ADHD symptoms in adults with psychoactive substance abuse and implications on sleep disorders
INTRODUCTION
Attention Deficit Hyperactivity Disorder (ADHD) has basal symptoms as attention and concentration deficiency, hyperkinetic behavior and impulsivity, classic symptoms especially for childhood. Although it has been previously thought that this disorder occurs only in childhood, it has now been shown that two-thirds of patients experience severe symptoms in adulthood [1]. The more symptoms there are in adulthood, the greater the dysfunctionality on different areas of life, and psychiatric comorbidities more difficult to assess and treat.
The prevalence of ADHD in childhood is reported at 4-8% [2]. Over time, it has been considered that ADHD-like symptoms are “outgrown” in their natural evolution as the patient ages. Subsequent scientific research has shown that this is not
generally the case, that in some patients there is a amelioration of symptoms (ussualy the hiperactivity diminishes), but 60% of them maintain overwhelming symptoms, and 90% of them experience adulthood dysfunctionality [3]. It has been shown that ADHD with predominantly genetic determinism does not improve over time, but patients learn to live with these symptoms with more or less success [4]. Predictors of chronic adverse outcome are based on the presence of comorbidities such as aggressive behaviour at young age, low cognitive status or learning disorder, significant heredo-collateral history for the diagnosis of ADHD, low socio-economic status, or family difficulties in terms of educational shortcomings [5].
According to studies conducted predominantly on American population, the prevalence of adults ADHD is estimated at 3-5% [6]. An epidemiological research conducted in 10 countries, reports a prevalence of ADHD in adults, ranging from 1.2 to 7.3% [7]. Very few of the study subjects were treated for ADHD, most of them were treated for comorbid disorders.
If in children the basic symptoms refer to hyperkinesia, attention and concentration deficit, in adults the symptoms do not disappear, the clinical picture is just transformed. Most symptoms of hyperkinesia improve after 12-15 years of age, it is persistent a poor motor hyperactivity or a permanent restlessness [8]. The inattentive component remains burdensome and what exacerbates over time is the impulsivity-like symptomatology by inhibition of self-regulation processes.
Adults with ADHD can be very distracted, have low planning and organizational skills, have increased irritability and low tolerance to minor frustrations. They need strong sensations and feel the desire to take risks, their permanent state is a restlesness one. In addition, they present complicated associated disorders such as anxiety, depression, various addictions, sleep disorders, bipolar disorder or personality disorder. All this leads to an functional inability at work, at school or in social environment.
For these reasons, adults with ADHD have frequent history of repeating a school year or even abandoning school, and from a professional point of view, they risk failure or even dismissal due to the inability to respect the deadlines. They are also frequently involved in accidents, are sick and incapacitated, and often have psysical complaints, symptoms that their entourage do not understand. Once the diagnosis is established, there are guidelines for appropriate treatment that was demonstrate to be effective in adult patients.
This paper aims to investigate the presence of ADHD-related sleep disorders in adulthood in a group of patients diagnosed with chronic psychoactive substance use. In the following, we will summarize the current knowledge on these psychiatric associations.
SLEEP DISORDERS IN ADULTS WITH ADHD
Adults with ADHD are experiencing sleep disturbances similar to those seen in children. Adults with ADHD report with difficulties in folling asleep at apropriate hours and waking up the next day [9]. Almost 80% of ADHD adults fell asleep after 1 am and prefer to wake up late [9]. If they go to bed early they have difficulty falling asleep. Sleeping at night is also difficult. Day fatigue can accentuate the clinical picture of distractibility and concentration deficiency. Most of the patients presented the same sleep patterns during childhood [10].
There are combined reports about adult night mobility, measured by actigraphs[11]. All sleep problems have in common the fact that sleep is fragmented, the awakings are frequent during the night, and that sleep duration is diminished.
AD HD AND ADDICTION TO ALCOHOL AND DRUGS
Comorbidity with conduct disorder, personality disorder, bipolar disorder, and abandonment and school negligence increase this risk for thsese patiens to abuse drugs as cannabis, heroin, ethnobotanicals and also alcohol [12].
Adolescents with ADHD begin to abuse alcohol and drugs at smaller ages, and there is a further increase in substance abuse around the age of 40 compared to the control group. This is possibly associated with loss of hope for symptom relief. According to current studies there is no predilection for a particular psychoactive substance, adults with ADHD use all types of drugs [12].
Addictive behaviours are controlled by the dopaminergic system, which functions on the reward pattern. Patients say they are calmer, they get to relax or concentrate better when they drink alcohol or take drugs, helping them also in sleep problems [13].
The objective is to establish as well as possible a set of ADHD symptoms in case of early set up and evolution of ADHD, in addition to the symptoms of the installation, nature and severity of substance abuse, because patients with comorbidities may receive an appropriate treatment [12].
Goossensen reports in 2006 a prevalence of ADHD symptoms in addictive patients between 2030% [14]. The presence of addiction in patients with ADHD predisposes to chronicity and unfavorable prognosis comparing to patients without this disorder.
MATERIALS AND METHOD
In the study, 104 patients, young adults, were selected from psychiatric services with addiction profiles for inclusion in the study. Inclusion criteria for patients in the study:
– age between 18 and 28 years
– the existence of a chronic diagnosis of psychoactive substances
– patients’ agreement to participate in the study, after being informed about the research objective and design, and after assured about the anonymity of the responses and the confidentiality of the data.
Exclusion criteria:
– the existence of a pervasive developmental disorder, regardless of the degree of impairment in functionality
– associated diagnosis of intellectual disability
– expressing disagreement to participate in the study
– psychosis induced by substance use
The instruments used to evaluate subjects included in the study, were:
• DIVA 2.0 – ADHD Diagnostic Adult Adult Interview, based on DSM-IV criteria.
– Developed in 2010 by J.J.S. Kooij, also translated into Romanian
• Morningness -Eveningness Questionnaire –evaluates possible associated sleep disorders
– a self-evaluation questionnaire
– investigates personal circadian rhythm
– investigates sleep patterns
– investigates the time of day (morning, afternoon or evening) in which there is an alert peak in the examined subjects.
Depending on the scores obtained by the patients after the DIVA instrument, two groups of subjects were divided:
– control group: addictive patients without criteria for a diagnosis of adult ADHD
– control group: addictive patients with positive results for a diagnosis of adult ADHD.
RESULTS
In the study, were included 63 male subjects (60.58%) and 41 female subjects (39.42%).
There were 48 adults who met the final criteria for ADHD out of a total of 68 adults who, declaring, met these criteria at the age of maturity. 20 of them did not meet criteria for childhood. Of the 54 subjects who met the ADHD criteria in their childhood, only 6 did not meet these criteria in adulthood.
A Fisher test showed that there was no statistically significant influence of the ADHD status (presence / absence of diagnosis) on the type of sleep reported by the subjects.
A z-scale comparison test showed that the proportion of subjects who consumed heroin and had the type of intermediate sleep was significantly higher compared to those who consumed the same drug but had another partnumber of sleep. A z-scale comparison test showed that the proportion of intermediate-alcohol drinkers was significantly lower compared to those who consumed alcohol but had other types of sleep.
A z-scale comparison test showed that the proportion of subjects with alcohol-like sleep with morning-sleep (p1 = 0.44) was significantly higher than that of alcohol-consuming subjects but other types of sleep (p2 = 0.21).
CONCLUSIONS / DISCUSSIONS
Most studies reported by the literature on the topic of association of substance use with adult ADHD pathology were performed in groups of patients diagnosed with ADHD in which were investigated behavioral problems secondary to the use of psychostimulants. This research also brings novelty by the retrospective investigation of ADHD symptoms in adulthood in a group of patients admitted to a psychiatric addiction service.
Research conducted by Fischer in 2002 and Wilens in 2004 reported percentages ranging from 25% to 55% of ADHD adults with a history of substance abuse or addiction [15,16]. The present study demonstrates that 46% of the included subjects, have specific symptoms fitted for the diagnosis of adult ADHD. Of the 54 subjects who met the ADHD criteria in their childhood, only 6 did not meet these criteria in adult life, resulting in 89% of the selected patients continuing being symptomatic , causing dysfunctionality in adulthood.
The presence of an ADHD diagnosis increases the susceptibility of up to two times in chronic consumption of psychostimulants [17]. In fact, patients with ADHD are more likely to start drinking at younger ages, receive multiple and recurrent diagnoses of conduct disorders secundary to drug abuse and major difficulties in following treatment recommendations and reaching remission [18]. The findings of this research align with these difficulties in the pathology of ADHD, most of the patients enrolled in the study, having more than one admission
to psychiatric services and reporting more than two addictive substances consumed simultaneously in the past 6 months.
In research on the presence of comorbidities in ADHD patients, sleep problems are commonly reported in both children and adults, and the situation where patients fail to rest a sufficient number of hours of sleep, report much more frequently ADHD symptoms [19]. In individuals with hipnic problems, the most common occurrences are short duration of sleep and its fragmentation, these events causing secondary fatigue, daytime sleepiness, accentuation of behavioral, attentional problems and somatic disorders, all causing impairment in the quality of life.
Insomnia is a sleep disorder characterized by difficulties in inducing sleep or maintaining it. Delay in bedtime, frequent nocturnal awakenings or low need for sleep are frequently found in young adults with ADHD. Unhealthy sleep routines mainly affect the sleep initiation procedure.
However, in the present study, there was no statistically significant relationship between the type of sleep investigated by the applied instrument and the presence or absence of ADHD symptoms.
The circadian rhythm coordinates the individual preferences of sleep and wake hours, body temperature, hormone secretion, circulatory system and food intake. The morning and evening types investigated in our study are based on the preferred period in the 24 hours of a day, whether to be active or to go to bed. The morning type goes early to bed and engages in peak performance in the early hours of the morning, while the evening type goes to bed very late, preferring to conduct activities during the evening. The intermediate type is characterized by a balanced circadian rhythm.
In the present study, most subjects in the control group are the intermediary type. Contrary to expectations, several subjects were found in the control group with the nocturnal type compared to subjects with ADHD. It is noteworthy that the proportion of subjects with alcohol consumption with morning type was significantly higher than that of alcoholconsuming subjects but with other types of sleep.
We consider it important to continue investigating the implications of substance use in sleep disorders in ADHD-diagnosed patients both in adolescence and adulthood. The identification of these implications is of major importance for the screening of ADHD symptoms in patients with chronic substance use.
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