554618
research-article2014
JADXXX10.1177/1087054714554618Journal of Attention DisordersNehlin et al.
Article
The Patient’s Perspective on the Link Between ADHD and Substance Use: A Qualitative Interview Study
Journal of Attention Disorders 1–8 © 2014 SAGE Publications Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714554618 jad.sagepub.com
Christina Nehlin1,2, Fred Nyberg1, and Caisa Öster1,2
Abstract Objective: The primary aim of this study was to investigate how adult individuals with ADHD perceive the role of alcohol and drugs in their lives. A secondary aim was to identify factors that those individuals consider useful in the treatment and prevention of co-occurring ADHD and substance use disorders (SUDs). Method: A qualitative interview study with ADHD outpatients (n = 14) at a psychiatric clinic. Data were analyzed based on pre-defined areas of interest using a deductive content analysis method. Results: The yearning for belongingness was identified as an important driving force underlying substance use. The participants felt that alcohol/drugs helped them being normal and thus respected and accepted. Early diagnosis of ADHD was perceived essential to avoid SUD. Conclusion: Adults with ADHD may have strong rational and emotional reasons for the use of alcohol and drugs. When planning for the treatment of adult ADHD, investigation of personal reasons for alcohol/drug use deserves a place. (J. of Att. Dis. XXXX; XX(X) XX-XX) Keywords adult ADHD, substance abuse, reasons for co-occurrence, qualitative
Introduction The co-occurrence of ADHD and substance use disorder (SUD) is a prevalent phenomenon that has been demonstrated in numerous studies over the past decade (Arias et al., 2008; Bernardi et al., 2012; Gudjonsson, Sigurdsson, Sigfusdottir, & Young, 2012; Lee, Humphreys, Flory, Liu, & Glass, 2011; Nogueira et al., 2014; Ohlmeier et al., 2008; van Emmerik-van Oortmerssen et al., 2012). In individuals with ADHD, substance use problems are generally of a more serious character: Not only do the disorders have an earlier onset and a more severe course, but treatment outcomes are poorer as well (Arias et al., 2008; Kollins, 2008). Although highly co-occurring, the specific nature of the link between ADHD and SUD remains unclear. In one of the few studies in this area, persons with ADHD mainly used stimulants for other reasons than the euphoric effect, but the researchers were unable to present what those reasons were (Wilens et al., 2007). Several explanations for the common co-occurrence have been suggested. Neurobiological research has observed a significant genetic predisposition for SUD in patients with ADHD in which the hyperactivity component in ADHD shares a common genetic background with that of alcohol dependence (Edwards & Kendler, 2012). Conduct disorder (CD), commonly associated with ADHD, has been suggested as a mediating factor for the increased risk of a SUD
(Flory & Lynam, 2003; Nogueira et al., 2014; SerraPinheiro et al., 2013). Other studies, however, noted a direct link between ADHD and SUD when controlling for CD (Arias et al., 2008). Self-medication of ADHD symptoms and personality factors associated with ADHD such as impulsivity are other possible explanations (Arias et al., 2008; Wilens et al., 2007). A recent study investigating differences in the expression of impulsivity, anger, and aggression in ADHD, borderline personality disorder (BPD), and comorbid ADHD–BPD reported that ADHD and ADHD– BPD patients showed a higher level of impulsivity than BPD and controls (Prada et al., 2014). Furthermore, comorbid ADHD–BPD patients exhibited higher levels of SUD and more pronounced aggression than the other groups. Another study (Roberts, Peters, Adams, Lynam, & Milich, 2014) examined the relation among ADHD symptoms such as hyperactivity and impulsivity, substance use rates, and personality processes associated with impulsive behavior in a group of young adults. Here, hyperactive and impulsive 1
Uppsala University, Sweden Uppsala University Hospital, Sweden
2
Corresponding Author: Christina Nehlin, Uppsala University, Department of Neuroscience, Psychiatry, Uppsala University Hospital, ing 10, 3rd floor, Uppsala 75185, Sweden. Email: [email protected]
Downloaded from jad.sagepub.com at MCGILL UNIVERSITY LIBRARY on February 23, 2015
2
Journal of Attention Disorders
symptoms were found to be associated with alcohol and nicotine use, whereas inattentive symptoms were only associated with alcohol use. Data suggesting that comorbid ADHD and SUD are associated with a more severe course of substance use and with social and psychiatric impairment have also been described (Moura et al., 2013). Yet, the link between ADHD and substance use has not been studied from the patient’s perspective. There is a lack of studies focusing on experiences and thoughts of individuals with ADHD and SUD as expressed in their own words. Qualitative studies of persons with psychiatric disorders and SUD are scarce, but the few available studies have pointed out that alcohol/drug habits in persons with psychiatric disorders may be of a particular kind. In an interview study with severely mentally ill substance users, a number of unique high-risk situations for drug use were identified (Bradizza & Stasiewicz, 2003). Two of these high-risk situations were interpersonal conflicts and loss of appetite. In another interview study, patients with bipolar disorder and SUD reported that they trusted their own drug experiences more than they trusted the advice of staff members, suggesting that they will only accept advice if it fits with their own personal experiences (Healey, Peters, Kinderman, McCracken, & Morriss, 2009). In an interview study with young female psychiatric patients, drinking alcohol was presented as a means of self-harm (Nehlin, Fredriksson, & Öster, 2013). One factor that is essential for successful treatment is that the patient feels that the caregiver understands his or her needs (Cooley & Lajoy, 1980). Thus, caregivers may take general benefits from studies in which individuals share their experiences and thoughts. From a scientific point of view, such information may lead to the forming of new hypotheses regarding the reasons for the strong link between ADHD and SUD. The primary aim of this study was to investigate how adult individuals with ADHD perceive the role of alcohol and drugs in their lives, in particular in relation to their ADHD symptoms. A further aim was to identify factors that individuals with ADHD consider useful in the treatment and prevention of co-occurring ADHD and SUD.
Method This study was explorative and descriptive with a qualitative approach. A qualitative content analysis may be executed in an inductive manner by which themes are created without the use of theories or concepts, or in a deductive manner whereby themes are pre-defined (Rhodes & Coomber, 2010). A semi-structured interview with openended questions was used to capture informants’ perceptions as well as their experiences and feelings (Patton, 2002). Areas of interest, based on theory and clinical expertise, were defined by the present authors. Those areas were
as follows: (a) the role of alcohol/drugs in relation to ADHD symptoms, (b) wanted and unwanted effects of alcohol/ drugs on ADHD symptoms, (c) risk situations for alcohol/ drug use specific for persons with ADHD, and (d) recommendations for treatment and prevention of co-occurring alcohol/drug problems and ADHD as perceived by persons with ADHD. Because SUD normally is most intensive during the younger years, we aimed at interviewing young persons (
research-article2014
JADXXX10.1177/1087054714554618Journal of Attention DisordersNehlin et al.
Article
The Patient’s Perspective on the Link Between ADHD and Substance Use: A Qualitative Interview Study
Journal of Attention Disorders 1–8 © 2014 SAGE Publications Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1087054714554618 jad.sagepub.com
Christina Nehlin1,2, Fred Nyberg1, and Caisa Öster1,2
Abstract Objective: The primary aim of this study was to investigate how adult individuals with ADHD perceive the role of alcohol and drugs in their lives. A secondary aim was to identify factors that those individuals consider useful in the treatment and prevention of co-occurring ADHD and substance use disorders (SUDs). Method: A qualitative interview study with ADHD outpatients (n = 14) at a psychiatric clinic. Data were analyzed based on pre-defined areas of interest using a deductive content analysis method. Results: The yearning for belongingness was identified as an important driving force underlying substance use. The participants felt that alcohol/drugs helped them being normal and thus respected and accepted. Early diagnosis of ADHD was perceived essential to avoid SUD. Conclusion: Adults with ADHD may have strong rational and emotional reasons for the use of alcohol and drugs. When planning for the treatment of adult ADHD, investigation of personal reasons for alcohol/drug use deserves a place. (J. of Att. Dis. XXXX; XX(X) XX-XX) Keywords adult ADHD, substance abuse, reasons for co-occurrence, qualitative
Introduction The co-occurrence of ADHD and substance use disorder (SUD) is a prevalent phenomenon that has been demonstrated in numerous studies over the past decade (Arias et al., 2008; Bernardi et al., 2012; Gudjonsson, Sigurdsson, Sigfusdottir, & Young, 2012; Lee, Humphreys, Flory, Liu, & Glass, 2011; Nogueira et al., 2014; Ohlmeier et al., 2008; van Emmerik-van Oortmerssen et al., 2012). In individuals with ADHD, substance use problems are generally of a more serious character: Not only do the disorders have an earlier onset and a more severe course, but treatment outcomes are poorer as well (Arias et al., 2008; Kollins, 2008). Although highly co-occurring, the specific nature of the link between ADHD and SUD remains unclear. In one of the few studies in this area, persons with ADHD mainly used stimulants for other reasons than the euphoric effect, but the researchers were unable to present what those reasons were (Wilens et al., 2007). Several explanations for the common co-occurrence have been suggested. Neurobiological research has observed a significant genetic predisposition for SUD in patients with ADHD in which the hyperactivity component in ADHD shares a common genetic background with that of alcohol dependence (Edwards & Kendler, 2012). Conduct disorder (CD), commonly associated with ADHD, has been suggested as a mediating factor for the increased risk of a SUD
(Flory & Lynam, 2003; Nogueira et al., 2014; SerraPinheiro et al., 2013). Other studies, however, noted a direct link between ADHD and SUD when controlling for CD (Arias et al., 2008). Self-medication of ADHD symptoms and personality factors associated with ADHD such as impulsivity are other possible explanations (Arias et al., 2008; Wilens et al., 2007). A recent study investigating differences in the expression of impulsivity, anger, and aggression in ADHD, borderline personality disorder (BPD), and comorbid ADHD–BPD reported that ADHD and ADHD– BPD patients showed a higher level of impulsivity than BPD and controls (Prada et al., 2014). Furthermore, comorbid ADHD–BPD patients exhibited higher levels of SUD and more pronounced aggression than the other groups. Another study (Roberts, Peters, Adams, Lynam, & Milich, 2014) examined the relation among ADHD symptoms such as hyperactivity and impulsivity, substance use rates, and personality processes associated with impulsive behavior in a group of young adults. Here, hyperactive and impulsive 1
Uppsala University, Sweden Uppsala University Hospital, Sweden
2
Corresponding Author: Christina Nehlin, Uppsala University, Department of Neuroscience, Psychiatry, Uppsala University Hospital, ing 10, 3rd floor, Uppsala 75185, Sweden. Email: [email protected]
Downloaded from jad.sagepub.com at MCGILL UNIVERSITY LIBRARY on February 23, 2015
2
Journal of Attention Disorders
symptoms were found to be associated with alcohol and nicotine use, whereas inattentive symptoms were only associated with alcohol use. Data suggesting that comorbid ADHD and SUD are associated with a more severe course of substance use and with social and psychiatric impairment have also been described (Moura et al., 2013). Yet, the link between ADHD and substance use has not been studied from the patient’s perspective. There is a lack of studies focusing on experiences and thoughts of individuals with ADHD and SUD as expressed in their own words. Qualitative studies of persons with psychiatric disorders and SUD are scarce, but the few available studies have pointed out that alcohol/drug habits in persons with psychiatric disorders may be of a particular kind. In an interview study with severely mentally ill substance users, a number of unique high-risk situations for drug use were identified (Bradizza & Stasiewicz, 2003). Two of these high-risk situations were interpersonal conflicts and loss of appetite. In another interview study, patients with bipolar disorder and SUD reported that they trusted their own drug experiences more than they trusted the advice of staff members, suggesting that they will only accept advice if it fits with their own personal experiences (Healey, Peters, Kinderman, McCracken, & Morriss, 2009). In an interview study with young female psychiatric patients, drinking alcohol was presented as a means of self-harm (Nehlin, Fredriksson, & Öster, 2013). One factor that is essential for successful treatment is that the patient feels that the caregiver understands his or her needs (Cooley & Lajoy, 1980). Thus, caregivers may take general benefits from studies in which individuals share their experiences and thoughts. From a scientific point of view, such information may lead to the forming of new hypotheses regarding the reasons for the strong link between ADHD and SUD. The primary aim of this study was to investigate how adult individuals with ADHD perceive the role of alcohol and drugs in their lives, in particular in relation to their ADHD symptoms. A further aim was to identify factors that individuals with ADHD consider useful in the treatment and prevention of co-occurring ADHD and SUD.
Method This study was explorative and descriptive with a qualitative approach. A qualitative content analysis may be executed in an inductive manner by which themes are created without the use of theories or concepts, or in a deductive manner whereby themes are pre-defined (Rhodes & Coomber, 2010). A semi-structured interview with openended questions was used to capture informants’ perceptions as well as their experiences and feelings (Patton, 2002). Areas of interest, based on theory and clinical expertise, were defined by the present authors. Those areas were
as follows: (a) the role of alcohol/drugs in relation to ADHD symptoms, (b) wanted and unwanted effects of alcohol/ drugs on ADHD symptoms, (c) risk situations for alcohol/ drug use specific for persons with ADHD, and (d) recommendations for treatment and prevention of co-occurring alcohol/drug problems and ADHD as perceived by persons with ADHD. Because SUD normally is most intensive during the younger years, we aimed at interviewing young persons (
