Perceptual abnormalities related to sensory gating deficit are core symptoms in adults with ADHD
Introduction
Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent childhood developmental disorders (Barkley, 2003). In adulthood, ADHD remains a high prevalent psychiatric disorder with an estimated prevalence of about 3% in adults (Caci et al., 2014). Inattention, hyperactivity and impulsivity are the core symptoms of ADHD (American Psychiatric Association, 2000). However, childhood (C-ADHD) and adult patients (A-ADHD) also report being flooded with sensory stimuli (Faraone et al., 2000, Biederman, 2005). For example, they report being “very sensitive towards sounds which are unheard by others such as the humming of a refrigerator, a clock ticking, or fans” (Ghanizadeh, 2011). This phenomenon has recently been extensively studied in C-ADHD through the concept of sensory modulation disorder (SMD).
SMD refers to the difficulty in responding to sensory input in a graded and adaptive manner relative to the degree, nature or intensity of the sensory input (Miller et al., 2007). The main subtype of SMD is sensory over-responsivity (SOR) (also called sensory hyper-sensitivity) (Reynolds and Lane, 2008). SOR refers to faster, longer or more intense responses to the sensory input (Miller et al., 2007). C-ADHD and SOR share several clinical characteristics and over half of children with ADHD exhibit SOR (Yochman et al., 2006). Moreover, the behavioral responses of children with SOR to an adverse sensory input may be inattention, hyperactivity or impulsivity (Miller et al., 2012). SMD (and subtypes) is not recognized in the DSM 5 (American Psychiatric Association, 2014) and the question remains whether SMD is a disorder specific to C-ADHD (Miller et al., 2012, Yochman et al., 2013). However, symptoms of SOR can be evaluated in children by validated parent-report questionnaires (Ghanizadeh, 2011) and in adults by validated self-report questionnaires (Brown et al., 2001, Bar-Shalita et al., 2009). There is evidence that symptoms of SOR are related to several disabilities in daily life (Yochman et al., 2004, Miller et al., 2007) and that they continue during childhood into adulthood (Brown et al., 2001). The prevalence of SOR in the adult population is unknown (Mazor-Karsenty et al., 2015) but it seems that women are more likely to have higher SOR scores than men (Engel-yeger, 2012). However, research on SOR symptoms in adults is very scarce and is even rarer in A-ADHD. Thus, studies are needed to confirm the presence of perceptual abnormalities related to SOR in adult patients with ADHD.
Furthermore, adult patients with schizophrenia also report being flooded with sensory stimuli (McGhie and Chapman, 1961), as do patients with A-ADHD (Ghanizadeh, 2011). For example, they report “always noticing when automatic appliances turn on and off (like the refrigerator or the heating and cooling system)” (Hetrick et al., 2012). These perceptual abnormalities have been related to a sensory gating deficit (Micoulaud-Franchi et al., 2014a). Sensory gating deficit is the inability to filter or gate intrusive sensory information (Javitt and Freedman, 2014). Recently it was found that children with SOR exhibited sensory gating deficit (Davies et al., 2009). A validated self-report questionnaire, the Sensory Gating Inventory (SGI), has been designed to investigate perceptual abnormalities related to sensory gating deficit (Hetrick et al., 2012, Micoulaud-Franchi et al., 2014b). The SGI is composed of 36 items addressing a broad range of subjective daily perceptual experiences related to sensory gating.
The SGI has been used to investigate perceptual abnormalities in healthy subjects (Hetrick et al., 2012, Micoulaud-Franchi et al., 2014b), in patients with schizophrenia (Micoulaud-Franchi et al., 2014a) and in adult patients with ADHD (Sable et al., 2012). The SGI provides valuable information on four dimensions of perceptual anomalies related to sensory gating (perceptual modulation, over-inclusion, distractibility and Fatigue–Stress Modulation) (Hetrick et al., 2012, Micoulaud-Franchi et al., 2014b). In schizophrenia, patients reported higher SGI scores (on the overall scores and on each of the four dimensions) than healthy subjects (Micoulaud-Franchi et al., 2014a). In A-ADHD, adult patients reported higher SGI scores on the distractibility dimension than healthy students so the SGI is a potential diagnostic tool for A-ADHD (Sable et al., 2012). These studies suggest similarities between the perceptual abnormalities reported by patients with A-ADHD and by those with schizophrenia. However, comparative research on perceptual abnormalities between adults with ADHD and patients with schizophrenia is very scarce. Thus, studies are needed to compare perceptual abnormalities related to SOR and sensory gating deficit in adult patients with ADHD and in patients with schizophrenia. To our knowledge, the SGI is the only self-report questionnaire on perceptual abnormalities that has been used both in A-ADHD and in schizophrenia separately, suggesting that it can be a useful instrument to compare these two disorders.
The purpose of the present study was to confirm perceptual abnormalities in a group of adult patients with ADHD and to better characterize them. For this purpose, we (i) compared SGI scores in patients with A-ADHD with those in healthy subjects and schizophrenic patients, (ii) analyzed the relationship between SGI scores and ADHD symptoms (relationship with psychotic symptoms also analyzed in the schizophrenia groups) and (iii) established a threshold for the SGI to detect perceptual abnormalities in A-ADHD. We hypothesized that adult patients with ADHD would report higher SGI scores than healthy subjects and similar scores to those in patients with schizophrenia except for the distractibility dimension. A higher score for the distractibility dimension was expected in patients with ADHD. We also hypothesized a relationship between SGI scores and ADHD symptom scores and the good capacity of the SGI to detect perceptual abnormalities in A-ADHD.
Section snippets
Subjects
Seventy adult patients with ADHD were recruited from the Department of Sleep Medicine, Montpellier University Hospital, France and the Department of Psychiatry, Marseille University Hospital, France. Comparison subjects were 70 outpatients with chronic and clinically stable schizophrenia and 70 healthy subjects. Patients with ADHD were diagnosed by a psychiatrist during a face-to-face interview (RL for the patients recruited from Montpellier, and JAMF and FV for those from Marseille) according
Sample characteristics
As shown in Table 1, gender, age and education level were not significantly different between the three groups.
All included patients with A-ADHD exhibited the criteria for a retrospective history of ADHD in childhood. The mean WURS-25 score for patients with ADHD was 60.40 (SD=14.25) and 84.3% (n=59) of the patients had a score above 46, which is in line with the psychometric properties of this scale to detect ADHD in childhood (Ward et al., 1993). The mean overall ASRS score was 51.65
Discussion
This study is the first to investigate perceptual abnormalities in a large sample of adult patients with ADHD (n=70) through the Sensory Gating Inventory (SGI). The SGI was previously used separately in patients with A-ADHD (Sable et al., 2012) and those with schizophrenia (Hetrick et al., 2012, Micoulaud-Franchi et al., 2014b). The study is original in that it compared A-ADHD patients with an identical number of schizophrenia patients and healthy controls who were similar in gender, age and
Role of the funding source
This work was supported by CNRS (Centre National de la Recherche Scientifique) UMR 7291.
Conflict of interest
The authors declare no conflicts of interest.
Acknowledgments
We acknowledge Alexandra Baillif, Pauline Peri and Laura Brandejsky for their technical assistance in administering the SGI to patients with ADHD, and Jean Vion-Dury, Michel Cermolacce, Catherine Faget, Mélanie Faugere and Daouia Djenane for their technical assistance in administering it to patients with schizophrenia.
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