CASE STUDY 4

This is a 41-year-old, single white female who was referred by her employer for an evaluation of attention deficit hyperactivity disorder (ADHD) and anxiety.

As an adult, she complains about being fidgety, difficulty staying on tasks, a disorganized and messy office, forgetfulness and misplacing things, a tendency to run late (which she compensates by setting her watch ahead), low frustration tolerance for annoying tasks and situations, inattentiveness and being easily bored. She has no checkbook, “because it is impossible for me to keep track,” and admits to impulsive spending that creates financial problems and bank fees. Perhaps most important is the fact that the employer, who has also been treated for ADHD, recognized the patient’s impairments in work performance and prompted the evaluation. The patient acknowledges, “Without her encouragement, I probably wouldn’t be here.”

As a child, the patient recalls being easily distracted in class, impulsive behavior but not disruptive, fidgeting and restlessness, difficulty sustaining attention on tasks and often having difficulty finishing tasks. As class work became more challenging, the patient simply stopped doing homework assignments. She acknowledges outbursts and at times breaking things. Her disorganization and difficulty efficiently sequencing tasks led to longer time on tasks than should have been necessary. Reading assignments also took longer than classmates because of slow reading. At age 5, she was diagnosed with ADHD and treated with methylphenidate with good response. She attended a “special school” from grades 1-6 for “dyslexia and behavioral problems.” The medication was stopped in high school for unclear reasons. Sixth grade was repeated due to poor academic performance. She does recall working hard for her grades in high school and college.

Three months before the evaluation, the patient complained of an episode of depressed mood, social withdrawal, quiet, negative thoughts, thought about her death and passive suicidal ideation, amotivation, disturbed sleep, decreased appetite, no interest, anhedonia, urges to cry, and sense of despair. This episode lasted one month and slowly remitted. A stressor at the time was her orientation into a religious order to which she was committed. She had a previous treatment for depression after the breakup of an intimate relationship and treated with fluoxetine. She denies a history of hypomania/mania.

In addition, she has long-standing anxiety with sense of tension, worry and being “on edge” on a daily basis. She denies ritualistic behavior, social anxiety or panic symptoms.

Psychiatric history includes diagnosis of ADHD at age 5 and treatment with methylphenidate into her teens. Fluoxetine treatment for depression following the relationship breakup at age ??. She had psychological testing at age ??, results unknown. There was a brief trial of methylphenidate, but it was stopped after complaints of tachycardia. An Atomoxetine trial ended quickly because of nausea and vomiting. In 1999, she was started on mirtazapine for persistent, severe initial insomnia which she has continued off and on to the present. In the past two years, the patient had trials of methylphenidate that increased her nail-biting and methylphenidate LA that caused initial insomnia.

Her family history consists of a mother described as having very similar cognitive symptoms as the patient. Also present is a nephew with possible ADHD and a father with a history of significant alcohol abuse.

Her medical history includes hypothyroidism, chronic pain from lumbar disc irritation and s/p colonectomy for megacolon in 2005. She is maintained on Synthroid, Remeron for sleep and Skelexan for TMJ symptoms.

She denies any current alcohol or drug use. She admits to a history of marijuana and alcohol use, which started in high school and progressed to “a lot” of LSD abuse in college. The LSD abuse stopped in 1991 and alcohol/marijuana use declined thereafter. She now smokes 4-5 cigars daily.

Her parents divorced when she was 13 and she lived with her mother thereafter. She describes her mother as physically abusive, with abuse that started as a young child. As she got older, her brother “also beat me up.” At age 7, she reports being sexually assaulted once by a group of boys and subsequently teased by them. She worried for a year that she was pregnant because she hadn’t told anyone what had happened. There is no history of arrests, rape or pregnancy.

She lives in a religious residence with four other “sisters” and is trying to become a member. She had maintained a lesbian relationship for four years before it dissolved.

The patient rated her presenting symptoms on the ADHD Rating Scale and scored 53, reflecting extremely severe ADHD without medication. (maximum score on the scale is 54 with research threshold score of 24).