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)