adhd bipolar ptsd - 02-05-2014.pptpsychologyinterns.org/.../adhd_bipolar_ptsd-02-05-2014.pdf2/5/2014...

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Adam Andreassen, Psy.D.Executive DirectorHeart of America Psychology Training Consortium

PresidentMidwest Assessment & Psychotherapy Solutions (MAPS)

� Experience a more comprehensive conceptualization of research-relevant symptoms related to both ADHD and Bipolar Disorder as well as PTSD that goes beyond the narrow framework of the DSM

� Improve clinical interviewing skills in order to focus on asking the questions that most likely illicit relevant information

� Become more familiar with the assets and limitations of inventories and psychological testing results.

� Become more competent in ruling in or ruling out other co-morbid conditions.

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Appendicitis Strep ThroatFever

Geller & DelBello, 2008

Mania

(elated mood and grandiosity)

Major Depressive

Disorder

(low mood and

anhedonia)

Autism

(communication and social deficits)

ADHD

(no cardinal

symptoms)

Irritability and Hyperactivity

Geller & DelBello, 2008

1% 8%

Barkley, 2006

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� Anxiety disorder: 10-50%

� MDD: 15-75%

� Bipolar I: 6-27%; (BAD I carries a very high risk for comorbid ADHD, even though ADHD carries a low risk for BAD I)

� ODD: Up to 85%

� Conduct Disorder: 15-56% (worse prognosis)

� PTSD may be circular with ADHD: 1-6%

� Tourette syndrome or tick disorder: 12-34%

� PDD: Up to 26%

(Barkley, 2006)

� Around WWI ADHD symptoms were often associated with an outbreak of encephalitis

� Clinicians began to see similar symptoms in other organic based disorders (brain injured child, MBD)

� Also “spoiled child” syndrome

� 1930’s began to notice improved effects with amphetamine use to control headaches

Barkley 2006

� 1950’s movement to hyperkinetic impulse disorder

� Later in the decade more specific learning problems were identified rather than generalizing MBD

� 1970’s began to focus on impulsivity as well

� 1980’s focus on attention problems

� Later focus on educational needs

� 21st century continues to look at further subtypes

Barkley 2006

� The word “manic” traces back to Ancient Greek.

� Mania and melancholia have been tied together for centuries

� Biphasic Mental Illness causing recurrent oscilliations between mania and depression (1854 Jules Baillarger).

� Emil Kraepelin coined term manic depressiion (1900’s)

� 1952 placed in the Diagnostic Manual

� No early differentiation between unipolar and bipolar� Both were considered manic-depressive illness� More recent research has also noted some differences in

the energy components between unipolar and bipolar depressed patients

� Bipolar disorder has been seen to have a greater genetic link than unipolar depression

� However, conflicting results have been found with relatives of “well-defined” unipolar depressives rarely exhibiting bipolar disorder

� Could occur on a polygenic or continuous spectrum:Unipolar Bipolar

Adams and Sutker (2001)

� Cyclicity can range from less than 48 hours to several years

� High degree of inter-individual variability

� Typical cycle length of Bipolar disorder is less than in unipolar major depression

� 13-20% rapid cycling (≥4 depressed or manic episodes per year)

Adams and Sutker (2001)

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� Rapid cycling is more common among women� Initial mood episode is usually depressive� Rapid cycling generally develops later � Later age of manic onset may be an indication of secondary mania

and can be indistinguishable from patients with primary mania� Can also occur during schizoaffective disorder� Difficulty in distinguishing from Borderline Personality disorder� Some view BPD as subsyndromal mood disorder and some assert

they can coexist, data is unclear due to overlapping symptom presentation

Adams and Sutker (2001)

� Approximately 10-15% of adolescents with recurrent MDE will develop Bipolar, mixed episodes may be more likely in adolescents and young adults

� First episode in males more likely to be manic and in females depressed

� Completed suicide occurs in 10-15%

� More likely to occur in mixed or depressive state

APA 2000

� Onset after 40 should alert that there may be a general medical condition or substance issue

� Bipolar II may be more common in women

� Cyclothymic disorder usually begins in adolescence or early adult life

APA 2000

Theory of kindling� Somewhat controversial� Important to assumptions of early psychosocial

interventions� First applied to seizure disorders� Combination of stress and genetic vulnerability

leads to greater destabilization until full onset� Brain becomes further sensitized with each episode

until spontaneous occurrence without stressors� Will result in less inter-episodic recovery time and

treatment resistanceGeller & DelBello, 2008

� Unipolar depression is more prevalent among women but Bipolar is more evenly distributed by gender

� However, a major Amish study found no gender differences

� Age and hospitalization trends1. First unipolar hospitalization tends to occur between 40

and 492. First bipolar hospitalization tends to occur between 20

and 29� According to NIMH:1. Median age of onset for unipolar depression is 252. Median age of onset for bipolar is 19Adams and Sutker (2001)

� Historically children have been viewed as honest reporters

� However, most clinicians have encountered children who deny disruptive behaviors or claim mental illness contrary to findings

Rogers (2008)

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� Study of 53 dually diagnosed offenders found malingering to be 15%, similar to adult offenders

� Other studies have found 8% of children have engaged in acquiescence and 10% in nay-saying during psychological assessment

� 8% attempted to please the interviewer� 14% provided guarded responses� 12% of 6 to 8-year-olds presented a socially desirable

set of responses� Assessment must discern minimal denial and "white

lies” from exaggerated reporting and extreme denialRogers (2008)

� Children (and their parents on their behalf) may be motivated to malinger symptoms to gain external incentives or deny symptoms to avoid consequences

� Conduct Disorder adolescents may feign ADHD to obtain medication

� May feign symptoms to avoid school work or avoid peer difficulty

� Influence custody decisions� Avoid juvenile justice system� Gain academic accommodations� Gain money and services� Manage peer status� Unintentional parent and child misrepresentationRogers (2008)

� ADHD has a small risk for Bipolar Disorder (6-27%)

� Children with early-onset Bipolar Disorder have a very high probability (91-98%) of meeting the criteria for ADHD

� HOWEVER, once subtracting out symptom overlap only about ½ of ADHD and Bipolar children retained the Bipolar Diagnosis

� 6-10% of children may have legitimate comorbidity

� Follow-up studies have also been inconclusive

(Barkley, 2006)

� Distinct period of abnormally and persistently elevated, expansive, or irritable mood for 1 week (unless hospitalization is necessary)

� Three or more (4 if just irritable) and PRESENT TO A SIGNIFICANT DEGREE

1. Inflated self-esteem or grandiosity2. Decreased NEED for sleep3. More talkative than USUAL4. Flight of ideas or racing thoughts5. Distractibility6. INCREASE in goal-directed activity or psychomotor agitation7. Excessive involvement in pleasurable activities with a high

potential for painful consequences� Not a MDE� Marked impairment or hospitalization� Not due to drugs or GMC

� Fidgety Phil- Hoffman 1865� Still and Tredgold were the first to focus clinical attention

on the condition in the turn of the 20th century� Still noticed problems with attention and impulsivity,

and noted relationships with defiance and delinquency� Believed they were driven by immediate gratification

and many were insensitive to punishment “defect in moral control”

� Considered that some of the problem may be a secondary response to an acute brain disease that may remit, and noted it affected mentally retarded as well as typical intellect

(Barkley, 2006)

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� In infancy:1. Exhibit poor and irregular sleep2. Colic3. Feeding problems4. Dislike being cuddled or held still for long� Toddler:1. Driven to run rather than walk2. Driven to handle everything� Major problems as adults:1. Low self-esteem2. Poor social skills

Kolb & Whishaw (2003)

� Elementary school:1. Demanding2. Oppositional3. Do not play well with others4. Poor tolerance of frustration, high level of activity, poor

concentration, and poor self-esteem may lead to a referral� Adolescence:1. May be failing school2. 25-50% have encountered legal problems3. Withdraw from school4. Fail to develop social relations and maintain steady

employment

Kolb & Whishaw (200)

� ADHD, Inattentive Type

� ADHD, Sluggish Cognitive Tempo

� ADHD, Hyperactive-Impulsive Type

� ADHD, Combined Type

� Often fails to give close attention to details and make careless mistakes

� Difficulty sustaining attention

� Does not listen when spoken to directly

� Not following through on instructions

� Difficulty organizing tasks

� Often loses things

� Often forgetful in everyday activities

� Inattentive Type plus:

� Fidgets with hands or feet in seat

� Leaves seat in the classroom

� Runs or climbs about excessively

� Difficulty playing in leisure activity

� Is often “on the go” or appears “driven by a motor

� Often talks excessively

� Changing culture

� One size fits all?

� Concept called comorbidity

� Relief Factor: “Have a name”

� Cultural medication solution

� Changing parenting styles

� Impact of schools

� Lack of investment in natural treatments

� Treatment of “spectrums”

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� High rates of disruptive disorders

� Low rates of engagement with academic instruction and achievement

� Inconsistent completion/accuracy of school work

� Poor performance on homework, tests & long-term assignments

� Difficulties getting along with peers

� Limited data for school based interventions in gen ed setting

� One size fits all

� Emphasis on reduction of disruptive behavior rather than improvement in social behavior or academic skills

� Focus on short-term outcomes

� Few studies of adolescents

� Concept of Executive Functioning and brain development

� The ability to plan and organize event in a sequential manner with sound judgment

� Also involves:

� Nonverbal and verbal working memory

� Emotional Self-Regulation

� Planning and Problem-Solving

� Theory suggesting that ADHD (and Conduct, Antisocial, etc) individuals seek/require more stimulation to transcend their excessively low arousal rate

� In one study ADHD individuals required more noise levels to establish the same stimulation level (due to less dopamine)

-See Wikipedia – “Low Arousal Theory”

� A disorder of “time blindness” (Barkley)

� ADHD lives in the moment only

� Point of Performance Problem

� It is a disorder of:

� Performance, not skill

� Doing what you know, not knowing what you do

� The when and where not the how and what

� It is not a Attention-Deficit but rather Inattention Deficit Disorder (Inattention to mental events and future possibilities).

� Delayed responding and intrinsic motivation

� Time, delays, and thinking ahead

� Problem-solving strategies, and changing cognitive sets.

� The compassion and willingness of others to make accommodations are vital to success

� It is a chronic medical/psychological disability

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� 40% of children in some studies suffer from sleep problems

� 15% exhibit bedtime resistance

� 10% or more experience daytime drowsiness

� Students with C’s, D’s, and F’s went to bed on average 40 minutes later than A students

� Insufficient sleep leads to many other problems

� If he or she can fall asleep within 15-30 minutes

� Can wake up easily at the time they need to get up

� Awake and alert all day and do not require a nap

� Check with his or her teacher; kindergarten teacher survey that nearly 10% of students fall asleep at school

� Make bedtime special� Think about bedtime do not just do it� Bedtime should be a regular routine� Keep the ritual simple� Sleep habits/rituals should work everywhere

and anywhere� Keep them physical during the day� Be mindful of light� It is not about what happens AT bedtime but

usually at least one hour before

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� AGE Hours4 11.55 116 117 118 10-119 10-1110 1011 1012-13 9.5-10

� During a manic episode there is reduced need for sleep in 69-99% of patients.

� Prominent feature of Bipolar in youth

� May be the early marker (earliest symptom reported by parents) for BAD in youth (Faedda, et al)

� Higher rates of sleep disturbance and decreased need for sleep in comparison to ADHD children.

� Critical for affect regulation

� Important for cognitive functioning

� Impacts health

� Associated with substance use

� Contributes to impulsivity and risk taking

� Does the child fall asleep often while we are driving?

� Does the child seem irritable, cranky, over-emotional, hyper, or have trouble paying attention?

� On some nights does the child crash much earlier than his or her bedtime?

� The TOUGHEST ddx in the business� Considerable overlap of symptoms� Harvard Medical School Study: 94% of children with

mania meet the criteria for ADHD, Hyperactive Type� “When one hears the clatter of hoofbeats on the roof,

one looks for horses not zebras.” (Anthony & Scott)� ADHD should only be considered after ruling out a

mood disorder� Diagnosis may depend upon your own bias or

conceptualization of childhood disorders (mania merely as a defense, ADHD as an attachment disorder)

� Is ADHD an early developmental path to full-blown Bipolar?

� Destructiveness: ADHD careless destruction v. BAD occurs in anger

� Temper-tantrums: ADHD children calm down in 20-30 minutes; BAD for hours

� Regression during outbursts: BAD may lose memory of tantrum; regression more severe in BAD

� Triggers: ADHD-triggered by sensory and emotional overstimulation; BAD-react more to limit setting

� ADHD does not show depressive as primary predominant symptom

� Arrousal in morning: ADHD- arouse quickly and alert within minutes; BAD-fuzzy thinking and irritable

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� Sleep disturbances often occur with night terrors of MOR themes

� BAD children may show some giftedness in specific cognitive abilities (verbal and artistic).

� Misbx: ADHD-accidental due to not paying attention to details; BAD-intentionally provoked

� Risk-seeking: ADHD-unaware of consequences; BAD is risk-seeking

� Reality testing: ADHD unremarkable; Bipolar -oh boy!

� Pre-ads/Young Ads

� MDD

� Rapid-cycling

� Chronic, continuous cycling

� Nonepisodic

� Older Ads/Adults

� Mania

� Discrete with sudden onsets/clear offsets

� Weeks

� Improved functioning

� Child: Speech-language disorders

ADHD, ODD, Conduct Disorder, Sexual Abuse

� Ads: ADHD, ODD, CD, Sexual Abuse, Schizophrenia, SA

� Adults: Psychosis, SA, Antisocial Personality Disorders

�Do not fall neatly into current adult nosology

�Longitudinal monitoring because diagnoses are unstable and comorbidities may not be seen each time, or be developed yet

�60% of bipolar adults report first symptoms as children or adolescents.

�Positive family history with early age of onset could signify genetic anticipation and higher genetic loading.

� ADHD

� Conduct disorder

� Oppositional defiant disorder

� Substance abuse

� Depression/anxiety disorders

� “Bad child” – delinquent, violent

Pediatric mania is easily misdiagnosed –differential diagnosis or comorbidity?

�Early age of onset is associated with increased family history of the disorder.

�Fewer stressors are seen in early onset cases.

�Morbid risk of bipolar disorder in first-degree relatives is 4-6 times higher than in the general population.

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� Excessively comorbid by adult standards

� Chronic irritability/mixed – Can be associated with aggression and unpredictable behavior

� Frequent temper outbursts, often aggressive

� Positive family history

� Comorbid ADHD (more likely in younger children and in males)

� High rates of conduct disorder and delinquency in adolescents

� 20-30% of adolescents with MDD will have an eventual manic episode.

�Increased energy: 100%

�Irritability: 98%

�Accelerated speech: 97%

�Elated mood: 89%

�Rapid cycling: 87%

�ADHD: 87%

�Grandiosity: 86%

�Oppositional defiant, conduct disorder: 76%

Geller, et al.; 2001.

� The use of BP, NOS most commonly given

� Higher genetic component-

� 48% of first degree relatives for children verses 25% for adults

� Accepting reported bipolar dx in family members

� Comorbidity is the rule rather than the exception

� The Handle Symptoms

� Adolescents more likely to be rapid cylcers

� Anger does not = Bipolar Disorder

� Two extremes of diagnosing in reaction to diagnostic trends

�ADHD: 4.9 years

�ODD: 6.1 years

�Bipolar disorder: 6.7 years

�Unipolar depression: 6.7 years

�Psychosis: 9.2 years

Frazier, et al.; 2001.

� Usually not exacerbated by stimulants

� Definitely can be exacerbated by antidepressants

� Mood stabilizers and atypical antipsychotics the standards for treatment

� Mood instability trumps ADHD in priority and sequence of treatment.

� Misleading research

� Kindling effect

� Sensitivity verses specificity

� The “spectrum”

� Comorbidity

� Grisso-”moving targets.”

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� Improved assessment methodology

� Again, “spectrum” assessment trends

� Sleep Apnea

� Asthma

� Inner Ear Infections

� Pervasive Development Disorders

� #1 6-12 year olds with inattention, hyperactivity, impulsivity, academic underachievement ADHD assessment conducted

� #2 The dx of ADHD must meet DSM criteria

� #3 The assessment requires evidence directly obtained from parents in various settings

� Scales are a clinical option

� Do not use broadband scales

� # 4 Assessment information from school

� #5 Evaluation of co-existing Conditions

� #6 Other diagnostic tests

� THE MTA STUDY (largest treatment study of ADHD ever conducted).

� The study represented the combined efforts of investigators at 6 different sites around the country and included 579 children ages 7 to 9.9 years who were diagnosed as having ADHD, Combined Type using state-of-the-art diagnostic procedures.

� After participants had been identified they were randomly assigned to 1 of 4 different treatment conditions. Fourteen months later, the participants were carefully evaluated so that the impact of the different treatments could be evaluated (CT, CC, MO, BTO).

� Not a study of what worked but rather a study that measure the effectiveness among treatments

� Behavioral-psychosocial treatment most appropriate when:

� Milder ADHD

� Preschool-age children

� There is a presence of comorbid social skills deficits

� The family prefers psychosocial treatment

� A combo of medication/psychosocial treatment when:

� More severe cases

� Significant aggression or severe problems in school are present.

� Severe family disruption caused by ADHD symptoms

� There is a need for a rapid response.

� Combined type present

� For all age groups except preschool

� With the presence of comorbid externalizing disorders, mental retardation, or central nervous system problems

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� Parent Management Training

� Organization Skill Enhancement

� Social Skill Development

� Child Interventions

� ADHD Monitoring System

� Working Memory Training

� School Based Interventions� Daily Report Card

� Classroom Techniques

� Teacher Techniques

� Adequate assessment & diagnosis

� Interface of other medical conditions� Sleep debt/apnea

� Poor diet

� Learning problems

� Executive Dysfunction interventions

� Parent management training

� Lifestyle management

� Neurofeedback/relaxation

� Chiropractic intervention

� Diet and Nutrition

� Research on psychotherapy has been largely ignored with Bipolar patients as compared with Depressed patients due to the large focus on the biological basis of the disorder

� Therapy tends to focus on increasing medication compliance and managing the consequences of behaviors

� Some newer focus has surged, particularly with CBT focusing on stress management, compliance, and managing manic cognitive distortions

Adams and Sutker (2001)

� Interpersonal and Social Rhythm Therapy

� It postulates that stressful events, disruptions in circadian rhythms and personal relationships, and conflicts arising out of difficulty in social adjustment often lead to relapses.

� Cognitive Behavioral Therapy (CBT)

� Medication Adherence and Psychoeducation

� Is Family Therapy Effective?

� Evidence for Alternative Treatments?

� Herbal Supplements

� Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)

� Lithium (Treatment and maintenance)

� Tegretol (Treatment and maintenance, particularly for rapid cycling)

� Depakote (Manic episodes that do not respond to lithium, up to 20%)

� Wellbutrin (some use with bipolar)Adams and Sutker, 2001

� Also some use of antipsychoticsGeller & DelBello, 2008

� Clinical triall to study people who are bipolar experiencing a depressed state.

� Largest federally funded study on Bipolar Disorder

� Purpose: explore a range of treatment options for Bipolar Disorder

� Assessed long-term psychosocial treatments v. short-term, talk therapy treatment outcomes

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� Longer-term treatments (30 50 minute sessions):

� CBT

� Interpersonal and Social Rhythm Therapy (SRT)

� Family Focused Treatment (FFT)

� Short-term aka “collaborative care”:

� 3 50 minutes sessions over six weeks

� Educational videotape

� Other educational workbook activities

� Developed a treatment contract to prevent episodes

� Results:

� Of 293 patients, 59% recovered from depression

� The intensive therapies:

� More successful recovery rate (64 percent v. 52%)

� Recovery rate was faster following (113 v. 146 days)

� More likely (1 ½ times) to remain well during any given month of the study.

� Therapies (77% of FFT recovered, 65% IPSRT, 60% CBT).

� Overview of testing that has traditionally been utilized in the assessment of ADHD/Bipolar Disorder

� Evidence-Based Assessment:

� Intelligence/Achievement Testing

� Neuropsychological Testing

� Projective Testing

� Inventories

� Performance Tests

� Intelligence/Achievement:� Evidence is conflicting whether can adequately

discriminate groups of ADHD children from non-ADHD.

� IQ/Achievement probably contribute in more indirect ways particularly in the area of establishing impairment.

� Assists in ruling-in/ruling-out reasons for complaints.

� Assist in identification of cogntive factors impacting inattention.

� Should they be considered in every assessment case?

� Neuropsychological Tests:

� Stroop Word-Color Test: cannot be used accurately

� Rey-Osterrieth Complex Figure Drawing: cannot be used accurately

� Trails Making Test: cannot be used accurately

� Continuous Performance Tests: the most evidence-based of current tests.

� Limited studies demonstrate the predictive validity of the use of projective methods to discriminate ADHD from non-ADHD.

� Rorschach has some promising research

� Observational Measures:

� Clinical Observations

� Test Observation Form (TOF)

� Response to medication

� The petri dish experiment

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� Rorschach should never be sole source for diagnosis of ADHD!!!!!!

� Tend to narrow stimulus field; simplify more complex situations (High Lambda; 1.53 Comprehensive System; F%/Simplicity in R-PAS)

� No significant differences between Adj D or D (No Equivalent in R-PAS) between ADHD, Clinical Group, Control Group

� Fewer Sum C; more shading; lower Afr (R8910% in R-PAS); fewer blends

� Lower egocentricity scores (No Equivalent in R-PAS)/more negative judgments about relationship between self/others

� Fewer COP’s and fewer AG (AGM in R-PAS)� Less comfort in interpersonal situations; lower Pure H

� Lower WSum6 (7.78); (WSumCog in R-PAS)

� Lower P’s

� CDI significant (No Direct Equivalent in R-PAS)

� Unconventional thought process, but without the significant distortions seen in clinical population

� More exaggerated Lambda’s

� Thinking distortions more related avoid most stimuli

� Premature disengagement from stimuli (lower Zd/Zf).

� First Challenge: PTSD is only ONE outcome of trauma

� Trauma = From a psychological perspective it’s an emotional response to a terrible event

� Appraisal is important indicator

� All my fault?

� Totally helpless?

� High Arousal will look similar to ADHD even though ADHD is triggered by a LOW arousal!

� Bipolar is more like organic arousal that will look like triggered (PTSD) arousal AND low arousal response (ADHD)

� How to differentiate?

� History Helps

� Age of onset

� Key events?

� Treatment and Response to Intervention

� Caveats?

� Sleep influence

� Sleep History

� Medical History (Sleep Apnea, Frequent Ear Infections, etc)

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� ADHD

� Defer until last

� May still be underlying, but need to identify most acute complaints first

� Also no CARDINAL symptoms mean even if you answer all diagnostic questions in the affirmative you have not confirmed ADHD!

� Where so many fail!!!

� Bipolar

� Can you identify manic or mixed symptoms? (Required)

� How long are outbursts occurring? (more than an hour?)

� How intense are outbursts?

� Can increased energy be confirmed?

� Remember the brain! (ADHD – Executive Functioning; Bipolar – Emotional Dysregulation; PTSD – Triggering events and external influence)

� PTSD

� Can triggering event be identified? If not, trauma can still be relevant even if you don’t diagnose PTSD

� Attention Problems/Hyperactivity could be in fact keyed-up OVER-ATTENTION (monitoring)

� Any subtle behavioral clues?

� How do they respond when you give them a focusing task?

� Many individuals with anxiety/ptsd focus well and actually calm themselves with tasks

� Underlying ADHD can increase risk of PTSD

� Problems gathering and using information can complicate appraisal of events which heavily influences PTSD factors

� Can ADHD be identified prior to traumatic events

� ADHD is a performance-based issue; may need performance-based assessment alongside full evaluation

� Bipolar – many mood factors are easier to identify when paired with test data

� PTSD – Residual effects of trauma also easier to isolate with testing

� But sometimes time or resources don’t allow this approach

� Let the conceptualization guide the assessment

� Don’t jump straight to diagnosis!

� Is this patient:

� Anxious and keyed up (as well as avoidant) because they need to avoid certain outcomes

� Requiring something novel and interesting to further arouse focus and consistency?

� Prone to “losing it” for extended time periods? (more sustained in duration than is typical for PTSD)

� Shoe Shopping!

� Try on different diagnoses…

� If this is ADHD, the following behaviors do/don’t make sense as explained by dx

� Try to reduce the equation to fewest number of diagnoses

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� ADHD – Peeling back layer of the onion (what’s left)

� Degrees of certainty rather than “confirming”

� Additive: Sleep Problems? Sleep Apnea? Early Ear Infections, Asthma, etc

� PTSD – Don’t rush to it as dx just because a trauma occurred – it’s a very specific set of reactions

� One of the most effective ways of narrowing it down

� Bipolar – Is affect brain lighting up and flooding person?

� Genetics, etc

� Remember age of onset info

� Assess mood upon awaking! (Cranky/Sluggish v. Good to go!)

� IF PTSD, diagnose ADHD primarily if able to identify underlying premorbid condition

� IF Bipolar, ADHD is unlikely

� IF ADHD, Bipolar is unlikely

Axis I Attention-Deficit Hyperactivity D/O

Bipolar D/O

ITS BOTH :}

aandreassen@haptconline.org