A 35-year-old man comes to the office due to problems with irritability, anxiety, and low self-esteem. He was recently fired due to poor work performance at his data entry job and worries about finding a new job and supporting himself. The patient is currently in a relationship but mentions that his girlfriend is upset by his frequent lateness and forgetfulness and has threatened to leave him. Further history indicates that his problems are long-standing and date back to childhood when he had behavioral problems in school. The patient frequently feels overwhelmed due to being disorganized. He frequently procrastinates, is bored easily at work, and jumps to another project before completing what he is working on. The patient drinks 3 or 4 beers a week and smokes marijuana twice a month. On mental status examination, he is cooperative and talkative but appears tense, restless, and easily distracted. Which of the following is the most likely diagnosis in this patient?
Attention deficit hyperactivity disorder | |
Clinical features |
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Treatment |
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This patient's disorganization, forgetfulness, excessive procrastination, difficulty completing tasks, irritability, restlessness, and distractibility are suggestive of adult attention-deficit hyperactivity disorder (ADHD). Evidence of behavioral problems since childhood (some symptoms prior to age 12 are required) and the chronic nature of his difficulties further support this diagnosis. ADHD frequently persists into adulthood and may go unrecognized or misdiagnosed as an anxiety, mood, or personality disorder.
Although the same diagnostic criteria are used, adults with ADHD are less overtly hyperactive compared to children. They typically experience a sense of inner restlessness, irritability, impulsive speech, and decision making and executive skills dysfunction (eg, difficulties in organizing/prioritizing tasks, lack of follow-through, forgetfulness, poor time management) that can result in significant social and occupational impairment (eg, unemployment, reduced productivity, relationship difficulties). Stimulant medication is the first-line treatment for adult ADHD.
(Choice A) Adjustment disorder is diagnosed when symptoms occur in response to a stressor and do not meet the criteria for another mental disorder. This patient's symptoms and impairment are long-standing and are likely the cause of his employment and relationship difficulties.
(Choice C) Bipolar disorder is differentiated from ADHD in adults by an episodic course consisting of discrete periods of severe manic or depressive symptoms. Although mood instability, impulsivity, restlessness, and talkativeness are seen in both disorders, this patient has a chronic (not episodic) course and lacks other bipolar symptoms.
(Choice D) Patients with borderline personality disorder also exhibit emotional dysregulation and impulsivity, but this patient lacks the identity disturbance and recurrent suicidal behaviors that characterize this disorder.
(Choice E) Generalized anxiety disorder involves excessive anxiety about multiple issues. This patient's anxiety is related to realistic worries about his job situation.
(Choice F) Patients with ADHD often struggle with poor self-esteem due to years of underachievement and may experience comorbid depression. However, this patient does not have sufficient depressive symptoms to diagnose persistent depressive disorder.
(Choice G) The amount and extent of this patient's alcohol and marijuana use are insufficient to explain his symptoms and lifelong impairment.
Educational objective:
Attention-deficit hyperactivity disorder (ADHD) often persists into adulthood. Adults with ADHD are less overtly hyperactive but experience chronic problems with distractibility, disorganization, and impulsivity that cause significant social and occupational impairment.