ADHD Case Presentation


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Case presentation on ADHD and comorbidity

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ADHD Case Presentation

  1. 1. Addicted to Chaos A case presentation with an unexpected end DrYasir Hameed (SpR) Dr Jaap Hamelijnck (Consultant) Eastern RecoveryTeam 18 March 2014
  2. 2. Overview  The story will flow from present to past. keep an eye on small details  How easy to miss the whole picture, especially in crisis  Stop, think and then think again, and again
  3. 3. “You only see what your eyes want to see” In psychiatry, this is exceptionally true….
  4. 4. Meet SB  35 year old single woman, lives alone, working in a pub, presented with serious overdose in August 2013 and long history of mental health problems going back to 12 years of age  Childhood?
  5. 5. Chief complaint  Low mood for most adult life  Relationship difficulties  Poor self esteem  SUICIDAL
  6. 6. HPI 1) Self harm and suicide  Started to think about suicide since age 12  Started to superficially cut herself at age  Gets a “buzz out of it”, hoping someday she will do it properly  Overdoses at age 13 and 18. Constant thoughts of suicide
  7. 7. August 2013 overdose  Overdose was well planned  Left detailed suicidal note  66 tablets of venlafaxine XL 150 mg  Initial referral stated 6 tablets  ITU: seizures and loss of consciousness
  8. 8. Referral to ERT August 20313  “…an impulsive but deliberate overdose”  “….was one of several more serious self harm attempts Susan has made in her adult life”  “S---- denies any further intent to harm herself at this time, did not want crisis team support, but was open to having her medications further reviewed by a psychiatrist”
  9. 9. HPI 2) Mood  Variable,“moody”  Easily irritable  Worrier  Impulsive (gambling, binge eating, binge drinking, shoplifting)
  10. 10. Substance misuse  Alcohol  Cannabis  Amphetamine Variable and no dependence
  11. 11. Relationship difficulties  Five short relationships since age 17  Love/hate relationship with family, friends and the church  Poor self esteem  Feels unloved
  12. 12. “I need help but I don’t know how or what, all I wanted has been provided for me, therapist, CPN, and I am still poorly-that is why I want to kill myself” SB
  13. 13. Any initial thoughts?
  14. 14. Past psychiatric history  Has been know to psychiatric services since she was 18 years old  Disturbed as a child, no help sought  At age of 15-16 treated for depression by GP, not getting along with her step father  Comfort eating, overweight, sometime make herself sick
  15. 15. Summary of psychiatric assessments  Age 18-19 (1997): ◦ Referred by GP for severe depression and anxiety and suicidal thoughts ◦ Overdose ◦ Relationship ending ◦ Poor engagement and chaotic
  16. 16.  April 1999: Consultant clinical psychologist report ◦ Several patterns of addictive behaviour ◦ Amphetamine gave her confidence and good feeling about herself ◦ Poor response to antidepressants ◦ Sees suicide as the only escape ◦ Very poor self-image ◦ She wants to get better and work
  17. 17.  October 2000 ◦ Admitted informally for a week ◦ Suicidal thoughts ◦ Reversed sleep pattern ◦ Poor concentration and motivation Discharge report: “discrepancy between her account of her mental state and the observations made by staff on the ward.There were no positive signs of any depressive symptoms during her stay on the ward. She has become more settled and she was socialising well with others”
  18. 18.  June 2001 ◦ Re-referred from GP ◦ “I would be grateful for your help regarding (S) whose mother, (AS) is a colleague of yours in Occupation Therapy” ◦ Very depressed  Nov 2001 ◦ Clinical psychologist: Moderately depressed with moderate-severe anxiety ◦ Main problems: her personality development has been influenced by her weight and her perception of her body shape
  19. 19. From 2002-2012  Overdoses and self harm, not meeting the criteria for acute services (2012)  Offered psychological input  Not much information recorded
  20. 20.  Jan 2013: ◦ Completed 16 session of CAT ◦ Difficulty in managing her daily life and how busy her head is and how impossible it is to switch off. ◦ “Could not really say that therapy had helped or that she would be able to use this to inform her future. However has made some changes to her life in a positive way and her relationships have improved with friends and family. No further input at present. Close”
  21. 21. Family history  All reports from psychiatrists mentioned no family history of mental illness until I assessed her in 2013!
  22. 22. Medication and allergies  Treated with fluoxetine, paroxetine, Temazepam and venlafaxine until 2013  No allergies  No significant past medical history
  23. 23. Personal history  6th of five daughters  Pregnancy was uneventful, mother did not smoke or drink alcohol  Normal delivery  Normal developmental milestones, spoke early and could not stop talking!
  24. 24. Personal history (cont’d)  Religious upbringing of Mormon parents  Parents separated when she was 9  Bullying  Poor social skills, never said appropriate things, and never saw it as inappropriate
  25. 25. Personal history (cont’d)  Left school aged 16 with poor grades and obtained BTEC diploma in Nursery Nursing  Few seasonal jobs  Short term relationships
  26. 26. Social history  Drink socially but binges when low or anxious  Smokes 2-3 cigarettes a day  Cannabis on and off and used speed  In debt
  27. 27. Premorbid personality  Moody, easily irritable, worrier. Few friends.  Feels unloved  Feels judged by others
  28. 28. Diagnosis?
  29. 29. My first appointment  Diagnostic labels she already had: ◦ Adjustment disorder ◦ “Immature personality problem” ◦ Borderline Personality Disorder ◦ Recurrent depression ◦ Generalised anxiety disorder  Medication: ◦ Venlafaxine 75 mg bd
  30. 30. My initial thoughts (Nov 2013)  Current problems: chronic low mood and anxiety, unable to sleep, unable to shut down, very sensitive to comments  Preoccupation with death, yarning for death, fantasies about death  Imp: ? Personality, willing to engage, medication review, switched venlafaxine to sertraline
  31. 31. Second appointment (Jan 2014)  Struggled with the switching.  Reported elation in mood for three to four days  Significant mood swings  Very suicidal  Christmas was disastrous  Everybody is avoiding her  Feels she betrayed her family
  32. 32.  Past periods of hypomania lasting about a week with irritability, hyperactivity, lacking sleep, much more interested in sex, talk excessively, overspending, then depressed
  33. 33.  Two of her sisters had been treated for bipolar  ?mother
  34. 34.  She was told that she has manic depression  Mood disorder questionnaire: answered yes to all 13 questions with problems affecting her life significantly
  35. 35. And more…  Constant difficulty in sustaining her concentration and attention, since she was a child  Had problems at school due to her hyperactive behaviour  Can’t remember her childhood  Used amphetamine during early twenties for 6 months and had significant calming effect
  36. 36. History from mother  As an OT, she always suspected that her child had ADHD  S never slept well, always on the go, poorly attentive. No one could cope with her  Completed an checklist for screening of ADHD for her daughter and she was positive  Was embarrassed to bring her forward for assessment (fear of stigma)
  37. 37. Following appointments  Quetiapine added  Mood diary suggestive of bipolar disorder  Moods are general more stable following quetiapine  Alcohol drinking is part of her job and boredom, never drinks at home, effect on her medication  Gained some weight, worried  Suicidal thoughts are slightly improving
  38. 38.  ADHD assessments completed and confirmed the diagnosis of combined ADHD (DSM IV) using structured interview (DIVA®)  Age of onset: 3 years  Features of Oppositional Defiant Disorder and Conduct Disorder as a child (deliberately destroyed property, lied to obtain goods, shoplifting)
  39. 39. Assessment tools Current symptoms scale- self report form: IA 6/9. HI 8/9. Most areas affected. ODD 4/8. Childhood symptoms scale- self report form: IA 8/9. HI 8/9. Most areas affected. ODD 4/8. CD 3/15. Current Symptoms Scale-other: IA 9/9. HI 8/9. age of onset 3 years.All areas affected. Childhood Symptoms Scale-other: IA 8/9. HI 9/9.All areas affected. ODD 8/8. ASRS-v1.1 Part A 4/6. Part B 10/12.
  40. 40. The Conners’ Adult ADHD Rating Scales–Self Report: LongVersion (CAARS–S:L)  The Conners' Adult ADHD Rating Scale, a 66-item assessment has a diagnostic sensitivity of 82%, specificity of 87%, and PPV of 85%.
  41. 41. Self report score
  42. 42.  “S did not sleep at night until she was nearly 4 years old. She never settled to anything for long. She was a sad child”  Mother’s comment on assessment forms
  43. 43.  Asperger's assessment is undergoing, high Autism Quotient (AQ), and Relatives Questionnaire (RQ) scores suggestive of Asperger’s
  44. 44.  Methylphenidate started with remarkable results  Suicidal ideation completely gone  Mood is much better  Still long way to go…
  45. 45. ADHD/Bipolar/Personality Disorder? Incidence rates of bipolar disorder in clinical samples of adults with ADHD have ranged from 3%-17% (Brown, 2011) Among children with ADHD estimated incidence of bipolar disorder has ranged from 2.4% to 21% (Arnold, et al. 2011) Overlap between ADHD and BD not only insufficient ability to manage and modulate emotions but in addition, two additional executive functions often impaired a) ability to inhibit and manage actions, and b) ability to regulate levels of arousal.
  46. 46. ADHD and personality disorder: Miller, Nigg and Faranoe (2007) studies 363 adults with ADHD and compared them to non-ADHD controls in relationship to personality disorder.Adults with ADHD had a higher incidence of both cluster B and C. Controls % ADHD % Cluster A No difference Cluster B 9.5 24.4 Cluster C 4.3 21.0 The most frequent Cluster B personality disorder in ADHD was Borderline PD In Cluster C, the most common type was OC PD
  47. 47. In the differential diagnostic assessment, the following criteria are used: 1.The frequency of the mood swing (4–5 times a day in ADHD and cluster B personality disorders, a minimum of 2–3 days in a hypomanic episode) 2.The course (chronic in ADHD and cluster B personality disorder, episodic in bipolar disorder) 3.The age of onset (childhood in ADHD, usually later in the bipolar and personality disorders)
  48. 48. ADHD and Suicide The incidence of death from suicide is nearly 5 times higher among adults who had had childhood ADHD compared with control participants (N = 367) Barbaresi et al. Mortality,ADHD, and Psychosocial Adversity in Adults With Childhood ADHD:A Prospective Study. PEDIATRICSVolume 131,Number 4,April 2013.
  49. 49. The chance of suicidal tendencies in adolescents and adults with ADHD compared to controls is elevated mainly in the presence of hyperactivity/impulsivity, depression or dysthymia, and the antisocial behavioural disorder (Barkley and Fischer 2005 ; Semiz et al. 2008 )
  50. 50.  In research, among adolescents 36 % of the patients with ADHD had suicidal thoughts before the age of 18, versus 22 % of a control group.  For suicide attempts, these numbers were 16 % versus 3 %. (Barkley and Fischer 2005 )
  51. 51. Young women diagnosed with ADHD, were three to four times more likely to attempt suicide and two to three times more likely to report injuring themselves than comparable young women in a control group Hinshaw et al. Prospective Follow-Up of Girls With Attention-Deficit/Hyperactivity Disorder Into Early Adulthood: Continuing Impairment Includes Elevated Risk for Suicide Attempts and Self-Injury. Journal of Consulting and Clinical Psychology.American Psychological Association. 2012,Vol. 80, No. 6, 1041–105.
  52. 52. ADHD and Autistic Spectrum Disorders (ASD)  41 % of the children with autistic spectrum disorders also had many ADHD characteristics, and 22 % of those with ADHD characteristics also had the diagnosis autistic spectrum disorder.  Suggested a joint genetic influence in both disorders (Ronald et al. 2008 ) .
  53. 53. Conclusion  Think about ADHD when you see the red flags  ADHD is real and treatable Refer  Learn more about ADHD
  54. 54. Red flags ADHD in Adults.The latest assessment and treatment strategies. Russel Barkley PhD. 2010  Self-control  Responsibilities and restless  Impulse-control  Time management and organisation  Repeated failures in self care programmes such as weight loss, smoking cessation, or substance abuse treatment  Poor educational achievement  Poor occupational functioning  Poor satisfaction with interpersonal relationships  Substance dependence and abuse