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
Serious

Anxiety D/O
18.1%

22.3%

Moderate SEVERITY
37.3%
Mild

40.4%

COMORBIDITY

PREVALENCE

Mood D/O
9.5%

PREVALENCE

Impulse Control D/O

(ADHD) 8.9%
Substance Use D/O
3.8%
Any disorder
26.2%

Kessler RC et al. Arch Gen Psychiatry. 2005;62(6):617-627.

3 or
more
dx

23%

49.9%
Serious

COMORBIDITY25.5%

2 dx 22%

Serious

1 dx

9.6%
Serious

55%

Diagnostic Rationale
multiple
symptoms

1 diagnosis

multiple
symptoms

1 diagnosis does not

explain symptoms

multiple
symptoms

>1 diagnosis better explains

patients 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)

30%

Non-ADHD Controls (N=199)

25%

10%

22.7
P<0.05

14.8

5%
0%

28.8

P<0.001

20%
15%

P<0.05

P<0.01

20.1

13.0
9.3

6.7
2.8
Post-College Degree

Unemployed

Able SL et al. Psychol Med. 2007;37(1):97-107.

1 Traffic Citation (past 5

yrs)

Problem Drinking

Bipolar Disorder: Possible

Consequence of Misdiagnosis
60
50
40
30

*P<0.05
- Misdiagnosed vs Depression
- Misdiagnosed vs Bipolar
- Depression vs Bipolar

* 58.7

56.7
41.6

20

*
39.2

*
*46.2
35.8

10
0

Depression
PGWB score, overall
(mean)

Bipolar

Misdiagnosed

SF-8 mental component

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
Outcomes

Make Great Safety

Nets Avoid Missing
Important Pieces of
Information

Time Efficient

Advantages of Using
Scales & Screeners

Good Sensitivity
& Specificity

Avoid Making an
Incorrect Diagnosis
& Missing
Comorbidities

Avoid Potential
Catastrophic Results
(eg, hospitalization,
suicide)

Diagnostically, How Well Are We Doing?

KAPPAS FOR IN-PERSON INTERVIEWS
0.73
0.86
0.76
1
KAPPAS FOR IN-PERSON INTERVIEWS
Average Kappa = 0.83
Major depression
0.73
MEDICAL/NEUROLOGICAL
DIAGNOSES
KAPPAS
Alcohol dependence
0.86
1
Ischemic
stroke
(average) 0.53
Bipolar disorder
0.76
2
Colorectal
Adenocarcinoma
0.78
Panic disorder
1
3
Renal stenosis
0.43
Average Kappa = 0.83
4
Knee osteoarthritis
0.1
NOTE:
Values
above
0.60
indicate
substantial
interrater
reliability
Breast cancer5
0.89
Average Kappa = 0.55
NOTE: Values above 0.60 indicate substantial interrater reliability
PSYCHIATRIC DIAGNOSES
Major depression
Alcohol dependence
Bipolar disorder
Panic
disorderDIAGNOSES
PSYCHIATRIC

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
Ruskin
etTreat.
al. Psychiatric
Serv. 1998;49(8):1086-1088.
CancerPE
Res
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
Comprehensive
Clinical
Interview
Listens to
Patient
Description
Gathers
Longitudinal
History

Collects Family/
Collateral
Information

Accurate
Diagnosis
or Diagnoses
Utilizes
Screeners &
Scales

Utilizes
Diagnostic
Trees

Assesses for
Comorbidities

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

Inattentive

Bipolar Disorder
Depressed

Manic
Hyperactivity/
Impulsivity
Hypo-manic

Combined

Mixed

Irritability Across Disease States

(Partial List)

Irritability
ADHD1

GAD1

Bipolar
Depressive
Disorders1 Endocrine
Disorders1
Disorders3
CNS injuries/
infections2

Dementia4
PTSD1

Substance
Use and
Withdrawal
States1

Sleep
Disorders5
PMDD1

A shared symptom of multiple psychiatric and medical conditions

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.

Distractibility Across Disease States

(Partial List)

Distractibility
Bipolar
disorders
Depressive
disorders

Psychotic
disorders
Anxiety
disorders

ADHD

A shared symptom of multiple psychiatric conditions

American Psychiatric Association. DSM-IV-TR. 2000.

Substance use
disorders

Symptom Overlap = Diagnostic

Confusion
Symptoms
Distractibility
Impulsivity

Anxiety
Disorders

Talkative

Increased Motor Activity

Bipolar
Disorder

ADHD

Physical Restlessness
Loss of Normal Social Inhibitions

McIntyre R. Primary Psychiatry. 2009;16:7(Suppl 5):8-9; American Psychiatric Association. DSM-IVTR. 2000.

Non-overlapping Symptoms
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

Can be present in manic /
mixed phase
1Craney

Psychoses

(delusions, hallucinations,
or thought disorders)3,4

None

Inflated Self-Esteem3

None

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.

ADHD: Across the Lifespan

Inattention1

Disorganized2

Forgetfulness affects work/

home/financial/personal life2

Hyperactivity1

Fidgets or squirms in seat2

Cant sit still in business

meetings, restlessness2

Impulsivity1

Blurts out answers2

Intrusive Behavior2

1Polanczyk

G, Rohde LA. Curr Opin Psychiatry. 2007;20(4):386-392; 2Adler LA. J Clin Psychiatry.
2004;65(Suppl 3):8-11.

ADHD: Symptom Progression

Across the Lifespan
Disruptive behavior

Alcohol/substance abuse problems

Doesnt listen well

Drops out

Pre-School

School-age

Delayed ABCs & colors

Adolescent

Poor academic performance

Kicked out of daycare

In-school suspension

College

Adult

Poor money management

Significant job impairment

Spencer TJ et al . J Pediatr Psychol. 2007;32(6):631-642; Biederman J. Biol Psychiatry.

2005;57(11):12151220.

The Phases of Bipolar Disorder

Mania
Mixed
Normal
Mood
Depression
Stahl SM. Stahls Essential Psychopharmacology: Neuroscientific Basis and Practical Applications.
2nd Edition. 2000.

N=600

Misdiagnosis: Patients With

Bipolar Disorder
Patients were incorrectly diagnosed with:
69% Previously
Misdiagnosed

Unipolar Depression

60%

Anxiety Disorders

26%

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.
Hirschfield RM et al. J Clin Psychiatry. 2003;64(2):161-174.

NDMDA 2000 Survey

What About the Comorbidity of

These Disorders?

Adult ADHD Ring of Fire

NCS-R: Psychiatric Comorbidities
Any
Substance
Use
Disorder
3.0*
Panic
Disorder
3.0*
GAD
3.2*

Specific
Phobias
2.8*

Major
Depression
2.7*

Adult ADHD
Comorbidities
PTSD
3.9*

OCD
1.5

Bipolar
Depression
7.4*
Social
Phobias
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

OCD
3-39%1,2

Substance
Abuse
41%4,5

1Yerevanian

Panic
Disorder
7-33%1-4

ADHD
~20%6

Bipolar Disorder
Comorbidities
GAD
11-43%1,3,4

Phobias
10-26%2-4

Alcohol
Abuse
46%4,5

BI et al. J Affect Disord. 2001;67(1-3):167-173; 2Henry C et al. J Clin Psychiatry. 2003;64(3):331Z et al. J Affect Disord. 2001;67(1-3):175-179; 4Tamam L, Ozpoyraz N. Psychopathology.
335;
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.
3Rihmer

What We Learned from STEP-BD

Earlier Age of
Onset (BD) =
More Virulent

Greater
Propensity to
Depression

Higher Rates
of
Comorbidity
(Anxiety/SUDs)

Shorter
Well
Intervals

Poorer
Prognosis

More
Depressive
Episodes

Bipolar
Disorder
+
ADHD

Hx of
Aggression
& Violence

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.

ADHD and SUD Comorbidity

9
8
7
6
5
4
3
2
1
0

Odds Ratio w/o ADHD

7.9*

Odds Ratio with ADHD

Alcohol Abuse

3.0*

2.8

2.5
1.0

*P<0.05

1.0

Alcohol
Dependence

1.0

1.5

Drug Abuse

Kessler RC et al. Am J Psychiatry. 2006;163(4):716-723.

1.0

Drug
Dependence

1.0

Any SUD

Bipolar Disorder With SUD:

Lifetime Comorbidity
With Any Comorbid SUDs

Comorbid SUDs
60%

56.3%
48.3%

50%

39.7% 100% of
Bipolar
Patients 60.3%

38.0%

40%

30.4%

30%
20%
10%

No Comorbid SUDs

0%

Alcohol
Alcohol
Abuse Dependence

Merikangas KR et al. Arch Gen Psychiatry. 2007;64(9):543-552.

Drug
Abuse

Drug
Dependence

Screening Safety Nets

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

Where the Rubber Meets the Road:

Practical Clinical Tips and Resources
Too
soft!

Too
hard!

Just
right!

Novice
Clinician

Maturing
Clinician

Seasoned
Clinician

Resources of Interest

Resources

www.psychtoolkit.com

They actually
save me time in
my practice.

Has changed the

way I practice
medicine.

What Others Are Saying About

Using Scales and Screeners
Stimulated my
thinking. Recommit
again to using
instruments.

Through using scales

and screeners, I
continue to uncover
previously undiagnosed
bipolar patients.

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)