ADHD is defined by early-onset (before age 12) of persistent (six months or longer) symptoms of inattention, hyperactivity, and impulsivity that aren’t according to development, causing impairment of normal functioning in a minimum of two settings, particularly home and school. It’s the foremost common psychiatric disorder in children, mostly in school-age boys.
Generally, the diagnosis of ADHD is predicated on the presentation of impairing levels of attention, hyperactivity, and impulsivity. However, ADHD can present with different symptoms like mood swings, irritability, emotional dysregulation, low frustration tolerance, sleep problems, low self-esteem, and making the diagnosis difficult due to overlapping with mood disorders and personality disorders.
ADHD
ADHD onset usually begins before the age of 12 years, with a prevalence of 1.7% to 16%. ADHD follows a chronic and unremitting course that persists into adulthood in half the cases. The hyperactive-impulsive type is related to trajectories of improvement, while the inattentive type is usually related to adverse outcomes. Hyperactive ADHD is more prevalent in men, while inattentive ADHD type is more common in girls. The severity and persistence of ADHD during development are related to adult criminal and antisocial behaviors.
Clinical picture:
Hyperactivity in ADHD is characterized by talkativeness, restlessness, fidgeting, thanks to lack of inhibition (but could also be sometimes redirected), engaging in risky behaviors (without being conscious of the consequences); the hyperactivity is present all day and may worsen when prolonged attention or on-task behavior is predicted, especially in structured activities.
In children with ADHD, attention difficulties, resistance to completing homework, and poor concentration often interfere with academic achievement.
School and social relationships are often impaired by accidental inappropriate behaviors associated with inattention, impulsivity, and poor motor coordination. Mood fluctuations are frequent in children and adolescents with ADHD, with self-esteem worsening over time, but generally don’t have dysphoric mood as a predominant symptom; mood shifts are usually associated with demands of learning and irritability is usually aggravated by withdrawal from stimulants.
People with ADHD are generally good sleepers, tend to rise quickly, are alert in minutes, circadian rhythms are normal, and there isn’t a decreased need for sleep. Parents can report resistance during bedtime but without sleep problems, including middle and late insomnia or nightmares. Psychotic symptoms and hyper-sexual behavior aren’t a part of the ADHD clinical presentation.
Bipolar disorder
The onset of manic depression features a lifetime prevalence of 2.1% in adults and 1.8% in children; a minimum of two-thirds of the patients with manic depression report onset before age.
The episodic course is merely one among many courses of illness. The need for periodicity (recurring episodes of mania and depression) to diagnose bipolar disorder has often resulted in the misdiagnosis of these with a chronic, non-episodic course of illness.
Circadian rhythms are altered, leading to more significant fluctuations in energy and activity. Evening hours are preferred with improved mood and energy within the later part of the day, early/middle/late insomnia, and sleep resistance.
Psychosis, including delusions, hallucinations, catatonic features, and bizarre behavior, occurs frequently. Suicidality, including morbid ideation, suicidal ideation, and suicide attempts, are familiar in children, and adolescents with manic depression as are various sorts of aggression (e.g., verbal aggression, anger dyscontrol, violent behavior destroying property or physical aggression).
An increased and intelligent interest in sexual content, also as increased sexual behaviors, is described in children and adolescents with manic depression. In such cases of inappropriately precocious sexualized behavior, it’s imperative to rule out any entirely inappropriate exposure to adult material, or sexual assault.
Borderline personality disorder
Onset and course: Consistent with DSM-5 criteria, a diagnosis of borderline mental disorder shouldn’t be made before the age of 18; however, diagnosis is often made earlier when symptoms are apparent and protracted. The height frequency of symptoms appears to be at 14 years aged.
Symptom remission (a reduction within the number of symptoms below the diagnostic threshold) is common, mainly when the diagnosis is formed during adolescence. However, despite the high remission rate, a borderline mental disorder in adolescence is far from harmless.
A borderline personality disorder is very comorbid with depression, anxiety, drug abuse, and eating disorders, with a high risk for suicide. Suicide risk is higher within the event of co-occurrence with a mood disorder or drug abuse and with an increasing number of suicide attempts. Functioning in borderline mental disorder is more highly impaired than in other personality disorders.
Clinical picture:
A borderline personality disorder may be a mental disorder with a chronic and pervasive pattern of instability in interpersonal relationships, mood, self-esteem, and marked impulsivity. Associated features are an increased risk for self-harm, transient stress-induced psychotic symptoms, and suicide. There appear to be two sets of symptoms, one (characterized by anger and feelings of abandonment) tends to be stable while the opposite (characterized by self-harm and suicide attempts) is a smaller amount persistent.
Patients with a borderline personality disorder can experience a particular sort of inattention as a part of dissociative states once they feel emotionally stressed, particularly in response to feelings of failure, rejection, and loneliness. Inattentive symptoms in ADHD are particularly prominent in situations that lack external stimulation (e.g., during boring, routine, or familiar tasks).
Patients with borderline personality disorder have a bent to resort to self-injurious behavior to alleviate tension; ADHD patients are more likely to manage emotional symptoms through extreme sports, novelty-seeking, sexual intercourse, and aggression.
Treatment
Stimulants are the cornerstone of pharmacotherapy of ADHD and help reduce the impact of cognitive deficits on academic performance and improving classroom behavior, social interaction, and increasing time on task.
Despite the widespread use of stimulants in the pediatric and adult population, the consequences of acute exposure during development and chronic exposure in youths and adults are poorly understood. More research is required to assess safety, primarily due to the extent of abuse, although several studies suggest relative safety.
Therapeutic approaches are often quite a different counting on the first diagnosis; as an example, mood-stabilizing agents and atypical antipsychotics could be beneficial for youngsters with early-onset manic depression but are unlikely to reinforce attention in children with ADHD and are related to serious adverse effects. On the opposite hand, stimulants are shown to be ineffective within the treatment of manic depression. However, some findings indicate that stimulants added to mood stabilizers didn’t end in a manic exacerbation.
In the comorbidity between ADHD and manic depression, treatment should first be directed to the foremost severe condition (almost always bipolar disorder). Treatment of ADHD should be considered when ADHD symptoms persist following mood stabilization and have a moderate to severe impact on the quality and functioning of life.
Treatment could also be needed piecemeal, for instance, mood stabilizers for manic depression, followed by stimulants/atomoxetine for ADHD. If a transparent diagnosis of ADHD is formed, and manic depression is merely suspected, then ADHD should be treated first while monitoring potential worsening of bipolar symptoms—stimulants or atomoxetine might exacerbate subthreshold mania. If bipolar symptoms emerge during treatment of ADHD, stop the ADHD treatment until bipolar disorder symptoms are stabilized, then review the diagnosis of ADHD before considering further treatment.
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