Transcript Diagnosing Common Psychiatric Disorders in Primary Care

DIFFERENTIAL DIAGNOSIS OF
ADHD
UPIQ Learning Collaborative
November 13, 2015
Kristi Kleinschmit, MD
[email protected]
Objectives
• Case presentations
• Discussion of differential diagnosis,
reviewing diagnostic criteria and targeted
psychiatric review of systems to help come
to diagnosis.
• Rule is comorbidity, not simplicity
• Review of assessment tools that can aid in
diagnosis. Screeners available at
www.uacap.org
Differential Diagnosis
• Anxiety spectrum
• Depression/Mood Disorders
• Asperger’s/Autism
• Oppositional Defiant Disorder/Conduct
Disorder
• Trauma
• Learning disabilities
• Sleep issues
• Substance Abuse
• Medical issues
Differential Diagnosis
• Anxiety spectrum
6% to 20% of children (AACAP)
• Depression
• Asperger’s/Autism
• Oppositional Defiant Disorder/Conduct Disorder
• Trauma
• Learning disabilities
• Sleep issues
• Substance Abuse
• Medical Issues
GAD Criteria (DSM IV)
A. At least 6 months of "excessive anxiety and worry" about
a variety of events and situations.
B. Difficulty controlling the anxiety and worry.
C. The presence for most days over the previous six months
of 1 or more of the following symptoms:
1. Feeling wound-up, tense, or restless
2. Easily becoming fatigued or worn-out
3. Concentration problems
4. Irritability
5. Significant tension in muscles
6. Difficulty with sleep
D. The symptoms are not part of another mental disorder,
cause “clinically significant distress or problem functioning,”
and are not due to substance or medical illness.
Social Phobia
A. Marked fear or anxiety of social situations
involving possible scrutiny
• In kids, anxiety must occur in peer setting, not just with
adults.
B. Fear of acting in a humiliating/embarrassing way,
leading to rejection
C. Social situations usually provoke fear/anxiety
• Crying, tantrums, freezing, failing to speak
D. Avoidance of endured with intense anxiety
Other Anxiety Disorders
• Separation Anxiety
• Obsessive Compulsive Disorder (ask for cleaning,
organizing, counting, rituals/routines, checking
behavior, evenness)
• Panic Disorder (ask about panic attacks)
Targeted Review of Systems
• Is he shy? (although not always the case)
• Any history of separation anxiety?
• Is he a worrier? Upset if anyone home late? Needs
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things just so?
Nightmares??
Does he seem to get easily upset when things do
not go the way he expects them to? Melt downs
with disappointments?
Does he have frequent stomachaches or headaches
or other somatic complaints?
Perfectionistic? Needs lots of reassurance?
Tense, avoidant, irritable?
Interviewing the Child
Most kids don’t admit to “worrying.” Try asking if they
feel nervous, chest tightness, sweaty palms, shaky,
trouble sleeping, heart racing.
Ask about panic attacks and what triggers.
• “I can’t sleep because my brain won’t shut off.
• “My thoughts race at bedtime.”
• “My stomach always hurts before school”
• “I’m afraid the kids won’t like me or will laugh at me.”
• “I feel scared for no reason”
Mental Status Exam: Activity may be fidgety. May
have constricted affect, intermittent eye contact,
overinclusive speech or minimal speech.
Concentration may be impaired.
Anxiety versus Depression
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Irritability prominent
Poor concentration
Sleep problems
Prominent need for
reassurance
Lots of somatic complaints
(aches)
Poor eating if nausea, but
not consistent.
Anxious avoidance, due to
worries of failure, perfection.
Some things still fun.
Oppositional often.
Suicidality rarely
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Irritability prominent
Poor concentration
Sleep problems
Prominent selfdeprecation/worthless
• Some somatic complaints,
(poor energy)
• Decrease appetite
• Isolation, Anhedonia,
nothing is fun anymore.
• Oppositional sometimes.
• Suicidality one of criteria
Anxiety versus ADHD
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Fidgety
Poor concentration
Distractible
Doesn’t turn in
assignments due to fear
of failure
Lots of somatic
complaints (aches)
Insomnia.
Perfectionistic, so
paralyzed to begin things
Rarely impulsive or risktaking.
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Fidgety
Poor concentration
Distractible
Doesn’t turn in
assignments due to
forgetfulness
No real somatic
complaints
Sleep is restless
Careless mistakes
Resistance to start HW
Impulsive
Anxiety Screeners
• SCARED (Screen for Child Anxiety Related Disorders)
• Validated for ages 8 and older
• Self-report and parent/teacher forms
• Free online at www.uacap.org
• GAD-7
• Quicker to fill out, not as much differentiation between disorders
• Free online at www.uacap.org
• CY-BOCS for OCD
Differential Diagnosis
• Anxiety spectrum
• Depression
• 10% of ages 12-17 (NIMH, 2013)
• Asperger’s/Autism
• Oppositional Defiant Disorder/Conduct Disorder
• Trauma
• Learning disabilities
• Sleep issues
• Substance Abuse
• Medical Issues
DSM IV Criteria for Major Depression
(unchanged in DSM 5)
A) Five (or more) of the following symptoms have been present during the same
2-week period and represent a change from previous functioning; at least one
of the symptoms is either (1) depressed mood or (2) loss of interest or
pleasure
1) depressed mood most of the day, nearly every day (subjective or objective).
Note: In children and adolescents, can be irritable mood.
2) markedly diminished interest or pleasure in all, or almost all, activities
3) significant weight loss when not dieting or weight gain or decrease or
increase in appetite nearly every day. Note: In children, consider failure to
make expected weight gains.
4) insomnia or hypersomnia nearly every day
5) psychomotor agitation or retardation nearly every day
6) fatigue or loss of energy nearly every day
7) feelings of worthlessness or excessive or inappropriate guilt
8) diminished ability to think or concentrate, or indecisiveness, nearly every
day
9) recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide attempt or a specific plan for
committing suicide
C) The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Targeted Review of Systems
• Irritable or sad?
• Decreased interest in friends, previously enjoyed
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activities? Isolative?
Poor sleep, poor energy?
Changes in appetite?
Talking of wishing to die, being worthless, hopeless?
Ruminations of wrong-doing? Easily down on self?
Seeming to move too fast or too slow.
Interviewing the Child
o Most kids don’t admit to feeling sad either. Try
asking about being hard on themselves when they
make mistake. Being more snappy with
family/friends.
• Trouble sleeping, poor energy or concentration.
• Body moving too fast or too slow
• Guilty feelings
• Hopeless, worthless, should have never been born?
• “Everyone would be better off if I wasn’t here.”
Mental Status Exam: Constricted/blunted affect, slow
soft speech, thoughts of suicide or worthlessness.
Concentration may be off.
Diagnostic Screener
• PHQ 9-A
Differential Diagnosis
• Anxiety spectrum
• Depression
• Asperger’s/Autism
• 1 in 54 8 y/o’s in Utah (Utah ADDM 2010)
• Oppositional Defiant Disorder/Conduct Disorder
• Trauma
• Learning disabilities
• Sleep issues
• Substance Abuse
• Medical Issues
Autism
• DSM diagnostic changes:
• Used to be 3 domains (social, communication, and
restrictive/repetitive interests). Now there are 2: Social
communication/interaction and Restrictive/repetitive patterns
• All is Autism, no more Aspergers, Rhett’s, PDD NOS
• Often higher functioning is missed until older
• Gold standard for diagnosis is clinical interview and
Autism Diagnostic Observation Scale (ADOS) and/or
Autism Diagnostic Interview (ADI).
• Clinical interview can be used to diagnose
• Utah Autism Info:
• http://www.cdc.gov/ncbddd/autism/states/addm-utah-fact-
sheet.pdf
Targeted Review of Systems
o Does he struggle to make/keep friends? Friends too
old or too young?
o Can he hold a conversation, or does he
monopolize?
o History of imaginative play?
o Restricted interests or inflexible routines?
o Does he make eye contact?
o Can he read the social tone of a room?
o Does he share things about his day with you?
o Think of autism as an anxiety disorder:
o Melt downs with unexpected change or transitions
Differential Diagnosis
• Anxiety spectrum
• Depression
• Asperger’s/Autism
• Oppositional Defiant
Disorder/Conduct Disorder
• 6% prev/ 4% prev. (SAMHSA 2009)
• Trauma
• Learning disabilities
• Sleep issues
• Substance Abuse
• Medical Issues
DSM 5 updates
• ODD
• Angry/irritable mood; Arugmentative Behavior; Vindictiveness
• < 5 y/o, most days for 6 months; >5 y/o: once per week x 6 mos
• Mild: Only 1 setting; Moderate: 2 settings; Severe: 3 or more
• Conduct Disorder
• Aggression to people and animals; Destruction of Property;
Deceitfulness or Theft; Serious violations of rules
• Childhood-onset (<10 y/o) vs Adolescent onset (no sx < 10 y/o)
• wIth limited prosocial emotions
• Mild, moderate, or severe
When you see ODD/CD, think “What else
am I missing?”
• Of those with lifetime ODD, 92.4% meet criteria for at
least one other lifetime DSM-IV disorder.
• Mood (45.8%),
• Anxiety (62.3%)
• Impulse-control (68.2%)
• Substance use (47.2%) disorders.
• Conduct Disorder: 39% girls, 46% boys met criteria for at
least one other DSM diagnosis (Maughen 2004)
• 1/3 to ½ of kids with ODD have ADHD
• 25% of children and up to 50% of teens with CD have
ADHD
Screeners
• Vanderbilt has good screeners for ODD/CD
• School or psychologist could do further testing
• Think of disruptive behavior disorders when ADHD
screeners are weakly positive, or different between
settings
Differential Diagnosis
• Anxiety spectrum
• Depression
• Asperger’s/Autism
• Oppositional Defiant Disorder/Conduct Disorder
• Trauma/psychosocial stressors
• Learning disabilities
• Sleep issues
• Substance Abuse
• Medical Issues
Wide range of traumatic experiences and
psychosocial stressors
• Sexual/Physical abuse/Neglect
• Domestic violence exposure
• Animal attack
• Loss of caregiver (death, deportation, incarceration)
• Car accidents
• Witnessing violence to others
• Natural disasters
• Chronic hospitalizations
• Homelessness
• Food insecurity
• Parentified children
• Many, many others…..
Screening tool
• Trauma-informed clinical interview
• Traumatic Experiences Questionnaire for Young Children
(TEQ) 10-13 (www.uacap.org)
Differential Diagnosis
• Anxiety spectrum
• Depression
• Asperger’s/Autism
• Oppositional Defiant Disorder/Conduct Disorder
• Trauma
• Learning disabilities
• Sleep issues
• Substance Abuse
• Medical Issues
Learning Disabilities
• 5% of school-aged children have diagnosis and services
for LD, thought to miss another 15% who struggle.
• National Center for Learning Disabilities 2014
• Can be missed during elementary school, especially in
disruptive kids or quiet kids
• Parents to request testing through school, or outpatient
psychological assessment (insurances vary on payment)
Differential Diagnosis
• Anxiety spectrum
• Depression
• Asperger’s/Autism
• Oppositional Defiant Disorder/Conduct Disorder
• Trauma
• Learning disabilities
• Sleep issues
• Substance Abuse
• Medical Issues
Sleep Disorders Prevalence
• Obstructive Sleep Apnea 1-3%
• “Behavioral Insomnia” 5% of school-aged kids
• Primary Insomnia 5-20% (greater in teens)
• Parasomnia: 5-35%
• PLMD and RLS 2-78%
• Narcolepsy TBD, adults 1 per 2000
• ICD-9 PCP billing data reviewed: only 3.7% had sleep
disorder diagnosis (Meltzer 2010)
Differential Diagnosis
• Anxiety spectrum
• Depression
• Asperger’s/Autism
• Oppositional Defiant Disorder/Conduct Disorder
• Trauma
• Learning disabilities
• Sleep issues
• Substance Abuse
• 5% of teens past year (CDC 2011)
• Often can co-occur with ADHD
• Medical issues
Differential Diagnosis
• Anxiety spectrum
• Depression
• Asperger’s/Autism
• Oppositional Defiant Disorder/Conduct
Disorder
• Trauma
• Learning disabilities
• Sleep issues
• Substance Abuse
• Medical issues
Medical Issues to think about
• Intra-uterine insult
• Substance exposure, prenatal infection
• Prematurity
• Seizures
• Hearing loss
• Vision problems
• Elevated Lead levels, anemia, hypo/hyper thyroidism
• Head trauma
References:
• American Academy of Child and Adolescent Psychiatry. Child and Adolescent Mental Illness and
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Drug Abuse Statistics. www.AACAP.org. Last reviewed March 18, 2009.
American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment
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American Academy of Child and Adolescent Psychiatry. Practice Parameter for the Assessment
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American Academy of Pediatrics. Enhancing Pediatric Mental Health Care: Report from the
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American Psychiatric Association (2013), Diagnostic and Statistical Manual of Mental Disorders,
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