This first reply is to  QT on her ADHD case of Harold. The purpose of this reply is to compare our decision-making of adult ADHD case presentations and to add information to the discussion. I chose to do my initial reply on Greg, and you chose Harold and while their cases and ages are different, they do have some presenting similarities of adult ADHD. Harold complains of having poor concentration, feeling overwhelmed with the deadlines at work, and unable to pay attention. It appears Harold has ADHD symptoms coming from multiple areas in the prefrontal cortex. According to Stahl (2013), ADHD symptoms are thought to be linked to different areas such as problems with keeping attention and problem solving being from the dorsolateral prefrontal cortex, hyperactivity symptoms from the prefrontal motor cortex, and selective attention being a malfunction of the dorsal anterior cingulate cortex.

I agree with you that ADHD can have overlapping symptoms with other medical and psychiatric disorders. Bukstein (2018) states that adults with ADHD often have other co-morbid disorders such as mood disorders, anxiety, substance use, and intermittent explosive disorder to name a few. I agree with you that we need more information, background, and history on Harold. It appears to me that the majority of his symptoms are with executive dysfunction. Harold verbalizes difficulty with working memory, shifting tasks, remaining focused for long periods of time, and issues with prioritizing and follow-through, and these are all signs of adult ADHD (Bukstein, 2018).

I agree with your medication choice of atomoxetine of 40 mg daily by mouth in the morning for the reasons we have both stated in our initial posts. This was my first choice as well for Greg, and it would have been my first choice for Harold. As you stated you can increase to 80 mg daily by mouth after 1 week, and go up to 100 mg per day (Putzantian & Carlat, 2020; Stahl et al., 2020). The onset of action can be seen as early as the first day of taking the medication (Stahl et al., 2020). For some patients’ atomoxetine can cause gastrointestinal upset and the dosing needs to be broken into twice a day (Stahl et al., 2020). The only other thing is that I would be sure to get baseline LFTs due to the rare chance of hepatotoxicity (Putzantian & Carlat, 2020; Stahl et al., 2020).

To add to the discussion on the treatment of Harold, cognitive behavioral therapy (CBT) has proven to be effective as I wrote in my initial discussion. According to Fullen et al. (2020), some additional modalities proven to be successful in adult ADHD treatment are mindfulness, dialectical behavior therapy, and neurofeedback. Harold may also benefit from yoga, regular exercise, a healthy whole foods diet, and regular sleep.Hanging indentation not retained

References

Bukstein, O. (2018). Attention deficit hyperactivity disorder in adults: Epidemiology, pathogenesis, clinical features, course, assessment, and diagnosis. Retrieved February 28, 2021 from https://www.uptodate.com/contents/attention-deficit-hyperactivity-disorder-in-adults

Fullen, T., Jones, S.L., Emerson, L.M., Adamou, M. (2020). Psychological treatments in adult ADHD: A systematic review. Journal of Psychopathology and Behavior Assessment, 42, 500–518. https://doi.org/10.1007/s10862-020-09794-8

Puzantian, T., & Carlat, D. J. (2020). Medication fact book for psychiatric practice. Carlat Publishing (5th ed.).

Stahl, S. M., Grady, M. M., & Muntner, N. (2020). Stahl’s essential psychopharmacology: Prescriber’s guide. Cambridge University Press (6th ed.).

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge University Press.

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