Addicted to ChaosAddicted to Chaos

A case presentation with A case presentation with an unexpected endan unexpected end

Dr Yasir Hameed (SpR)Dr Jaap Hamelijnck (Consultant)Eastern Recovery Team18 March 2014

OverviewOverviewThe 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

““You only see what your You only see what your eyes want to see”eyes want to see”

In psychiatry, this is exceptionally true….

Meet SBMeet SB35 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?

Chief complaintChief complaintLow mood for most adult life

Relationship difficulties

Poor self esteem

SUICIDAL

HPI 1) Self harm and HPI 1) Self harm and suicidesuicideStarted 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

August 2013 overdoseAugust 2013 overdoseOverdose 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

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”

HPI 2) MoodHPI 2) MoodVariable, “moody”

Easily irritable

Worrier

Impulsive (gambling, binge eating, binge drinking, shoplifting)

Substance misuseSubstance misuseAlcohol

Cannabis

Amphetamine

Variable and no dependence

Relationship difficultiesRelationship difficultiesFive short relationships since age

17

Love/hate relationship with family, friends and the church

Poor self esteem

Feels unloved

“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

Any initial thoughts?Any initial thoughts?

Past psychiatric historyPast psychiatric historyHas 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

Summary of psychiatric Summary of psychiatric assessmentsassessmentsAge 18-19 (1997):

◦Referred by GP for severe depression and anxiety and suicidal thoughts

◦Overdose◦Relationship ending◦Poor engagement and chaotic

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

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”

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

From 2002-2012From 2002-2012Overdoses and self harm, not meeting

the criteria for acute services (2012)

Offered psychological input

Not much information recorded

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”

Family historyFamily historyAll reports from psychiatrists

mentioned no family history of mental illness until I assessed her in 2013!

Medication and allergiesMedication and allergiesTreated with fluoxetine,

paroxetine, Temazepam and venlafaxine until 2013

No allergies

No significant past medical history

Personal historyPersonal history6th 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!

Personal history (cont’d)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

Personal history (cont’d)Personal history (cont’d)Left school aged 16 with poor

grades and obtained BTEC diploma in Nursery Nursing

Few seasonal jobs

Short term relationships

Social historySocial historyDrink socially but binges when

low or anxious Smokes 2-3 cigarettes a day

Cannabis on and off and used speed

In debt

Premorbid personalityPremorbid personalityMoody, easily irritable, worrier.

Few friends.

Feels unloved

Feels judged by others

Diagnosis?Diagnosis?

My first appointmentMy first appointmentDiagnostic labels she already had:

◦Adjustment disorder◦“Immature personality problem”◦Borderline Personality Disorder◦Recurrent depression◦Generalised anxiety disorder

Medication:◦Venlafaxine 75 mg bd

 

My initial thoughts (Nov My initial thoughts (Nov 2013)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

Second appointment (Jan Second appointment (Jan 2014)2014)Struggled with the switching. Reported elation in mood for

three to four daysSignificant mood swingsVery suicidalChristmas was disastrousEverybody is avoiding herFeels she betrayed her family

Past periods of hypomania lasting about a week with irritability, hyperactivity, lacking sleep, much more interested in sex, talk excessively, overspending, then depressed

Two of her sisters had been treated for bipolar

?mother

She was told that she has manic depression

Mood disorder questionnaire: answered yes to all 13 questions with problems affecting her life significantly

And more…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 childhoodUsed amphetamine during early

twenties for 6 months and had significant calming effect

History from motherHistory from motherAs 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)

Following appointmentsFollowing appointmentsQuetiapine 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

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)

Assessment toolsCurrent 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-v1.1Part A 4/6. Part B 10/12.

The Conners’ Adult ADHD Rating Scales–The Conners’ Adult ADHD Rating Scales–Self Report: Long Version (CAARS–S:L)Self Report: Long Version (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%.

Self report scoreSelf report score

“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

Asperger's assessment is undergoing, high Autism Quotient (AQ), and Relatives Questionnaire (RQ) scores suggestive of Asperger’s

Methylphenidate started with remarkable results

Suicidal ideation completely gone

Mood is much better

Still long way to go…

ADHD/Bipolar/Personality ADHD/Bipolar/Personality Disorder?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.

ADHD and personality ADHD and personality disorder: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 differenceCluster B 9.5 24.4Cluster 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

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 personalitydisorders, 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)

ADHD and SuicideThe 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. PEDIATRICS Volume 131,Number 4, April 2013.

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 )

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 )

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.

ADHD and Autistic Spectrum ADHD and Autistic Spectrum Disorders (ASD)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 ) .

ConclusionConclusionThink about ADHD when you see

the red flags

ADHD is real and treatable

Refer

Learn more about ADHD

Red flagsRed flagsADHD in Adults. The latest assessment and treatment strategies. Russel Barkley ADHD in Adults. The latest assessment and treatment strategies. Russel Barkley PhD. 2010PhD. 2010

Self-controlResponsibilities and restlessImpulse-controlTime management and organisationRepeated failures in self care

programmes such as weight loss, smoking cessation, or substance abuse treatment

Poor educational achievementPoor occupational functioningPoor satisfaction with interpersonal

relationshipsSubstance dependence and abuse