New psychotherapeutic approaches in adult ADHD – acknowledging biographical factors

Page 6 of 10 New psychotherapeutic approaches in adult ADHD – acknowledging biographical factors Caroline Lücke1*, Alexandra P. Lam1, Helge H. O. Müller1, Alexandra Philipsen1,2 1Medical Campus University of Oldenburg, School of Medicine and Health Sciences, Psychiatry and Psychotherapy – University Hospital, Karl-Jaspers-Klinik, Bad Zwischenahn, Germany 2Department of Psychiatry and Psychotherapy, Medical Faculty, University Medical Center – University of Freiburg, Freiburg, Germany


Background: Current practice of psychotherapy in ADHD
Attention deficit hyperactivity disorder (ADHD) is a chronic psychiatric disorder, starting in early childhood and often continuing into adult age.With its three main clinical features, inattention, hyperactivity and impaired impulse control, ADHD frequently interferes with the professional and private life of patients, leading to a variety of problems such as underachievement at work, disturbance of relationships and social contacts or even to serious secondary disorders like depression (review: 1 ).According to the criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5 th edition (DSM-5) for the diagnosis of ADHD, several symptoms of inattention and hyperactivity-impulsivity must be present, occur in at least two situations, interfere with daily functioning, and must have been present before the age of 12 years 2 .Pharmacological therapy with methylphenidate is regarded to be firstline treatment in adult ADHD and is very effective in alleviating ADHD core symptoms 3 .However, a considerable proportion of patients have residual symptoms under medication 4 or have contraindications for medication.Therefore, alternatives to pharmacological approaches are needed.In the development of psychotherapeutic approaches, most programs have been based on the principle of cognitive behavioral therapy (CBT) 5,6 and there is evidence that these are effective in reducing ADHD symptoms, at least with regard to self-reported symptom evaluation 7 .Furthermore, approaches that combine principles of CBT with aspects of dialectic behavior therapy (DBT) have been developed, offering ADHD patients further strategies to specifically target difficulties in emotion and impulse control, based on the concept of mindfulness 8 .A common feature of the existing psychotherapeutic treatments in ADHD is a main emphasis on the ADHD symptoms and their direct consequences in daily life, while internalized secondary problems, such as low self-esteem or a depressive coping-style are usually not the primary focus of these programs 5 .

General developments in psychotherapeutic programs: incorporation of biographical factors
In the development of new psychotherapeutic approaches on other psychiatric conditions, programs have been suggested, that, in addition to behavioral work, integrate the recognition and targeting of patients' (usually negative) biographical experiences.While, of course, the general idea of targeting childhood traumas is not new, and is an important factor in traditional psychoanalysis, the idea to combine and integrate this focus with behavioral-based approaches is a relatively young development.One of these promising approaches is Cognitive Behavioral Analysis System of Psychotherapy (CBASP) 9 , which is already widely used in clinical practice, however this program has been specifically developed for the treatment of chronic depression and, to our knowledge has not been adapted for use in other psychiatric conditions.Another important psychotherapeutic approach acknowledging a patient's personal history is Schema therapy, developed by Young et al. 10 .Schema therapy seeks to identify and alleviate early maladaptive schemas.These are internalized assumptions and expectancies an individual has developed about their own identity in relation to the and the world around them.Early maladaptive schemas are formed during childhood from chronic negative experiences with others, such as parents or peers, interfere with the development of a stable and resilient personality, and persist until adulthood.Examples of early maladaptive schemas are "Abandonment/Instability", referring to the expectation that one will soon lose anyone with whom an emotional attachment has been formed, or "Failure", referring to the belief that one is incapable of performing as well as one's peers in different areas of life 10 .As described by Young, the identification of a patient's temperamental factors and their interaction with other developmental factors is part of the structured assessment process in schema therapy, since these factors may contribute to the development and manifestation of the patient's specific maladaptive schemas 10,11 .Schema therapy seeks to reduce the power early memories and feelings linked to maladaptive schemas have on the patients' functioning and well-being until the present day, and tries to replace maladaptive behavior with more mature beliefs and strategies, such as the basic assumptions of self-worth and self-efficacy and the ability of appropriate problem-solving.Schema therapy is not restricted to the use in certain psychiatric conditions but was originally developed for patients with severe, chronic conditions, such as personality disorders, who do not sufficiently respond to usual psychotherapeutic treatment.The extension of schema therapy to the areas of depression and anxiety has been suggested, and is subject to current research 12,13 .

Existence of maladaptive schemas in ADHD: results from recent studies
Given that ADHD is a chronic developmental disorder, usually starting in early childhood, it seems reasonable to assume that biographical factors may play a role in the psychopathology of adult ADHD patients as well.Children with ADHD often show a poor school performance due to inattention, are reprimanded for hyperactive behavior or get into conflicts due to their impulsivity.The often noisy and disruptive behavior of ADHD patients promotes harsh and inappropriate reactions from parents and caregivers and many children with ADHD are rejected by their peers for violent behavior 14 .Transferred to Young's theory of schema therapy, ADHD traits could be seen as temperamental factors interplaying with other biographical circumstances in the development of maladaptive schemas.Already more than a decade ago, Ramsay & Rostain discussed the importance of internalized core beliefs, also known as schemas, in relation to adult ADHD and ADHD-specific psychotherapy 15 and suggested the targeting of a patient's "compensatory strategies", linked to his schemas, by CBT.The same authors created the concept of ADHD as an "Axis 1.5 disorder", emphasizing the fundamental influence of ADHD traits on a patient's personal development 16 .
Recently, two studies have systematically investigated the presence of early maladaptive schemas in adult ADHD: Miklosi et al. 17 assessed a sample of non-clinical adults for symptoms of ADHD, using the Adult ADHD Self-Report Scale (ASRS) 18 , as well as for the manifestation of maladaptive schemas, using 4 subscales of the short form Young Schema Questionnaire (YSQ) 10 .Participants who showed elevated scores for more than 8 ADHD symptoms on the ASRS, suggesting a possible ADHD diagnosis, had significantly higher scores on the YSQ for all investigated subscales (social isolation, defectiveness/shame, failure, and insufficient self-control/self-discipline).While this study had some limitations, including the lack of a clinical, observer-based ADHD diagnosis in "patients", the small number of individuals with ADHD symptoms (n=15), and the investigation of only a small proportion of maladaptive schemas, it provided first implications that maladaptive schemas may be increased in ADHD patients.
In a further study by our own group 19 the existence of maladaptive schemas was investigated in a clinical sample of 80 adults with diagnosed ADHD and compared to a control group of 80 healthy adults.ADHD diagnoses were secured clinically by a careful assessment of the ICD10 and DSM-IV diagnostic criteria, including a retrospective evaluation of childhood ADHD using the Wender Utah Rating Scale 20 .Furthermore the CAARS questionnaire 21 and the ADHD Checklist 22 were used to examine the severity and the subtype of ADHD in patients.Participants were screened for the whole range of maladaptive schemas as defined by Young et al. 10 , using the complete YSQ-S2.ADHD patients had significantly higher YSQ scores compared to healthy controls for all maladaptive schemas, with the exception of "Vulnerability to Harm or Illness".In line with the expectations based on typical biographical experiences of ADHD patients, the schemas "Failure", "Defectiveness/ Shame", "Subjugation" and "Emotional Deprivation" were most pronounced in ADHD sufferers.The fact that the "Vulnerability to Harm or Illness" schema did not significantly differ between groups corresponds well with the increased prevalence of high-risk behavior in ADHD patients, such as tobacco or drug usage, fast driving or risky sexual behavior 23 .This tendency for high-risk behavior has been connected to an "intuitive-existential" style of decision making in ADHD 24 , with a primary focus on the expected reward of an action and an inclination to neglect the possibility of harmful events.It thus seems plausible to assume that this internal trait of ADHD counteracts negative external experiences, which could lead to development of a "Vulnerability" schema, resulting in normal levels of this schema in ADHD patients.
In addition to the existence of maladaptive schemas, the study also showed a significantly elevated prevalence of comorbid psychiatric disorders in ADHD patients compared to healthy controls.Particularly affective disorders, anxiety, alcohol abuse and personality disorders were common comorbidities in the ADHD group, all of which can be seen as potentially linked to maladaptive schemas.
On an individual level, Weusten et al. 25 have recently described an interesting case of schema therapy in an elderly patient with a severe personality disorder, dermatillomania and comorbid ADHD.With increasing age, the overall psychiatric burden of this patient had accumulated, especially after forced retirement, with the consequential loss of structure and social contacts.The authors discuss how the undiagnosed and untreated ADHD likely had profound influence on the development of the patient's personality disorder, which was connected to the maladaptive schemas "Failure", "Social alienation" and "Lack of self-control."Schema-focused therapy was conducted in this patient and an improvement regarding his most prominent schemas as well as his dermatillomania could be reached, while some of his symptoms, like anxiety, had increased after the first 20 therapy sessions.A concurrent medication with Methylphenidate, which may also have helped with his ability to profit from schema therapy, was declined by the patient.This case study underlines the fact that, while schema therapy seems an interesting therapy approach in ADHD, the interplay with other factors, such as age, the burden of individual symptoms and comorbidities is complex and highly individual.

Schema therapy in ADHD: Implications for future research
Taken together, the described cases and studies support the theory of maladaptive schemas as a relevant factor in the psychopathology of adult ADHD patients and encourage further research on schema therapy in these patients as a potentially promising approach.However, up to date no pilot studies or randomized controlled trials investigating schema therapy in ADHD patients have been conducted.The design of such studies needs to be carefully planned, particularly with regard to the outcome parameters which are expected to improve under schema therapy.Since the core symptoms of ADHD, inattention, hyperactivity and impulsivity can be seen as traits with a primarily neurobiological genesis, rather than a biographical origin, the substantial improvement of ADHD core symptoms under schema therapy seems unlikely.In contrast, the focus of schema therapy would likely be on the improvement of secondary problems, such as ineffective coping strategies and biased self-perception, resulting from the development of maladaptive schemas during childhood.In example, a "failure" schema could lead to reduced self-esteem, anxiety, social retreat and the tendency to quickly give up on difficult tasks while an emotional deprivation schema may lead to demanding behavior and instability of relationships.Such specific problems are difficult to measure and compare by validated instruments, all the more so since different patients usually have their own specific combination of maladaptive schemas and related consequences.However, consequences of maladaptive schemas can often be closely linked to common comorbidities in ADHD patients, such as depression and anxiety, which are well known from the literature 26 and were confirmed in our recent study (see above) 19 .Thus, to obtain scientifically sound and comparable results, it might be feasible for a study on schema therapy in ADHD to focus on a subgroup of patients with a clearly defined comorbidity, such as depression, that is easily measurable and can be expected to improve under schema therapy.An alternative study approach could be the usage of more generalized outcome measurements such as the Clinical Global Impression scales (referring to a patient's overall psychiatric morbidity) or measurements of health-related quality of life and daily functioning, which may improve in patients with different maladaptive schemas by targeting their specific combination in therapy.
A further difficulty with regard to the design of studies is the usually high individualization of schema therapy, resulting in difficulties to provide an 'equal' treatment to all participants.However, more standardized attempts on schema therapy have already been developed, such as the manual on group schema therapy for borderline personality disorder by Farrell and Shaw 27 and these may be adapted for the use in ADHD.

Conclusions
In conclusion, schema therapy or similar therapy forms, focusing on the potential burden of the patient's personal history, seem to be interesting and promising approaches in the psychotherapy of adult ADHD.Since the focus of these approaches is very different from the standard form of psychotherapy, CBT, these should be seen as an extension or addition, rather than an alternative to CBT.Particularly patients, who continue to suffer from significant secondary problems, such as depression or anxiety, under standard pharmacological and/or psychotherapeutic treatment, may profit from more biography oriented approaches such as schema therapy.