Clinical Pearls in Differential Diagnosis: Differentiating Adult - - PowerPoint PPT Presentation

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

What Do You See?

What you see isn't always what you get.

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

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

Delayed Identification of ADHD and Bipolar Disorder and the Consequences

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

* * 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) 10 20 30 40 50 60

*P<0.05

• Misdiagnosed vs Depression
• Misdiagnosed vs Bipolar
• Depression vs Bipolar

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

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

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

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

• r 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.

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

To Understand the Differential Diagnosis of ADHD from Bipolar Disorder, We Must First Know the Individual Disorders Well

Diagnostic Muddy Water?

Inattentive Hyperactivity/ Impulsivity Combined Mixed Manic Depressed Hypo-manic

ADHD Bipolar Disorder

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

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

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

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,

• r thought disorders)3,4

None Can be present in manic / mixed phase Inflated Self-Esteem3 None

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

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

The Phases of Bipolar Disorder

Stahl SM. Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 2nd Edition. 2000.

Mania Depression Mixed Normal Mood

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%

What About the Comorbidity of These Disorders?

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*

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.

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

• f

Comorbidity (Anxiety/SUDs) Hx of Aggression & Violence

1.0 1.0 1.0 1.0 1.0 2.5 2.8 1.5 7.9* 3.0*

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

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

PHQ-9 DAST-10 MDQ BSDS

Screening Safety Nets

BSDS MDQ DAST-10 PHQ-9 ASRS GAD-7

Where the Rubber Meets the Road: Practical Clinical Tips and Resources

Novice Clinician Maturing Clinician Seasoned Clinician

Too hard! Too soft! Just right!

Resources of Interest

www.psychtoolkit.com

Resources

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.”

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)