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We report on a unique clinical case of psychosis precipitated by Attention Deficit Hyperactivity Disorder (ADHD) and explore its implications for clinical practice as well as our understanding of these conditions. We describe a clinical case of a 46-year-old male presenting with auditory, olfactory, tactile, and visual hallucinations. We reviewed the literature on reported cases in which psychotic symptoms were treated with stimulant medications for ADHD comorbidity. This case report reveals the potential for properly selected patients to benefit from a consideration of ADHD comorbidity and a trial of treatment with that focus. In addition, the literature reveals a pathophysiologic association between psychosis and ADHD supported by neurobiological data. However, far more research is required to fully understand these conditions and their relationship. We conclude that ADHD and psychosis have some related pathophysiologic mechanisms but their connection has not been adequately explored. This case adds support to literature suggesting that in refractory psychosis, clinicians should re-evaluate the diagnosis and one of the considerations should be ADHD. In certain cases, the presence of psychotic symptoms with ADHD should not exclude the use of stimulants. background Psychosis is a common presenting problem in emergency departments (ED). Such episodes may present with positive symptoms, which include delusions, thought disorder, disorganized thinking, and hallucinations. They may also present with negative symptoms, which include deficits in normal functioning such as flat affect, alogia, avolition, and anhedonia. Cognitive symptoms of psychosis are also well documented, including deficits in working memory, attention, and executive functioning. The management of psychosis is dependent on the cause, and therefore establishing etiology may be the most significant step in caring for the psychotic patient. Several disorders associated with psychosis, including schizophrenia, are also associated with ADHD.1-5 However, there is a lack of available data examining the relationship between ADHD and psychosis. In addition, stimulants commonly prescribed for ADHD management are considered to be contraindicated during psychotic episodes as they have been shown to exacerbate or even trigger positive symptoms in some patients.6 These barriers have prevented a thorough examination of the connections between psychosis and ADHD, despite there being a theoretical relationship.2,3 We describe a relatively unique case, in which the presentation of psychosis was managed successfully by treatment with stimulant medication even though criteria for adult ADHD was not met. The difficulty in meeting adult ADHD criteria in this case relates to the similarity of cognitive symptoms seen in psychosis with ADHD symptoms, which include poor attention and executive functioning, and to psychomotor effects of ongoing antipsychotic medication. Criteria for a history of childhood ADHD were likely met on retrospective review of the case. case presentation initial visit JP was a 46-year-old male seen for a consultation following an ED visit 6 months prior where he presented with depressive symptoms. At that time, he was started on psychotropic medication (including lithium and risperidone) for a possible mood disorder. At the time of consultation, his mood was stable. However, he also admitted to experiencing visual, auditory, olfactory, and tactile hallucinations, and paranoid delusions for several months. JP’s visit to the ED was his first encounter with psychiatric care. He did have a history of alcohol abuse though he stated he had successfully stopped consuming alcohol 12 years ago. He also described a history of marijuana use which ended 2 years ago. His past medical history was otherwise unremarkable. Following his initial consult, JP was tried on various medications in attempts to address his psychotic symptoms. These included Invega Sustenna (paliperidone palmitate), Loxitane (loxapine), Risperdal (risperidone), and Zyprexa (olanzapine). He was also tried on lithium, Epival (divalproex sodium), and Prozac (fluoxetine) to continue managing his mood. Unfortunately, over the next 12 months he continued to have paranoid and persecutory delusions, with the occasional return of his visual, auditory, olfactory, and tactile hallucinations. new management At 18 months from his initial ED presentation, JP revealed that his brother was also seeing the same psychiatrist. It was discovered that he was being treated successfully for ADHD with Dexedrine (dextroamphetamine), which is an amphetamine-based psychostimulant. JP did not have any overt symptoms of ADHD that would have led to a clinical diagnosis of ADHD. However, given evidence of the genetic heritability of ADHD7 and the successful treatment of JP’s brother, a trial of Dexedrine was decided upon.

Improvement in refractory psychosis after initiating management for underlying ADHD