Makindo Medical Notes

Behavioural difficulties in Adults

Behavioural and personality difficulties in adults often present with impulsivity, aggression, social dysfunction, or difficulty regulating emotions. While some reflect persistence of childhood disorders (e.g. ADHD, Conduct Disorder → Antisocial Personality Disorder), others emerge in adolescence or adulthood, such as personality disorders, substance misuse, or late-diagnosed autism. 🌟 Early recognition, risk assessment, and multidisciplinary care are vital to reduce morbidity, offending behaviour, and suicide risk.

⚡ Adult ADHD

In around 40–60% of children with ADHD, symptoms persist into adulthood. Hyperactivity often lessens, but difficulties with attention, organisation, and impulsivity remain.

• 🧩 Symptoms: Poor concentration, disorganisation, forgetfulness, restlessness, impulsive spending or risk-taking, unstable employment/relationships.
• 💊 UK Management: NICE NG87 – specialist assessment, stimulants (methylphenidate, lisdexamfetamine), non-stimulants (atomoxetine, guanfacine), and CBT for organisational skills. Workplace adjustments via the Equality Act 2010.
• ⚠️ Risks: High rates of anxiety, depression, substance misuse if untreated.

🚨 Antisocial Personality Disorder (ASPD)

Often an extension of childhood Conduct Disorder. Characterised by disregard for rules, impulsivity, and lack of empathy. Strong association with criminality and substance misuse.

• 🧩 Symptoms: Repeated offending, aggression, deceit, irresponsibility, lack of remorse.
• 🛠️ UK Management: Forensic psychiatry input, CBT or schema therapy, anger management. No specific pharmacological treatment, but comorbidities should be treated.
• ⚠️ Safeguarding: High risk of violence and exploitation of others → multiagency risk management (MAPPA).

😡 Borderline Personality Disorder (BPD)

Defined by emotional instability, impulsivity, and unstable relationships. Frequent presentations to A&E with self-harm or crises.

• 🧩 Symptoms: Fear of abandonment, rapid mood swings, impulsive behaviours (overspending, risky sex, substance use), self-harm, recurrent suicidal ideation.
• 🛠️ UK Management: NICE NG78 – Dialectical Behaviour Therapy (DBT), crisis planning, support from community mental health teams. Medication only for comorbidity (e.g. depression, anxiety).
• ⚠️ Risks: High suicide risk; self-harm is a key red flag.

🧩 Autism Spectrum Disorder (ASD) in Adults

ASD often persists into adulthood, and many individuals are diagnosed late, especially women and those with high-functioning autism. Behavioural challenges may include rigidity, sensory overload, and difficulties with social interaction.

• 🧩 Symptoms: Social communication difficulties, repetitive behaviours, intense special interests, sensory hypersensitivity.
• 🛠️ UK Management: Reasonable adjustments at work/education, speech & occupational therapy, CBT adapted for autism, social support, EHCPs for young adults in education.
• ⚠️ Risks: Anxiety, depression, and isolation if unrecognised or unsupported.

🧠 Substance Use Disorders

Substance misuse frequently coexists with adult behavioural disorders. Maladaptive patterns of alcohol or drug use contribute to aggression, social dysfunction, and poor health.

• 🧩 Symptoms: Tolerance, withdrawal, loss of control, continued use despite harm.
• 🛠️ UK Management: NICE guidance – detox programmes (alcohol, opioids), substitution therapy (methadone, buprenorphine), relapse prevention (acamprosate, naltrexone), CBT, motivational interviewing, peer support groups.
• ⚠️ Risks: Overdose, liver failure, criminality, homelessness.

⚠️ Risk Factors

• 🧬 Genetic: Family history of ADHD, mood disorders, substance misuse.
• 🏠 Environmental: Childhood trauma, neglect, socioeconomic deprivation.
• 🧠 Developmental: Conduct disorder, learning difficulties, early offending behaviour.
• ⚕️ Medical: Brain injury, epilepsy, chronic mental illness.

🔍 Assessment in Adults

Usually performed by psychiatrists, psychologists, or forensic services depending on risk.

• 📚 History: Developmental history, psychiatric history, substance use, forensic record.
• 👀 Observation: Interpersonal style, emotional regulation, aggression triggers.
• 🧠 Psychological Testing: ADHD adult self-report scale (ASRS), PD questionnaires, autism diagnostic tools (ADOS-2, AQ-10).
• ⚖️ Risk Assessment: Suicide risk, violence risk, safeguarding of dependents.

🛠️ Management Strategies

• 👨‍👩‍👧 Psychological Therapy: CBT, DBT (for BPD), schema therapy, motivational interviewing for substance misuse.
• 🏥 Community & Forensic Teams: Crisis teams, probation services, MAPPA for high-risk offenders.
• 💊 Pharmacological:
  • Stimulants / atomoxetine for ADHD
  • SSRIs for comorbid anxiety/depression
  • Antipsychotics (e.g. risperidone) only for severe aggression, psychosis, or comorbid disorders
• 🛡️ Safeguarding: Involvement of social services if risk to children/vulnerable adults.

🚩 Red Flags in Adults

• Recurrent violence or offending behaviour → ASPD risk, forensic referral.
• Repeated A&E attendances with self-harm or suicidality → urgent crisis intervention.
• Substance misuse with withdrawal, overdose, or safeguarding risk.
• Late-diagnosed ASD with severe anxiety, unemployment, or isolation.

📈 Prognosis

✅ Prognosis varies: ADHD often improves with recognition and support; BPD symptoms may lessen with age; ASD is lifelong but manageable with adjustments. ⚠️ ASPD and substance misuse carry poorer outcomes if untreated, with risks of crime, homelessness, and early mortality. 🌟 Protective factors include early recognition, stable support networks, and engagement with mental health services.

✅ Conclusion

Adult behavioural disorders are diverse and often complex, requiring a biopsychosocial approach. Collaboration between psychiatry, psychology, social services, and primary care is essential. Early intervention, risk management, and long-term support can significantly improve quality of life and reduce harm.

📊 Comparison Table: Adult Behavioural & Psychiatric Disorders