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traductor ggoglepsychotherapy of adults with comorbid attention-deficit/hyperactivity disorder and psychoactive substance use disorder ron b. aviram, ph.d. madeline rhum, ph.d. frances r. levin, m.d received september 6, 2000; revised february 9, 2001; accepted february 17, 2001. from the new york state psychiatric institute, new york, new york. address correspondence to dr. aviram, new york state psychiatric institute, division of neuroscience-unit 42, 1051 riverside drive, new york, ny 10032. copyright
2001 american psychiatric association psychotherapy for comorbid attention-deficit/ hyperactivity disorder (adhd) and psychoactive substance use disorder (psud) is described. the authors suggest that relapse prevention is an appropriate initial treatment because it is well suited to manage both substance abuse and comorbid symptomatology such as impulsivity, distractibility, and avoidance associated with adhd. clinical vignettes describe typical interactions between patients and their therapists, highlighting opportunities for therapists to focus on overlapping symptoms. adhd is one of the most common comorbid diagnoses with psud, and it is important that efficacious psychotherapies be developed to complement psychopharmacological approaches. clinicians should consider psychotherapy as part of a multimodal treatment approach that includes medication and perhaps family therapy. additional contributions from clinicians who have experience conducting psychotherapy with this population are needed in order to develop effective treatments. (the journal of psychotherapy practice and research 2001; 10:179–186) recent findings indicate that attention-deficit/ hyperactivity disorder (adhd) is strongly associated with increased risk for substance abuse.1,2 still, relatively few adults who enter substance abuse treatment have been previously diagnosed with adhd. several factors may have contributed to this trend historically. for example, until recently adhd was considered to be a childhood disorder that did not extend into adulthood.3,4 this perception may have influenced clinicians to overlook adhd as a possible explanation for adult symptomatology that resembled adhd symptoms. however, more recent findings indicate that between 15% and 35% of adults with substance abuse problems had adhd as children and continue to report significant symptoms of inattention and hyperactivityimpulsivity as adults.2,5 additionally, adulthood adhd may have been masked by symptoms associated with psychoactive substance use disorder (psud). indeed, evidence indicates that substance abuse often develops in teenagers with adhd, and that the age of onset for psud in young people with adhd averages 3 years earlier than for individuals who do not have adhd.6 adhd and substance use disorder 180 j psychother pract res, 10:3, summer 2001 in these cases, early onset of substance abuse may have overshadowed adhd symptoms and could explain the low detection rates of adhd in adult substance abusers. the psychosocial difficulties that people with adhd encounter are thought to contribute to increased vulnerability to drug and alcohol use; for example, they may use drugs or alcohol to enhance peer acceptance or to avoid painful feelings.7 adults with substance abuse problems and undiagnosed adhd often report that they realized something was wrong with them throughout their lives but attributed their difficulties to the drug use. in the worst cases, these individuals create a lifestyle that accommodates to the difficulties they encounter. they may have learned to establish lives with few demands or responsibilities and resigned themselves to superficial and conflictual relationships. they may have stopped working and have few time commitments, which both allows them to avoid acknowledging the difficulties that stem from adhd and permits ongoing drug use. unfortunately, this pattern promotes a feeling of hopelessness about developing satisfying and productive lives. when the diagnosis of adhd is made, they gain an organizing framework from which to understand a lifetime of interpersonal and work-related difficulties. although medications have been extremely helpful in reducing restlessness and increasing attentional capacities, there are special considerations with this comorbid population. levin et al.8 suggest that desipramine and bupropion may be good alternative medications to avoid the risk of abuse that is present with methylphenidate. they add that sustained-release methylphenidate could be used with individuals who do not respond to an antidepressant. several papers have addressed medication treatment with this population; however, we will focus here on psychotherapeutic efforts to manage this comorbid condition. as part of a multimodal treatment,9 it is necessary to target psychological and social factors that have become problematic. in the past, the professional literature rarely discussed psychotherapeutic interventions that addressed the psychosocial difficulties arising from adhd. more recently, however, several papers have appeared that discuss the need for incorporating therapy into the treatment plan.9,10 in our experience, the relationship that develops with a therapist helps these individuals overcome their resistance to treatment and medications—and such resistance can otherwise lead to early withdrawal from treatment. it is imperative that an accurate assessment for this comorbid condition occur early in treatment. the results of such an assessment have implications for the course of illness and provide an opportunity to anticipate specific problems that may arise with this population. if comorbidity is not addressed effectively, it is likely to limit the benefit of treatment. for example, carroll and rounsaville11 found that despite more treatment exposure, cocaine abusers with childhoodadhd did worse in treatment than cocaine users with no history of adhd. further support for the importance of an accurate assessment was reported by wilens et al.,12 who found that adhd adults had slower remission rates and experienced longer duration of psud in comparison with non-adhd adults. in our experience it is not so much that patients with comorbid adhd and psud will have unique symptoms that are not found with either disorder independently. rather, they present with a greater number of symptoms, that may have greater severity, than if the patient did not have the comorbid c

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