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)
0
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
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.
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, or 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 of
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*
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 S
cree
ning
Saf
ety
Net
s
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)