics added to identify case presentation)

The prodrome of schizophrenia is characterized by nonspecific symptoms that include cognitive problems, often characterized by patients as "difficulties concentrating."  The construct of "basic symptoms" attempts to capture these nonpsychotic, subjective cognitive problems that begin during the prodrome and might presage the onset of psychosis.  Two basic symptoms that would lead to a complaint of "difficulties concentrating" are thought interference (the intrusion of often banal thoughts) and disturbances of receptive language (problems with the meaning of words).  Both are of particular interest because of their potential as specific predictors of schizophrenia.  

College students who present for treatment with self-diagnosed "pseudo-attention deficit disorder" should be asked about misuse of stimulants and followed closely, since a small percentage will be in the early phases of schizophrenia.  Although the impact of stimulants on the course of schizophrenia is not known, sensitization has been described with stimulants, raising the possibility that stimulant use is a risk factor for some cases of schizophrenia."

This observation, from psychiatryonline, indicates both that some attention problems that look like attention deficit might be early indications of schizophrenia, and that misuse of stimulants, especially together with use of hallucinogenic (or other recreational) drugs, might conduce toward psychosis in certain individuals.  

This information is important to consider in light of the widespread practice of prescribing stimulants for individuals with attention problems without either taking a detailed and fairly thorough case history, or having the opportunity to review the results of psychological testing that might indicate the presence of cognitive patterns that explain the attention problems in other ways than as a result of hyperactivity.  In my evaluations, I typically spend an hour or more taking a case history from a patient--sometimes several hours over parts of several sessions--and an hour and a half taking a developmental case history from the parents if they are available; and that's not including perhaps 10 or more hours of testing.  The current standard of practice for prescription of stimulants is a single medical interview, often not even lasting an hour.   

While we don't have any test that will objectively confirm the existence of attention deficit disorder, a fairly thorough case history and the results of a fairly comprehensive battery of psychological tests can provide a much more informed basis for clinical judgment. 

It's important to remember that stimulants will help most people to concentrate better at first, so the fact that a patient reporting attention problems concentrates better after beginning stimulant treatment by no means indicates that the problem was attention deficit disorder.  Stimulants are in demand on college campuses for exactly that reason, especially at exam time.  It has long been known that stimulant abuse is associated with an increase in paranoid symptoms, especially when used on a long term basis, and more recently stimulants have been observed to exacerbate bipolar symptoms in patients who had hypomanic or cyclic tendencies before beginning the stimulant.  Now we see that stimulant abuse may also be associated with  psychosis.  

This doesn't mean that stimulants aren't very useful, even sometimes necessary, for patients with the kind of attention disorders for which they can really make a great deal of difference.  It means that the prescription of stimulants for attention disorder should follow a much more detailed and thorough assessment than is current in general practice.  

I hope that my former evaluatee's research, part of his path of recovery on his own personal journey, will help others to avoid this particular pitfall of medication misuse.  I know he hopes for that as well.

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