Introduction
This case illustrates the interference of attention-deficit 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 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., Reference Young, Klosko and Weishaar2003).
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 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.
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 self-esteem.
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 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
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., Reference Kooij, Buitelaar, van den Oord, Furer, Rijnders and Hodiamont2005), 4.2% (Michielsen et al., Reference Michielsen2012), or 4.4% (Ivanchak et al., Reference Ivanchak, Abner, Carr, Feeeman, Seybert, Ranseen and Jicha2011). A Dutch study showed that ADHD in old age remains associated with more anxiety and depressive symptoms (Michielsen et al., Reference Michielsen2013). PD in older adults, however, is a research area in development, although age-specific criteria for PD are lacking (Van Alphen et al., Reference Van Alphen, Rossi, Segal and Rosowsky2013). 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., Reference Reimherr, Marchant, Williams, Strong, Halls and Soni2010).
Manor and colleagues (2011) noted in a small sample of older adults with ADHD that distress associated with this disorder was significant, yet self-awareness 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 comorbid ADHD into account, for example, by applying more structuring or proposing pharmacological interventions.
Conclusions
A few studies (Kooij et al., Reference Kooij, Buitelaar, van den Oord, Furer, Rijnders and Hodiamont2005; Ivanchak et al., Reference Ivanchak, Abner, Carr, Feeeman, Seybert, Ranseen and Jicha2011; Michielsen et al., Reference Michielsen2012) 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.
