Differentiating Adult ADHD from Bipolar Disorder
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Transcript of Differentiating Adult ADHD from Bipolar Disorder
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November 7-10, 2011 • The Venetian Las Vegas • Las Vegas, NV
Clinical Pearls in Differential Diagnosis: Differentiating Adult ADHD from Bipolar Disorder
Saundra Jain, MA, PsyD, LPC Executive Director
Mental Aerobics Project Lake Jackson, Texas
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What Do You See?
What you see isn't always what you get.
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12-Month Prevalence: Focus on Severity and Comorbidities
Kessler RC et al. Arch Gen Psychiatry. 2005;62(6):617-627.
SEVERITY COMORBIDITY
40.4%
37.3%
22.3%
Mild
Moderate
Serious
PREVALENCE
PREVALENCE Anxiety D/O
18.1% Mood D/O
9.5% Impulse Control D/O
(ADHD) 8.9% Substance Use D/O
3.8% Any disorder
26.2%
SEVERITY COMORBIDITY
55%
22%
23%
1 dx
2 dx
3 or more
dx
9.6% Serious
25.5% Serious
49.9% Serious
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Diagnostic Rationale
Hirschfeld RM. Prim Care Companion J Clin Psychiatry. 2001;3(6):244-254.
• 1 diagnosis multiple symptoms
• 1 diagnosis does not explain symptoms
multiple symptoms
• >1 diagnosis better explains patient’s symptoms
multiple symptoms
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Delayed Identification of ADHD and Bipolar Disorder and
the Consequences
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Undiagnosed ADHD: Impairment in Adults
Able SL et al. Psychol Med. 2007;37(1):97-107.
14.8
6.7
13.0
28.8
22.7
2.8
9.3
20.1
0%
5%
10%
15%
20%
25%
30%
35%
Post-College Degree Unemployed 1 Traffic Citation (past 5 yrs)
Problem Drinking
Undiagnosed ADHD (N=752) Non-ADHD Controls (N=199)
P<0.001
P<0.01
P<0.05
P<0.05
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*
* 58.7
41.6
*
* 56.7
39.2
*
* 46.2 35.8
Bipolar Disorder: Possible Consequence of Misdiagnosis
PGWB, Psychological General Well-Being Index; SF-8, Medical Outcomes Study 8-Item Short-Form Health Survey. Awad AG et al. Prim Care Companion J Clin Psychiatry. 2007;9(3):195-202.
Depression Bipolar Misdiagnosed
PGWB score, overall (mean)
SF-8 mental component summary score (mean)
0
10
20
30
40
50
60
*P<0.05 - Misdiagnosed vs Depression - Misdiagnosed vs Bipolar - Depression vs Bipolar
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Advantages of Using Scales and Screeners
Advantages of Using Scales & Screeners
Time Efficient
Avoid Making an Incorrect Diagnosis
& Missing Comorbidities
Avoid Potential Catastrophic Results (eg, hospitalization,
suicide)
Good Sensitivity & Specificity
Make Great Safety Nets – Avoid Missing Important Pieces of
Information
Improve Patient Outcomes
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Diagnostically, How Well Are We Doing?
1Johnson CJ et al. Stroke. 1995;26(1):46-51; 2Vobecky J et al. Cancer. 1989;64(6):1261-1265; 3Schreij G et al. J Hypertens. 1999;17(12 Pt 1):1737-1741; 4Weidow J et al. Acta Orthop. 2006;77(2):262-266; 5Gao J et al. Breast Cancer Res Treat. 2008;108(1):121-127.
PSYCHIATRIC DIAGNOSES KAPPAS FOR IN-PERSON INTERVIEWS Major depression 0.73 Alcohol dependence 0.86 Bipolar disorder 0.76 Panic disorder 1
Average Kappa = 0.83 NOTE: Values above 0.60 indicate substantial interrater reliability
Ruskin PE et al. Psychiatric Serv. 1998;49(8):1086-1088.
PSYCHIATRIC DIAGNOSES KAPPAS FOR IN-PERSON INTERVIEWS Major depression 0.73 Alcohol dependence 0.86 Bipolar disorder 0.76 Panic disorder 1
Average Kappa = 0.83 MEDICAL/NEUROLOGICAL DIAGNOSES KAPPAS Ischemic stroke1 (average) 0.53 Colorectal Adenocarcinoma2 0.78 Renal stenosis3 0.43 Knee osteoarthritis4 0.1 Breast cancer5 0.89
Average Kappa = 0.55
NOTE: Values above 0.60 indicate substantial interrater reliability
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CAGE ASRS-VI.1
ADHD-RS
?
HAM-D
PHQ-9 MINI
BSDS
?
BPRS
DAST-10 MDQ
GAD-7 HAM-A ?
Selecting a Screener or Scale: A Great Safety Net
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Listens to Patient
Description
Obtains Comprehensive
Clinical Interview
Gathers Longitudinal
History
Collects Family/ Collateral
Information
Utilizes Screeners &
Scales
Assesses for Comorbidities
Utilizes Diagnostic
Trees Accurate Diagnosis
or Diagnoses
Scales and Screeners: An Important Step In a Diagnostic Assessment
Work Group on Psychiatric Evaluation. Practice Guidelines for the Psychiatric Evaluation of Adults, Second Edition. 2006. www.psychiatryonline.com/content.aspx?aID=137162. Accessed Aug. 11, 2011.
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CAGE ASRS-VI.1
ADHD-RS
?
HAM-D
PHQ-9 MINI
BSDS
?
BPRS
DAST-10 MDQ
GAD-7 HAM-A ?
Selecting a Screener or Scale: A Great Safety Net
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To Understand the Differential Diagnosis of ADHD from Bipolar Disorder, We Must First Know the Individual Disorders Well
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Diagnostic Muddy Water?
Inattentive
Hyperactivity/ Impulsivity
Combined Mixed
Manic
Depressed
Hypo-manic
ADHD Bipolar Disorder
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Irritability Across Disease States (Partial List)
1American Psychiatric Association. DSM-IV-TR. 2000; 2Lima FS et al. Behav Neurol. 2007;18(2):81-90; 3Sonino N et al. Adv Psychosom Med. 2007;28:21-33; 4Hoe J et al. Intl J Geriatr Psychiatry. 2007;22(10):1031-1036; 5Oginska H, Pokorski J. Chronobiol Int. 2006;23(6):1317-1328.
Irritability
Depressive Disorders1
Bipolar Disorders1
Substance Use and
Withdrawal States1
GAD1
PTSD1
ADHD1
A shared symptom of multiple psychiatric and medical conditions
PMDD1
CNS injuries/ infections2
Endocrine Disorders3
Dementia4 Sleep
Disorders5
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Distractibility Across Disease States (Partial List)
American Psychiatric Association. DSM-IV-TR. 2000.
Distractibility
Depressive disorders
Bipolar disorders
Anxiety disorders ADHD
Psychotic disorders
Substance use disorders
A shared symptom of multiple psychiatric conditions
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Symptom Overlap = Diagnostic Confusion
McIntyre R. Primary Psychiatry. 2009;16:7(Suppl 5):8-9; American Psychiatric Association. DSM-IV-TR. 2000.
Anxiety Disorders
Bipolar Disorder ADHD
Symptoms • Distractibility • Impulsivity • Talkative • Increased Motor Activity • Physical Restlessness • Loss of “Normal” Social Inhibitions
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Non-overlapping Symptoms
1Craney JL et al. Bipolar Disord. 2003;5(4):243-256; 2American Psychiatric Association. DSM-IV-TR. 2000; 3McIntyre R. Primary Psychiatry. 2009;16:7(Suppl 5):8-9; 4Baldwin P et al. Schizophr Bull. 2005;31(3):624-638.
Bipolar Disorder Feature ADHD More episodic and
cyclical nature Course of illness1 More chronic and
not cyclical
Typically >7 years of age Age of onset2 <7 years of age
+ for mood disorders Family history2 + for ADHD
Decreased need for sleep Sleep impairment1 Variable, less disruption
Present in some cases Psychoses
(delusions, hallucinations, or thought disorders)3,4
None
Can be present in manic / mixed phase Inflated Self-Esteem3 None
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ADHD: Across the Lifespan
1Polanczyk G, Rohde LA. Curr Opin Psychiatry. 2007;20(4):386-392; 2Adler LA. J Clin Psychiatry. 2004;65(Suppl 3):8-11.
Inattention1
Hyperactivity1
Impulsivity1
Disorganized2
Fidgets or squirms in seat2
Blurts out answers2
Forgetfulness affects work/ home/financial/personal life2 Can’t sit still in business meetings, restlessness2
Intrusive Behavior2
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ADHD: Symptom Progression Across the Lifespan
Spencer TJ et al . J Pediatr Psychol. 2007;32(6):631-642; Biederman J. Biol Psychiatry. 2005;57(11):1215–1220.
Pre-School School-age Adolescent College Adult
Disruptive behavior
Doesn’t listen well
Alcohol/substance abuse problems
Drops out
Delayed ABC’s & colors
Kicked out of daycare
Poor academic performance
In-school suspension
Poor money management
Significant job impairment
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The Phases of Bipolar Disorder
Stahl SM. Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 2nd Edition. 2000.
Mania
Depression
Mixed
Normal Mood
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Misdiagnosis: Patients With Bipolar Disorder
NDMDA, National Depressive and Manic-Depressive Association. Hirschfield RM et al. J Clin Psychiatry. 2003;64(2):161-174.
• For 35% of those with prior misdiagnosis, lapse in time from first treatment seeking to accurate diagnosis was 10 years or longer
• On average, people with Bipolar Disorder who were previously misdiagnosed received 3.5 misdiagnoses and consulted 4 physicians before receiving an accurate diagnosis
69% Previously Misdiagnosed
NDMDA 2000 Survey
N=600 Patients were incorrectly diagnosed with: • Unipolar Depression 60% • Anxiety Disorders 26% • Schizophrenia 18% • Borderline or Antisocial PD 17% • Alcohol or Substance Abuse/Dependence 14% • Schizoaffective Disorder 11%
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What About the Comorbidity of These Disorders?
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Adult ADHD “Ring of Fire” NCS-R: Psychiatric Comorbidities
NCS-R, National Comorbidity Survey Replication. Kessler RC et al. Am J Psychiatry. 2006;163(4):716-723.
Major Depression
2.7*
Bipolar Depression
7.4*
Adult ADHD Comorbidities
Odds Ratio (95% CI) *P<0.05
Any Substance
Use Disorder
3.0*
OCD 1.5
Specific Phobias
2.8*
Social Phobias
4.9*
Panic Disorder
3.0*
PTSD 3.9*
GAD 3.2*
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Substance Abuse 41%4,5
Alcohol Abuse 46%4,5
Bipolar Disorder Comorbidities
Phobias 10-26%2-4
Panic Disorder 7-33%1-4
OCD 3-39%1,2
GAD 11-43%1,3,4
ADHD ~20%6
Bipolar Disorder “Ring of Fire” Psychiatric Comorbidities
1Yerevanian BI et al. J Affect Disord. 2001;67(1-3):167-173; 2Henry C et al. J Clin Psychiatry. 2003;64(3):331-335; 3Rihmer Z et al. J Affect Disord. 2001;67(1-3):175-179; 4Tamam L, Ozpoyraz N. Psychopathology. 2002;35(4):203-209; 5Regier DA et al. JAMA. 1990;264(19):2511-2518; 6Kessler RC et al. Am J Psychiatry. 2006;163(4):716-723.
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What We Learned from STEP-BD
STEP-BD, Systematic Treatment Enhancement Program for Bipolar Disorder. Nierenberg AA et al. Biol Psychiatry. 2005;57(11):1467-1473; McIntyre R. Primary Psychiatry. 2009;16:7(Suppl 5):8-9.
Bipolar Disorder
+ ADHD
Poorer Prognosis
Shorter Well
Intervals
Earlier Age of Onset (BD) = More Virulent
Greater Propensity to Depression More
Depressive Episodes
Higher Rates of
Comorbidity (Anxiety/SUDs)
Hx of Aggression & Violence
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1.0 1.0 1.0 1.0 1.0
2.5 2.8
1.5
7.9*
3.0*
0 1 2 3 4 5 6 7 8 9
Alcohol Abuse Alcohol Dependence
Drug Abuse Drug Dependence
Any SUD
Odds Ratio w/o ADHD Odds Ratio with ADHD
ADHD and SUD Comorbidity
Kessler RC et al. Am J Psychiatry. 2006;163(4):716-723.
*P<0.05
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56.3%
38.0%
48.3%
30.4% 100% of Bipolar Patients
Bipolar Disorder With SUD: Lifetime Comorbidity
With Any Comorbid SUDs
Merikangas KR et al. Arch Gen Psychiatry. 2007;64(9):543-552.
60.3%
39.7%
No Comorbid SUDs
Comorbid SUDs
0%
10%
20%
30%
40%
50%
60%
Alcohol Abuse
Alcohol Dependence
Drug Abuse
Drug Dependence
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PHQ-9 DAST-10 MDQ BSDS S
cree
ning
Saf
ety
Net
s
BSDS
MDQ
DAST-10
PHQ-9
ASRS
GAD-7
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Where the Rubber Meets the Road: Practical Clinical Tips and Resources
Novice Clinician
Maturing Clinician
Seasoned Clinician
Too hard!
Too soft!
Just right!
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Resources of Interest
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www.psychtoolkit.com
Resources
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What Others Are Saying About Using Scales and Screeners
“Stimulated my thinking. Recommit
again to using instruments.”
“They actually save me time in
my practice.”
“Through using scales and screeners, I
continue to uncover previously undiagnosed
bipolar patients.”
“Has changed the way I practice
medicine.”
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Scales and Screeners • ADHD Rating Scale (ADHD-RS) • Adult ADHD Self-Report Scale (ASRS-VI.I) • Bipolar Spectrum Diagnostic Scale (BSDS) • Brief Psychiatric Rating Scale (BPRS) • CAGE (Cut down on drinking, Annoyances with criticisms about
drinking, Guilt about drinking, and using alcohol as an Eye opener) • Drug Abuse Screening Test (DAST-10) • Generalized Anxiety Disorder 7-item Scale (GAD-7) • Hamilton Rating Scale for Anxiety (HAM-A) • Hamilton Rating Scale for Depression (HAM-D) • Mood Disorder Questionnaire (MDQ) • Mini International Neuropsychiatric Interview (MINI) • Patient Health Questionnaire (PHQ-9)