A 32-year-old man comes to the physician at his wife's insistence for evaluation of depression and anxiety. He was recently fired from his job as a computer technician due to frequent lateness, mistakes, and failure to meet deadlines. The patient feels discouraged about losing his job, but explains that "it was impossible to sit still staring at a boring computer screen all day." He is worried about finding a new job and his finances. The patient still enjoys sports and socializing with friends and has no sleep or appetite disturbance. His wife complains that he is "impossible to live with" because he never listens and leaves the house in a total mess. The patient considers himself to be very intelligent and creative but has been an underachiever since grade school, when he frequently got in trouble. He has no psychiatric history. The patient drinks 1 or 2 beers on most days and last used marijuana 6 months ago. He does not use other drugs.
Which of the following is the most likely diagnosis?

Question

A 32-year-old man comes to the physician at his wife's insistence for evaluation of depression and anxiety.  He was recently fired from his job as a computer technician due to frequent lateness, mistakes, and failure to meet deadlines.  The patient feels discouraged about losing his job, but explains that "it was impossible to sit still staring at a boring computer screen all day."  He is worried about finding a new job and his finances.  The patient still enjoys sports and socializing with friends and has no sleep or appetite disturbance.  His wife complains that he is "impossible to live with" because he never listens and leaves the house in a total mess.  The patient considers himself to be very intelligent and creative but has been an underachiever since grade school, when he frequently got in trouble.  He has no psychiatric history.  The patient drinks 1 or 2 beers on most days and last used marijuana 6 months ago.  He does not use other drugs.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's inattention to detail, distractibility, restlessness, disorganization, and poor time management causing impairment both at work and at home suggest adult attention deficit hyperactivity disorder (ADHD). His longstanding history of underperformance dating back to childhood suggests that similar symptoms were likely present prior to age 12 (a requirement for the diagnosis). It is not unusual for children and teenagers with ADHD to experience behavioral and disciplinary issues related to their ADHD symptoms. Up to 60% of patients with ADHD continue to have problematic ADHD symptoms as adults. They may have comorbid depressive and anxiety symptoms, and ADHD may go unrecognized. Although a comprehensive history may show behavioral problems or ADHD diagnosis as a child, some patients may seek help for the first time as adults when increasing work demands reveal their deficits. DSM-5 ADHD criteria apply to both children and adults. Diagnosis requires determining whether symptoms were present prior to age 12 and focusing on adult manifestations of symptoms. Adults with ADHD are less overtly hyperactive compared to children. A sense of inner restlessness, irritability, and impulsivity are common and can lead to abrupt termination of relationships or jobs, traffic accidents, and speeding. Executive dysfunction due to difficulties in organizing and prioritizing tasks, lack of follow-through, forgetfulness, and poor time management can result in significant occupational impairment (underemployment, reduced work productivity). Stimulant medication is the first-line treatment for ADHD in adults. DSM-5 ADHD criteria (Choice A) This patient's anxiety is related to realistic worries about his job situation. His underlying difficulties resulting in occupational dysfunction are more likely explained by ADHD. (Choice C) Narcissistic personality disorder is characterized a pervasive pattern of grandiose sense of self-importance, need for admiration, and lack of empathy. This patient does not exhibit any of these characteristics, as his interpersonal problems are more likely due to ADHD. (Choice D) Patients with ADHD often struggle with poor self-esteem due to years of underachievement and may experience co-morbid dysthymia (persistent mild depression lasting at least 2 years). However, this patient does not have sufficient depressive symptoms and his discouragement is situational. (Choice E) The extent of this patient's substance use would not explain his persistent problems dating back to childhood. Educational objective: Attention deficit hyperactivity disorder (ADHD) often persists into adulthood. Compared to children, adults with ADHD are less overtly hyperactive but experience chronic problems with distractibility, disorganization, and impulsivity that cause significant social and occupational impairment. __________ References: Clinical practice: Adult attention deficit-hyperactivity disorder. (http://www.ncbi.nlm.nih.gov/pubmed/24224626) Comorbidities in adult attention-deficit/hyperactivity disorder: a practical guide to diagnosis in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/25295649)

A 32-Year-Old Man Comes to the Physician at His Wife's