Paradoxical Reaction in ADHD

In our outpatient clinic for adults with attention deficit hyperactivity disorder (ADHD), 10–20% of those affected repeatedly complained about abnormally extended (24 hours) or (more often) notably shortened or reduced effectiveness of local anesthesia injections for dental treatment. Some patients reported paradoxical reactions to postoperative administration of tranquillizers (including benzodiazepines). These drugs made them “even more awake”, much to their doctor’s surprise.

One female patient reported that she had followed the surgeons’ conversations during the initial 10 minutes of the operation under full anesthesia and complete muscle relaxation. The surgeons were surprised at the amount of details she remembered. In other patients, anesthetics worked for ”too long” or had “too strong an effect.”

Many people with ADHD have next to no reaction or react paradoxically to caffeine (coffee/black tea/cola) and other stimulants (nicotine, “Red Bull,” amphetamines). One female patient also reported excessive awareness —and better cognition—when taking antihistamines (for example, “Fenistil” [dimethindene maleate]).

Such “idiosyncratic” reactions seem to be stable over time, which means that the different effects are predictable.

We therefore advise our ADHD patients to inform their anesthesiologist before an operation that they may react differently to caffeine, antihistamines/low-potency neuroleptics, benzodiazepines (and also central and peripheral anesthetic drugs).

Many mentally healthy people also react in a primarily unexpected way to caffeine, etc. It therefore may make sense to ask patients preoperatively about untypical reactions to this (not very long) list of different substances, in order to anticipate possible intraoperative and postoperative problems and to avoid these where possible.

Presumably such atypical reactions are genetically determined. Therefore “idiosyncrasies” in family members may as well provide a hint for an increased risk of abnormal reactions to anesthetics.

DOI: 10.3238/arztebl.2011.0541a

PD Dr. med. Berthold Langguth

Klinik und Poliklinik f�r Psychiatrie,
Psychosomatik und Psychotherapie

Bezirksklinikum Regensburg

Dr. med. R�diger B�r

PD Dr. med. Norbert Wodarz

Dr. med. Markus Wittmann

Abteilung Psychiatrie

Bezirksklinikum Regensburg

Dr. med. Rainer Laufk�tter

Ambulanz f�r ADHS im Erwachsenenalter

Universit�tsklinik f�r Psychiatrie,
Psychosomatik und Psychotherapie

Bezirksklinikum Regensburg

Rainer.Laufkoetter@medbo.de

Conflict of interest statement
Dr Langguth holds patents for cyclobenzaprine in the therapy of tinnitus and naltrexone in the therapy of tinnitus. He has received honoraria for acting as an adviser to Merz and Novartis. He has received a publication-related honorarium from Merz. He has received conference, travel, and hotel expenses, as well as honoraria for speaking at continuing medical educational events from ANM, AstraZeneca, Pfizer, Servier, Merz and Medtronic. Furthermore, he has received funding for research projects that he himself initiated, from the German Research Foundation (DFG), Tinnitus Research Initiative, the American Tinnitus Association and AstraZeneca.
Dr B�r declares that no conflict of interest exists .
Dr Wodarz has received honoraria for acting as an adviser and conference expenses from Essex Pharma. He has received travel expenses and hotel expenses as well as honoraria for speaking at continuing medical educational events from Janssen-Cilag and Essex Pharma. He has received honoraria from Lundbeck, Essex-Pharma, MSD, IFE Europe, and Novartis for conducting commissioned clinical studies.
Dr Wittmann has received honoraria for acting as an adviser from Bristol-Meyer-Squibb and conference, travel, and hotel expenses, as well as honoraria for continuing medical educational events, from Astra Zeneca, Lilly, Glaxo Smith, Wyeth, Janssen, Servier, Pfizer, and Bristol-Myers Squibb. He has received a publication-related honorarium from Servier.
Dr Laufk�tter has received conference, travel, and hotel expenses from Janssen and AstraZeneca.