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Stop losing psych points: ADHD vs Autism vs Conduct & Anorexia vs Bulimia —what the PANCE is really testing

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Attention-Deficit/Hyperactivity Disorder (ADHD)

Neurodevelopmental disorder characterized by inattention, hyperactivity, and impulsivity.

  • Onset before age 12 ).
  • Symptoms present in ≥2 settings (school, home, work).
  • More common in boys during childhood; ~50% persist into adulthood.
  • Strong genetic component.

Clinical Presentation

Inattention (≥6 symptoms if ≤16; ≥5 if ≥17):

  • Difficulty sustaining attention
  • Careless mistakes in schoolwork/work
  • Poor organization
  • Loses items, forgetful
  • Easily distracted

Hyperactivity/Impulsivity (≥6 symptoms if ≤16; ≥5 if ≥17):

  • Fidgets, leaves seat when expected to remain seated
  • Runs/climbs inappropriately (children)
  • Talks excessively, blurts out answers, interrupts
  • Difficulty waiting turn
  • “On the go,” driven by a motor

Functional impairment required (academic, social, occupational).

Labs, Studies, and Physical Exam Findings

  • Clinical diagnosis (no specific lab test).
  • Rule out thyroid disease, hearing/vision problems, sleep disorders.
  • Validated scales: Vanderbilt Assessment, Conners Rating Scales.

Treatment

First-line: Stimulants (most effective)

  • Methylphenidate (Ritalin, Concerta)
  • Amphetamines (Adderall)

Non-stimulant alternatives

  • Atomoxetine (SNRI) → useful if substance abuse risk or stimulant contraindication
  • Guanfacine, clonidine (α2-agonists) → hyperactivity, impulsivity, sleep
  • Bupropion (off-label)

Non-pharmacologic

  • Behavioral therapy (esp. children)
  • Parent training, school accommodations (IEPs/504 plans)
  • Exercise, structured routine

Key Differentiators

  • ADHD vs Normal Childhood Behavior → ADHD is pervasive, impairing, across ≥2 settings; normal kids may be distractible, but not functionally impaired.
  • ADHD vs ODD → ODD = defiance/hostility toward authority, not inattention.
  • ADHD vs Conduct Disorder → Conduct = violation of rights/social norms (aggression, theft, cruelty).
  • ADHD vs Autism Spectrum Disorder → ASD = deficits in social communication + restricted interests, not primarily attention/impulsivity.

Test Alert

  • ADHD diagnosis requires evidence of symptoms before age 12.
  • A 28-year-old with new-onset inattention after losing a job does not have ADHD. Think depression, anxiety, or adjustment disorder.

Autism Spectrum Disorder (ASD)

Neurodevelopmental disorder with deficits in social communication and restricted, repetitive behaviors.

  • Symptoms present in early childhood (often recognized by age 2–3).
  • More common in boys.
  • Strong genetic component.

Clinical Presentation

Core Features (DSM-5):

  • Deficits in social communication and interaction
    • Poor eye contact
    • Difficulty forming relationships/peer interactions
    • Limited or absent speech, echolalia
    • Impaired understanding of social cues
  • Restricted/repetitive patterns of behavior
    • Motor movements (hand-flapping, rocking)
    • Insistence on routines/sameness
    • Intense, fixated interests
    • Hypo- or hyper-reactivity to sensory input

Associated Findings:

  • Intellectual disability (common but not required)
  • Language delays
  • Seizures (higher prevalence)
  • May have strengths in specific areas (e.g., math, music, memorization)

Labs, Studies, and Physical Exam Findings

  • Clinical diagnosis (no single test).
  • Early screening: Modified Checklist for Autism in Toddlers (M-CHAT) at 18 and 24 months.
  • Rule out hearing/vision impairment, metabolic/genetic conditions.

Treatment

  • Early intervention is critical → improves long-term outcomes.
  • Behavioral interventions: Applied Behavior Analysis (ABA), speech therapy, occupational therapy.
  • Educational support: structured learning environments, IEPs.

Pharmacologic (symptom-targeted):

  • Irritability/aggression → risperidone, aripiprazole (FDA-approved).
  • ADHD symptoms → stimulants or atomoxetine.
  • Anxiety/OCD features → SSRIs.

Key Differentiators

  • ASD vs ADHD → ADHD = inattention/impulsivity; ASD = impaired social reciprocity + restricted interests.
  • ASD vs Intellectual Disability → ID = global cognitive delay; ASD = uneven profile, specific deficits in communication/social reciprocity.
  • ASD vs Social (Pragmatic) Communication Disorder → Social Communication Disorder = communication issues only, without restricted/repetitive behaviors.
  • ASD vs Schizophrenia → Schizophrenia develops later (adolescence/adulthood), includes psychosis; ASD begins in early childhood.

Test Alert

  • Restricted/repetitive behaviors are required for diagnosis.
  • A child with delayed language but no repetitive interests or stereotyped behaviors does not meet criteria for ASD.

Disruptive, Impulse-Control, and Conduct Disorders

Behavioral disorders marked by problems with self-control, defiance, or violation of social norms/rights of others.

  • Typically diagnosed in childhood/adolescence.
  • More common in males.
  • Associated with family conflict, inconsistent parenting, and comorbid ADHD.

Clinical Presentation

Oppositional Defiant Disorder (ODD)

  • Pattern of angry/irritable mood, argumentative/defiant behavior, vindictiveness.
  • Targets authority figures (parents, teachers).
  • Does not involve aggression toward people/animals, theft, or serious violation of rights.
  • Symptoms last ≥6 months.

Conduct Disorder (CD)

  • More severe than ODD.
  • Repetitive, persistent behavior violating basic rights or societal norms.
    • Aggression toward people/animals (fighting, cruelty)
    • Destruction of property (fire-setting, vandalism)
    • Deceitfulness/theft
    • Serious rule violations (truancy, running away)
  • Childhood onset = worse prognosis.
  • May progress to Antisocial Personality Disorder in adulthood.

Intermittent Explosive Disorder (IED)

  • Recurrent episodes of verbal or physical aggression.
  • Out of proportion to stressor, impulsive, not premeditated.
  • Onset usually late childhood or adolescence.

Labs, Studies, and Physical Exam Findings

  • Clinical diagnosis.
  • Rule out ADHD, mood disorders, substance use.
  • No specific labs.

Treatment

ODD

  • Parent management training
  • Consistent discipline strategies
  • CBT, family therapy

Conduct Disorder

  • Multimodal therapy: family intervention, behavioral therapy
  • Treat comorbid ADHD (stimulants can reduce aggression)
  • Severe/refractory: atypical antipsychotics (risperidone)

Intermittent Explosive Disorder

  • CBT
  • Pharmacologic options: SSRIs, mood stabilizers, or antipsychotics in refractory cases

Key Differentiators

  • ODD vs Conduct Disorder → ODD = defiance toward authority, but no aggression/theft/serious rights violation; CD = aggression, property destruction, theft, serious violations.
  • Conduct Disorder vs Antisocial Personality Disorder → CD = diagnosis <18 years old; if ≥18 with same pattern = Antisocial Personality Disorder.
  • IED vs CD → IED = impulsive, out-of-proportion aggression; CD = planned, repetitive, violation of rights.

Test Alert

  • If aggression/rights violation occurs before age 18 = Conduct Disorder.
  • If the same pattern persists into adulthood (≥18) = Antisocial Personality Disorder.

Eating Disorders

Psychiatric conditions characterized by disturbed eating behaviors and body image.

  • Peak onset: adolescence to early adulthood
  • More common in females
  • Associated with perfectionism, family conflict, history of trauma, and psychiatric comorbidities (depression, anxiety, OCD)

Clinical Presentation

Anorexia Nervosa

  • Restriction of energy intake → significantly low body weight
  • Intense fear of gaining weight or becoming fat
  • Distorted body image (perceives self as overweight despite being underweight)
  • Two subtypes:
    • Restricting type → diet/fasting/excessive exercise
    • Binge-eating/purging type → binge eating + purging behaviors
  • Physical findings: amenorrhea, bradycardia, hypotension, hypothermia, lanugo hair, osteoporosis

Bulimia Nervosa

  • Recurrent binge-eating episodes + inappropriate compensatory behaviors (vomiting, laxatives, diuretics, excessive exercise)
  • Occurs at least once/week for 3 months
  • Patients usually normal weight or overweight (not underweight like anorexia)
  • Physical findings:
    • Dental enamel erosion
    • Parotid gland enlargement
    • Russell’s sign (calluses on knuckles)
    • Electrolyte disturbances (hypokalemia, metabolic alkalosis)

Binge Eating Disorder

  • Recurrent binge-eating episodes without compensatory behaviors
  • Associated with obesity
  • Loss of control, distress about bingeing
  • Physical findings: obesity-related complications (HTN, diabetes, hyperlipidemia)

Labs, Studies, and Physical Exam Findings

  • Anorexia: low BMI, hypokalemia, hypochloremic metabolic alkalosis, ↑ BUN/creatinine, low estrogen, osteoporosis
  • Bulimia: electrolyte imbalances (low K⁺, low Cl⁻), metabolic alkalosis
  • Binge Eating: labs may show obesity-related metabolic syndrome (↑ glucose, ↑ cholesterol, ↑ triglycerides)

Treatment

Anorexia Nervosa

  • Nutritional rehabilitation (first priority)
  • Psychotherapy (CBT, family-based therapy in adolescents)
  • Pharmacotherapy: SSRIs may help with comorbid depression/anxiety, but nutrition must be corrected first
  • Hospitalization if severe malnutrition, electrolyte imbalance, bradycardia, suicidality

Bulimia Nervosa

  • First-line: CBT + SSRIs (fluoxetine FDA-approved)
  • Nutritional counseling
  • Avoid bupropion (↑ seizure risk with purging)

Binge Eating Disorder

  • First-line: CBT
  • Pharmacologic: SSRIs, lisdexamfetamine (FDA-approved), topiramate
  • Weight management strategies

Key Differentiators

  • Anorexia vs Bulimia → Anorexia = significantly underweight; Bulimia = normal/overweight.
  • Bulimia vs Binge Eating Disorder → Bulimia = binge + compensatory behaviors; Binge Eating = binge only, no purging.
  • Anorexia medical complication → highest mortality rate of all psychiatric disorders (due to arrhythmia, suicide).

Test Alert

  • An underweight patient with electrolyte abnormalities → Anorexia Nervosa.
  • A patient with binge-purge cycle but normal weight → Bulimia Nervosa.
  • A patient with binge eating and obesity, no purging → Binge Eating Disorder.