We report the case of a 38-year-old Caucasian man, with dual citizenship in the USA and Switzerland, who has been in treatment at the outpatient service of the Psychiatric University Hospital for the last four years. During childhood and adolescence, his family frequently relocated from Switzerland to the USA, and vice versa. His father, an entrepreneur, described the patient as being an “uneasy” child who was different from his siblings, and he had sought professional help for his son from a child psychiatrist in the USA. This psychiatrist diagnosed the patient, who was then nine years old, with ADHD, and over the course of the next five years, the patient received up to 10
mg of immediate-release MPH (Ritalin®). Later on, his dosage was increased to 20
mg of sustained-release MPH (Ritalin SR®) daily, which initially improved the patient’s symptoms of hyperactivity and inattention.
Twenty-five years ago, while he was still living in the USA, the patient’s medication was changed—for the same indication—to desipramine (Norpramin®), and MPH (Ritalin®) was discontinued. Nevertheless, most of his difficulties persisted throughout elementary- and middle school. Between ages 14 and 16, the patient was therefore sent to a school that specialized in the instruction of students with learning disabilities such as dyslexia. At age 18, he developed obsessive-compulsive traits and received counselling; his medication was also changed at that time to clomipramine (Anafranil®) 75
Soon afterward, the family again relocated from the USA to Switzerland, where the patient attended high school—followed, in 1993, by college in the USA. Still suffering from symptoms of inattention and hyperactivity, he did not finish his studies at this college, and failed in several other attempts to obtain a secondary degree in the USA, Great Britain, and Switzerland. The patient recalled that he never seemed able to “focus.”
For unknown reasons, he did not receive further stimulant medication until six years ago, when a Swiss psychiatrist prescribed immediate-release MPH (Ritalin®) 60
mg/daily to reduce the patient’s distractibility at his newfound job as a sales clerk. The patient experienced MPH as highly effective, but not sustainable throughout the course of a day. During the following 14
months, he therefore began to use Ritalin® excessively, both orally and rectally, in dosages up to 4800-6000
mg/daily, by applying to thirty different doctors in three different cantons of Switzerland. He thereby fulfilled the criteria for stimulant dependence, although he never used any substance other than MPH.
Four years ago, the patient was referred to our outpatient service for treatment. He received clinical diagnostic interviewing (SCID I, SCID II) and his ADHD was re-evaluated using recommended practice parameters [12
]. In addition, his plasma levels of methylphenidate were obtained, a routine medical workup was performed, and information on his past medical history was collected.
Physical examination revealed chronic back pain, and a local rheumatologist diagnosed ankylosing spondylitis (Bekhterev's disease). No other pathology was found, nor did the patient have any history of palpitations, tachycardia and dyspnea, or other adverse cardiovascular effects commonly associated with stimulant use. His blood pressure and heart rate were within the normal range, and an ECG showed no abnormalities.
The diagnostic (SCID) testing confirmed the presence of an obsessive-compulsive disorder and revealed a combined personality disorder. There was no further history of substance misuse or dependency; the patient reported only a recreational use of cannabis. The patient first received immediate-release MPH 200
mg. This was later changed to 240
mg, and finally to 270
mg MPH per day. We repeatedly checked the plasma levels of MPH in the blood under all these dosages and found them to be within the reference range. Moreover, when the patient received extended-release MPH at a dosage of 378
mg/day, his blood plasma remained within reference range. The reference range is 43-257
nmol, and we found his plasma levels to be between 60
Using a combined psychosocial (CBT) and pharmacotherapeutic treatment approach, the patient’s daily Ritalin® dosage could initially be reduced to 200
mg/daily orally. However, the patient still experienced pronounced symptoms of ADHD at this dosage, and these symptoms were also reported by his family members. He exhibited high levels of distractibility both within the clinical setting (e.g., during group therapy), and at home, where he was unable to help around the house or contribute to the care of his newborn child.
While his signs of OCD diminished with fluoxetine 40
mg/daily, his ADHD symptoms only improved dramatically after his dosage was increased to 378
mg of extended-release MPH (Concerta®). This was reflected in an increase of his score on the Global Assessment of Functioning scale from 43 to 68; and at home, the patient was able to care for his child several days a week and re-establish interpersonal relationships. No further excessive use of methylphenidate has been recorded for the past 24