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 SEVERITY COMORBIDITY PREVALENCE Anxiety D/O 3 or 49.9% 18.1% Serious 22.3% more 23% Serious dx Mood D/O 9.5% COMORBIDITY 25.5% SEVERITY PREVALENCE Moderate 37.3% 2 dx 22% Serious Impulse Control D/O (ADHD) 8.9% 9.6% Mild 40.4% 1 dx 55% Substance Use D/O Serious 3.8% Any disorder 26.2% Kessler RC et al. Arch Gen Psychiatry. 2005;62(6):617-627.

Diagnostic Rationale multiple • 1 diagnosis symptoms multiple • 1 diagnosis does not symptoms explain symptoms multiple • >1 diagnosis better explains symptoms patient’s symptoms Hirschfeld RM. Prim Care Companion J Clin Psychiatry . 2001;3(6):244-254.

Delayed Identification of ADHD and Bipolar Disorder and the Consequences

Undiagnosed ADHD: Impairment in Adults 35% Undiagnosed ADHD (N=752) P <0.05 Non-ADHD Controls (N=199) 30% 28.8 P <0.001 25% 22.7 20% 20.1 P <0.05 15% 14.8 P <0.01 13.0 10% 9.3 5% 6.7 2.8 0% Post-College Degree Unemployed 1 Traffic Citation (past 5 Problem Drinking yrs) Able SL et al. Psychol Med. 2007;37(1):97-107.

Bipolar Disorder: Possible Consequence of Misdiagnosis * P <0.05 - Misdiagnosed vs Depression - Misdiagnosed vs Bipolar 60 - Depression vs Bipolar * * 50 * * 58.7 40 56.7 * * 46.2 30 41.6 39.2 35.8 20 10 0 Depression Bipolar Misdiagnosed PGWB score, overall SF-8 mental component (mean) summary score (mean) 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.

Advantages of Using Scales and Screeners Improve Patient Time Efficient Outcomes Make Great Safety Avoid Making an Advantages of Using Nets – Avoid Missing Incorrect Diagnosis Important Pieces of & Missing Scales & Screeners Information Comorbidities Avoid Potential Good Sensitivity Catastrophic Results & Specificity (eg, hospitalization, suicide)

Diagnostically, How Well Are We Doing? KAPPAS FOR IN-PERSON INTERVIEWS PSYCHIATRIC DIAGNOSES Major depression 0.73 Alcohol dependence 0.86 Bipolar disorder 0.76 Panic disorder 1 KAPPAS FOR IN-PERSON INTERVIEWS PSYCHIATRIC DIAGNOSES Average Kappa = 0.83 Major depression 0.73 MEDICAL/NEUROLOGICAL DIAGNOSES KAPPAS Alcohol dependence 0.86 Ischemic stroke 1 (average) 0.53 Bipolar disorder 0.76 Colorectal Adenocarcinoma 2 0.78 Panic disorder 1 Renal stenosis 3 0.43 Average Kappa = 0.83 Knee osteoarthritis 4 0.1 NOTE: Values above 0.60 indicate substantial interrater reliability Breast cancer 5 0.89 Average Kappa = 0.55 NOTE: Values above 0.60 indicate substantial interrater reliability 1 Johnson CJ et al. Stroke . 1995;26(1):46-51; 2 Vobecky J et al. C ancer . 1989;64(6):1261-1265; 3 Schreij G et al. J Hypertens . 1999;17(12 Pt 1):1737-1741; 4 Weidow J et al. Acta Orthop . 2006;77(2):262-266; 5 Gao J et al. Breast Ruskin PE et al. Psychiatric Serv. 1998;49(8):1086-1088. Cancer Res Treat . 2008;108(1):121-127.

Selecting a Screener or Scale: A Great Safety Net HAM-D BSDS CAGE BPRS ASRS-VI.1 MDQ PHQ-9 MINI ADHD-RS DAST-10 ? ? ? GAD-7 HAM-A

Scales and Screeners: An Important Step In a Diagnostic Assessment Obtains Collects Family/ Comprehensive Collateral Clinical Information Interview Utilizes Listens to Accurate Diagnostic Patient Diagnosis Trees Description or Diagnoses Gathers Assesses for Longitudinal Utilizes Comorbidities History Screeners & Scales 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.

Selecting a Screener or Scale: A Great Safety Net HAM-D BSDS CAGE BPRS ASRS-VI.1 MDQ PHQ-9 MINI ADHD-RS DAST-10 ? ? ? GAD-7 HAM-A

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

Diagnostic Muddy Water? ADHD Bipolar Disorder Depressed Inattentive Manic Hyperactivity/ Impulsivity Hypo-manic Combined Mixed

Irritability Across Disease States (Partial List) Irritability Sleep ADHD 1 Substance GAD 1 Disorders 5 Dementia 4 Use and Bipolar Depressive Withdrawal PMDD 1 Disorders 1 Endocrine Disorders 1 States 1 PTSD 1 Disorders 3 CNS injuries/ infections 2 A shared symptom of multiple psychiatric and medical conditions 1 American Psychiatric Association. DSM-IV-TR . 2000; 2 Lima FS et al . Behav Neurol . 2007;18(2):81-90; 3 Sonino N et al. Adv Psychosom Med . 2007;28:21-33; 4 Hoe J et al. Intl J Geriatr Psychiatry . 2007;22(10):1031-1036; 5 Oginska H, Pokorski J. Chronobiol Int . 2006;23(6):1317-1328.

Distractibility Across Disease States (Partial List) Distractibility Bipolar Psychotic disorders disorders Depressive Substance use Anxiety disorders disorders disorders ADHD A shared symptom of multiple psychiatric conditions American Psychiatric Association. DSM-IV-TR . 2000.

Symptom Overlap = Diagnostic Confusion Symptoms Anxiety • Distractibility Disorders • Impulsivity Bipolar ADHD • Talkative Disorder • Increased Motor Activity • Physical Restlessness • Loss of “Normal” Social Inhibitions McIntyre R. Primary Psychiatry . 2009;16:7(Suppl 5):8-9; American Psychiatric Association. DSM-IV- TR . 2000.

Non-overlapping Symptoms Bipolar Disorder Feature ADHD More episodic and More chronic and Course of illness 1 cyclical nature not cyclical Typically Age of onset 2 <7 years of age >7 years of age Family history 2 + for mood disorders + for ADHD Sleep impairment 1 Decreased need for sleep Variable, less disruption Psychoses None Present in some cases (delusions, hallucinations, or thought disorders) 3,4 Can be present in manic / Inflated Self-Esteem 3 None mixed phase 1 Craney JL et al. Bipolar Disord . 2003;5(4):243-256; 2 American Psychiatric Association. DSM-IV-TR . 2000; 3 McIntyre R. Primary Psychiatry . 2009;16:7(Suppl 5):8-9; 4 Baldwin P et al. Schizophr Bull. 2005;31(3):624-638.

ADHD: Across the Lifespan Forgetfulness affects work/ Disorganized 2 Inattention 1 home/financial/personal life 2 Can’t sit still in business Hyperactivity 1 Fidgets or squirms in seat 2 meetings, restlessness 2 Impulsivity 1 Blurts out answers 2 Intrusive Behavior 2 1 Polanczyk G, Rohde LA. Curr Opin Psychiatry . 2007;20(4):386-392; 2 Adler LA. J Clin Psychiatry . 2004;65(Suppl 3):8-11.

ADHD: Symptom Progression Across the Lifespan Disruptive behavior Alcohol/substance abuse problems Doesn’t listen well Drops out Pre-School School-age Adolescent College Adult Delayed ABC’s & colors Poor money management Poor academic performance Kicked out of daycare Significant job impairment In-school suspension Spencer TJ et al . J Pediatr Psychol. 2007;32(6):631-642; Biederman J. Biol Psychiatry. 2005;57(11):1215–1220.

The Phases of Bipolar Disorder Mania Mixed Normal Mood Depression Stahl SM. Stahl ’ s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 2nd Edition. 2000.

Misdiagnosis: Patients With Bipolar Disorder N=600 Patients were incorrectly diagnosed with: • Unipolar Depression 60% 69% Previously • Anxiety Disorders 26% Misdiagnosed • Schizophrenia 18% • Borderline or Antisocial PD 17% • Alcohol or Substance Abuse/Dependence 14% • Schizoaffective Disorder 11% • 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 NDMDA, National Depressive and Manic-Depressive Association. NDMDA 2000 Survey Hirschfield RM et al. J Clin Psychiatry . 2003;64(2):161-174.

What About the Comorbidity of These Disorders?

Adult ADHD “ Ring of Fire ” NCS-R: Psychiatric Comorbidities Specific Any Major Phobias Depression Substance OCD 2.7* Use 1.5 2.8* Disorder 3.0* Adult ADHD Bipolar Depression Panic Comorbidities Disorder 7.4* 3.0* Social GAD Phobias PTSD 3.2* 3.9* 4.9* Odds Ratio (95% CI) * P <0.05 NCS-R, National Comorbidity Survey Replication. Kessler RC et al. Am J Psychiatry . 2006;163(4):716-723.

Bipolar Disorder “ Ring of Fire ” Psychiatric Comorbidities Panic ADHD Disorder ~20% 6 7-33% 1-4 OCD Phobias 3-39% 1,2 10-26% 2-4 Bipolar Disorder Comorbidities Alcohol Substance Abuse Abuse GAD 46% 4,5 41% 4,5 11-43% 1,3,4 1 Yerevanian BI et al. J Affect Disord . 2001;67(1-3):167-173; 2 Henry C et al. J Clin Psychiatry . 2003;64(3):331- 335; 3 Rihmer Z et al. J Affect Disord . 2001;67(1-3):175-179; 4 Tamam L, Ozpoyraz N. Psychopathology . 2002;35(4):203-209; 5 Regier DA et al. JAMA . 1990;264(19):2511-2518; 6 Kessler RC et al. Am J Psychiatry . 2006;163(4):716-723.