5/25/2019 “THINKING THROUGH ADULT ADHD :” HOW THOUGHTS TURN INTENTIONS INTO ACTIONS (OR NOT)[W39] JUNE 21 2019 PENNSYLVANIA PSYCHOLOGICAL ASSOCIATION CONVENTION PITTSBURGH, PA J. Russell Ramsay, Ph.D. Adult ADHD Treatment & Research Program University of Pennsylvania Perelman School of Medicine DISCLOSURES (PAST 12 MONTHS) • Speaker honoraria : • 2019 APSARD Conference session • 2019 APA Convention CE workshop • Paid fee/royalties for CE webinars/recordings (J&K Seminars, TZK Seminars) • Book royalties (Routledge/Taylor&Francis, American Psychological Association) • Honoraria for article/reviews (New Hope Media, LLC [Additude Magazine]) • Honoraria for APA Psychotherapy Video Training Series DVD • Honoraria for expert opinion survey on best practices (SUNY Research Fnd) • Advisor/consultant for Mantra Health, Inc. LEARNING OBJECTIVES • Recognize and summarize the premises about the nature of ADHD and psychosocial treatment that provide the basis for the CBT approach presented here. • Recognize the main CBT intervention target in each treatment domain: cognitive, behavioral, emotional, implementation, and interpersonal as presented here. • Name the most commonly endorsed cognitive distortion endorsed in a chart review study of adults with ADHD. • Leave the workshop with at least three (3) new implementation-focused strategies to use in clinical practice. 1 5/25/2019 WHAT IS THE PREVAILING MODEL OF ADHD? “There is much more than the ‘A’ and the ‘H.’” ADULT ADHD: SYMPTOMS AND IMPAIRMENTS What are the underlying problems that provide targets for treatment? Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.20 2 5/25/2019 TWO DIMENSIONS OF SYMPTOMS Inhibitory (H-I symptoms) Executive (Inattention) • Motor – restless, active, “ballistic” v smooth • Poor persistence toward goals, future • Verbal – talkative, break in • Distractible (poor resistance to irrelevant internal and external events) • Cognition – task-irrelevant thoughts, rapid decisions, internal distractibility • Deficient re-engagement after disruption • Motivation – discount rewards/future, low • Poor working memory, forgetful, poor delay of gratification sequencing (NV > V WM difficulties) • Emotion – impulsive, reactive, poor top-down • Poor self-monitoring, self-evaluation control INTERDIGITATING MODELS FOR UNDERSTANDING ADHD • Executive Function / Self-Regulation • Dopamine deficiency • Reward deficiency • Default Mode Network • Genetics • Neuroimaging ADHD is neurodevelopmental disorder of self-dysregulation . It is a chronic delay in the onset and employment of self-regulation capacities and skills. WHAT ARE EXECUTIVE FUNCTIONS (EFS)? • Self-regulation across time to choose, enact, and sustain actions toward a goal usually “(T)hose self-directed in the context of others and actions of the often relying on social and individual that are cultural means for the being used to self- maximization of one’s long- regulate.” 1 term welfare as the person defines that to be – but for which there is not proximal enough reward or consequence. 2 1Barkley (1997). ADHD and the nature of self-control . New York: Guilford. 2Barkley (2012). Executive functions: What they are, what they do, how they evolved . New York: Guilford. 3 5/25/2019 WHAT ARE EXECUTIVE FUNCTIONS (EFS)? EF usually emerges as a single factor: “How efficiently do you do what you set out to do?”, but there are five semi-distinct domains that emerge in ratings of daily functioning: 1. Self-management to time 2. Self-organization and problem solving 3. Self-restraint (inhibition) 4. Self-motivation 5. Emotional regulation Barkley, R. A. (2011). Barkley deficits of executive functioning scale . New York: Guilford. WHAT ARE EXECUTIVE FUNCTIONS (EFS)? 4 factor model of ADHD (DSM-5) = (1) EF deficits-inattention (2) hyperactivity (3) impulsivity (4) emotional dyscontrol with EF-inattention being most consistent & discriminating factor. Adler et al. (2017). International Journal of Methods in Psychiatric Research, 26, e1555. doi: 10.1002/mpr.1555 BARKLEY’S HYBRID MODEL OF EXECUTIVE FUNCTIONS Self-Awareness (“Self”) ↓ Behavioral Inhibition Non-Verbal Self-Regulation Verbal Working of Affect, Motivation Re-Constitution Working Memory Memory & Arousal The capacity to Private, self- Ability to self-regulate Capacity to hold events in directed speech as and induce dismantle mind so as to a means of motivation, drive and (analyze) and use them to informing, arousal states in reassemble control a influencing and support of goal- (synthesize) response controlling one’s directed behavior behavioral own behavior sequences Barkley (1997). ADHD and the nature of self-control . New York: Guilford. (p. 56) Barkley (2016). In K. D. Vohs & R. F. Baumeister (Eds.), Handbook of self-regulation (3rd ed.) (pp. 497-513). New York: Guilford. 4 5/25/2019 BROWN’S EXECUTIVE FUNCTION DEFICIT MODEL Brown, T. E. (2013). A new understanding of ADHD in children and adults: Executive function impairments . New York: Routledge. ADHD AND EMOTIONAL DYSCONTROL EMOTIONAL IMPULSIVITY IN ADULTS WITH ADHD 90 80 70 60 ADHD 50 Community 40 30 20 10 0 Impatience Quick to anger or get Easily frustrated Over-react emotionally Easily excited upset From Barkley, R., Murphy, K. & Fischer, M. (2008). ADHD in adults: What the science says . New York: Guilford 5 5/25/2019 EMOTIONAL IMPULSIVITY IN ADHD CHILDREN FOLLOWED TO ADULTHOOD 80 70 60 50 ADHD-P 40 ADHD-NP Controls 30 20 10 0 Impatient Quick to anger, get Easily frustrated Over-react Easily excited upset emotionally ADHD-P = Persistent ADHD, ADHD-NP = Non Persistent ADHD From Barkley, R., Murphy, K. & Fischer, M. (2008). ADHD in Adults: What the Science Says . New York: Guilford ADHD AS A MOTIVATIONAL DEFICIT: DOPAMINE/ REWARD DEFICIENCY SYNDROME (RDS) DOPAMINE: REWARD DEFICIENCY SYNDROME/MOTIVATIONAL DEFICIT • Dopamine binding lower for ADHD adults when compared with controls Volkow et al. (2009). JAMA, 302 (10), 1084-1091. • Correlation of Dopamine receptors and DAT and achievement scale of MPQ (trait motivation) • MPQ lower among ADHD adults vs controls • MPQ correlate with Dopamine among ADHD; MPQ inversely correlated with ADHD measures Volkow et al. (2011). Molecular Psychiatry, 16 , 1147-1154. 6 5/25/2019 SUMMARY: CLINICAL IMPLICATIONS OF RDS • Motivational deficits commonly encountered • Trouble activating , getting started • Easy boredom / trouble sustaining attention • Sense of “being lazy” or insufficiently disciplined (cognitive attribution) • Require more frequent, immediate, and stronger/salient rewards (vs delayed) • ADHD individuals do best with salient (interesting) tasks and frequent rewards • Higher risk of developing addictive behaviors • Intense novelty seeking • Chemical dependency • Non-chemical addictions (e.g., internet use, gaming, gambling) DEFAULT MODE NETWORK (DMN) ROLE OF THE DMN • Active during the brain’s resting state, mind-wandering, “idling mode” • ADHD = difficulties shifting out of this mode into concentrated attention • DMN must be actively suppressed when brain required to direct attention (degree of suppression correlates with task difficulty) • “Default mode interference” is thought to be a central source of inattention- distractibility-mind-wandering symptoms, specifically “hypoconnectivity” between DMN and “salience” network • “Mind-orbiting” issues? Silberstein et al. (2016). Brain and Behavior, 6 , e00582. doi: 10.1002/brb3.582 Utevsky et al. (2014). Journal of Neuroscience, 34 , 932–940. doi:10.1523/JNEUROSCI.4227-13.2014 7 5/25/2019 GENETICS GENE X ENVIRONMENT VIEW • Recent GWAS meta-analysis identified 12 reliable genetic sites • ADHD has historically been viewed as genetically complex • More recent gene x environment models • View genetics as a predisposition or vulnerability for ADHD • The proclivities interact with various environmental factors: • Toxins • Stress • Lifestyle • These environmental factors are more amenable to change Demontis et al. (2018). Nature Genetics , Advance online publication. doi: 10.1038/s41588-018-0269-7 Faraone & Larsson (2018). Molecular Psychiatry . Advance online publication. doi: 10.1038/s41380-018-0070-0 Nigg (2018). Getting ahead of ADHD . NY: Guilford. WHY IS THIS TOPIC IMPORTANT: FUNCTIONAL IMPAIRMENTS “Show me where it hurts.” 8 5/25/2019 LIFE OUTCOMES: ADULT ADHD • Workplace problems • Physical health issues/mortality • Relationship problems • Legal issues • Lower educational attainment • Lower SES • Employment problems • Psychiatric comorbidity (anxiety, depression, substance use) • Lower self-esteem • Substance use disorders • Lower social functioning • Risk for suicide (ADHD + SUD + • Lower satisfaction in life domains psychiatric comorbidity) • Disengagement Barbaresi et al. (2013). Pediatrics, 131 , 637-644. Barkley & Fischer (2018). J of Attention Disorders , advance online. Barkley et al. (2008). ADHD in adults: What the science says . New York: Guilford. Biederman et al. (2006). Journal of Clinical Psychiatry, 67 , 524-540. Biederman et al. (2012). Journal of Clinical Psychiatry, 73 , 941-950. Brook et al. (2013). Pediatrics, 131 , 5-13. Galéra et al. (2012). British Journal of Psychiatry, 201 , 20-25. Harpin et al. (2013). Journal of Attention Disorders , online ahead of print. Nigg (2013). Clinical Psychology Review, 33 , 215-228. Klein et al. (2012). Archives of General Psychiatry, 69 , 1295-1303. Weiss & Hechtman (1993). Hyperactive children grown up (2 nd ed.). New York: Guilford. Faraone, S. V. et al. (2015) Attention-deficit/hyperactivity disorder