CASE STUDY 3

Tom is a 47-year-old, married white male self-referred for evaluation of attention deficit hyperactivity disorder (ADHD), prompted by his wife and diagnoses of his two children approximately two years ago.

As an adult, he complains of easy distractibility leading to difficulty sustaining attention on a task, disorganization that results in difficulty sequencing tasks efficiently, taking longer to complete tasks than it should, becoming easily bored and leaving tasks unfinished, restlessness and needing to stay active, difficulty remaining seated (especially when bored or not engaged), interrupting conversations because he’s afraid he’ll forget his thoughts, forgetfulness and misplacing things (resulting in spending inordinate amount of time searching for items), poor sense of time passage and chronic tardiness. His coworkers and wife tell him that he is inconsistent and undependable, although he has creative and useful suggestions at work and home. “I’ve been this way my whole life but always managed to get by.” Because of his children’s successful treatment, his wife has firmly suggested “you finally get this taken care of.”

As a child, he recalls no hyperactivity, although he was restless. His grades in elementary school were average, but when he moved into 9th grade, there was a noticeable decline that continued through 11th grade, where he was getting “D’s”. He admits to lack of interest in school at that point. Somehow, he improved his grades to “A’s” in 12th grade and graduated high school in 1972. Because of relatively poor high school performance and uncertainty of his ability, he enrolled in a local community college. There, he did above average and bored with the schoolwork, transferred to a more competitive university. However, after two semesters, he was unable to keep up, lost interest and dropped out.

He admits to cocaine abuse (his drug of choice) that started in high school and continued until 1979. There was some alcohol and marijuana use, but these were not his drugs of choice. In 1998, feeling badly that he never finished an undergraduate degree, he enrolled in a university, but again dropped out after only one semester because of difficulty sustaining attention, disorganization, distractibility and, ultimately, frustration.

Tom denies a history or current symptoms of major depression, mania/hypomania, dysthymia, panic disorder, ritualistic behavior or excessive worry, social anxiety, current substance or alcohol use, hallucinations/delusions or arrests.

He is twice divorced, now married for the third time and residing with his wife and two children at home. Although his academic achievement is less than his potential intellect, the patient was able to establish himself in a successful career as Vice President of Marketing for a national company. After years in the position, he resigned and started a consulting company that has grown to sponsor an annual international science technology conference.

His medical history includes hypertension treated with Minopril. Coffee consumption is 4 cups per day. There is no history of MI, CVA, seizure, thyroid disease, fainting, chest pain/pressure, major surgery, hospitalizations or sudden deaths in the family.

His past psychiatric treatment started at age 13 when he participated in therapy with his father. This was initiated presumably because of academic difficulty and problematic behavior at home. During his mid-twenties, Tom and his then wife attended marital therapy for what would become his first divorce. He returned to individual therapy at age 40 for general dissatisfaction with his functioning and marital difficulties. This therapy continued for five years, during which he received no psychotropic medication. At age 44, after smoking one pack per day for 22 years, he decided to stop smoking with the aid of Zyban which proved to be effective. During this time, he noticed his focus and concentration were better and ascribed it to smoking cessation.

His family psychiatric history is overwhelmingly significant. His father was treated for an unknown psychiatric disorder with lithium. The patient’s brother has been formally diagnosed with ADHD and depression and was treated for a brief time but nonadherent with treatment. The brother’s two children have been formally diagnosed and treated for ADHD. The patient’s sister has been formally diagnosed and treated for ADHD. The patient’s son and daughter have been formally diagnosed and treated for ADHD with OROS-methylphenidate. There is a paternal cousin diagnosed with ADHD and another paternal cousin with Tourette’s syndrome.