Download A Diagramatic Approach to Individuals with Multiple Psychiatric

A Diagrammatic Approach to
Individuals with Multiple
Psychiatric Symptoms:
Focus on Bipolar Disorder
Patsy Hoyer FNP, IU Health Neurology
Laura Hawkins, Psychiatric NP
private practice
Patsy and Laura have no financial conflicts to
disclose
1 % population has classic Bipolar 1
• Include spectrum or forme fruste=5%
• Note: ADHD =5% (more men than women)
• (75% of children with ADHD go into adulthood
with impairments)
Bipolar disorder is multi-symptomatic, and
spectrum conditions may be hard to identify
Clinical talk from our experiences
• Important. The correct diagnosis significantly
improves the likelihood of providing correct
treatment (Obviously).
• This diagram is useful to organize and
compare symptoms of various diagnoses
• Helpful when shown to patients
• Often drawn for them on exam table paper
Elements for Consideration
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Current symptoms and functioning
Longitudinal history, emergence, and chronicity
Associated symptoms
Medications tried before and response
Medical conditions, meds, TSH, Vit D
Drug and alcohol use, current and past, ?to get
high, social, self-medicate
• Family Psychiatric history (often not done),
*genetics is not a diagnosis
Classic Bipolar Disorder
• Mania only need one
• Depression (s)
• Mixed episodes-anger/rages
Anxiety
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About 20% of population
Excessive worry
Various presentations
Generalized, pobias, panic attaks, OCD,
avoiders, agoraphobia, hoarders, people who
keep little clutter
• PTSD is a variant
PTSD
• 3-5% population
• History of trauma, experienced or witnessed
• Intrusive thoughts, nightmares, avoidance,
can be angry and aggressive, depressed
*Data from military: soldiers with ADHD are at
higher risk in same situations. (reason?)
Depression
• 7% of population had a depressive episode in
last year. More Women than men.
• Present as sad, empty, having somatic and
cognitive changes that affect ability to
function including changes in sleep energy,
lack of interest, low self esteem, hopelessness.
• May be passive or very irritable.
*High rates of comorbidity (including ADHD of
16% in first presentation)
Alcohol and Drug Use
• Often begins as self medication
*Addiction very hard to treat unless
underlying/comorbid conditions are also treated
Borderline Personality Disorder
• Believed to be more frequent in women
• Often diagnosed as PTSD or Bipolar disorder—
some mania checklists will not distinguish from
Bipolar disorder
• Activities to avoid abandonment, unstable
relationships, and self image, impulsivity, suicidal
ideation, self harm, anger and dissociation
• The Drama Queen-Tip to consider: Negative
manipulated feelings in provider
The hard part
• People can have multiple diagnoses on this
list
• Testing them out may take expert evaluation,
but suspicion is the critical first step
*May be initially, or when there is treatment
failure: re-evaluate medication; re-evaluate the
diagnosis
The Diagram Bipolar Comments
ManiaDigfast Mnemonic, can be used
• Distractibility
• Indiscretions
• Grandiosity
• Flight of ideas
• Activity increase
Bipolar ADHD Co-morbidity
• 20% of individuals with ADHD may also have
bipolar disorder
• 20-80% of individuals with Bipolar Disorder
may have ADHD
Comparison of
Mania and ADHD
Inattention
Distractibility
Wandering thoughts
Hyperactivity
Impulsivity
Racing thoughts
Hypermotor
Grandiosity
Bad choices with
consesquences
*Decreased need sleep
Diagram-Family History Bipolar
• will include others with diagnosed or
suspected bipolar disorder
• Suicides
• Rages
• Individuals with ADHD, depression, anxiety
and schizophrenia, alcohol and drug abuse
and addictions, possibly prison and jail
sentences.
Diagram Emergence
• Emergence, some in childhood (up to 40% of
depressed children will convert in 4 years)
• Adolescence—really terrible teens (ask what
high school was like)
• Young adulthood
• Post partum
• Menopause
• Anytime and Major bad life changing event
Treatment when patient has
Suspected Spectrum Condition
• Avoid SSRI’s
• Avoid Xanax (“only use for the mother of the
bride”)
• (Avoid prednisone-can destabilize)
• Consider vistaril, buspirone for anxiety,
propranolol for panic attacks, wellbutrin,
mirtazepine for depression
• Get consultation
• Everyone needs therapy often do better with
therapy when medication initiated
Laura Hawkins, Psychiatric NP
CASE STUDIES
CC: “I might have mild depression”
• 37 y/o married, Middle Eastern female,
graduate student
• Treatment history: several sessions of
counseling
• Loss of fertility
• Loss of father
• Loss of supportive academic department
• Religious/cultural adjustment
Presenting symptoms: Anxiety
• Constant worry
• Forgetful, poor short term memory, mind goes
blank
• Easily frustrated
• Sleeps 3-4 hours, wakes often
• Panic: shortness of breath, chest tightness
with presentations
Presenting symptoms: Depression
• Depressed mood, sadness, loneliness,
hopelessness
• Fatigue
• Poor concentration
• Decreased appetite
• 10 lbs weight gain over last year
• Social withdrawal
• Low motivation
• Poor sleep
• No suicidality
Presenting symptoms: Hypomania
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Elevated moods lasting 1 day, ~ once monthly
Increased goal directed behavior, productive
Impulsivity, interrupts
Racing thoughts
Decreased sleep without fatigue
• Diagnosis:
– Other Specified Bipolar and Related Disorder
– Generalized Anxiety Disorder
• Treatment:
– lamotrigine 100 mg qd
– buspirone 10 mg TID
– Continue psychotherapy
CC: “I think I’m suffering from manic
depression”
• Treatment history: several sessions of counseling
• 19 y/o single, white, male, Sophmore college
student
• Stable upbringing, intact, middle class family
• Some bullying in elementary school
• Childhood depression symptoms, worsening
through Freshman year at college
• No family mental health history
Presenting symptoms: Depression
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Depressed mood, worsening last several months
Normal appetite
Gained 10-20 lbs over last year
Sleeps well, 9 hours/night
Normal focus, procrastinates
Normal pleasure
No suicidality
No undue guilt
Worries, “a lot”
Presenting symptoms: Mania
• “Euphoric mood” throughout previous
summer
• Increased confidence in social situations
• Normal sleep
• Normal rate/volume of speech
• No racing thoughts
• No distractibility
• “A little,” increase in sexual desire
• Diagnosis:
– Dysthymia
• Social confidence remained despite return of
depressed mood
• Lack of school stress during summer
• Growth and development
• Treatment:
– fluoxetine 20 mg daily, later increased to 40 mg
daily
– Continued psychotherapy
CC: “stress, anxiety, anger, I pluck my
facial hair out”
• 33 y/o married, white, male, 14 y/o daughter
from prior marriage, works as skilled
machinist
• Family history: several maternal uncles,
alcoholic; daughter, ADHD
• Unstable upbringing
• High School grad., was diagnosed with
learning disability
Substance history
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Smokes 1 ½ packs cigarettes/day since age 17
Daily marijuana use age 16-18
Heavy daily drinking for 8 years, ended age 28
Resumed daily drinking one year ago, one 12pack beer weekly
• Xanax 0.5 3-6/day (above prescribed)
– Wife reports buying from co-worker
– “I know I’m an addict”
Presenting symptoms
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Anger, irritability
Racing thoughts
Constant worry about many things
Constant fatigue
Mind goes blank
Restless sleep
Plucks facial hair
Washes hands 30 times/day
Obsessive work
Evaluation for ADHD
• Remembers getting in trouble for:
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Being class clown
Talking in class
Not sitting still
Interrupting the teacher
Not listening
• Remembers:
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Made careless mistakes
Messy desk, backpack
Lost papers and homework
Forgetful
Hard time waiting his turn
Would only do homework, “because Mom would whip my butt”
Evaluation for ADHD
• Endorsed all inattention and hyperactivity
symptoms currently
• Hard to shift tasks at work
• Relationship with wife: “I consider my wife
smart and I’m stupid. It’s easier for me to
throw a fit than it is to think about a smart
reply.”
• Diagnosis:
– Generalized Anxiety Disorder
– Attention Deficit/Hyperactivity Disorder, Combined
Type
– Trichotillomania
– R/O Obsessive Compulsive Disorder
• Treatment:
– quetiapine 50 mg daily at hs, titrated from 25 mg to
100 mg daily
– propranolol LA 60 mg daily in AM
– Dextroamphetamine/amphetamine XR 10 mg daily
titrated to 40 mg daily
– Continued psychotherapy