Download Kevin Leehey M.D. Child, Adolescent, and Adult Psychiatry

Kevin Leehey M.D.
Child, Adolescent, and Adult Psychiatry
Board Certified
520-296-4280
leeheymd.com
Differentiating and Treating
Bipolar Disorder and ADHD
July 27, 2007
Kevin Leehey M.D.
Differentiating and Treating
Bipolar Disorder and ADHD
The current # 1 controversy in Child and
Adolescent Psychiatry is how to
diagnose and treat Bipolar Disorder in
youth; especially before puberty.
Differentiating and Treating
Bipolar Disorder and ADHD
Why does it matter so much?
Bipolar Disorder (BD)
BD is frequently a disabling chronic and
recurrent life long disorder with a worrisome
prognosis.
BD medications are “big guns” with variable
benefit and side effects.
Early onset BD may have worse prognosis.
Hard to get health and other insurance.
Employment, military, police, and professional
licenses are often problems.
Genetics and family planning.
Stigma
Why does Mania matter so much?
The presence of Mania (or Hypomania)
changes the diagnosis to Bipolar I or II
(with few exceptions) for life.
DSM IV-TR Mania Dx requires 3 Sx of 7 if
elevated mood for 7d, 4 if only irritable mood
1) Inflated self esteem or grandiosity
2) Decreased need for sleep
3) More talkative than usual; pressured speech
4) Flight of ideas or subjective feeling that
thoughts are racing
5) Distractibility
6) Increase in goal directed activity
7) Excessive involvement in pleasurable
activities with a high potential for painful
consequences
ADHD Diagnostic Criteria
Six (or more) of the symptoms of inattention have
persisted for at least six-months to a degree that is
maladaptive and inconsistent with developmental
level
Or six (or more) of the symptoms of hyperactivityimpulsivity have persisted for at least six-months to a
degree that is maladaptive and inconsistent with
developmental level
Present before the age of seven.
Inattention :
a)
b)
c)
d)
e)
f)
g)
h)
i)
Often fails to give close attention to details or makes careless mistakes
in schoolwork, work, or other activities
Often has difficulty sustaining attention in tasks or play activities
Often does not seem to listen when spoken to directly
Often does not follow through on instructions and fails to finish
schoolwork, chores, or duties in the workplace (not due to oppositional
behavior or failure to understand instructions)
Often has difficulty organizing tasks and activities
Often avoids, dislikes, or is reluctant to engage in tasks requiring
sustained mental effort (such as schoolwork or homework)
Often loses things necessary for tasks or activities (ie: toys, school
assignments, pencils, books, or tools)
Is often easily distracted by extraneous stimuli
Is often forgetful in daily activities
Hyperactivity:
Often fidgets with hands or feet
and squirms in seat
Often leaves seat in classroom
or in other situations in which
remaining seated is expected
Often runs about or climbs
excessively in situations in
which it is inappropriate (in
adolescents or adults, may be
limited to subjective feelings of
restlessness)
Often has difficulty playing or
engaging in leisure activities
quietly
Is often “on the go” or often
acts as if “driven by a motor
Often talks excessively
Impulsivity:
Often blurts out answers
before questions have been
completed
Often has difficulty awaiting
his/her turn
Often interrupts or intrudes
on others (eg: butts into
conversations or games)
Differentiating and Treating
Bipolar Disorder and ADHD
The DSM IV criteria for ADHD and the
Manic and Hypomanic phases of
Bipolar Disorder overlap thereby making
it easier for an ADHD youth to be
diagnosed BD; and vice versa.
DSM IV-TR Mania dx requires 3 Sx of 7 if
elevated mood for 7d; 4 if only irritable mood
1) Inflated self esteem or grandiosity
2) Decreased need for sleep
3) More talkative than usual or pressure to keep talking
(“often talks excessively”)
4) Flight of ideas or subjective feeling that thoughts are
racing
5) Distractibility
6) Increase in goal directed activity
7) Excessive involvement in pleasurable activities with a
high potential for painful consequences
Sources of Controversy
Overlapping signs and symptoms
Overlapping Diagnostic Criteria
Patient sampling errors in research
Redefining the syndrome of BD in youth
especially pre puberty
Youth with both ADHD and BD
Youth with ADHD who later develop BD
“ADHD” Youth who turn out to have only BD
Arguments about the coming DSM V
BP in kids redefined
Broad Phenotype, eg, Bipolar NOS
Chronic continuous irritable, anger, or sad
Not episodic
Often Mixed (simultaneous manic and
depressive) signs and symptoms
Ultra Rapid Cycling - even multi per day
Neither 5d (Hypomania) nor 7d (Mania) nor
14 day (Major Depression) durations required
Only 25% have Bipolar as adults !
“Affective storms”, rage, extreme reactivity
Hyperarousal, extreme agitation, volatility,
intrusiveness, restlessness, lability
Bipolar Disorder
Initial presentation in youth is most often
Major Depression, not Mania or
Hypomania.
Narrow Phenotype Criteria
DSM IV-TR tightly followed
“A distinct period of abnormally and
persistently elevated, expansive, or
irritable mood, lasting at least…”
Intermediate Phenotype Criteria BD
Same as DSM IV-TR except 5 and 7
day periods not required, 1-3 days
enough. Elevated, expansive not
required; irritable is enough.
Differentiating BD and ADHD
ADHD earlier onset
ADHD is continuous, not episodic
DSM IV - TR (Narrow Phenotype)
ADHD alone does not include psychosis
ADHD alone does not include Major
Depression or suicidal ideas or behavior
Extreme incapacitating anxiety may indicate
BD (ADHD alone doesn’t include severe
anxiety)
Differentiating BD and ADHD
Grandiosity, elevated mood, racing thoughts,
flight of ideas, and much increased
inappropriate behavior (silly, daredevil,
sexual), decreased need for sleep, all
together indicate BD, not ADHD
Irritablity, rapid speech, high energy, and
distractibilty often occur in both ADHD and
BD - they do not differentiate.
Family History is an important guide.
Make the diagnosis over a period of time
(unless mania)
Medications for ADHD-1
Stimulants
Methylphenidate
Short and extended duration
Amphetamines
Short and extended duration
Pemoline (Cylert)
Medications for ADHD-2
Non-stimulants
Atomoxetine (Stattera)
Tricyclics (Imipramine, Desipramine)
Buproprion (Wellbutrin)
Partial alpha agonists [Guanfacine (Tenex),
Clonidine]
Medications for ADHD-3
Beads/sprinkle
Adderall XR, Ritalin LA, Metadate CD, Focalin XR
Liquid
Methylin, Amantadine (Symmetrel)
Chewable
Methylin
Patch
- Catapres, MPH (Daytrana)
Osmotic pressure release
- Concerta
Compounding
Prescribing for ADHD-1
Co-morbidity: Depression, anxiety, tics, substances,
bipolar, nicotine
Height, weight
Appetite decrease and low weight is the most
common limiting stimulant side effect
Class II, no “refills”, 60 days, less on base post, out of
state varies, 90 day mail order
Match side effects as well as good effects
Prescribing for ADHD-2
Duration
Convenience
Weight (height less of a concern)
Tics
“Meaner”
Abuse of stimulants
Truck driver, pilot
Treating Bipolar Disorder
Mood stabilizers
Antipsychotics
Antidepressants, antianxiety
Sleep
Stimulants and nonstimulants for ADHD
Psychosocial, family, psychoeducation,
PCP
Principles in Treating Bipolar
Disorder and ADHD
If ADHD present, treat ADHD
If BD present, treat BD
If both present, treat both. Usually, first
stabilize the mood disorder. Then see
what’s needed.
Psychosocial treatments also. School,
family, PCP, activities, psychoeducation
Treating Bipolar Disorder
Few studies and no specific BD FDA
approved meds pre puberty.
We use the same meds as in
adolescents and adults.
Monitor as adults but extra caution labs, weight, BMI, (height), AIMS, EKG
Assume kids are more sensitive to side
effects, pediatric psychopharmacology
Treating Bipolar Disorder
Stimulants are not contraindicated but use
with caution unless also Mood Stabilizer
Antidepressants are not contraindicated but
use with caution unless Mood Stabilizer.
Atypical Antipsychotics are fast, often help
and cover multi targets.
We need better medicines !
Don’t neglect developmentally informed
psychosocial interventions !
Mood Stabilizers
lithium
valproic acid (Depakote)
carbamazepine (Tegretol)
oxcarbazepine (Trileptal)
lamotrigine (Lamictal)
Antipsychotics
risperidone (Risperdal)
quetiapine (Seroquel)
ariprazole (Abilify)
ziprasidone (Geodon)
olanzapine (Zyprexa)
clozapine (Clozaril)
perphenazine
chlorpromazine
Case 1
John is a 7 year old 50 pound boy in his 6th
week of taking 10 mg TID (am, noon and 4
pm) of mixed amphetamine salts for
presumed ADHD who now shows
prominent impulsive rageful aggression
with 5 lb weight loss and new 2 hour sleep
onset delay.
What do you do?
Case 2
Cherie is an 8 year old girl dressed in excessive
“jewelry”, gaudy self made purse, and tight
teen “fashion” clothes her mother abhors but
can’t stop. She has just begun, totally on her
own, collecting cash door to door to save the
rain forest. She was irritable and very down
for 2 months but is now way up. She has
always been moody. Academics, peer and
family relationships have suffered. She’s
skipping meals and sleeps 4 hours: “I don’t
need to eat or sleep”. Maternal aunt has BD.
What do you do?
Case 3
Connor is a 16 year old in a boarding school for
boys with serious substance abuse. Even in
this group he is loud, volatile, and moody. He
calmly tells you he wants off the Trileptal he
was given while living at home. His history is
dramatic for athletic skill unfulfilled by
consequences for drug use, drug deals,
promiscuity, impulsivity, fights and property
damage, and impressive risk taking.
What do you do?
Case 4
Ann is a 13 year old athlete and dancer
who was started on Depakote by her
neurologist for seizures (no BD SSx). In
the first month she gained 5 unneeded
excess lbs which upsets Ann and her
mother. Her mother, whom you know
through the kids’ sports asks your help.
What do you do?
Finis
Kevin Leehey M.D.
1980 E. Fort Lowell Rd. Suite 150
Tucson, AZ 85719
Phone: 520-296-4280
Fax: 520-296-3835
leeheymd.com
[email protected]