Download - ADHD Case Presentation
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