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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 • • • • • • 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 • • • • 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 • • • • • 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 • • • • • • • • • 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 • • • • 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 • • • • • • • • • 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: – – – – – Being class clown Talking in class Not sitting still Interrupting the teacher Not listening • Remembers: – – – – – – 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