ADHD and Mood Disorders

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Attention Deficit Hyperactivity Disorder

Things you should know

Affects children and adolescents
Symptoms must occur in multiple settings and continue for at least 6 months.
30–50% of people diagnosed in childhood continue to have symptoms into adulthood

I came in to see my physician assistant today because of…

Inattentive Symptoms
- Fails to give close attention to details or makes careless mistakes in schoolwork
- Has difficulty keeping attention during tasks or play
- Does not seem to listen when spoken to directly
- Does not follow through on instructions and fails to finish things
- Has problems organizing tasks and activities
- Avoids or dislikes tasks that require sustained mental effort
- Often loses toys, assignments, pencils, books, or tools needed for tasks or activities
- Is easily distracted
- Is often forgetful in daily activities

Hyperactivity Symptoms
- Fidgets with hands or feet or squirms in seat
- Leaves seat when remaining seated is expected
- Runs about or climbs in inappropriate situations
- Has problems playing or working quietly
- Talks excessively
Impulsivity Symptoms
- Blurts out answers before questions have been completed
- Has difficulty awaiting turn
- Interrupts or intrudes on others’ conversations

Diagnosis

Diagnosis is made clinically with input from teachers and parents.
- At least 6 separate symptoms for at least 6 months.
An adult must have had symptoms as child for this diagnosis to be applied

Treatment

Psychosocial
- Behavioral Therapy
- Psychoeducational Input
- Cognitive Behavioral Therapy
- Interpersonal Psychotherapy
- Family Therapy
- School-based Interventions
- Social skills training
- Parent management training
- Neurofeedback
Medications
- Stimulant Medications
  - Ritalin (methylphenidate)
- Non-stimulant medications that can be used as alternatives
  - Atomoxetine
  - Bupropion
  - Guanfacine
  - Clonidine
To help a child with ADHD, the following is advised:
- Talk regularly with the child’s teacher
- Consistent schedule
- Limit distractions
- Healthy diet
- Sleep
- Provide clear and consistent communication

Adjustment Disorder

Things you should know

Specific stressful event

Symptoms

Emotional
- Sadness
- Hopelessness
- Lack of enjoyment
- Crying spells
- Nervousness
- Anxiety
- Worry
- Desperation
- Trouble sleeping
- Difficulty concentrating
- Feeling overwhelmed and thoughts of suicide
Behavioral
- Fighting
- Reckless driving
- Ignoring important tasks deliberately
- Avoiding family or friends
- Performing poorly in school
- Skipping school
- Vandalizing property

Diagnosis

For an adjustment disorder to be diagnosed, the following criteria must be met:

Having emotional or behavioral symptoms within three months of a specific stressor occurring in life
Experiencing more stress than would normally be expected in response to the stressor
An improvement of symptoms within six months after the stressful event ends
The symptoms are not the result of another diagnosis

Treatment

Psychotherapy
- Counseling or Talk Therapy.
- Individual therapy, group therapy or family therapy
Medications
- Antidepressants
- Anti-anxiety medications

Bipolar

Things you should know

A mental disorder characterized by periods of elevated mood and periods of depression
Types of Bipolar Disorder
- Bipolar I disorder
  - One more manic episodes
  - Episodes of depression are common but are not necessary for diagnosis.
- Bipolar II disorder
  - One or more major depressive episodes + at least one hypomanic episode
- Cyclothymic disorder
  - A more mild form of bipolar disorder
  - Hypomania and depression can be disruptive, but the highs and lows are not as severe as they are with other types of bipolar disorder

Symptoms

Manic phase
- Euphoria
- Racing thoughts
- Inflated self-esteem
- Poor judgment
- Rapid speech
- Aggressive behavior
- Agitation or irritation
- Increased physical activity
- Risky behavior
- Spending sprees or unwise financial choices
- Increased drive to perform or achieve goals
- Increased sex drive
- Decreased need for sleep
- Easily distracted
- Careless or dangerous use of drugs or alcohol
- Frequent absences from work or school
- Delusions or a break from reality (psychosis)
- Poor performance at work or school
Depressive phase
- Sadness
- Hopelessness
- Suicidal thoughts or behavior
- Anxiety
- etc.

Diagnosis

Psychological evaluation
- Use of Bipolar Spectrum Diagnostic Scale
Mood charting
- a daily record of moods, sleep patterns and other factors

Treatment

Psychosocial
- Psychotherapy
- Cognitive behavioral therapy
- Family-focused therapy
Medication
- Mood stabilizers
  - Lithium – narrow therapeutic window. Serum level must be checked every 4-8 weeks
  - Valproic Acid
  - Carbamazepine
- Antipsychotics
  - Risperidone
  - Aripiprazole
- Acute manic episode
  - Haloperidol
  - Benzodiazepines

Depressive Disorder

Things you should know

A mental disorder characterized by a pervasive and persistent low mood and low self-esteem and by a loss of interest or pleasure in normally enjoyable activities
Causes:
- Alcohol or drug abuse
- Certain medical conditions, including underactive thyroid, cancer, or long-term pain
- Certain medicines, such as steroids
- Sleeping problems
- Stressful life events, such as death or illness of someone close to you, divorce, childhood abuse or neglect, loneliness, relationship breakup
Classification of Depression:
- Melancholic depression
  - Loss of pleasure in most or all activities
  - Failure of reactivity to pleasurable stimuli
  - Quality of depressed mood more pronounced than that of grief or loss
  - Worsening of symptoms in the morning hours
  - Early-morning waking
  - Psychomotor retardation
  - Excessive weight loss
  - Excessive guilt
- Atypical depression
  - Mood reactivity
  - Significant weight gain or increased appetite – comfort eating
  - Hypersomnia – excessive sleep or sleepiness
  - Leaden Paralysis – sensation of heaviness in limbs
  - Significant social impairment as a consequence of hypersensitivity to perceived interpersonal rejection
- Catatonic depression – rare but severe
  - Disturbances of motor behavior and other symptoms
  - Mute and almost stuporous
  - Either remains immobile or exhibits purposeless or even bizarre movements – posturing and waxy flexibility – move as if made by wax. Seen in catatonic schizophrenia as well.
- Psychotic depression
  - Includes delusions / hallucinations
- Postpartum depression
  - Incidence Rate: 10–15% among new mothers
  - Occurs within one month of delivery
- Seasonal affective disorder (SAD)

Symptoms

Feeling hopeless and helpless, worthless, guilty, self-hate
Agitation, restlessness, irritability, and anger
Withdrawn or isolated
Fatigue and lack of energy
Loss of interest or pleasure in activities that were once enjoyed
Sudden change in appetite, often with weight gain or loss
Thoughts of death or suicide
Trouble concentrating
Trouble sleeping or sleeping too much
Hallucinations and delusions- severe depression

Diagnosis

Laboratory tests
- TSH and Thyroxine levels to exclude hypothyroidism
- Basic electrolytes and serum calcium to rule out a metabolic disturbance
- Complete blood count including ESR to rule out a systemic infection or chronic disease
Psychological evaluation
- Diagnostic and Statistical Manual of Mental Disorders (DSM) Criteria for Depression
  - Depressed mood, such as feeling sad, empty or tearful
  - Significantly diminished interest or feeling no pleasure in all
  - Significant weight loss when not dieting, weight gain, or decrease or increase in appetite
  - Insomnia or increased desire to sleep
  - Either restlessness or slowed behavior that can be observed by others
  - Fatigue or loss of energy
  - Feelings of worthlessness, or excessive or inappropriate guilt
  - Trouble making decisions, or trouble thinking or concentrating
  - Recurrent thoughts of death or suicide, or a suicide attempt

Treatment

Psychotherapy
- Cognitive behavioral therapy (CBT)
- Interpersonal psychotherapy (IPT) Family therapy
- Psychoanalysis
Medications – Patients on stable medications should continue use for a minimum of 6 months.
- Selective serotonin reuptake inhibitors (SSRIs) – safer and generally cause fewer bothersome side effects
  - Fluoxetine (Prozac)
  - Paroxetine (Paxil)
  - Sertraline (Zoloft)
  - Citalopram (Celexa)
  - Escitalopram (Lexapro)
- Serotonin and norepinephrine reuptake inhibitors (SNRIs)
  - Duloxetine (Cymbalta)
  - Venlafaxine (Effexor XR)
  - Desvenlafaxine (Pristiq).
- Norepinephrine and dopamine reuptake inhibitors (NDRIs)
  - Bupropion (Wellbutrin) falls into this category
- Atypical antidepressants
  - Trazodone
  - Mirtazapine (Remeron)
  - Vilazodone (Viibryd)
- Tricyclic antidepressants.
  - Imipramine (Tofranil)
  - Nortriptyline (Pamelor)
- Monoamine oxidase inhibitors (MAOIs) used less frequently due to side effect profile
  - Tranylcypromine (Parnate)
  - Phenelzine (Nardil)
  - Selegiline (Emsam
Electroconvulsive therapy (ECT) – a procedure whereby pulses of electricity are sent through the brain under general anesthesia.
- Effective but typically limited to severe refractory depression.
- Treatment may used with pregnant woman.
Bright light therapy
Physical exercise – recommended for management of mild depression

Dysthymic Disorder

Things you should know

Less severe but longer lasting depression
“bad state of the mind”
Neurotic depression, dysthymic disorder, or chronic depression
F>M

Symptoms

Adults:
- Loss of interest in daily activities
- Sadness or feeling down
- Hopelessness
- Tiredness and lack of energy
- Low self-esteem, self-criticism or feeling incapable
- Trouble concentrating and trouble making decisions
- Irritability or excessive anger
- Decreased activity, effectiveness and productivity
- Avoidance of social activities
- Feelings of guilt and worries over the past
- Poor appetite or overeating
- Sleep problems
Children
- Irritability
- Behavior problems
- Poor school performance
- Pessimistic attitude
- Poor social skills
- Low self-esteem

Diagnosis

Psychological evaluation
- Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria:
  - During a majority of days for two years or more, the adult patient reports depressed mood or appears depressed to others for most of the day.
  - When depressed, the patient has two or more of:
    - Decreased or increased appetite
    - Insomnia or hypersomnia
    - Fatigue
    - Reduced self-esteem
    - Decreased concentration or problems making decisions
    - Feelings of hopelessness or pessimism
  - During a two-year period, the above symptoms are never absent longer than two consecutive months.
  - No other diagnosis fits – for example
    - No manic episodes
    - No medical cause
    - No major depressive episodes
    - etc

Treatment

Psychotherapy – often effective in treating dysthymia
- Cognitive-behavioral therapy
- Psychodynamic psychotherapy
- Interpersonal psychotherapy)
- Group psychotherapy and self-help
- Support groups
Medications
- Antidepressants
  - Selective serotonin reuptake inhibitors (SSRIs)
  - Serotonin and norepinephrine reuptake inhibitors (SNRIs)
  - Tricyclic antidepressants (TCAs)

Study Tips

When doing full lenght questions always use a timer. 60 seconds per question.

Key Terms and Ideas

Waxy flexibility should make you think of what two possible diagnosis?
- Catatonic depression and catatonic schizophrenia
Can ECT be used during pregnancy?
- Yes
In order to diagnose dysthymic disorder symptoms must occer over what period of time?
- 2 years.
Is a major depressive episode necessary for the the diagnosis of bipolar?
- Not for bipolar I
Name two SSRIs
- Fluoxetine (Prozac)
- Paroxetine (Paxil)
- Sertraline (Zoloft)
- Citalopram (Celexa)
- Escitalopram (Lexapro)

<< Click here to get 23 Psych questions straight from my book, The Final Step >>