ADHD bipolar PTSD - 02-05-2014.pptpsychologyinterns.org/.../ADHD_bipolar_PTSD-02-05-2014.pdf2/5/2014...
Transcript of ADHD bipolar PTSD - 02-05-2014.pptpsychologyinterns.org/.../ADHD_bipolar_PTSD-02-05-2014.pdf2/5/2014...
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Adam Andreassen, Psy.D.Executive DirectorHeart of America Psychology Training Consortium
PresidentMidwest Assessment & Psychotherapy Solutions (MAPS)
� Experience a more comprehensive conceptualization of research-relevant symptoms related to both ADHD and Bipolar Disorder as well as PTSD that goes beyond the narrow framework of the DSM
� Improve clinical interviewing skills in order to focus on asking the questions that most likely illicit relevant information
� Become more familiar with the assets and limitations of inventories and psychological testing results.
� Become more competent in ruling in or ruling out other co-morbid conditions.
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Appendicitis Strep ThroatFever
Geller & DelBello, 2008
Mania
(elated mood and grandiosity)
Major Depressive
Disorder
(low mood and
anhedonia)
Autism
(communication and social deficits)
ADHD
(no cardinal
symptoms)
Irritability and Hyperactivity
Geller & DelBello, 2008
1% 8%
Barkley, 2006
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� Anxiety disorder: 10-50%
� MDD: 15-75%
� Bipolar I: 6-27%; (BAD I carries a very high risk for comorbid ADHD, even though ADHD carries a low risk for BAD I)
� ODD: Up to 85%
� Conduct Disorder: 15-56% (worse prognosis)
� PTSD may be circular with ADHD: 1-6%
� Tourette syndrome or tick disorder: 12-34%
� PDD: Up to 26%
(Barkley, 2006)
� Around WWI ADHD symptoms were often associated with an outbreak of encephalitis
� Clinicians began to see similar symptoms in other organic based disorders (brain injured child, MBD)
� Also “spoiled child” syndrome
� 1930’s began to notice improved effects with amphetamine use to control headaches
Barkley 2006
� 1950’s movement to hyperkinetic impulse disorder
� Later in the decade more specific learning problems were identified rather than generalizing MBD
� 1970’s began to focus on impulsivity as well
� 1980’s focus on attention problems
� Later focus on educational needs
� 21st century continues to look at further subtypes
Barkley 2006
� The word “manic” traces back to Ancient Greek.
� Mania and melancholia have been tied together for centuries
� Biphasic Mental Illness causing recurrent oscilliations between mania and depression (1854 Jules Baillarger).
� Emil Kraepelin coined term manic depressiion (1900’s)
� 1952 placed in the Diagnostic Manual
� No early differentiation between unipolar and bipolar� Both were considered manic-depressive illness� More recent research has also noted some differences in
the energy components between unipolar and bipolar depressed patients
� Bipolar disorder has been seen to have a greater genetic link than unipolar depression
� However, conflicting results have been found with relatives of “well-defined” unipolar depressives rarely exhibiting bipolar disorder
� Could occur on a polygenic or continuous spectrum:Unipolar Bipolar
Adams and Sutker (2001)
� Cyclicity can range from less than 48 hours to several years
� High degree of inter-individual variability
� Typical cycle length of Bipolar disorder is less than in unipolar major depression
� 13-20% rapid cycling (≥4 depressed or manic episodes per year)
Adams and Sutker (2001)
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� Rapid cycling is more common among women� Initial mood episode is usually depressive� Rapid cycling generally develops later � Later age of manic onset may be an indication of secondary mania
and can be indistinguishable from patients with primary mania� Can also occur during schizoaffective disorder� Difficulty in distinguishing from Borderline Personality disorder� Some view BPD as subsyndromal mood disorder and some assert
they can coexist, data is unclear due to overlapping symptom presentation
Adams and Sutker (2001)
� Approximately 10-15% of adolescents with recurrent MDE will develop Bipolar, mixed episodes may be more likely in adolescents and young adults
� First episode in males more likely to be manic and in females depressed
� Completed suicide occurs in 10-15%
� More likely to occur in mixed or depressive state
APA 2000
� Onset after 40 should alert that there may be a general medical condition or substance issue
� Bipolar II may be more common in women
� Cyclothymic disorder usually begins in adolescence or early adult life
APA 2000
Theory of kindling� Somewhat controversial� Important to assumptions of early psychosocial
interventions� First applied to seizure disorders� Combination of stress and genetic vulnerability
leads to greater destabilization until full onset� Brain becomes further sensitized with each episode
until spontaneous occurrence without stressors� Will result in less inter-episodic recovery time and
treatment resistanceGeller & DelBello, 2008
� Unipolar depression is more prevalent among women but Bipolar is more evenly distributed by gender
� However, a major Amish study found no gender differences
� Age and hospitalization trends1. First unipolar hospitalization tends to occur between 40
and 492. First bipolar hospitalization tends to occur between 20
and 29� According to NIMH:1. Median age of onset for unipolar depression is 252. Median age of onset for bipolar is 19Adams and Sutker (2001)
� Historically children have been viewed as honest reporters
� However, most clinicians have encountered children who deny disruptive behaviors or claim mental illness contrary to findings
Rogers (2008)
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� Study of 53 dually diagnosed offenders found malingering to be 15%, similar to adult offenders
� Other studies have found 8% of children have engaged in acquiescence and 10% in nay-saying during psychological assessment
� 8% attempted to please the interviewer� 14% provided guarded responses� 12% of 6 to 8-year-olds presented a socially desirable
set of responses� Assessment must discern minimal denial and "white
lies” from exaggerated reporting and extreme denialRogers (2008)
� Children (and their parents on their behalf) may be motivated to malinger symptoms to gain external incentives or deny symptoms to avoid consequences
� Conduct Disorder adolescents may feign ADHD to obtain medication
� May feign symptoms to avoid school work or avoid peer difficulty
� Influence custody decisions� Avoid juvenile justice system� Gain academic accommodations� Gain money and services� Manage peer status� Unintentional parent and child misrepresentationRogers (2008)
� ADHD has a small risk for Bipolar Disorder (6-27%)
� Children with early-onset Bipolar Disorder have a very high probability (91-98%) of meeting the criteria for ADHD
� HOWEVER, once subtracting out symptom overlap only about ½ of ADHD and Bipolar children retained the Bipolar Diagnosis
� 6-10% of children may have legitimate comorbidity
� Follow-up studies have also been inconclusive
(Barkley, 2006)
� Distinct period of abnormally and persistently elevated, expansive, or irritable mood for 1 week (unless hospitalization is necessary)
� Three or more (4 if just irritable) and PRESENT TO A SIGNIFICANT DEGREE
1. Inflated self-esteem or grandiosity2. Decreased NEED for sleep3. More talkative than USUAL4. Flight of ideas or racing thoughts5. Distractibility6. INCREASE in goal-directed activity or psychomotor agitation7. Excessive involvement in pleasurable activities with a high
potential for painful consequences� Not a MDE� Marked impairment or hospitalization� Not due to drugs or GMC
� Fidgety Phil- Hoffman 1865� Still and Tredgold were the first to focus clinical attention
on the condition in the turn of the 20th century� Still noticed problems with attention and impulsivity,
and noted relationships with defiance and delinquency� Believed they were driven by immediate gratification
and many were insensitive to punishment “defect in moral control”
� Considered that some of the problem may be a secondary response to an acute brain disease that may remit, and noted it affected mentally retarded as well as typical intellect
(Barkley, 2006)
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� In infancy:1. Exhibit poor and irregular sleep2. Colic3. Feeding problems4. Dislike being cuddled or held still for long� Toddler:1. Driven to run rather than walk2. Driven to handle everything� Major problems as adults:1. Low self-esteem2. Poor social skills
Kolb & Whishaw (2003)
� Elementary school:1. Demanding2. Oppositional3. Do not play well with others4. Poor tolerance of frustration, high level of activity, poor
concentration, and poor self-esteem may lead to a referral� Adolescence:1. May be failing school2. 25-50% have encountered legal problems3. Withdraw from school4. Fail to develop social relations and maintain steady
employment
Kolb & Whishaw (200)
� ADHD, Inattentive Type
� ADHD, Sluggish Cognitive Tempo
� ADHD, Hyperactive-Impulsive Type
� ADHD, Combined Type
� Often fails to give close attention to details and make careless mistakes
� Difficulty sustaining attention
� Does not listen when spoken to directly
� Not following through on instructions
� Difficulty organizing tasks
� Often loses things
� Often forgetful in everyday activities
� Inattentive Type plus:
� Fidgets with hands or feet in seat
� Leaves seat in the classroom
� Runs or climbs about excessively
� Difficulty playing in leisure activity
� Is often “on the go” or appears “driven by a motor
� Often talks excessively
� Changing culture
� One size fits all?
� Concept called comorbidity
� Relief Factor: “Have a name”
� Cultural medication solution
� Changing parenting styles
� Impact of schools
� Lack of investment in natural treatments
� Treatment of “spectrums”
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� High rates of disruptive disorders
� Low rates of engagement with academic instruction and achievement
� Inconsistent completion/accuracy of school work
� Poor performance on homework, tests & long-term assignments
� Difficulties getting along with peers
� Limited data for school based interventions in gen ed setting
� One size fits all
� Emphasis on reduction of disruptive behavior rather than improvement in social behavior or academic skills
� Focus on short-term outcomes
� Few studies of adolescents
� Concept of Executive Functioning and brain development
� The ability to plan and organize event in a sequential manner with sound judgment
� Also involves:
� Nonverbal and verbal working memory
� Emotional Self-Regulation
� Planning and Problem-Solving
� Theory suggesting that ADHD (and Conduct, Antisocial, etc) individuals seek/require more stimulation to transcend their excessively low arousal rate
� In one study ADHD individuals required more noise levels to establish the same stimulation level (due to less dopamine)
-See Wikipedia – “Low Arousal Theory”
� A disorder of “time blindness” (Barkley)
� ADHD lives in the moment only
� Point of Performance Problem
� It is a disorder of:
� Performance, not skill
� Doing what you know, not knowing what you do
� The when and where not the how and what
� It is not a Attention-Deficit but rather Inattention Deficit Disorder (Inattention to mental events and future possibilities).
� Delayed responding and intrinsic motivation
� Time, delays, and thinking ahead
� Problem-solving strategies, and changing cognitive sets.
� The compassion and willingness of others to make accommodations are vital to success
� It is a chronic medical/psychological disability
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� 40% of children in some studies suffer from sleep problems
� 15% exhibit bedtime resistance
� 10% or more experience daytime drowsiness
� Students with C’s, D’s, and F’s went to bed on average 40 minutes later than A students
� Insufficient sleep leads to many other problems
� If he or she can fall asleep within 15-30 minutes
� Can wake up easily at the time they need to get up
� Awake and alert all day and do not require a nap
� Check with his or her teacher; kindergarten teacher survey that nearly 10% of students fall asleep at school
� Make bedtime special� Think about bedtime do not just do it� Bedtime should be a regular routine� Keep the ritual simple� Sleep habits/rituals should work everywhere
and anywhere� Keep them physical during the day� Be mindful of light� It is not about what happens AT bedtime but
usually at least one hour before
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� AGE Hours4 11.55 116 117 118 10-119 10-1110 1011 1012-13 9.5-10
� During a manic episode there is reduced need for sleep in 69-99% of patients.
� Prominent feature of Bipolar in youth
� May be the early marker (earliest symptom reported by parents) for BAD in youth (Faedda, et al)
� Higher rates of sleep disturbance and decreased need for sleep in comparison to ADHD children.
� Critical for affect regulation
� Important for cognitive functioning
� Impacts health
� Associated with substance use
� Contributes to impulsivity and risk taking
� Does the child fall asleep often while we are driving?
� Does the child seem irritable, cranky, over-emotional, hyper, or have trouble paying attention?
� On some nights does the child crash much earlier than his or her bedtime?
� The TOUGHEST ddx in the business� Considerable overlap of symptoms� Harvard Medical School Study: 94% of children with
mania meet the criteria for ADHD, Hyperactive Type� “When one hears the clatter of hoofbeats on the roof,
one looks for horses not zebras.” (Anthony & Scott)� ADHD should only be considered after ruling out a
mood disorder� Diagnosis may depend upon your own bias or
conceptualization of childhood disorders (mania merely as a defense, ADHD as an attachment disorder)
� Is ADHD an early developmental path to full-blown Bipolar?
� Destructiveness: ADHD careless destruction v. BAD occurs in anger
� Temper-tantrums: ADHD children calm down in 20-30 minutes; BAD for hours
� Regression during outbursts: BAD may lose memory of tantrum; regression more severe in BAD
� Triggers: ADHD-triggered by sensory and emotional overstimulation; BAD-react more to limit setting
� ADHD does not show depressive as primary predominant symptom
� Arrousal in morning: ADHD- arouse quickly and alert within minutes; BAD-fuzzy thinking and irritable
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� Sleep disturbances often occur with night terrors of MOR themes
� BAD children may show some giftedness in specific cognitive abilities (verbal and artistic).
� Misbx: ADHD-accidental due to not paying attention to details; BAD-intentionally provoked
� Risk-seeking: ADHD-unaware of consequences; BAD is risk-seeking
� Reality testing: ADHD unremarkable; Bipolar -oh boy!
� Pre-ads/Young Ads
� MDD
� Rapid-cycling
� Chronic, continuous cycling
� Nonepisodic
� Older Ads/Adults
� Mania
� Discrete with sudden onsets/clear offsets
� Weeks
� Improved functioning
� Child: Speech-language disorders
ADHD, ODD, Conduct Disorder, Sexual Abuse
� Ads: ADHD, ODD, CD, Sexual Abuse, Schizophrenia, SA
� Adults: Psychosis, SA, Antisocial Personality Disorders
�Do not fall neatly into current adult nosology
�Longitudinal monitoring because diagnoses are unstable and comorbidities may not be seen each time, or be developed yet
�60% of bipolar adults report first symptoms as children or adolescents.
�Positive family history with early age of onset could signify genetic anticipation and higher genetic loading.
� ADHD
� Conduct disorder
� Oppositional defiant disorder
� Substance abuse
� Depression/anxiety disorders
� “Bad child” – delinquent, violent
Pediatric mania is easily misdiagnosed –differential diagnosis or comorbidity?
�Early age of onset is associated with increased family history of the disorder.
�Fewer stressors are seen in early onset cases.
�Morbid risk of bipolar disorder in first-degree relatives is 4-6 times higher than in the general population.
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� Excessively comorbid by adult standards
� Chronic irritability/mixed – Can be associated with aggression and unpredictable behavior
� Frequent temper outbursts, often aggressive
� Positive family history
� Comorbid ADHD (more likely in younger children and in males)
� High rates of conduct disorder and delinquency in adolescents
� 20-30% of adolescents with MDD will have an eventual manic episode.
�Increased energy: 100%
�Irritability: 98%
�Accelerated speech: 97%
�Elated mood: 89%
�Rapid cycling: 87%
�ADHD: 87%
�Grandiosity: 86%
�Oppositional defiant, conduct disorder: 76%
Geller, et al.; 2001.
� The use of BP, NOS most commonly given
� Higher genetic component-
� 48% of first degree relatives for children verses 25% for adults
� Accepting reported bipolar dx in family members
� Comorbidity is the rule rather than the exception
� The Handle Symptoms
� Adolescents more likely to be rapid cylcers
� Anger does not = Bipolar Disorder
� Two extremes of diagnosing in reaction to diagnostic trends
�ADHD: 4.9 years
�ODD: 6.1 years
�Bipolar disorder: 6.7 years
�Unipolar depression: 6.7 years
�Psychosis: 9.2 years
Frazier, et al.; 2001.
� Usually not exacerbated by stimulants
� Definitely can be exacerbated by antidepressants
� Mood stabilizers and atypical antipsychotics the standards for treatment
� Mood instability trumps ADHD in priority and sequence of treatment.
� Misleading research
� Kindling effect
� Sensitivity verses specificity
� The “spectrum”
� Comorbidity
� Grisso-”moving targets.”
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� Improved assessment methodology
� Again, “spectrum” assessment trends
� Sleep Apnea
� Asthma
� Inner Ear Infections
� Pervasive Development Disorders
� #1 6-12 year olds with inattention, hyperactivity, impulsivity, academic underachievement ADHD assessment conducted
� #2 The dx of ADHD must meet DSM criteria
� #3 The assessment requires evidence directly obtained from parents in various settings
� Scales are a clinical option
� Do not use broadband scales
� # 4 Assessment information from school
� #5 Evaluation of co-existing Conditions
� #6 Other diagnostic tests
� THE MTA STUDY (largest treatment study of ADHD ever conducted).
� The study represented the combined efforts of investigators at 6 different sites around the country and included 579 children ages 7 to 9.9 years who were diagnosed as having ADHD, Combined Type using state-of-the-art diagnostic procedures.
� After participants had been identified they were randomly assigned to 1 of 4 different treatment conditions. Fourteen months later, the participants were carefully evaluated so that the impact of the different treatments could be evaluated (CT, CC, MO, BTO).
� Not a study of what worked but rather a study that measure the effectiveness among treatments
� Behavioral-psychosocial treatment most appropriate when:
� Milder ADHD
� Preschool-age children
� There is a presence of comorbid social skills deficits
� The family prefers psychosocial treatment
� A combo of medication/psychosocial treatment when:
� More severe cases
� Significant aggression or severe problems in school are present.
� Severe family disruption caused by ADHD symptoms
� There is a need for a rapid response.
� Combined type present
� For all age groups except preschool
� With the presence of comorbid externalizing disorders, mental retardation, or central nervous system problems
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� Parent Management Training
� Organization Skill Enhancement
� Social Skill Development
� Child Interventions
� ADHD Monitoring System
� Working Memory Training
� School Based Interventions� Daily Report Card
� Classroom Techniques
� Teacher Techniques
� Adequate assessment & diagnosis
� Interface of other medical conditions� Sleep debt/apnea
� Poor diet
� Learning problems
� Executive Dysfunction interventions
� Parent management training
� Lifestyle management
� Neurofeedback/relaxation
� Chiropractic intervention
� Diet and Nutrition
� Research on psychotherapy has been largely ignored with Bipolar patients as compared with Depressed patients due to the large focus on the biological basis of the disorder
� Therapy tends to focus on increasing medication compliance and managing the consequences of behaviors
� Some newer focus has surged, particularly with CBT focusing on stress management, compliance, and managing manic cognitive distortions
Adams and Sutker (2001)
� Interpersonal and Social Rhythm Therapy
� It postulates that stressful events, disruptions in circadian rhythms and personal relationships, and conflicts arising out of difficulty in social adjustment often lead to relapses.
� Cognitive Behavioral Therapy (CBT)
� Medication Adherence and Psychoeducation
� Is Family Therapy Effective?
� Evidence for Alternative Treatments?
� Herbal Supplements
� Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)
� Lithium (Treatment and maintenance)
� Tegretol (Treatment and maintenance, particularly for rapid cycling)
� Depakote (Manic episodes that do not respond to lithium, up to 20%)
� Wellbutrin (some use with bipolar)Adams and Sutker, 2001
� Also some use of antipsychoticsGeller & DelBello, 2008
� Clinical triall to study people who are bipolar experiencing a depressed state.
� Largest federally funded study on Bipolar Disorder
� Purpose: explore a range of treatment options for Bipolar Disorder
� Assessed long-term psychosocial treatments v. short-term, talk therapy treatment outcomes
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� Longer-term treatments (30 50 minute sessions):
� CBT
� Interpersonal and Social Rhythm Therapy (SRT)
� Family Focused Treatment (FFT)
� Short-term aka “collaborative care”:
� 3 50 minutes sessions over six weeks
� Educational videotape
� Other educational workbook activities
� Developed a treatment contract to prevent episodes
� Results:
� Of 293 patients, 59% recovered from depression
� The intensive therapies:
� More successful recovery rate (64 percent v. 52%)
� Recovery rate was faster following (113 v. 146 days)
� More likely (1 ½ times) to remain well during any given month of the study.
� Therapies (77% of FFT recovered, 65% IPSRT, 60% CBT).
� Overview of testing that has traditionally been utilized in the assessment of ADHD/Bipolar Disorder
� Evidence-Based Assessment:
� Intelligence/Achievement Testing
� Neuropsychological Testing
� Projective Testing
� Inventories
� Performance Tests
� Intelligence/Achievement:� Evidence is conflicting whether can adequately
discriminate groups of ADHD children from non-ADHD.
� IQ/Achievement probably contribute in more indirect ways particularly in the area of establishing impairment.
� Assists in ruling-in/ruling-out reasons for complaints.
� Assist in identification of cogntive factors impacting inattention.
� Should they be considered in every assessment case?
� Neuropsychological Tests:
� Stroop Word-Color Test: cannot be used accurately
� Rey-Osterrieth Complex Figure Drawing: cannot be used accurately
� Trails Making Test: cannot be used accurately
� Continuous Performance Tests: the most evidence-based of current tests.
� Limited studies demonstrate the predictive validity of the use of projective methods to discriminate ADHD from non-ADHD.
� Rorschach has some promising research
� Observational Measures:
� Clinical Observations
� Test Observation Form (TOF)
� Response to medication
� The petri dish experiment
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� Rorschach should never be sole source for diagnosis of ADHD!!!!!!
� Tend to narrow stimulus field; simplify more complex situations (High Lambda; 1.53 Comprehensive System; F%/Simplicity in R-PAS)
� No significant differences between Adj D or D (No Equivalent in R-PAS) between ADHD, Clinical Group, Control Group
� Fewer Sum C; more shading; lower Afr (R8910% in R-PAS); fewer blends
� Lower egocentricity scores (No Equivalent in R-PAS)/more negative judgments about relationship between self/others
� Fewer COP’s and fewer AG (AGM in R-PAS)� Less comfort in interpersonal situations; lower Pure H
� Lower WSum6 (7.78); (WSumCog in R-PAS)
� Lower P’s
� CDI significant (No Direct Equivalent in R-PAS)
� Unconventional thought process, but without the significant distortions seen in clinical population
� More exaggerated Lambda’s
� Thinking distortions more related avoid most stimuli
� Premature disengagement from stimuli (lower Zd/Zf).
� First Challenge: PTSD is only ONE outcome of trauma
� Trauma = From a psychological perspective it’s an emotional response to a terrible event
� Appraisal is important indicator
� All my fault?
� Totally helpless?
� High Arousal will look similar to ADHD even though ADHD is triggered by a LOW arousal!
� Bipolar is more like organic arousal that will look like triggered (PTSD) arousal AND low arousal response (ADHD)
� How to differentiate?
� History Helps
� Age of onset
� Key events?
� Treatment and Response to Intervention
� Caveats?
� Sleep influence
� Sleep History
� Medical History (Sleep Apnea, Frequent Ear Infections, etc)
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� ADHD
� Defer until last
� May still be underlying, but need to identify most acute complaints first
� Also no CARDINAL symptoms mean even if you answer all diagnostic questions in the affirmative you have not confirmed ADHD!
� Where so many fail!!!
� Bipolar
� Can you identify manic or mixed symptoms? (Required)
� How long are outbursts occurring? (more than an hour?)
� How intense are outbursts?
� Can increased energy be confirmed?
� Remember the brain! (ADHD – Executive Functioning; Bipolar – Emotional Dysregulation; PTSD – Triggering events and external influence)
� PTSD
� Can triggering event be identified? If not, trauma can still be relevant even if you don’t diagnose PTSD
� Attention Problems/Hyperactivity could be in fact keyed-up OVER-ATTENTION (monitoring)
� Any subtle behavioral clues?
� How do they respond when you give them a focusing task?
� Many individuals with anxiety/ptsd focus well and actually calm themselves with tasks
� Underlying ADHD can increase risk of PTSD
� Problems gathering and using information can complicate appraisal of events which heavily influences PTSD factors
� Can ADHD be identified prior to traumatic events
� ADHD is a performance-based issue; may need performance-based assessment alongside full evaluation
� Bipolar – many mood factors are easier to identify when paired with test data
� PTSD – Residual effects of trauma also easier to isolate with testing
� But sometimes time or resources don’t allow this approach
� Let the conceptualization guide the assessment
� Don’t jump straight to diagnosis!
� Is this patient:
� Anxious and keyed up (as well as avoidant) because they need to avoid certain outcomes
� Requiring something novel and interesting to further arouse focus and consistency?
� Prone to “losing it” for extended time periods? (more sustained in duration than is typical for PTSD)
� Shoe Shopping!
� Try on different diagnoses…
� If this is ADHD, the following behaviors do/don’t make sense as explained by dx
� Try to reduce the equation to fewest number of diagnoses
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� ADHD – Peeling back layer of the onion (what’s left)
� Degrees of certainty rather than “confirming”
� Additive: Sleep Problems? Sleep Apnea? Early Ear Infections, Asthma, etc
� PTSD – Don’t rush to it as dx just because a trauma occurred – it’s a very specific set of reactions
� One of the most effective ways of narrowing it down
� Bipolar – Is affect brain lighting up and flooding person?
� Genetics, etc
� Remember age of onset info
� Assess mood upon awaking! (Cranky/Sluggish v. Good to go!)
� IF PTSD, diagnose ADHD primarily if able to identify underlying premorbid condition
� IF Bipolar, ADHD is unlikely
� IF ADHD, Bipolar is unlikely
Axis I Attention-Deficit Hyperactivity D/O
Bipolar D/O
ITS BOTH :}