Objective Attention deficit hyperactivity disorder is a heterogeneous disorder of unknown etiology Little is known about the comorbidity of this disorder with disorders other than conduct Therefore, the authors made a systematic search of the psychiatric and psychological literature for empirical studies dealing with the comorbidity of attention deficit hyperactivity disorder with other disorders Data collection The search terms included hyperactivity, hyperkinesis, attention deficit disorder, and attention deficit hyperactivity disorder, cross-referenced with antisocial disorder (aggression, conduct disorder, antisocial disorder), depression (depression, mania, depressive disorder, bipolar), anxiety (anxiety disorder, anxiety), learning problems (learning, learning disability, academic achievement), substance abuse (alcoholism, drug abuse), mental retardation, and Tourette's disorder Findings The literature supports considerable comorbidity of attention deficit hyperactivity disorder with conduct disorder, oppositional defiant disorder, mood disorders, anxiety disorders, learning disabilities, and other disorders, such as mental retardation, Tourette's syndrome, and borderline personality disorder Conclusions Subgroups of children with attention deficit hyperactivity disorder might be delineated on the basis of the disorder's comorbidity with other disorders These subgroups may have differing risk factors, clinical courses, and pharmacological responses Thus, their proper identification may lead to refinements in preventive and treatment strategies Investigation of these issues should help to clarify the etiology, course, and outcome of attention deficit hyperactivity disorder

Comorbidity of attention deficit hyperactivity disorder with conduct, depressive, anxiety, and other disorders.

Objective In an attempt to surmount the problem of retrospectively establishing the childhood diagnosis of attention deficit hyperactivity disorder, the authors constructed the 61-item Wender Utah Rating Scale (WURS) for adults to use to describe their own childhood behavior. In this paper they present their initial data collection and evaluation of the instrument's validity. Method The scale was administered to 81 adult outpatients with attention deficit hyperactivity disorder, 100 "normal" adults, and 70 psychiatric adult outpatients with unipolar depression. The authors analyzed data from the 25 items of the scale that showed the greatest difference between the patients with attention deficit hyperactivity disorder and the normal comparison subjects and the relationship between the WURS and the patients' parents' judgment of childhood activity as measured by the Parents' Rating Scale. Results The patients with attention deficit hyperactivity disorder had significantly higher mean scores on all 25 items than did the two comparison groups. The difference between the mean total scores of the patients with attention deficit hyperactivity disorder and the normal subjects was also highly significant. A cutoff score of 46 or higher correctly identified 86% of the patients with attention deficit hyperactivity disorder, 99% of the normal subjects, and 81% of the depressed subjects. Correlations obtained between WURS scores and Parents' Rating Scale scores were moderate but impressive. The ability of WURS scores to predict response to methylphenidate replicated the authors' finding regarding the ability of Parents' Rating Scale scores to predict response to pemoline. Conclusions The WURS is sensitive in identifying childhood attention deficit hyperactivity disorder and may be useful in recognizing attention deficit hyperactivity disorder in patients with ambiguous adult psychopathology.

The Wender Utah Rating Scale: an aid in the retrospective diagnosis of childhood attention deficit hyperactivity disorder.

Abstinence symptoms and psychiatric diagnoses were evaluated in 30 chronic cocaine abusers. Structured diagnostic interviews were done within an experimental design intended to maximize differentiation of enduring symptoms from symptoms linked to binges of cocaine use. Longitudinal evaluations showed a three-phase sequence of post-cocaine abuse abstinence symptoms. Over half the sample also met criteria for ed 3 DSM-III, axis I psychiatric disorders. The findings present specific implications for treatment design.

Abstinence Symptomatology and Psychiatric Diagnosis in Cocaine Abusers: Clinical Observations

ContextIntense debate persists about the need for placebo-controlled groups
in clinical trials of medications for major depressive disorder (MDD). There
is continuing interest in the development of new medications, but because
effective antidepressants are already available, ethical concerns have been
raised about the need for placebo groups in new trials.ObjectiveTo determine whether the characteristics of placebo control groups in
antidepressant trials have changed over time.Data Sources and Study SelectionWe searched MEDLINE and PsychLit for all controlled trials published
in English between January 1981 and December 2000 in which adult outpatients
with MDD were randomly assigned to receive medication or placebo. Seventy-five
trials met our criteria for inclusion.Data ExtractionData were extracted from the articles by 2 of the authors and discrepancies
were resolved via discussion and additional review by a third author.Data SynthesisThe mean (SD) proportion of patients in the placebo group who responded
was 29.7% (8.3%) (range, 12.5%-51.8%). Most studies examined more than a single
active medication, and, in the active medication group with the greatest response,
the mean (SD) proportion of patients responding was 50.1% (9.0%) (range, 31.6%-70.4%).
Both the proportion of patients responding to placebo and the proportion responding
to medication were significantly positively correlated with the year of publication
(for placebo: n = 75; r = 0.45; 95% confidence interval
[CI], 0.25-0.61; P<.001; for medication: n = 75; r = 0.26; 95% CI, 0.03-0.46; P
= .02). The association between year of publication and response rate was
more statistically robust for placebo than medication.ConclusionsThe response to placebo in published trials of antidepressant medication
for MDD is highly variable and often substantial and has increased significantly
in recent years, as has the response to medication. These observations support
the view that the inclusion of a placebo group has major scientific importance
in trials of new antidepressant medications and indicate that efforts should
continue to minimize the risks of such studies so that they may be conducted
in an ethically acceptable manner.

Placebo Response in Studies of Major Depression: Variable, Substantial, and Growing

The etiology of alcoholism in women is no longer a question of nature or nurture. Most observers would agree that alcoholism, both male and female, is mediated by genetic factors. The question is how much of the variance is explained by genetic factors and to what degree is this genetically mediated disorder moderated by personal characteristics of the woman. Among the most salient personal characteristics moderating the genetic vulnerability may be factors such as age, ethnicity, and presence of psychiatric comorbidity. Cultural factors and familial environmental factors are most likely predictors as well. Therefore, the chapter will discuss the genetic epidemiology of alcoholism in women. Genetic heterogeneity will be discussed and evidence presented that suggests the existence of two forms of alcoholism in women: one more environmentally determined and one more influenced by genetic mediation. Evidence for the existence of a genetic diathesis in women will be presented, noting extant literature involving twin and adoption designs. Suggestions for what might be transmitted from generation to generation (e.g., neurobiological factors, temperament) with special reference to preadolescent and adolescent girls will also be discussed.

Recent Developments in Alcoholism

This study replicated an earlier one dealing with the diagnosis and treatment of attention deficit disorder (ADD, or minimal brain dysfunction) in adults. Subjects who met provisional operational criteria for adult ADD were entered in a random-assignment, parallel, double-blind trial of placebo and pemoline, a noneuphorigenic psychostimulant drug effective in children with ADD. There was improvement in both the pemoline group and the placebo group, but the difference in improvement was not statistically significant. When the analyses were confined to that subgroup of patients whose parents had described them in the 95th percentile of childhood "hyperactivity" or when the hyperactivity score was partialled out statistically, pemoline was demonstrably more effective than placebo. Revised operational criteria for adult ADD are proposed.

Attention Deficit Disorder ('Minimal Brain Dysfunction') in Adults: A Replication Study of Diagnosis and Drug Treatment

• Minimal brain dysfunction (MBD) has long been considered a disorder limited to childhood. A number of longitudinal and adoption studies suggest that MBD may persist into adult life where its existence is concealed by the application of a variety of diagnostic labels. In order to test the hypothesis that MBD does persist into adulthood, 15 putative MBD adults were identified on the basis of current MBD-like complaints, self-description of MBD characteristics in childhood, and a parental rating (on a standardized form) of "hyperactivity" in childhood. Eleven of the 15 subjects were given a double-blind trial of methylphenidate hydrochloride, and all 15 were given an open trial of pemoline, imipramine hydrochloride, or amitryptiline hydrochloride. Eight of the 11 showed a significant response to the double-blind trial of methylphenidate. Of the 15, eight showed a good response to stimulants or tricyclic antidepressants, two showed a moderately favorable response, and five were unresponsive to drug therapy.

Diagnosis and treatment of minimal brain dysfunction in adults: a preliminary report.

Thirty-seven adult patients meeting the Utah criteria for attention deficit disorder, residual type, were entered into a double-blind crossover trial of methylphenidate and placebo. A moderate-to-marked therapeutic response occurred in 21 (57%) of the patients while receiving methylphenidate and in four (11%) while receiving placebo, a highly significant difference statistically and clinically. The responding patients showed significant improvement in the following areas: attentional difficulty, motor overactivity, affective lability, and impulsivity. The diagnosis of attention deficit disorder, residual type, should be considered in patients with prominent complaints of impulsivity, restlessness, emotional lability, and hot temper who do not suffer from schizophrenia or major mood disorder and do not have symptoms of schizotypal or borderline personality disorders.

A controlled study of methylphenidate in the treatment of attention deficit disorder, residual type, in adults.

The authors assessed the prevalence of attention deficit disorder, residual type, in a population of young adult male alcoholic patients in two residential alcohol treatment programs. They found the prevalence of the disorder in this sample to be 33% and hypothesize that attention deficit disorder in childhood (and adulthood) may be associated with an increased risk for the development of alcoholism. If substantiated, this finding could be of theoretical and therapeutic importance.

David R. Wood

Papers

Attention Deficit Disorder ('Minimal Brain Dysfunction') in Adults: A Replication Study of Diagnosis and Drug Treatment

Diagnosis and treatment of minimal brain dysfunction in adults: a preliminary report.

A controlled study of methylphenidate in the treatment of attention deficit disorder, residual type, in adults.

The prevalence of attention deficit disorder, residual type, or minimal brain dysfunction, in a population of male alcoholic patients.

A controlled study of methylphenidate in the treatment of attention deficit disorder, residual type, in adults