Driven To Distraction
Adults are as scatterbrained as kids. And the disorder may be rooted in basic biology
This is changing. Recently, doctors are reporting skyrocketing numbers of adults who believe that they may have the disorder. This may be a result, in part, of better information on the disorder. For example, descriptions of the malady now appear in ads from pharmaceutical giant Eli Lilly, which makes the new drug Strattera. The advertisement asks, "Are you disorganized? Do you procrastinate, fidget, lose things?" Strattera is the first nonstimulant drug for ADD and the only drug that is approved by the Food and Drug Administration for adults with the disorder. Sales of the drug topped $370 million last year. Still, as Thomas Spencer, assistant director of the Pediatric Psychopharmacology Clinic at Massachusetts General Hospital, says, "When I give a talk about it and describe the disorder, I say, `Now you all think that you have it.' The biggest controversy is that so many features of ADHD seem so common a variant of normal. But in fact, people who have the full-fledged disorder have many of the symptoms all the time."
While ADD has moved from the classroom and the pediatrician's office to boardrooms and master bedrooms, a number of questions remain. What do we actually know about the biology underlying attention disorders? Is this the newest strategy, as critics contend, for pharmaceutical companies to expand their market by transforming normal variants of behavior and temperament into a pathology requiring medication? Or is it a real and disabling brain disorder that requires treatment? Even though the legitimacy of the ADD diagnosis in children has been well established, how is an ADD adult different from the inattentive or hyperactive child? Given the complexity of adult lives and relationships, and the coping mechanisms developed over years of managing the disorder without medication, how is it possible to determine if someone has ADD or one of the many accompanying disorders with similar symptoms?
Because ADD has only recently been recognized in adults, the typical internist has little experience diagnosing and treating it. In a 2003 Harris Poll on physician perceptions of adult ADD, prepared for the New York University School of Medicine, 77 percent of physicians said adult ADD was not very well understood by the medical community. Seventy-two percent said it was more difficult to diagnose adults with ADD than it was to diagnose children. Three out of four physicians said they would take a more active role in diagnosing and treating adult ADD if there were effective prescription medications that were not stimulants or controlled substances (box, right). When an adult patient comes in complaining of memory problems, inattention, and difficulty in staying focused and completing tasks, physicians are far more likely to consider depression or anxiety as the cause rather than ADD. And for good reason. "The problem is that inattention is to psychiatry what fever is to medicine," says Paul Wender, a psychiatrist who began to explore adult ADD as far back as the 1970s.
Threesome. In fact, inattention is only one in a triad of symptoms that are in themselves subject to interpretation: an inability to sustain attention, impulsive behavior, and, sometimes, hyperactivity. According to the DSM-IV, the diagnostic bible of the American Psychiatric Association, symptoms can range from frequently losing things to persistent difficulty in completing tasks. Moreover, contrary to nearly every other medical or psychiatric disorder, in which adult pathology has been used as a window into childhood problems, ADD reverses the model. Children with ADD have been far more thoroughly studied than adults and even in the DSM--which is used to diagnose adults as well as children--a number of the symptoms involve points of reference straight from elementary school. For example, a symptom of inattention is "often loses things for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)." Hyperactivity is displayed when the patient "often leaves seat in classroom or in other situations in which remaining seated is expected" or "often runs about or climbs excessively in situations in which it is inappropriate." The description includes a parenthetical nod to adults: "(in adolescents or adults, may be limited to subjective feelings of restlessness)." With this peculiar age bias, many adults with the disorder can find themselves falling through diagnostic cracks.