Publications by authors named "Barbara Alm"

36 Publications

Validation of the German Version of the Mind Excessively Wandering Scale (MEWS-G).

Fortschr Neurol Psychiatr 2021 Feb 26. Epub 2021 Feb 26.

Klinik für Psychiatrie und Psychotherapie, Zentralinstitut für Seelische Gesundheit Klinische Fakultät Mannheim, Universität Heidelberg.

Increasing evidence shows that unintentional mind wandering is linked to Attention Deficit Hyperactivity Disorder (ADHD) and that its frequency contributes to symptom severity and functional impairment in ADHD. However, empirical data on mind wandering in adult ADHD are still scarce, and a validated scale to assess mind wandering in German adult ADHD patients is lacking. The primary aim of this study is to assess the psychometric properties of the German version of the recently published Mind Excessively Wandering Scale (MEWS-G) in terms of factorial structure and factor stability, internal consistency and construct validity. Analyses were performed in 128 adults with ADHD, clinical and healthy controls. As described for the original English 15-item version of the scale, we found lowest item-total-correlations for items 6, 10 and 14 with item-total correlation of all: 0.54/ADHD: 0.32 (item 6), all: 0.55/ADHD: 0.39 (item 10) and all: 0.11/ADHD: -0.04 (item 14). Item-total correlations for the remaining items were 0.65-0.86 and Cronbach Alpha was 0.96 indicating good internal consistency of the 12-item version of scale, on which we based all further analyses. Principal component analysis indicated a one- and two- factorial scale structure respectively explaining 71.7 % and 78.7 % of variance. Both factors showed good stability with lower stability of the factor-2 solution if sample size was reduced. The two-factorial solution also had many cross-loadings and a strong correlation of both factors in confirmatory factorial analysis (rf1f2 = 0.87). It probably describes related and interdependent, but not distinct facets of mind wandering, which strongly argues for the one factorial structure of the scale. Mean MEWS-G score in ADHD was 23.77 ± 7.85 compared to 7.64 ± 7.27 in controls (p < .0001). According to ROC, the optimal cut-off point to discriminate ADHD and controls is at MEWS-G score = 13. On the symptom level, MEWS-G score was correlated with ADHD, depressive and total psychiatric symptom scores, on the personality level with neuroticsm and negatively with conscientiousness and on the functional level with social interaction difficulties and impaired self-efficacy. In summary, our study shows that MEWS-G is a reliable, valid instrument to assess spontaneous mind wandering in adult ADHD and to discriminate between ADHD and controls.
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http://dx.doi.org/10.1055/a-1362-9743DOI Listing
February 2021

EEG Data Quality: Determinants and Impact in a Multicenter Study of Children, Adolescents, and Adults with Attention-Deficit/Hyperactivity Disorder (ADHD).

Brain Sci 2021 Feb 10;11(2). Epub 2021 Feb 10.

Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, 68159 Mannheim, Germany.

Electroencephalography (EEG) represents a widely established method for assessing altered and typically developing brain function. However, systematic studies on EEG data quality, its correlates, and consequences are scarce. To address this research gap, the current study focused on the percentage of artifact-free segments after standard EEG pre-processing as a data quality index. We analyzed participant-related and methodological influences, and validity by replicating landmark EEG effects. Further, effects of data quality on spectral power analyses beyond participant-related characteristics were explored. EEG data from a multicenter ADHD-cohort (age range 6 to 45 years), and a non-ADHD school-age control group were analyzed (n = 305). Resting-state data during eyes open, and eyes closed conditions, and task-related data during a cued Continuous Performance Task (CPT) were collected. After pre-processing, general linear models, and stepwise regression models were fitted to the data. We found that EEG data quality was strongly related to demographic characteristics, but not to methodological factors. We were able to replicate maturational, task, and ADHD effects reported in the EEG literature, establishing a link with EEG-landmark effects. Furthermore, we showed that poor data quality significantly increases spectral power beyond effects of maturation and symptom severity. Taken together, the current results indicate that with a careful design and systematic quality control, informative large-scale multicenter trials characterizing neurophysiological mechanisms in neurodevelopmental disorders across the lifespan are feasible. Nevertheless, results are restricted to the limitations reported. Future work will clarify predictive value.
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http://dx.doi.org/10.3390/brainsci11020214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7916500PMC
February 2021

Safety Profile of Methylphenidate Under Long-Term Treatment in Adult ADHD Patients - Results of the COMPAS Study.

Pharmacopsychiatry 2020 Nov 5;53(6):263-271. Epub 2020 Oct 5.

Department of Psychiatry and Psychotherapy - University of Bonn, Bonn, Germany.

Introduction: The Comparison of Methylphenidate and Psychotherapy in adult ADHD Study (COMPAS) was a prospective, randomized multicenter clinical trial, comparing methylphenidate (MPH) with placebo (PLAC) in combination with cognitive behavioral group psychotherapy (GPT) or individual clinical management (CM) over the period of 1 year. Here, we report results on treatment safety.

Methods: MPH and PLAC were flexibly dosed. Among 433 randomized patients, adverse events (AEs) were documented and analyzed on an "as received" basis during week 0-52. Electrocardiogram data were recorded at baseline and week 24.

Results: Comparing 205 patients who received ≥1 dose of MPH with 209 patients who received PLAC, AEs occurring significantly more frequently in the MPH group were decreased appetite (22 vs. 3.8%), dry mouth (15 vs. 4.8%), palpitations (13 vs. 3.3%), gastrointestinal infection (11 vs. 4.8%), agitation (11 vs. 3.3%), restlessness (10 vs. 2.9%), hyperhidrosis, tachycardia, weight decrease (all 6.3 vs. 1.9%), depressive symptom, influenza (both 4.9 vs. 1.0%), and acute tonsillitis (4.4 vs. 0.5%). Syncope occurred significantly more often in the PLAC group (2.4 vs. 0%). Clinically relevant ECG changes occurred very rarely in both groups. Serious AEs were rare and without a significant group difference. The comparison of 206 patients treated with GPT versus 209 patients who received CM revealed no major differences. Serious AE classified as psychiatric occurred in 5 cases in the CM group and in 1 case in the GPT group.

Conclusion: In this so far longest-running clinical trial, methylphenidate treatment was safe and well-tolerated.
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http://dx.doi.org/10.1055/a-1207-9851DOI Listing
November 2020

Effects of 12-Week Methylphenidate Treatment on Neurometabolism in Adult Patients with ADHD: The First Double-Blind Placebo-Controlled MR Spectroscopy Study.

J Clin Med 2020 Aug 11;9(8). Epub 2020 Aug 11.

Section for Experimental Neuropsychiatry, Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, 79104 Freiburg, Germany.

Attention deficit hyperactivity disorder (ADHD) is a frequent neurodevelopmental disorder that often persists into adulthood. Methylphenidate (MPH) is the first-line treatment for ADHD; however, despite its wide usage, little is known about its neurometabolic effects. Until now, no randomized and blinded clinical trials have been conducted addressing the neurometabolic signals of MPH administration in adults with ADHD. In the current study, the authors investigated how MPH intake and group psychotherapy (GPT) influence brain neurometabolism over the course of three months. The authors hypothesized a decrease in the anterior cingulate cortex (ACC) glutamate concentration following MPH administration. This study was part of a double-blind multicenter trial (Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS)) investigating the effects of MPH and GPT in patients with adult ADHD. Using single-voxel magnetic resonance spectroscopy (MRS) of the pregenual ACC and the left cerebellar hemisphere (CHL), we investigated the concentration of glutamate plus glutamine (Glx), N-acetyl-aspartate, creatine, total choline containing compounds, and myo-inositol in patients before and after 12 weeks of treatment. Neither MPH nor GPT significantly influenced the Glx concentration or any of the other metabolite concentrations in the ACC and CHL after 12 weeks. Therefore, contrary to the hypothesis, no change in the prefrontal Glx signal was detected after MPH treatment. Given that MRS does not differentiate between glutamate in the synaptic cleft and in neuronal tissue, MPH-induced down-regulation of glutamatergic neurotransmission in the ACC might only affect the concentration of glutamate in the synaptic cleft, while the general availability of glutamate in the respective neuronal tissue might be unaffected by MPH intake. The observed lack of any MPH-induced normalization in metabolite concentrations is less surprising, considering that the baseline sample did not significantly differ from a healthy control group. Future studies of other regions, such as the basal ganglia, and the use of novel methods, such as whole brain MRS and multimodal imaging approaches, are necessary.
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http://dx.doi.org/10.3390/jcm9082601DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7464267PMC
August 2020

Does helping mothers in multigenerational ADHD also help children in the long run? 2-year follow-up from baseline of the AIMAC randomized controlled multicentre trial.

Eur Child Adolesc Psychiatry 2020 Oct 5;29(10):1425-1439. Epub 2019 Dec 5.

Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center of Mental Health, University Hospital of Würzburg, Würzburg, Germany.

ADHD often affects multiple generations in a family. Previous studies suggested that children with ADHD benefit less from therapy if parents are also affected, since ADHD symptoms interfere with treatment implementation. This two-group randomised controlled trial examined whether targeting maternal ADHD boosts the efficacy of parent-child training (PCT) for the child's ADHD. Here, we report follow-up results 2 years from baseline. Mothers of 144 mother-child dyads (ADHD according to DSM-IV) were examined for eligibility (T1) and randomised to 12 weeks of intensive multimodal treatment comprising pharmacotherapy and DBT-based cognitive behavioural group psychotherapy (TG, n = 77) or clinical management comprising non-specific counselling (CG, n = 67) for Step 1 (concluded by T2). Subsequently, all dyads participated in 12 weekly PCT sessions for Step 2 (concluded by T3). In Step 3, participants received maintenance treatments for 6 months (concluded by T4). At 24 months after baseline (T5), we performed follow-up assessments. The primary endpoint was child ADHD/ODD score (observer blind rating). Outcomes at T5 were evaluated using ANCOVA. Assessments from 101 children and 95 mothers were available at T5. Adjusted means (m) of ADHD/ODD symptoms (range 0-26) in children did not differ between TG and CG (mean difference = 1.0; 95% CI 1.2-3.1). The maternal advantage of TG over CG on the CAARS-O:L ADHD index (range 0-36) disappeared at T5 (mean difference = 0.2; 95% CI - 2.3 to 2.6). Sensitivity analyses controlling for medication and significant predictors of follow-up participation showed unchanged outcomes. Within-group outcomes remained improved from baseline. At the 24-month follow-up, TG and CG converged. The superiority of intensive treatment regarding maternal symptoms disappeared. In general, cross-generational treatment seems to be effective in the long term. (BMBF grant 01GV0605; registration ISRCTN73911400).
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http://dx.doi.org/10.1007/s00787-019-01451-0DOI Listing
October 2020

Long-term Effects of Multimodal Treatment on Adult Attention-Deficit/Hyperactivity Disorder Symptoms: Follow-up Analysis of the COMPAS Trial.

JAMA Netw Open 2019 05 3;2(5):e194980. Epub 2019 May 3.

Department of Psychiatry and Psychotherapy, University of Bonn, Bonn, Germany.

Importance: Knowledge about the long-term effects of multimodal treatment in adult attention-deficit/hyperactivity disorder (ADHD) is much needed.

Objective: To evaluate the long-term efficacy of multimodal treatment for adult ADHD.

Design, Setting, And Participants: This observer-masked, 1.5-year follow-up of the Comparison of Methylphenidate and Psychotherapy in Adult ADHD Study (COMPAS), a prospective, multicenter randomized clinical trial, compared cognitive behavioral group psychotherapy (GPT) with individual clinical management (CM) and methylphenidate (MPH) with placebo (2 × 2 factorial design). Recruitment started January 2007 and ended August 2010, and treatments were finalized in August 2011 with follow-up through March 2013. Overall, 433 adults with ADHD participated in the trial, and 256 (59.1%) participated in the follow-up assessment. Analysis began in November 2013 and was completed in February 2018.

Interventions: After 1-year treatment with GPT or CM and MPH or placebo, no further treatment restrictions were imposed.

Main Outcomes And Measures: The primary outcome was change in the observer-masked ADHD Index of Conners Adult ADHD Rating Scale score from baseline to follow-up. Secondary outcomes included further ADHD rating scale scores, observer-masked ratings of the Clinical Global Impression scale, and self-ratings of depression on the Beck Depression Inventory.

Results: At follow-up, 256 of 433 randomized patients (baseline measured in 419 individuals) participated. Of the 256 patients participating in follow-up, the observer-masked ADHD Index of Conners Adult ADHD Rating Scale score was assessed for 251; the mean (SD) baseline age was 36.3 (10.1) years; 125 patients (49.8%) were men; and the sample was well-balanced with respect to prior randomization (GPT and MPH: 64 of 107; GPT and placebo: 67 of 109; CM and MPH: 70 of 110; and CM and placebo: 55 of 107). At baseline, the all-group mean ADHD Index of Conners Adult ADHD Rating Scale score was 20.6, which improved to adjusted means of 14.2 for the GPT arm and 14.7 for the CM arm at follow-up with no significant difference between groups (difference, -0.5; 95% CI, -1.9 to 0.9; P = .48). The adjusted mean decreased to 13.8 for the MPH arm and 15.2 for the placebo arm (difference, -1.4; 95% CI, -2.8 to -0.1; P = .04). As in the core study, MPH was associated with a larger reduction in symptoms than placebo at follow-up. These results remained unchanged when accounting for MPH intake at follow-up. Compared with participants in the CM arm, patients who participated in group psychotherapy were associated with less severe symptoms as measured by the self-reported ADHD Symptoms Total Score according to the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) of Conners Adult ADHD Rating Scale (AMD, -2.1; 95% CI, -4.2 to -0.1; P = .04) and in the subscale of reducing pure hyperactive symptoms, measured via the Diagnostic Checklist for the diagnosis of ADHD in adults (AMD, -1.3; 95% CI, -2.8 to 0.1; P = .08). Regarding the Clinical Global Impression scale assessment of effectiveness, the difference between GPT and CM remained significant at follow-up (odds ratio, 1.63; 95% CI, 1.03-2.59; P = .04). No differences were found for any comparison concerning depression as measured with the Beck Depression Inventory.

Conclusions And Relevance: Results from COMPAS demonstrate a maintained improvement in ADHD symptoms for adults 1.5 years after the end of a 52-week controlled multimodal treatment period. The results indicate that MPH treatment combined with GPT or CM provides a benefit lasting 1.5 years. Confirming the results of the core study, GPT was not associated with better results regarding the primary outcome compared with CM.

Trial Registration: isrctn.org Identifier: ISRCTN54096201.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.4980DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6547099PMC
May 2019

Sequential treatment of ADHD in mother and child (AIMAC study): importance of the treatment phases for intervention success in a randomized trial.

BMC Psychiatry 2018 12 13;18(1):388. Epub 2018 Dec 13.

Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Center for Mental Health, University Hospital of Würzburg, Würzburg, Germany.

Background: The efficacy of parent-child training (PCT) regarding child symptoms may be reduced if the mother has attention-deficit/hyperactivity disorder (ADHD). The AIMAC study (ADHD in Mothers and Children) aimed to compensate for the deteriorating effect of parental psychopathology by treating the mother (Step 1) before the beginning of PCT (Step 2). This secondary analysis was particularly concerned with the additional effect of the Step 2 PCT on child symptoms after the Step 1 treatment.

Methods: The analysis included 143 mothers and children (aged 6-12 years) both diagnosed with ADHD. The study design was a two-stage, two-arm parallel group trial (Step 1 treatment group [TG]: intensive treatment of the mother including psychotherapy and pharmacotherapy; Step 1 control group [CG]: supportive counseling only for mother; Step 2 TG and CG: PCT). Single- and multi-group analyses with piecewise linear latent growth curve models were applied to test for the effects of group and phase. Child symptoms (e.g., ADHD symptoms, disruptive behavior) were rated by three informants (blinded clinician, mother, teacher).

Results: Children in the TG showed a stronger improvement of their disruptive behavior as rated by mothers than those in the CG during Step 1 (Step 1: TG vs. CG). In the CG, according to reports of the blinded clinician and the mother, the reduction of children's disruptive behavior was stronger during Step 2 than during Step 1 (CG: Step 1 vs. Step 2). In the TG, improvement of child outcome did not differ across treatment steps (TG: Step 1 vs. Step 2).

Conclusions: Intensive treatment of the mother including pharmacotherapy and psychotherapy may have small positive effects on the child's disruptive behavior. PCT may be a valid treatment option for children with ADHD regarding disruptive behavior, even if mothers are not intensively treated beforehand.

Trial Registration: ISRCTN registry ISRCTN73911400 . Registered 29 March 2007.
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http://dx.doi.org/10.1186/s12888-018-1963-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6293507PMC
December 2018

Internalized stigma, anticipated discrimination and perceived public stigma in adults with ADHD.

Atten Defic Hyperact Disord 2019 Jun 19;11(2):211-220. Epub 2018 Oct 19.

Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, University Heidelberg, J 5, 68159, Mannheim, Germany.

The objective of this study is to assess internalized stigma, perceived public stigma, anticipated discrimination and their associations with demographic, psychiatric and psychosocial characteristics in adult ADHD. Stigmatization was assessed with the Internalized Stigma of Mental Illness Scale, the Questionnaire on Anticipated Discrimination and the Questionnaire on Public Stereotypes Perceived by Adults with ADHD. The sample comprised n = 104 adults with ADHD, of whom n = 24 (23.3%) reported high internalized stigma, n = 92 (88.5%) anticipated discrimination in daily life and n = 70 (69.3%) perceived public stigma. Internalized stigma and/or anticipated discrimination correlated with ADHD symptoms, psychological distress, self-esteem, functional impairment and quality of life and was associated with ADHD family history and employment status. Most frequently perceived stereotypes were doubts about the validity of ADHD as a mental disorder. Internalized stigma and anticipated discrimination are highly prevalent in adult ADHD and correlate with the burden of disease. ADHD is associated with characteristic public stereotypes, which are distinct from stereotypes related to other mental disorders. Stigmatization should be considered in the clinical management of adult ADHD and evaluated further in future studies.
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http://dx.doi.org/10.1007/s12402-018-0274-9DOI Listing
June 2019

A multicentre randomized controlled trial on trans-generational attention deficit/hyperactivity disorder (ADHD) in mothers and children (AIMAC): an exploratory analysis of predictors and moderators of treatment outcome.

Z Kinder Jugendpsychiatr Psychother 2019 Jan 7;47(1):49-65. Epub 2018 Aug 7.

2b bb) Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy.

Objective: We examined predictors and moderators of treatment outcome in mothers and children diagnosed with ADHD in a large multicentre RCT.

Method: In total, 144 mother-child dyads with ADHD were randomly assigned to either a maternal ADHD treatment (group psychotherapy and open methylphenidate medication, TG) or to a control treatment (individual counselling without psycho- or pharmacotherapy, CG). After maternal ADHD treatment, parent-child training (PCT) for all mother-child dyads was added. The final analysis set was based on 123 dyads with completed primary outcome assessments (TG: n = 67, CG: n = 56). The primary outcome was the change in each child's externalizing symptoms. Multiple linear regression analyses were performed.

Results: The severity of the child's externalizing problem behaviour in the family at baseline predicted more externalizing symptoms in the child after PCT, independent of maternal treatment. When mothers had a comorbid depression, TG children showed more externalizing symptoms after PCT than CG children of depressive mothers. No differences between the treatment arms were seen in the mothers without comorbid depression.

Conclusions: Severely impaired mothers with ADHD and depressive disorder are likely to need additional disorder-specific treatment for their comorbid psychiatric disorders to effectively transfer the contents of the PCT to the home situation (CCTISRCTN73911400).
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http://dx.doi.org/10.1024/1422-4917/a000602DOI Listing
January 2019

Does the efficacy of parent-child training depend on maternal symptom improvement? Results from a randomized controlled trial on children and mothers both affected by attention-deficit/hyperactivity disorder (ADHD).

Eur Child Adolesc Psychiatry 2018 Aug 23;27(8):1011-1021. Epub 2018 Jan 23.

Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital of Würzburg, Würzburg, Germany.

Multimodal treatment of children with ADHD often includes parent-child training (PCT). However, due to the high heritability, parents of children with ADHD are frequently also affected by the disorder, which is likely to constitute a significant barrier to successful treatment of the child. This secondary analysis of our randomized controlled multicentre AIMAC trial (ADHD in mothers and children) investigates whether children's outcomes following parent-child training in combination with maternal ADHD treatment depend on maternal symptom improvement. In a first step focusing on treatment of maternal ADHD, 144 mothers of mother-child dyads were randomized to multimodal ADHD treatment (group psychotherapy plus methylphenidate) or clinical management (mainly supportive counselling). After 12 weeks (T2), a 12-week PCT program (T2-T3) for all mother-child dyads was added to treat children's ADHD. Maternal symptomatology (CAARS-O:L; SCL-90-R) and children's externalizing symptoms (ADHD-ODD Scale, SDQ) were repeatedly assessed (T1 = baseline, T2, T3). Effects of changes in maternal symptomatology (T1-T2) on the change in children's symptom scores (T1-T3) were analysed using a general linear model, controlling for baseline scores, study centre, and maternal treatment group. 125 mother-child dyads were analysed. Mothers showed significant improvements in ADHD symptoms and overall psychopathology [CAARS-O:L ADHD index: mean - 3.54, SE 0.74 p < 0.0001; SCL-90-R Global Severity (GS): mean - 11.03, SE 3.90, p = 0.0056]. Although children's externalizing symptoms improved significantly (ADHD-ODD Scale: mean - 4.46, SE 0.58, p < 0.0001), maternal improvement had no effect on children's outcomes after Bonferroni-Holm correction for multiple testing. The findings do not support our hypothesis that children's outcomes following PCT for ADHD depend on maternal symptom improvements.Trial register CCT-ISRCTN73911400.
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http://dx.doi.org/10.1007/s00787-018-1109-0DOI Listing
August 2018

Daytime Sleepiness in Adults With ADHD: A Pilot Trial With a Multiple Sleep Latency Test.

J Atten Disord 2016 Dec 17;20(12):1023-1029. Epub 2014 Apr 17.

Central Institute of Mental Health, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.

Objective: To evaluate sleep latency (SL) during the multiple sleep latency test (MSLT) and subjective daytime sleepiness in adult ADHD and controls.

Method: Subjective daytime sleepiness was assessed by Epworth Sleepiness Scale (ESS) in 27 unmedicated adults with ADHD and in 182 controls. Thirteen ADHD patients and 26 controls underwent MSLT after one night of polysomnography (PSG).

Results: Mean MSLT-SL was 10.6 ± 4.8 min in ADHD and 12.2 ± 4.2 min in controls (n.s.). Mean ESS score was 9.3 ± 4.9 points in ADHD and 6.9 ± 3.4 points in controls (p < .005). MSLT-SL and ESS scores correlated inversely by trend (r = -.45, p < .1) but not with ADHD symptoms or ADHD subtype.

Conclusion: Adults with ADHD do not differ from controls in mean MSLT-SL but experience increased subjective daytime sleepiness. Patients with subjective higher daytime tiredness fell asleep faster during MSLT.
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http://dx.doi.org/10.1177/1087054714529456DOI Listing
December 2016

Associations of pineal volume, chronotype and symptom severity in adults with attention deficit hyperactivity disorder and healthy controls.

Eur Neuropsychopharmacol 2016 07 14;26(7):1119-26. Epub 2016 Apr 14.

Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; Department of Psychosomatic Medicine, Bad Dürkheim, Germany.

The pineal gland, as part of the human epithalamus, is the main production site of peripheral melatonin, which promotes the modulation of sleep patterns, circadian rhythms and circadian preferences (morningness vs. eveningness). The present study analyses the pineal gland volume (PGV) and its association with circadian preferences and symptom severity in adult ADHD patients compared to healthy controls. PGV was determined manually using high-resolution 3T MRI (T1-magnetization prepared rapid gradient echo) in medication free adult ADHD patients (N=74) compared to healthy controls (N=86). Moreover, the Morningness-Eveningness Questionnaire (MEQ), the ADHD Diagnostic Checklist and the Wender-Utah Rating Scale were conducted. PGV differed between both groups (patients: 59.9±33.8mm(3); healthy controls: 71.4±27.2mm(3), P=0.04). In ADHD patients, more eveningness types were revealed (patients: 29%; healthy controls: 17%; P=0.05) and sum scores of the MEQ were lower (patients: 45.8±11.5; healthy controls 67.2±10.1; P<0.001). Multiple regression analyses indicated a positive correlation of PGV and MEQ scores in ADHD (β=0.856, P=0.003) but not in healthy controls (β=0.054, P=0.688). Patients' MEQ scores (β=-0.473, P=0.003) were negatively correlated to ADHD symptoms. The present results suggest a linkage between the PGV and circadian preference in adults with ADHD and an association of the circadian preference to symptom severity. This may facilitate the development of new chronobiological treatment approaches for the add-on treatment in ADHD.
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http://dx.doi.org/10.1016/j.euroneuro.2016.03.016DOI Listing
July 2016

Nightmare frequency in adults with attention-deficit hyperactivity disorder.

Eur Arch Psychiatry Clin Neurosci 2017 Feb 14;267(1):89-92. Epub 2016 Mar 14.

Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Schlaflabor, Zentralinstitut für Seelische Gesundheit, Postfach 12 21 20, 68072, Mannheim, Germany.

Nightmare frequency in adult ADHD patients has not yet been studied systematically. In a sample of 65 patients, it could be shown that nightmare frequency was elevated in ADHD patients compared to a sample representative for Germany. Frequent nightmares (once a week or more often) were reported by 4.62 % of the patients and 1.77 % of the controls. This increase was neither explained by the increased dream recall in general nor by the presence of a comorbid mental disorder. Questions about nightmares should be included in the diagnostic procedures for ADHD patients, and it should be tested whether well-established nightmare treatment strategies like imagery rehearsal treatment might be beneficial to those patients with nightmares.
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http://dx.doi.org/10.1007/s00406-016-0686-5DOI Listing
February 2017

Effects of Group Psychotherapy, Individual Counseling, Methylphenidate, and Placebo in the Treatment of Adult Attention-Deficit/Hyperactivity Disorder: A Randomized Clinical Trial.

JAMA Psychiatry 2015 Dec;72(12):1199-210

Department of Psychiatry and Psychotherapy, University Medical Center Freiburg, University of Freiburg, Freiburg, Germany.

Importance: Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder with high prevalence in adulthood. There is a recognized need to assess the efficacy of psychotherapy in adult ADHD.

Objective: To evaluate the efficacy of cognitive behavioral group psychotherapy (GPT) compared with individual clinical management (CM) and that of methylphenidate hydrochloride compared with placebo.

Design, Setting, And Participants: Prospective, multicenter, randomized clinical trial of 18- to 58-year-old outpatients with ADHD from 7 German study centers. Patients were recruited between January 2007 and August 2010, treatment was finalized in August 2011, and final follow-up assessments occurred in March 2013.

Interventions: Sessions of GPT and CM were held weekly for the first 12 weeks and monthly thereafter (9 months). Patients received either methylphenidate or placebo for 1 year.

Main Outcomes And Measures: The primary outcome was the change in the ADHD Index of the Conners Adult ADHD Rating Scale from baseline to the end of the 3-month intensive treatment (blinded observer ratings). Secondary outcomes included ADHD ratings after 1 year, blinded observer ratings using the Clinical Global Impression Scale, and self-ratings of depression.

Results: Among 1480 prescreened patients, 518 were assessed for eligibility, 433 were centrally randomized, and 419 were analyzed as randomized. After 3 months, the ADHD Index all-group baseline mean of 20.6 improved to adjusted means of 17.6 for GPT and 16.5 for CM, with no significant difference between groups. Methylphenidate (adjusted mean, 16.2) was superior to placebo (adjusted mean, 17.9) (difference, -1.7; 97.5% CI, -3.0 to -0.4; P = .003). After 1 year, treatment effects remained essentially stable. Descriptive analyses showed that methylphenidate was superior to placebo in patients assigned to GPT (difference, -1.7; 95% CI, -3.2 to -0.1; P = .04) or CM (difference, -1.7; 95% CI, -3.3 to -0.2; P = .03). Regarding depression, no significant differences were found. In contrast, GPT was superior to CM for all visits in the Clinical Global Impression global assessment of effectiveness.

Conclusion And Relevance: Highly structured group intervention did not outperform individual CM with regard to the primary outcome. Psychological interventions resulted in better outcomes during a 1-year period when combined with methylphenidate as compared with placebo.

Trial Registration: isrctn.org Identifier: ISRCTN54096201.
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http://dx.doi.org/10.1001/jamapsychiatry.2015.2146DOI Listing
December 2015

Does intensive multimodal treatment for maternal ADHD improve the efficacy of parent training for children with ADHD? A randomized controlled multicenter trial.

J Child Psychol Psychiatry 2015 Dec 30;56(12):1298-313. Epub 2015 Jun 30.

Department of Psychiatry and Psychotherapy, University Medical Center Freiburg, Freiburg, Germany.

Background: This is the first randomized controlled multicenter trial to evaluate the effect of two treatments of maternal attention-deficit hyperactivity disorder (ADHD) on response to parent-child training targeting children's external psychopathology.

Methods: Mother-child dyads (n = 144; ADHD according to DSM-IV; children: 73.5% males, mean age 9.4 years) from five specialized university outpatient units in Germany were centrally randomized to multimodal maternal ADHD treatment [group psychotherapy plus open methylphenidate medication; treatment group (TG): n = 77] or to clinical management [supportive counseling without psychotherapy or psychopharmacotherapy; control group (CG): n = 67]. After 12 weeks, the maternal ADHD treatment was supplemented by individual parent-child training for all dyads. The primary outcome was a change in the children's externalizing symptom scores (investigator blinded to the treatment assignment) from baseline to the end of the parent-child training 6 months later. Maintenance therapy continued for another 6 months. An intention-to-treat analysis was performed within a linear regression model, controlling for baseline and center after multiple imputations of missing values.

Results: Exactly, 206 dyads were assessed for eligibility, 144 were randomized, and 143 were analyzed (TG: n = 77; CG: n = 66). After 6 months, no significant between-group differences were found in change scores for children's externalizing symptoms (adjusted mean TG-mean CG=1.1, 95% confidence interval -0.5-2.7; p = .1854), although maternal psychopathology improved more in the TG. Children's externalizing symptom scores improved from a mean of 14.8 at baseline to 11.4 (TG) and 10.3 (CG) after 6 months and to 10.8 (TG) and 10.1 (CG) after 1 year. No severe harms related to study treatments were found, but adverse events were more frequent in TG mothers than in CG mothers.

Conclusions: The response in children's externalizing psychopathology did not differ between maternal treatment groups. However, multimodal treatment was associated with more improvement in maternal ADHD. Child and maternal treatment gains were stable (CCT-ISRCTN73911400).
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http://dx.doi.org/10.1111/jcpp.12443DOI Listing
December 2015

A randomized controlled multicenter trial on the multimodal treatment of adult attention-deficit hyperactivity disorder: enrollment and characteristics of the study sample.

Atten Defic Hyperact Disord 2014 Mar 17;6(1):35-47. Epub 2013 Oct 17.

Department of Psychiatry and Psychotherapy, University Medical Center Freiburg, Hauptstrasse 5, 79104, Freiburg, Germany,

Adult ADHD is a frequent psychiatric disorder affecting relevant aspects of an individual's life. The aim of our study group was to carry out the first randomized controlled multicenter study to evaluate the effects of psychotherapy compared to clinical management in combination with psychopharmacological treatment with methylphenidate (MPH) or placebo (Plac) in a factorial four-arm design. Here, we present the enrollment procedure and description of adult ADHD patients recruited for the trial. Four hundred and thirty-three adult patients with ADHD were randomized at seven study sites in Germany to four treatment conditions: manualized dialectical-behavioral-therapy-based group psychotherapy (GPT) plus MPH or Plac, or clinical management (CM) including supportive counseling plus MPH or Plac with weekly sessions in the first 12 weeks and monthly sessions thereafter. Assessment for eligibility included standardized scales and instruments. After prescreening of 1,480 patients, 518 were evaluated for trial participation and 433 were randomized. The main reasons for prescreening failure were lack of interest in participating (n = 205), difficulties in meeting the time and effort requirements for participation (n = 186), and contraindications for psychopharmacological treatment with MPH (n = 194). The full analysis set (FAS) comprised 419 adult ADHD patients (mean age 35.2 years, males/females 1:1). Fifty-seven percent of the patients suffered from the combined ADHD subtype. Prevalence of at least one current or lifetime axis-I comorbidity was 66 %. Axis-II comorbidity rates was 18 % (patients with comorbid borderline and antisocial personality disorders were excluded). Our network was able to recruit an adult ADHD sample essentially comparable to community samples. A selection bias was created by excluding patients unable or unwilling to participate, or who had somatic and psychiatric contraindications for stimulant treatment (Current Controlled Trials ISRCTN54096201, FUNDING: Federal Ministry of Education and Research 01GV0606).
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http://dx.doi.org/10.1007/s12402-013-0120-zDOI Listing
March 2014

Impulsivity in relation to stress in patients with borderline personality disorder with and without co-occurring attention-deficit/hyperactivity disorder: an exploratory study.

J Nerv Ment Dis 2013 Feb;201(2):116-23

Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Mannheim, Germany.

Impulsivity is regarded as a key feature in borderline personality disorder (BPD). However, discrepancies in previous research indicate that the role of impulsivity in BPD is not yet fully understood. For example, state-dependent impulsivity in individuals with BPD may be related to co-occurring psychiatric conditions such as attention-deficit/hyperactivity disorder (ADHD) and to emotional states. We assessed self-reports of trait and state impulsivity and response inhibition before and after an experimental stress induction in 15 patients with BPD without ADHD, 15 patients with BPD and ADHD, 15 patients with ADHD, and 15 healthy participants. The patients in both BPD subgroups reported a stress-dependent increase of state impulsivity, which was not observed in the other groups. Response inhibition was impaired in the patients with BPD and ADHD but not in those without ADHD compared with the healthy participants. We suggest that stress levels and co-occurring ADHD should receive attention in future studies on impulsivity in BPD.
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http://dx.doi.org/10.1097/NMD.0b013e31827f6462DOI Listing
February 2013

A randomized controlled multicentre trial on the treatment for ADHD in mothers and children: enrolment and basic characteristics of the study sample.

Atten Defic Hyperact Disord 2013 Mar 16;5(1):29-40. Epub 2012 Oct 16.

Department of Child and Adolescent Psychiatry, University Hospital Würzburg, Füchsleinstr. 15, 97080 Würzburg, Germany.

Parental ADHD may be a significant barrier to a successful treatment for the child's ADHD. The objective of our randomized controlled trial was to evaluate whether the treatment for maternal ADHD improves the efficacy of a behavioural parent training for children's ADHD. Patient enrolment and a description of the full analysis set (FAS) of mother-child pairs with non-missing baseline data are presented. One hundred and forty-four mother-child pairs were randomized to two treatments for maternal ADHD: cognitive behavioural group psychotherapy plus open methylphenidate treatment or control treatment (supportive counselling). After 3 months of treatment for maternal ADHD, mother-child pairs participated in a behavioural parent-child training. Assessment for eligibility included standardized instruments. After pre-screening out of 444 mother-child pairs, 206 were evaluated for trial participation and 144 were randomized. The FAS was built up by 143 dyads (children: mean age 9.4 years, 73 % males; mothers: mean age: 38.3 years). Fifty-two per cent of the children and 66 % of the mothers had combined ADHD subtype. Current axis-I co-morbidity rates were 48 % in children and 31 % in mothers. Maternal axis-II co-morbidity was 20.1 %. Fifty-seven per cent of the mothers lived together with the father of the index-child, and 29 % were single mothers. Sixty-two per cent had part-time or full-time employment. There was a selection bias excluding mothers with lack of time and effort for participation and mothers affected by coexisting mental and physical illness. Nevertheless, for our trial we were able to collect a sample comparable to routine psychiatric outpatient settings (registration: CCT-ISRCTN73911400, funding: BMBF-01GV0605).
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http://dx.doi.org/10.1007/s12402-012-0092-4DOI Listing
March 2013

German validation of the conners adult ADHD rating scale-self-report: confirmation of factor structure in a large sample of participants with ADHD.

J Atten Disord 2013 Nov 21;17(8):690-8. Epub 2012 Mar 21.

1Department of Clinical Psychology, Philipps University Marburg, Germany.

Objective: The Conners Adult ADHD Rating Scales (CAARS) assess symptoms specific to adults that are frequently used and have been translated into German. The current study tests the factor structure of the CAARS in a large sample of German adults with ADHD and compares the means of the CAARS subscales with those of healthy German controls.

Method: CAARS were completed by 466 participants with ADHD and 851 healthy control participants. Confirmatory factor analysis was used to establish model fit with the American original. Comparisons between participants with ADHD and healthy controls and influences of gender, age, and degree of education were analyzed.

Results: Confirmatory factor analysis showed a very good fit with the model for the American original. Differences between ADHD participants and healthy controls on all Conners Adult ADHD Rating Scales-Self-Report (CAARS-S) subscales were substantial and significant.

Conclusion: The factor structure of the original American model was successfully replicated in this sample of adult German ADHD participants.
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http://dx.doi.org/10.1177/1087054711435680DOI Listing
November 2013

Evaluation of the efficacy and effectiveness of a structured disorder tailored psychotherapy in ADHD in adults: study protocol of a randomized controlled multicentre trial.

Atten Defic Hyperact Disord 2010 Dec 30;2(4):203-12. Epub 2010 Nov 30.

Department of Psychiatry and Psychotherapy, University Medical Center Freiburg, Germany.

ADHD is a serious risk factor for co-occurring psychiatric disorders and negative psychosocial consequences in adulthood. Previous trials on psychotherapeutic concepts for adult ADHD are based on behavioural (cognitive behavioural and dialectical behavioural) psychotherapeutic approaches and showed significant effects. The aim of our study group (COMPAS) is to carry out a first randomized and controlled multicentre study to evaluate the effects of a disorder tailored psychotherapy in adult ADHD compared to clinical management in combination with psychopharmacological treatment or placebo. A total of 448 adults with ADHD according to DSM-IV will be treated at seven university sites in Germany. In a four-arm design, patients are randomized to a manualized dialectical behavioural therapy (DBT) based group programme plus methylphenidate or placebo or clinical management plus methylphenidate or placebo with weekly sessions in the first 12 weeks and monthly sessions thereafter. Therapists are graduated psychologists or physicians. Treatment integrity is established by independent supervision. Primary endpoint (ADHD symptoms measured by the Conners Adult Rating Scale) is rated by interviewers blind to the treatment allocation. Intention-to-treat analysis will be performed within a linear regression model (Current Controlled Trials ISRCTN54096201). The trial is funded by the German Federal Ministry of Research and Education (01GV0606) and is part of the German network for the treatment of ADHD in children and adults (ADHD-NET).
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http://dx.doi.org/10.1007/s12402-010-0046-7DOI Listing
December 2010

Multiscale assessment of treatment efficacy in adults with ADHD: a randomized placebo-controlled, multi-centre study with extended-release methylphenidate.

World J Biol Psychiatry 2012 Jan 14;13(1):48-59. Epub 2010 Dec 14.

Neurocentre, Saarland University Hospital, University of the Saarland, Homburg, Germany.

Objectives: This trial was performed to test the efficacy and safety of an extended-release formulation of methylphenidate (MPH ER).

Methods: A total of 162 adults with ADHD according to DSM-IV were treated for 8 weeks with either two daily individually body weight-adjusted doses of MPH ER up to 1 mg/kg per day (N = 84) or placebo (N = 78). The primary efficacy outcome was the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) 8 weeks after randomization. Secondary efficacy measures were the ADHD Diagnostic Checklist (ADHD-DC), the Conners Adult Attention Deficit Disorder Scale (CAARS-S:L), the Clinical Global Impression (CGI) and the Sheehan Disability Scale (SDS).

Results: At week 8 a significantly higher decline of the total WRAADDS score was found in the MPH ER group as compared to the placebo group (P = 0.0003). The rates of responders were 50% in the MPH ER and 18% in the placebo group (P < 0.0001). Furthermore, similar effects were observed for the secondary efficacy variable: ADHD-DC score (P = 0.004), CAARS-S:L score (P = 0.008) and the SDS score (P = 0.017). 50% of the MPH ER group and 24.4% of the placebo group were improved "much" or "very much" according to the CGI rating (P = 0.0001). MPH ER treatment was well tolerated. At week 2 also the mean heart rate was significantly higher in the MPH ER group as compared to the placebo group (P = 0.01). No differences between the study groups were observed regarding mean blood pressure at any visit.

Conclusions: This clinical trial demonstrated statistically significant and clinical relevant effects of MPH ER in adults with ADHD for several self- and investigator-rated ADHD psychopathology and also functional efficacy measures.
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http://dx.doi.org/10.3109/15622975.2010.540257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279134PMC
January 2012

Twenty-four-week treatment with extended release methylphenidate improves emotional symptoms in adult ADHD.

World J Biol Psychiatry 2010 Aug;11(5):709-18

Neurocentre, University Hospital of the Saarland, Homburg/Saar.

Objectives: Treatment investigations with methylphenidate in adults with ADHD focus preferentially on the classical psychopathology: inattention, hyperactivity and impulsivity. ADHD-associated emotional symptoms, which are frequently present at least in ADHD subpopulations, were studied rarely. The vast majority of the placebo-controlled trials had observation periods between 4 and 8 weeks. To assess the medium- to long-term effects of extended release methylphenidate (MPH-ER) on emotional symptoms and other psychopathology frequently seen in ADHD patients, we conducted a large-scale, multicenter treatment study.

Methods: We performed a randomised, 24-week, double-blind, placebo-controlled study in adults with ADHD. The diagnosis was made on the basis of the DSM-IV criteria, which were confirmed by clinical history and a structured psychopathological interview and the use of rating instruments. 363 patients were randomized to MPH-ER or placebo at a ratio of 2:1. The duration of the titration period was 5 weeks followed by a maintainance phase of 19 weeks. The efficacy measures were the observer rated 10-item Emotional Dysregulation Scale (EDS) derived from the Wender-Reimherr Adult Attention Deficit Disorder Scale (WRAADDS) and a self-report, six-item Emotional Lability Scale (ELS) extracted from the long version of the Conners Adult ADHD Self Report Scale (CAARS:S:L). In addition we used the SCL-90-R for the assessment of ADHD associated and comorbid psychopathology.

Results: MPH-ER was statistically superior to placebo in reducing emotional symptoms as assessed by the EDS and the ELS. Obsessive-compulsive symptoms and those of problems with self-concept declined until the end of the observation period. The decline was more pronounced in MPH-ER treated individuals. The effects remained robust during the entire maintenance period until week 24. Symptoms of anxiety, depression, anger and hostility, phobia, paranoid ideations and psychoticism were not improved.

Conclusions: MPH-ER appears to be an efficacious treatment for emotional symptoms with ADHD. Also obsessive-compulsive symptoms and problems with self-concept were affected positively.
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http://dx.doi.org/10.3109/15622971003624197DOI Listing
August 2010

Sleep in adults with attention deficit hyperactivity disorder (ADHD) before and during treatment with methylphenidate: a controlled polysomnographic study.

Sleep 2008 Mar;31(3):375-81

Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Mannheim, Germany.

Study Objectives: Sleep problems are frequently associated with childhood ADHD, as indicated by numerous polysomnographic investigations showing increased nocturnal movements, reduced sleep efficiency, and decreased percentage of REM sleep (although findings are not consistent over all studies). Data on objective and subjective sleep parameters in adults with ADHD are sparse, and to date the impact of stimulants, the most widely used pharmacological treatment for ADHD, on sleep in adults with ADHD has not been examined. Thus the objectives of our study were to assess objective and subjective sleep parameters in adults with ADHD and the impact of stimulant medication on sleep.

Design: Two-group comparison and open-label therapy study.

Participants: We enrolled 34 nonmedicated patients with ADHD, of whom 24 were without current comorbid psychiatric disorders, and 34 sex- and gender-matched control subjects without current psychiatric disorders or psychotropic medication.

Interventions: Ten patients were treated with methylphenidate over > or =26 days with a mean daily dose of 36.7 +/- 11.2 mg.

Measurements: Polysomnographic recording over 2 consecutive nights as well as assessments of subjective sleep parameters were performed in all patients and controls before treatment and reassessed in those patients receiving methylphenidate.

Results: Compared to controls untreated patients showed increased nocturnal activity, reduced sleep efficiency, more nocturnal awakenings and reduced percentage of REM sleep. Treatment with methylphenidate resulted in increased sleep efficiency as well as a subjective feeling of improved restorative value of sleep.

Conclusions: Sleep problems in patients with ADHD continue from childhood to adulthood, with similar objective sleep characteristics in adults and children with ADHD. Medication with methylphenidate appears to have beneficial effects on sleep parameters in adults with ADHD.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2276739PMC
http://dx.doi.org/10.1093/sleep/31.3.375DOI Listing
March 2008

Increased NAA and reduced choline levels in the anterior cingulum following chronic methylphenidate. A spectroscopic test-retest study in adult ADHD.

Eur Arch Psychiatry Clin Neurosci 2008 Oct 11;258(7):446-50. Epub 2008 Mar 11.

Center for ADHD Research, Department of Psychiatry, Charité-University Medicine Berlin, Campus Benjamin Franklin, Eschenallee 3, 14050 Berlin, Germany.

The anterior cingulate cortex (ACC) is crucially involved in executive control of attention. Here, seven medication-naïve adult patients suffering from attention deficit/hyperactivity disorder (ADHD) were studied with 2D (1)H-magnetic resonance spectroscopic imaging (MRSI) of the ACC [Brodmann areas 24b'-c' and 32'] twice, once before initiation of stimulant treatment and once after 5-6 weeks of methylphenidate. Upon retest, all patients demonstrated marked clinical improvement. Analysis of regional brain spectra revealed a significantly decreased signal of choline containing compounds as well as increased N-acetyl-aspartate (NAA) levels following treatment with methylphenidate whereas total creatine remained unchanged. Our results add to a growing body of evidence implicating the ACC in the pathophysiology of ADHD and suggest that subtle structural changes might be associated with aspects of clinical improvement under stimulant treatment.
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http://dx.doi.org/10.1007/s00406-008-0810-2DOI Listing
October 2008

Structured group psychotherapy in adults with attention deficit hyperactivity disorder: results of an open multicentre study.

J Nerv Ment Dis 2007 Dec;195(12):1013-9

Department of Psychiatry and Psychotherapy, University of Freiburg Medical School, Freiburg, Germany.

Attention deficit hyperactivity disorder (ADHD) is a serious mental disorder that often persists in adulthood. In a pilot study, a structured skills training group program for adult ADHD led to significant symptomatic improvements. The present study evaluated the program's effectiveness, feasibility, and patient acceptability in a multicenter setting. Seventy-two adult ADHD patients were assigned to 13 two-hour weekly sessions at 4 different therapy sites. The therapy was well tolerated and led to significant improvements of ADHD, depressive symptoms, and personal health status (p < 0.001). The factors treatment site and medication did not contribute to the overall improvement. Patients regarded the program topics "behavioral analyses," "mindfulness," and "emotion regulation" as the most helpful. In this multicenter study, the therapy program showed therapist-independent effects and seemed to be disorder-specific. This warrants the effort of organizing further controlled studies.
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http://dx.doi.org/10.1097/NMD.0b013e31815c088bDOI Listing
December 2007

Subtype differences in adults with attention-deficit/hyperactivity disorder (ADHD) with regard to ADHD-symptoms, psychiatric comorbidity and psychosocial adjustment.

Eur Psychiatry 2008 Mar 19;23(2):142-9. Epub 2007 Nov 19.

Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, J 5, 68159 Mannheim, Germany.

Background: To date, nearly all research of subtype differences in ADHD has been performed in children and only two studies, with conflicting results, have covered this subject in adults with ADHD.

Objective: This study examined subtype differences in the clinical presentation of ADHD-symptoms, related psychopathological features, psychosocial functioning and comorbid psychiatric disorders in adults with ADHD.

Method: One hundred and eighteen adults with ADHD, diagnosed according to DSM-IV criteria, and a population based control group underwent diagnostic evaluations with clinical interviews for ADHD, DSM-IV disorders and demographic features. Comparisons were made between ADHD combined type (n=64), predominantly inattentive type (n=30) and predominantly inattentive type, anamnestically combined type (n=24), relative to each other and to a community control group (n=70).

Results: The four groups did not differ in age and gender composition. All ADHD groups had significantly less education, were significantly more often unemployed and reported significantly more lifetime psychiatric comorbidity than controls. In comparison to each other, the three ADHD groups differed mainly in core symptoms and the pattern of comorbid psychiatric disorders, whereas no prominent differences in associated psychopathological features and most of the assessed psychosocial functions could be found. Patients with ADHD combined type and inattentive, anamnestically combined type both presented with significantly more hyperactive symptoms and also showed more impulsive symptoms than those with the predominantly inattentive type. With a similar overall lifetime psychiatric comorbidity in the three groups, patients with ADHD combined type and inattentive, anamnestically combined type suffered significantly more from lifetime substance use disorders than patients with predominantly inattentive type.

Conclusion: Our results clearly show impaired psychosocial adjustment and elevated risk for additional psychiatric disorders in adults with all subtypes of ADHD, compared to healthy controls. They provide preliminary evidence that in adult ADHD there might be a subgroup of patients, which is classified as predominantly inattentive subtype according to current diagnostic criteria, but which in its clinical presentation is in between ADHD combined and inattentive type. Further studies are needed to evaluate this finding and to gain a clear picture of its validity.
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http://dx.doi.org/10.1016/j.eurpsy.2007.09.007DOI Listing
March 2008

Psychiatric comorbidity and functional impairment in a clinically referred sample of adults with attention-deficit/hyperactivity disorder (ADHD).

Eur Arch Psychiatry Clin Neurosci 2007 Oct;257(7):371-7

Department of Psychiatry and Psychotherapy Central Institute of Mental Health, J 5, 68159 Mannheim, Germany.

Objective: This exploratory study aims to compare lifetime psychiatric axis-I-comorbidity and psychosocial functioning in a clinically referred sample of adult patients with attention-deficit/hyperactivity disorder (ADHD) with a population-based healthy control group and to examine whether patients with ADHD and lifetime comorbid diagnoses differ from patients with pure ADHD in their functional impairment.

Method: Seventy adult patients with ADHD according to DSM-IV criteria and a gender- as well as age-matched population based control group underwent diagnostic evaluations with clinical interviews for ADHD, DSM-IV disorders and demographic information.

Results: The prevalence of psychiatric lifetime comorbidity was 77.1% in patients with ADHD and thus exceeded the rate in the control group, which was 45.7%. Significantly more patients suffered from depressive episodes, substance related disorders and eating disorders. Compared to the control group adults with ADHD were significantly impaired in a variety of psychosocial functions (education, occupational training). Patients with ADHD and lifetime diagnosis of comorbid psychiatric disorders differed from patients with pure ADHD in their psychosocial functioning only in the percentage of unemployed individuals, which was higher in patients with psychiatric comorbidity.

Conclusion: Adults with ADHD suffer significantly more often from other psychiatric disorders than individuals of the population-based control group and are impaired in several areas of psychosocial functioning. Poor psychosocial outcome is primarily related to ADHD and not to additional psychiatric disorders. Due to the limited number of assessed patients these results need to be confirmed by studies with larger sample size.
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http://dx.doi.org/10.1007/s00406-007-0712-8DOI Listing
October 2007

Cognitive MR spectroscopy of anterior cingulate cortex in ADHD: elevated choline signal correlates with slowed hit reaction times.

J Psychiatr Res 2008 Jun 14;42(7):587-95. Epub 2007 Aug 14.

Department of Psychiatry, Charité-University Medicine Berlin, Campus Benjamin Franklin, Eschenallee 3, 14050 Berlin, Germany.

The anterior cingulate cortex (ACC) plays a major role in modulating executive control of attention. Here, 15 medication-nai ve patients with attention deficit/hyperactivity disorder (ADHD) and 10 carefully matched healthy controls were studied with 2D (1)H-magnetic resonance spectroscopic imaging (MRSI) of the ACC [Brodmann areas 24b'-c' and 32']. Attentional skills were assessed using the identical pairs version of the continuous performance task (CPT-IP). Analysis of regional brain spectra revealed a significantly increased signal of choline-containing compounds (Ch) in the ACC of ADHD patients (p<0.05). Across and within groups, the Ch signal showed high correlations with slowed hit reaction times on the CPT-IP. No group differences in N-acetyl-aspartate (NAA) and creatine (tCr) were detectable. The combination of performance deficits and elevated Ch levels in the ACC supports the hypothesis that subtle structural abnormalities underlie the functional alterations in ACC activation previously observed in ADHD patients.
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http://dx.doi.org/10.1016/j.jpsychires.2007.06.006DOI Listing
June 2008