MHM Magazine

16 | MENTALHEALTHMATTERS | Issue 2 | 2021 MHM SLEEP DISORDERS Sleep deprivation is the most common cause for ‘ADHD’ symptoms in clinical practice.  However, Delayed Sleep Phase Syndrome is present in 60% of ADHD patients. This means their melatonin levels peak later making early sleep highly problematic. During lockdown, it was interesting to note that many ADHD patients were functioning better due to flexible working hours which enabled them to go to bed later but also get up later. OBESITY The association between obesity and ADHD hold true for women, not men. Studies have indicated there is a higher risk of obesity in ADHD patients. Stimulants are known to reduce appetite which is a reason why adults misuse ADHD medication. ADHD is linked to binge eating, poor food planning and increased nocturnal snacking, oral “fidgeting” and impulsivity. In addition, a late bedtime and resulting fatigue can result in high sugar snacking to stay awake.  Abnormalities in hormones leptin and ghrelin are also associated with ADHD. Leptin (satiety hormone) is reduced by 18%, while ghrelin (hunger hormone) is increased by 28% in ADHD patients, especially after sleep restriction. Sleep loss has been identified as a novel risk factor for insulin resistance and Type II Diabetes. SUBSTANCE USE DISORDERS There is a seven times increased risk of substance use disorder in untreated ADHD. People with untreated ADHD are at risk for more severe substance use disorder, earlier onset of use, extended duration of use, greater impairment of functioning, and a shorter transition time between use and dependence. There have been popular media claims that ADHD medication in childhood makes people more prone to substance use and abuse later. These claims are totally unfounded. In fact, studies have repeatedly shown proper treatment of childhood ADHD reduces the risk of developing SUD. It’s important to specifically ask patients presenting with ADHD about substance use. In patients with ADHD there’s an increased use of cannabis and cannabinoids, as well as codeine, caffeine and energy drinks. Any patient on psychopharmacological treatment should stay free of Ginseng, Gingko Biloba, and Guarana use as the side effects and interactions are potentially dangerous.  At GP level, substance abuse should be treated first under close supervision. At psychiatry level, it’s advised to treat the SUD and ADHD simultaneously. The first line treatment is atomoxetine with a long-acting stimulant as a second line treatment. By treating the ADHD, the impulsivity and need to self- medicate are reduced. In patients using cannabis, benzodiazepines, and codeine, it’s vital treatment is done simultaneously. These substances have an adverse effect on cognition and negate ADHD treatment.  BORDERLINE PERSONALITY DISORDER In clinical practice, the two personality disorders most seen in association with ADHD are narcissism and borderline personality disorder. One of the core criteria in BPD is Emotional Dysregulation – which is a core component of ADHD. There are international debates about the inclusion of Emotional Dysregulation in the DSM selection criteria for ADHD in addition to the current triad. Both BPD and ADHD display impulsivity, erratic moods, irritability and a long history of failed relationships both personal and in the workplace. The key is to identify the core feature – in ADHD, being attentional issues, whereas in BPD, the core feature is instability of mood, chronic feelings of emptiness, fear of abandonment, and self-harm. CONCLUSION SASOP indicates that an adult patient presenting for the first time with ADHD symptoms should be clinically assessed at psychiatric level. While there are guides and pointers for assessing and treating comorbid cases, every case needs an individualised approach. Early intervention, correct treatment, and careful monitoring in terms of effectiveness, risk-benefit profile and tolerance are crucial.  There is an increased need for combination therapy, both in terms of psychopharmacological agents as well as psychotherapeutic approaches. Lifestyle changes are vital to include in all forms of therapy. References available upon request ADHD Symptoms Hyperactivity Impulsivity Inattention Related Symptoms Excessive talkativeness Restlessness / psychomotor agitation Racing thoughts Impulsive behaviour Difficulty concentrating Decreased attention / distractibility Mood swings / anger / outbursts Bipolar Mood Disorder Euthymic • • • Hypomanic • • • • • • • Depressed • • • Anxiety Disorders GAD • • • •