C International Psychogeriatric Association 2013 International Psychogeriatrics (2014), 26:2, 341–343 doi:10.1017/S1041610213001816
CASE REPORT
Interference of attention-deficit hyperactivity disorder in an older adult with a severe personality disorder and dermatillomania ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
L. H. Weusten,1 S. M. J. Heijnen-Kohl,1 J. Ellison2 and S. P. J. van Alphen1,3 1 2 3
Department of Old Age Psychiatry, Mondriaan Hospital, Heerlen-Maastricht, the Netherlands McLean Hospital, Harvard Medical School, Belmont, Massachusetts, USA Department of Clinical and Life Span Psychology, Free University of Brussels (VUB), Brussels, Belgium
ABSTRACT
This case of a 65-year-old male with dermatillomania, diffuse anxiety symptoms, and avoidant personality disorder (PD) illustrates the interference of attention-deficit hyperactivity disorder (ADHD) in the diagnostic process and during schema-focused therapy. In conclusion, ADHD in older adults and interference with PD is a subject of clinical importance and worth further investigation. Key words: older adults, personality disorder, ADHD, schema-focused therapy, dermatillomania
Introduction This case illustrates the interference of attentiondeficit hyperactivity disorder (ADHD) in an older adult with a severe personality disorder (PD) concerning both diagnostic process and treatment.
Case report The patient is a 65-year-old male who received outpatient treatment for six years for dermatillomania (compulsive scratching), social phobia, and generalized anxiety disorder. Extensive cognitive behavioral therapy showed limited results. During this treatment an avoidant PD was established based on clinical diagnosis. Recently, he was referred to our department for the co-treatment of PD. For the purpose of constructing a holistic diagnostic assessment and treatment plan, we conducted additional personality assessment. A Structured Clinical Interview for DSM-IV-TR Axis II disorders (SCID-II) confirmed an avoidant PD. On the Young Schema Questionnaire (YSQ), relatively high scores were obtained on the schemas “failure,” “lack of self-control,” and “social alienation.” As we explored the origin of Correspondence should be addressed to: L. H. Weusten, Department of Old Age Psychiatry, Mondriaan Hospital, John F. Kennedylaan 301, 6419 XZ, Heerlen, the Netherlands. Phone: +31-45-5736363; Fax: +31-88-5066680. Email: [email protected]. Received 22 Jun 2013; revision requested 10 Jul 2013; revised version received 25 Jul 2013; accepted 18 Sep 2013. First published online 29 October 2013.
these schemas, the patient also reported problems in concentration and impulse control since his childhood. In a following diagnostic interview to assess ADHD in adults (DIVA 2.0), the criteria for ADHD, combined type, were met in both childhood and adulthood. An ADHD questionnaire completed by his 95-year-old mother supported his diagnosis of ADHD. His brother also described him as distractible, impulsive, and avoidant. A psychological assessment for educational advice, administered at the age of 12 years, mentioned that the patient was “still very childlike and immature,” “restless, mobile, and easily nervous and tense.” We concluded that our clinical observations and history were consistent with diagnoses of avoidant PD and comorbid ADHD, combined type. The patient, however, declined pharmacological treatment of ADHD symptoms as he did not perceive them as an important problem. The negative impact of his avoidant PD combined with dermatillomania was much more evident to him. We also expected improvement of his Axis I symptoms with treatment of the underlying PD. Therefore, we started schema-focused therapy (SFT) and targeted the PD. The SFT focuses on reducing underlying dysfunctional schemes and building healthy schemes (Young et al., 2003). The SFT consists of 40 weekly sessions. After 20 sessions so far, change has slowly started to emerge. The YSQ showed improvement in his most prominent schemas: “failure,” “social
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alienation,” and “lack of self-control.” The schema “self-sacrifice” showed an increase, which may be due to an increased involvement of the patient with his family and social environment in the course of the therapy. A symptom checklist (SCL-90) revealed an increase in interpersonal sensitivity, anxiety, and depressive and somatic symptoms. Our hypothesis is that with the SFT, Axis I symptoms may initially increase along with self-understanding. With respect to dermatillomania, the lesions have decreased as the patient became more accepting to his condition and the need for external boundary (such as bandages and regular medical appointments). The relation between scratching and low self-esteem became less strong.
his third stage of life. After the patient’s early, forced retirement, his self-esteem dropped and he lost an important factor of external structure. His psychological well-being worsened. Due to avoidant PD and ADHD the patient failed to address his problems actively and withdrew from social life, hiding behind his computer. This led to loneliness and lack of structure. Existential problems arose as he evaluated his life in an all-or-nothing manner; he felt that he had failed completely and had no control anymore. He perceived his life so far as being useless and as with coming of age his future perspectives diminished, he had little hope it ever would be.
Discussion Diagnostic interference In our opinion, the ADHD of the patient is entwined with his PD. The patient received a very strict and disciplined upbringing in his childhood. His parents did not tolerate his impulsive behavior and his father responded with physical abuse. This combination of ADHD and a disapproving, abusing environment probably contributed to a low self-esteem and development of an avoidant PD. Also, he has developed an aversion to obligations, probably because in his past much was imposed on him due to his ADHD. In this case, ADHD also played an important role in the activation and establishment of his maladaptive schemes, such as failure. His lack of impulse control and inattention contributed to problems such dermatillomania, computer addiction, binge eating, and financial problems, which in return led to feelings of low selfesteem. Treatment interference ADHD may interfere with the treatment of PD. During the sessions the patient had difficulties with focusing attention, such as during imagination. He also needed frequent structuring as he tended to stray from the subject. Also, he frequently forgot appointments or failed to do his homework. This is regarded as avoidance within the theory of SFT; however, it could also be due to ADHD. On the other hand, the SFT may also influence his ADHD symptoms by addressing the schema “lack of discipline,” which improved halfway through the therapy. Gerontological factors The impact of the PD and the comorbid ADHD became more profound as the patient entered
ADHD is a severe psychiatric disorder, including symptoms of inattention and/or hyperactivity and impulsivity. It is most commonly known as a child psychiatric disorder; however, it is well established that ADHD persists into adulthood. ADHD in older adults is a virtually unexplored area. A few studies in this area indicate that ADHD also persists into old age, with a prevalence of 2.5% (Kooij et al., 2005), 4.2% (Michielsen et al., 2012), or 4.4% (Ivanchak et al., 2011). A Dutch study showed that ADHD in old age remains associated with more anxiety and depressive symptoms (Michielsen et al., 2013). PD in older adults, however, is a research area in development, although age-specific criteria for PD are lacking (Van Alphen et al., 2013). It is striking, how little is known about chronic and severe psychiatric disorders in older adults, such as ADHD, autism, and PD, especially as these psychiatric disorders often co-exist (Reimherr et al., 2010). Manor and colleagues (2011) noted in a small sample of older adults with ADHD that distress associated with this disorder was significant, yet selfawareness of the condition could be quite limited as in the patient described here, despite the potential tolerability and effectiveness of treatment with methylphenidate. However speculative, with the medical treatment of ADHD symptoms the patient might have experienced more internal repose and therefore has been more able to create structure in his life. The patient might also have benefited more from the schema therapy, as medical treatment could have improved his ability to focus attention and do his homework. This case illustrates that ADHD can have a profound effect on the development and activation of dysfunctional schemes and can become entwined with PD. In the treatment of PD in older adults with ADHD, one must take the possible
Interference of ADHD with personality disorder
interference of comorbid ADHD into account, for example, by applying more structuring or proposing pharmacological interventions.
Conclusions A few studies (Kooij et al., 2005; Ivanchak et al., 2011; Michielsen et al., 2012) thus far indicate that ADHD persists into old age and may have an important effect on the quality of life. This case of an older adult illustrates that ADHD can become entwined with PD and may cause interference in both diagnostic process and treatment of PD. ADHD in older adults and interference with PD is a subject of clinical importance and worth further research to improve assessment and treatment.
Conflict of interest None.
Description of authors’ roles S. Heijnen-Kohl performed the psychotherapy. L. Weusten carried out diagnostic assessments and assessments to measure therapy effect. She is the main author of the paper, and all co-authors contributed in the writing of this paper.
Acknowledgments Written informed consent was obtained from the patient for publication of this case report. We would like to thank him for giving us permission to write and publish this case report.
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References Ivanchak, N., Abner, E. L., Carr, S. A., Feeeman, S. J., Seybert, A., Ranseen, J. and Jicha, G. A. (2011). Attention-deficit/hyperactivity disorder in childhood is associated with cognitive test profiles in the geriatric population but not with mild cognitive impairment or Alzheimer’s disease. Journal of Aging Research, 2011, 729801. doi:10.4061/2011/729801. Kooij, J. J. S., Buitelaar, J. K., van den Oord, E. J., Furer, J. W., Rijnders, C. A. T. and Hodiamont, P. P. G. (2005). Internal and external validity of attention-deficit hyperactivity disorder in a population-based sample of adults. Psychological Medicine, 35, 817–827. Manor, I., Rozen, S., Zemishlani, Z., Weizman, A. and Zalsman, G. (2012). When does it end? Attention-deficit/ hyperactivity disorder in the middle aged and older populations. Clinical Neuropharmacology, 34, 148–154. doi:10.1097/WNF.0b013e3182206dc1. Michielsen, M. et al. (2012). Prevalence of attention-deficit hyperactivity disorder in older adults in The Netherlands. British Journal of Psychiatry, 201, 298–305 doi:10.1192/ bjp.bp.111.101196. Michielsen, M., Comijs, H. C., Semeijn, E. J., Beekman, A. T., Deeg, D. J. and Kooij, S. J. J. (2013). The comorbidity of anxiety and depressive symptoms in older adults with attention-deficit/hyperactivity disorder: a longitudinal study. Journal of Affective Disorders, 148, 220–227. doi:10.1016/j.jad.2012.11.063. Reimherr, F. W, Marchant, B. K., Williams, E. D., Strong, R. E., Halls, C. and Soni, P. (2010). Personality disorders in ADHD part 3: personality disorder, social adjustment, and their relation to dimensions of adult ADHD. Annals of Clinical Psychiatry, 22, 103–122. Van Alphen, S. P. J., Rossi, G., Segal, D. L. and Rosowsky, E. (2013). Issues regarding the proposed DSM-5 personality disorders in geriatric psychology and psychiatry. International Psychogeriatrics, 25, 1–5. doi:10.1017/S1041610212001597. Young, J. E., Klosko, J. S. and Weishaar, M. E. (2003). Schematherapy: A Practitioner’s Guide. New York: Guilford Press.
CASE REPORT
Interference of attention-deficit hyperactivity disorder in an older adult with a severe personality disorder and dermatillomania ...........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
L. H. Weusten,1 S. M. J. Heijnen-Kohl,1 J. Ellison2 and S. P. J. van Alphen1,3 1 2 3
Department of Old Age Psychiatry, Mondriaan Hospital, Heerlen-Maastricht, the Netherlands McLean Hospital, Harvard Medical School, Belmont, Massachusetts, USA Department of Clinical and Life Span Psychology, Free University of Brussels (VUB), Brussels, Belgium
ABSTRACT
This case of a 65-year-old male with dermatillomania, diffuse anxiety symptoms, and avoidant personality disorder (PD) illustrates the interference of attention-deficit hyperactivity disorder (ADHD) in the diagnostic process and during schema-focused therapy. In conclusion, ADHD in older adults and interference with PD is a subject of clinical importance and worth further investigation. Key words: older adults, personality disorder, ADHD, schema-focused therapy, dermatillomania
Introduction This case illustrates the interference of attentiondeficit hyperactivity disorder (ADHD) in an older adult with a severe personality disorder (PD) concerning both diagnostic process and treatment.
Case report The patient is a 65-year-old male who received outpatient treatment for six years for dermatillomania (compulsive scratching), social phobia, and generalized anxiety disorder. Extensive cognitive behavioral therapy showed limited results. During this treatment an avoidant PD was established based on clinical diagnosis. Recently, he was referred to our department for the co-treatment of PD. For the purpose of constructing a holistic diagnostic assessment and treatment plan, we conducted additional personality assessment. A Structured Clinical Interview for DSM-IV-TR Axis II disorders (SCID-II) confirmed an avoidant PD. On the Young Schema Questionnaire (YSQ), relatively high scores were obtained on the schemas “failure,” “lack of self-control,” and “social alienation.” As we explored the origin of Correspondence should be addressed to: L. H. Weusten, Department of Old Age Psychiatry, Mondriaan Hospital, John F. Kennedylaan 301, 6419 XZ, Heerlen, the Netherlands. Phone: +31-45-5736363; Fax: +31-88-5066680. Email: [email protected]. Received 22 Jun 2013; revision requested 10 Jul 2013; revised version received 25 Jul 2013; accepted 18 Sep 2013. First published online 29 October 2013.
these schemas, the patient also reported problems in concentration and impulse control since his childhood. In a following diagnostic interview to assess ADHD in adults (DIVA 2.0), the criteria for ADHD, combined type, were met in both childhood and adulthood. An ADHD questionnaire completed by his 95-year-old mother supported his diagnosis of ADHD. His brother also described him as distractible, impulsive, and avoidant. A psychological assessment for educational advice, administered at the age of 12 years, mentioned that the patient was “still very childlike and immature,” “restless, mobile, and easily nervous and tense.” We concluded that our clinical observations and history were consistent with diagnoses of avoidant PD and comorbid ADHD, combined type. The patient, however, declined pharmacological treatment of ADHD symptoms as he did not perceive them as an important problem. The negative impact of his avoidant PD combined with dermatillomania was much more evident to him. We also expected improvement of his Axis I symptoms with treatment of the underlying PD. Therefore, we started schema-focused therapy (SFT) and targeted the PD. The SFT focuses on reducing underlying dysfunctional schemes and building healthy schemes (Young et al., 2003). The SFT consists of 40 weekly sessions. After 20 sessions so far, change has slowly started to emerge. The YSQ showed improvement in his most prominent schemas: “failure,” “social
342
L. H. Weusten et al.
alienation,” and “lack of self-control.” The schema “self-sacrifice” showed an increase, which may be due to an increased involvement of the patient with his family and social environment in the course of the therapy. A symptom checklist (SCL-90) revealed an increase in interpersonal sensitivity, anxiety, and depressive and somatic symptoms. Our hypothesis is that with the SFT, Axis I symptoms may initially increase along with self-understanding. With respect to dermatillomania, the lesions have decreased as the patient became more accepting to his condition and the need for external boundary (such as bandages and regular medical appointments). The relation between scratching and low self-esteem became less strong.
his third stage of life. After the patient’s early, forced retirement, his self-esteem dropped and he lost an important factor of external structure. His psychological well-being worsened. Due to avoidant PD and ADHD the patient failed to address his problems actively and withdrew from social life, hiding behind his computer. This led to loneliness and lack of structure. Existential problems arose as he evaluated his life in an all-or-nothing manner; he felt that he had failed completely and had no control anymore. He perceived his life so far as being useless and as with coming of age his future perspectives diminished, he had little hope it ever would be.
Discussion Diagnostic interference In our opinion, the ADHD of the patient is entwined with his PD. The patient received a very strict and disciplined upbringing in his childhood. His parents did not tolerate his impulsive behavior and his father responded with physical abuse. This combination of ADHD and a disapproving, abusing environment probably contributed to a low self-esteem and development of an avoidant PD. Also, he has developed an aversion to obligations, probably because in his past much was imposed on him due to his ADHD. In this case, ADHD also played an important role in the activation and establishment of his maladaptive schemes, such as failure. His lack of impulse control and inattention contributed to problems such dermatillomania, computer addiction, binge eating, and financial problems, which in return led to feelings of low selfesteem. Treatment interference ADHD may interfere with the treatment of PD. During the sessions the patient had difficulties with focusing attention, such as during imagination. He also needed frequent structuring as he tended to stray from the subject. Also, he frequently forgot appointments or failed to do his homework. This is regarded as avoidance within the theory of SFT; however, it could also be due to ADHD. On the other hand, the SFT may also influence his ADHD symptoms by addressing the schema “lack of discipline,” which improved halfway through the therapy. Gerontological factors The impact of the PD and the comorbid ADHD became more profound as the patient entered
ADHD is a severe psychiatric disorder, including symptoms of inattention and/or hyperactivity and impulsivity. It is most commonly known as a child psychiatric disorder; however, it is well established that ADHD persists into adulthood. ADHD in older adults is a virtually unexplored area. A few studies in this area indicate that ADHD also persists into old age, with a prevalence of 2.5% (Kooij et al., 2005), 4.2% (Michielsen et al., 2012), or 4.4% (Ivanchak et al., 2011). A Dutch study showed that ADHD in old age remains associated with more anxiety and depressive symptoms (Michielsen et al., 2013). PD in older adults, however, is a research area in development, although age-specific criteria for PD are lacking (Van Alphen et al., 2013). It is striking, how little is known about chronic and severe psychiatric disorders in older adults, such as ADHD, autism, and PD, especially as these psychiatric disorders often co-exist (Reimherr et al., 2010). Manor and colleagues (2011) noted in a small sample of older adults with ADHD that distress associated with this disorder was significant, yet selfawareness of the condition could be quite limited as in the patient described here, despite the potential tolerability and effectiveness of treatment with methylphenidate. However speculative, with the medical treatment of ADHD symptoms the patient might have experienced more internal repose and therefore has been more able to create structure in his life. The patient might also have benefited more from the schema therapy, as medical treatment could have improved his ability to focus attention and do his homework. This case illustrates that ADHD can have a profound effect on the development and activation of dysfunctional schemes and can become entwined with PD. In the treatment of PD in older adults with ADHD, one must take the possible
Interference of ADHD with personality disorder
interference of comorbid ADHD into account, for example, by applying more structuring or proposing pharmacological interventions.
Conclusions A few studies (Kooij et al., 2005; Ivanchak et al., 2011; Michielsen et al., 2012) thus far indicate that ADHD persists into old age and may have an important effect on the quality of life. This case of an older adult illustrates that ADHD can become entwined with PD and may cause interference in both diagnostic process and treatment of PD. ADHD in older adults and interference with PD is a subject of clinical importance and worth further research to improve assessment and treatment.
Conflict of interest None.
Description of authors’ roles S. Heijnen-Kohl performed the psychotherapy. L. Weusten carried out diagnostic assessments and assessments to measure therapy effect. She is the main author of the paper, and all co-authors contributed in the writing of this paper.
Acknowledgments Written informed consent was obtained from the patient for publication of this case report. We would like to thank him for giving us permission to write and publish this case report.
343
References Ivanchak, N., Abner, E. L., Carr, S. A., Feeeman, S. J., Seybert, A., Ranseen, J. and Jicha, G. A. (2011). Attention-deficit/hyperactivity disorder in childhood is associated with cognitive test profiles in the geriatric population but not with mild cognitive impairment or Alzheimer’s disease. Journal of Aging Research, 2011, 729801. doi:10.4061/2011/729801. Kooij, J. J. S., Buitelaar, J. K., van den Oord, E. J., Furer, J. W., Rijnders, C. A. T. and Hodiamont, P. P. G. (2005). Internal and external validity of attention-deficit hyperactivity disorder in a population-based sample of adults. Psychological Medicine, 35, 817–827. Manor, I., Rozen, S., Zemishlani, Z., Weizman, A. and Zalsman, G. (2012). When does it end? Attention-deficit/ hyperactivity disorder in the middle aged and older populations. Clinical Neuropharmacology, 34, 148–154. doi:10.1097/WNF.0b013e3182206dc1. Michielsen, M. et al. (2012). Prevalence of attention-deficit hyperactivity disorder in older adults in The Netherlands. British Journal of Psychiatry, 201, 298–305 doi:10.1192/ bjp.bp.111.101196. Michielsen, M., Comijs, H. C., Semeijn, E. J., Beekman, A. T., Deeg, D. J. and Kooij, S. J. J. (2013). The comorbidity of anxiety and depressive symptoms in older adults with attention-deficit/hyperactivity disorder: a longitudinal study. Journal of Affective Disorders, 148, 220–227. doi:10.1016/j.jad.2012.11.063. Reimherr, F. W, Marchant, B. K., Williams, E. D., Strong, R. E., Halls, C. and Soni, P. (2010). Personality disorders in ADHD part 3: personality disorder, social adjustment, and their relation to dimensions of adult ADHD. Annals of Clinical Psychiatry, 22, 103–122. Van Alphen, S. P. J., Rossi, G., Segal, D. L. and Rosowsky, E. (2013). Issues regarding the proposed DSM-5 personality disorders in geriatric psychology and psychiatry. International Psychogeriatrics, 25, 1–5. doi:10.1017/S1041610212001597. Young, J. E., Klosko, J. S. and Weishaar, M. E. (2003). Schematherapy: A Practitioner’s Guide. New York: Guilford Press.
