Abstract
IntroductionStimulant medication improves hyperactivity, inattention, and impulsivity in both pediatric and adult populations with Attention Deficit Hyperactivity Disorder (ADHD). However, data regarding the optimal dosage in adults is still limited.Case presentationWe report the case of a 38-year-old Caucasian patient who was diagnosed with Attention Deficit Hyperactivity Disorder when he was nine years old. He then received up to 10 mg methylphenidate (Ritalin®) and 20 mg sustained-release methylphenidate (Ritalin SR®) daily. When he was 13, his medication was changed to desipramine (Norpramin®), and both Ritalin® and Ritalin SR® were discontinued; and at age 18, when he developed obsessive-compulsive symptoms, his medication was changed to clomipramine (Anafranil®) 75 mg daily. Still suffering from inattention and hyperactivity, the patient began college when he was 19, but did not receive stimulant medication until three years later, when Ritalin® 60 mg daily was re-established. During the 14 months that followed, he began to use Ritalin® excessively, both orally and rectally, in dosages from 4800-6000 mg daily. Four years ago, he was referred to our outpatient service, where his Attention Deficit Hyperactivity Disorder was re-evaluated. At that point, the patient’s daily Ritalin® dosage was reduced to 200 mg daily orally, but he still experienced pronounced symptoms of, Attention Deficit Hyperactivity Disorder so this dosage was raised again. The patient’s plasma levels consistently remained between 60–187 nmol/l—within the recommended range—and signs of his obsessive-compulsive symptoms diminished with fluoxetine 40 mg daily. Finally, on a dosage of 378 mg extended-release methylphenidate (Concerta®), his symptoms of Attention Deficit Hyperactivity Disorder have improved dramatically and no further use of methylphenidate has been recorded during the 24 months preceding this report.ConclusionsSymptoms of Attention Deficit Hyperactivity Disorder (ADHD) in this adult patient, who also manifested a co-occurring obsessive compulsive disorder, dramatically improved only after application of a higher-than-normal dose of methylphenidate. We therefore suggest that clinicians consider these findings in relation to their adherence to current therapeutic guidelines.
Highlights
Stimulant medication improves hyperactivity, inattention, and impulsivity in both pediatric and adult populations with Attention Deficit Hyperactivity Disorder (ADHD)
Attention Deficit Hyperactivity Disorder (ADHD) is a prevalent mental disorder characterized by symptoms of inattention, hyperactivity, and impulsivity—all of which contribute to significant psychosocial impairment in the affected individuals [1]
The use of methylphenidate (MPH), has proved an efficacious pharmacological treatment for adult ADHD when administered in weight-adjusted doses equivalent to those used in a pediatric population [8]
Summary
In this adult patient, who has ADHD, an obsessivecompulsive disorder, and a combined personality disorder, we observed an excessive use of methylphenidate, which fulfilled the criteria of dependence at the time of his admission to our outpatient services. We observed dramatic improvement of his ADHD symptoms only after application of a higher-than-normal dose of MPH. To our knowledge, this is the first reported case of high-dose treatment in a patient with adult ADHD. We suggest that clinicians consider these findings in their work with patients when ADHD symptoms do not improve sufficiently with currently recommended dosages of stimulants. Soon after I started the medicine, I noticed the positive focus wore off so quickly between doses that I felt I required a higher dose in order to maintain focus for the entire day. I still experience focus issues from ADHD, the higher dosage of the medicine has been an aid in helping me manage and cope with those disabilities.”. Competing interests The authors declare that they have no competing interests
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