Please respond to each classmate with at least 125 words and references.
Discussion 1:
The DSM-5 diagnostic criteria for ADHD demonstrate three specific subtypes; predominantly Inattentive, predominately Hyperactive-Impulsive and Combined defined by the presence of excessive symptoms of inattention and/or hyperactivity-impulsivity (Epstein & Loren, 2013).
The present hypothesis that examines the symptoms of ADHD arise from inefficient information processing in various circuits that involve the prefrontal cortex (Stahl et al., 2021). The main symptom of “inattention” in ADHD is commonly described as “executive dysfunction” and the failure to sustain attention long enough to solve problems (Stahl et al., 2021). The assumption is that executive dysfunction is connected to inefficient processing in the dorsolateral prefrontal cortex (DLPFC) (Stahl et al., 2021).
Noradrenergic treatments for ADHD include selective norepinephrine re-uptake inhibitor (NRI). These NET inhibitors are known to have antidepressant properties (Stahl et al., 2021). The mechanism of action of NET inhibitors block the NET in the prefrontal cortex which then increases both DA and NE in the prefrontal cortex (Stahl et al., 2021). Selective noradrenaline (norepinephrine) re-uptake inhibitors (NRI’s) are psychotropic agents that block the uptake of norepinephrine by the presynaptic nerve terminals and increase the availability in the synaptic cleft by blocking the human norepinephrine transporter (hNET) (De Crescenzo et al., 2018).
Stimulant medications are effective medications for first-line treatment for ADHD and recommended by the clinical treatment guidelines for ADHD (Handelman, & Sumiya, 2022). It is appropriate to start with a controlled substance for first-line treatment of ADHD when DSM-5 TR criteria for ADHD have been met (Weber & Duchemin, 2023). Once a diagnosis is established the use of stimulants will be evaluated (Weber & Duchemin, 2023). It is important to identify the number of symptoms the patient is experiencing and if they are connected to functional impairment (Weber & Duchemin, 2023). In randomized clinical trials, stimulants have proven significant in efficacy for the first-line treatment of ADHD (Weber & Duchemin, 2023). Stimulants have an increase in several adverse psychiatric outcomes. A risk of stimulant use is increase in anxiety, addiction and misuse (Weber & Duchemin, 2023).
References:
De Crescenzo, F., Ziganshina, L. E., Yudina, E. V., Kaplan, Y. C., Ciabattini, M., Wei, Y., & Hoyle, C. H. V. (2018). Noradrenaline reuptake inhibitors (NRIs) for attention deficit hyperactivity disorder (ADHD) in adults. The Cochrane Database of Systematic Reviews, 2018(6), CD013044. https://doi.org/10.1002/14651858.CD013044
Epstein, J. N., & Loren, R. E. (2013). Changes in the Definition of ADHD in DSM-5: Subtle but Important. Neuropsychiatry, 3(5), 455–458. https://doi.org/10.2217/npy.13.59
Kenneth Handelman, & Fernando Sumiya. (2022). Tolerance to Stimulant Medication for Attention Deficit Hyperactivity Disorder: Literature Review and Case Report. Brain Sciences, 12(959), 959. https://doi.org/10.3390/brainsci12080959
Stahl, S. M., Grady, M. M., & Muntner, N. (2021). Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. Cambridge University Press.
Weber, S. R., & Duchemin, A.-M. (2023). Adult ADHD: A sensible approach to diagnosis and treatment: These steps can help ensure accurate diagnosis and optimal outcomes. Current Psychiatry, 22(11), 39+.
Discussion 2:
ADHD Diagnostic Criteria and Noradrenergic Treatment
Attention Deficit/Hyperactivity Disorder (ADHD) is a neuro-developmental condition characterized by significant levels of inattention, disorganization, and/or hyperactivity-impulsivity that adversely impact functioning (DSM-5 2017). It is characterized by its three main symptoms: inattention, hyperactivity, and impulsivity (Stahl et al., 2021). The diagnostic criterion for ADHD is shown in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). To be diagnosed with ADHD, an individual must have symptoms in two categories: inattention and hyperactivity. Symptoms of inattention include forgetfulness, inability to focus or complete tasks, and seeming not to listen inconsistent with developmental age (DSM-5 2017). Hyperactivity symptoms include overactivity, inability to stay seated, impatience, and intrusion or lack of respect for personal space (DSM-5 2017). Those with ADHD have a dysregulation of the prefrontal cortex and neurotransmitters (norepinephrine and dopamine) in response to “tasks of attention and problem solving” (Stahl et al.,2021, p 455). These neurotransmitters play a crucial role in attention, impulse control, and executive functions. Low levels of norepinephrine can result in cognitive dysfunction. So, when low norepinephrine levels are present in ADHD, noradrenergic receptors are stimulated to increase those levels in the brain (Stahl et al., 2021). Knowing that noradrenergic stimulation increases norepinephrine levels is the reason for noradrenergic treatment methods. Medication like atomoxetine, a non-stimulant and the only norepinephrine reuptake inhibitor (NRI) approved by the FDA, is often prescribed as it iinhibits the reuptake of norepinephrine, leading to increased levels in the synapse (De Crescenzo et al.,2018).
Controlled Substances and Prescribing Considerations
In some cases, stimulant medications like methylphenidate or amphetamines may be prescribed as they are considered “norepinephrine and dopamine reuptake blockers” (Stahl et al., 2021, p 469). These medications are considered controlled substances. First line treatment for ADHD is non-stimulant medication. The decision to start with a controlled substance as a first-line treatment depends on many factors, such as symptom severity, patient history, and response to non-stimulant medications. (DeCrescenzo et al., 2018). Before prescribing controlled substances for ADHD, providers need to perform a comprehensive assessment and assess comorbidities and other medications. It is important to frequently follow-up and monitor for side effects. Finally, providers should evaluate treatment progress and compliance while following safe prescribing rules.
References
De Crescenzo, F., Ziganshina, L. E., Yudina, E. V., Kaplan, Y. C., Ciabattini, M., Wei, Y., & Hoyle, C. H.(2018). Noradrenaline reuptake inhibitors (nris) for attention deficit hyperactivity disorder (ADHD) in adults. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd013044
Diagnostic and statistical manual of mental disorders: DSM-5. (2017). . American Psychiatric Association.
Stahl, S. M., Grady, M. M., & Muntner, N. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications. Cambridge University Press.
