Masking and Misdiagnosis: ADHD in adult mental health services. Dr Rob Baskind Clinical Lead and Consultant Psychiatrist Leeds Adult ADHD service

Transcription

1 Masking and Misdiagnosis: ADHD in adult mental health services Dr Rob Baskind Clinical Lead and Consultant Psychiatrist Leeds Adult ADHD service

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4 ADHD clinician career pathway 1. (Lucky) exposure to a successful ADHD case 2. Go learn about it 3. Try and see more ADHD 4. Get a job in an ADHD team 5. Yes!

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6 The Specialist Adult ADHD Psychiatrist.. A recent referral I am writing to refer this 44 year old patient who is concerned that she has some signs of ADHD. She has had symptoms for some time but only considered this diagnosis recently when her daughter was being assessed for the condition. She noticed that she was also answering all the questions in the same way as her daughter. We have completely the self-assessment questionnaire from the Leeds health pathways website and she does answer as agree or strongly agree to almost all of the questions and statements. In terms of past history, she has been diagnosed with bipolar disorder and has previous issues with alcohol dependence although is now in remission. She also has a diagnosis of fibromyalgia and struggles with chronic pain. She currently takes codeine, diazepam, aripiprazole and vensir XL.

7 The Specialist Adult ADHD Psychiatrist.. A recent referral I am writing to refer this 44 year old patient who is concerned that she has some signs of ADHD. She has had symptoms for some time but only considered this diagnosis recently when her daughter was being assessed for the condition. She noticed that she was also answering all the questions in the same way as her daughter. We have completely the self-assessment questionnaire from the Leeds health pathways website and she does answer as agree or strongly agree to almost all of the questions and statements. In terms of past history, she has been diagnosed with bipolar disorder and has previous issues with alcohol dependence although is now in remission. She also has a diagnosis of fibromyalgia and struggles with chronic pain. She currently takes codeine, diazepam, aripiprazole and vensir XL.

8 The Specialist Adult ADHD Psychiatrist.. A recent referral I am writing to refer this 44 year old patient who is concerned that she has some signs of ADHD. She has had symptoms for some time but only considered this diagnosis recently when her daughter was being assessed for the condition. She noticed that she was also answering all the questions in the same way as her daughter. We have completely the self-assessment questionnaire from the Leeds health pathways website and she does answer as agree or strongly agree to almost all of the questions and statements. In terms of past history, she has been diagnosed with bipolar disorder and has previous issues with alcohol dependence although is now in remission. She also has a diagnosis of fibromyalgia and struggles with chronic pain. She currently takes codeine, diazepam, aripiprazole and vensir XL.

9 The Specialist Adult ADHD Psychiatrist.. A recent referral I am writing to refer this patient who is concerned that she has some signs of ADHD. She has had symptoms for some time but only considered this diagnosis recently when her daughter was being assessed for the condition. She noticed that she was also answering all the questions in the same way as her daughter. We have completely the self-assessment questionnaire from the Leeds health pathways website and she does answer as agree or strongly agree to almost all of the questions and statements. In terms of past history, she has been diagnosed with bipolar disorder and has previous issues with alcohol dependence although is now in remission. She also has a diagnosis of fibromyalgia and struggles with chronic pain. She currently takes codeine, diazepam, aripiprazole and vensir XL.

10 Getting an ADHD assessment (and therefore the right diagnosis) (More often than not) You have to ask for it

11 ADHD

12 Untreated ADHD may lead to Diminished quality of life Failed years at university Employment difficulties/unemployment Sustained/increased substance misuse More severe mental health problems Self-harm/suicide Relationship breakdowns Unplanned pregnancies Re-offending Injuries Lower life expectancy

13 Is it so bizarre to think ADHD? Prevalence of 2.5% (+) Rapid, effective and robust treatment responses

14 Adult ADHD = Comorbidity Low self-esteem Depression (20-50%) Anxiety (20-50%) OCD (5-10%) Personality disorder (10-50%) Substance misuse (20% have ADHD) Bipolar Disorder (5-20%) Obesity Psychosis

15 Differentiating ADHD from other mental disorders Depression Chronic Mood instability Trait-like low mood rather than episodic state-like depression An absence of somatic symptoms (newly disturbed sleep, appetite, diminished energy levels) Bipolar Disorder A lack of distinct periods of abnormal and extreme mood states with corresponding periods of normal baseline functioning in between Tiredness due to lack of sleep rather than a reduced need for sleep A lack of grandiosity or psychotic features Ceaseless unfocused thoughts rather than episodic thought disorder (eg. Flight of ideas) Anxiety Ceaseless unfocused thoughts, as opposed to exaggerated apprehension and generalized worry An absence of somatic symptoms Situation avoidance due to frustration with own behaviors rather than phobic avoidance common to anxiety disorders Forgetfulness rather than hypervigilance Personality Disorder An absence of psychological disturbances, such as feelings of abandonment and chronic feelings of emptiness Chronic inattention symptoms

16 Prevalence of ADHD in nonpsychotic adult psychiatric care (ADPSYC): A multinational cross-sectional study in Europe Almost 2000 patients 15-17% met ADHD diagnostic criteria Depression most common

17 How much is the co-morbidity masking the ADHD?

18 So why is ADHD not being picked up? Multifactorial Organisational Clinician Patient factors

19 Organisational Funding and provision Other priorities Lack of training (requirements) Stigma

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21 Breaking down barriers the challenge of improving mental health outcomes (BMA, 2017) Inadequate funding at a time of increasing demand Access problems and lack of integration and prevention Inadequate provision and quality of services Understaffed workforce and insufficient training

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23 Accessing mental health services Often strict criteria At severe end of spectrum Severe and enduring MH problem Bipolar Disorder Psychosis Resistant depressive disorder Severe anxiety / OCD Personality disorder Eating disorders In crisis (Risk)

24 Clinician factors Poor knowledge Clinical skills Stigma Clinical and time pressures Lack of continuity with same patients Missing red flags Not considering underlying diagnoses Intolerance and misinterpretation of behaviours Helplessness

25 Use of stimulants leads to abuse and addiction Its normal. We all have these symptoms. Why the diagnosis? They just need to try harder.

26 Presenting complaints and contexts Presenting complaints Mood swings Feelings of being failure / Low self esteem / Depressed / frustrated Feeling easily overwhelmed Socially anxious / panic attacks Racing thoughts Voices inside head Can t sleep Exhaustion Contexts Relationship breakdown Loss of another job Educational Failure Debts Alcohol / drug binge Criminal conviction Self harm attempt Not responding to antidepressants / mood stabilisers / CBT Feel different

27 Patient factors Ignorance Keeping it hidden Barriers to seeking help Psychological impact of ADHD

28 Barriers to mental health seeking (Salaheddin et al, 2016) Fear of stigma Perceiving problem as not serious enough Reliance on self Difficulty accessing help Fear of negative outcome Difficulty identifying or expressing concerns

29 a young girl stuck in constant self blame for her inadequacies and stupidity underneath all that exterior was me A PATIENT S REFLECTIONS continuous self reflection left me exhausted Always labelled the gypsy spirit or Tasmanian Devil life kept repeating itself.. wanting to be accepted but ironically distancing myself from people as they bored me or left me overwhelmed. I made daily pledges to conform all the time I tried harder yet repeating identical behaviours I was always reminded I won t succeed unless I buckle down and you re not in primary school act your age.

30 I never gave up trying to be like everyone else; traveling through life aspiring to be the girl who had achieved increases in life expectations did overspill causing spirals into depression and anxiety my constant stream of internal chatter now filled with negativity and endless what if s All the time telling myself; it s ok to feel bored, it s normal to switch off when people talk at you I had heard too many comments, noted too many requests to calm and shouted out too many random times in meetings. I felt vulnerable, scared and no awareness where to turn for support Work colleagues mentioned ADHD numerous times over 15 years but I always laughed it off. Surely that s what naughty boys have? surely that wouldn t account for my sleep problems and my quirks?

31 Having ADHD leaves patients feeling.. Different Mentally and physically exhausted Hopeless Frustrated Overwhelmed Incompetent in all areas of life stupid Burnt out Not trusting own behaviour Needing to please

32 Depression? Is it surprising? Genetics Not performing Negative comments at school Poorer results with greater effort Internalising distress Nagged at home Bullying Employment failures Mental illness Criminal behaviours Drug and Alcohol problems Relationship breakdowns Financial stress Unemployment Reduced selfesteem Stress threshold sinks Learned Helplessness

33 Anxiety? Who s really exploring What s the worry? Is it about anything and everything.. Or linked to an (implicit or explicit) awareness of their own limitations? And arise at times of increased demand or expectations? Need to think core ADHD symptoms

34 DSM-5 symptoms of ADHD Inattention Lack of attention to details Difficulty sustaining attention Does not listen when directly spoken to Lack of follow-through on tasks Difficulty organising tasks and activities Avoids tasks requiring sustained mental effort Often loses things necessary for tasks or activities Easily distracted by external stimuli Forgetful in daily activities Hyperactive-impulsive Difficulties to keep still Unable to stay seated when expected Feeling physically and/or mentally restless Being loud and difficulty regulating volume of voice On the go as if driven by a motor Talks excessively Blurts out before questions completed Difficulties awaiting turn Interrupts or intrudes on others

35 DSM-5 symptoms of ADHD Inattention Lack of attention to details Difficulty sustaining attention Does not listen when directly spoken to Lack of follow-through on tasks Difficulty organising tasks and activities Avoids tasks requiring sustained mental effort Often loses things necessary for tasks or activities Easily distracted by external stimuli Forgetful in daily activities Hyperactive-impulsive Difficulties to keep still Unable to stay seated when expected Feeling physically and/or mentally restless Being loud and difficulty regulating volume of voice On the go as if driven by a motor Talks excessively Blurts out before questions completed Difficulties awaiting turn Interrupts or intrudes on others

36 DSM-5 symptoms of ADHD Inattention Lack of attention to details Difficulty sustaining attention Does not listen when directly spoken to Lack of follow-through on tasks Difficulty organising tasks and activities Avoids tasks requiring sustained mental effort Often loses things necessary for tasks or activities Easily distracted by external stimuli Forgetful in daily activities Hyperactive-impulsive Difficulties to keep still Unable to stay seated when expected Feeling physically and/or mentally restless Being loud and difficulty regulating volume of voice On the go as if driven by a motor Talks excessively Blurts out before questions completed Difficulties awaiting turn Interrupts or intrudes on others

37 DSM-5 symptoms of ADHD Inattention Lack of attention to details Difficulty sustaining attention Does not listen when directly spoken to Lack of follow-through on tasks Difficulty organising tasks and activities Avoids tasks requiring sustained mental effort Often loses things necessary for tasks or activities Easily distracted by external stimuli Forgetful in daily activities Hyperactive-impulsive Difficulties to keep still Unable to stay seated when expected Feeling physically and/or mentally restless Being loud and difficulty regulating volume of voice On the go as if driven by a motor Talks excessively Blurts out before questions completed Difficulties awaiting turn Interrupts or intrudes on others

38 DSM-5 symptoms of ADHD Inattention Lack of attention to details Difficulty sustaining attention Does not listen when directly spoken to Lack of follow-through on tasks Difficulty organising tasks and activities Avoids tasks requiring sustained mental effort Often loses things necessary for tasks or activities Easily distracted by external stimuli Forgetful in daily activities Hyperactive-impulsive Difficulties to keep still Unable to stay seated when expected Feeling physically and/or mentally restless Being loud and difficulty regulating volume of voice On the go as if driven by a motor Talks excessively Blurts out before questions completed Difficulties awaiting turn Interrupts or intrudes on others

39 DSM-5 symptoms of ADHD Inattention Lack of attention to details Difficulty sustaining attention Does not listen when directly spoken to Lack of follow-through on tasks Difficulty organising tasks and activities Avoids tasks requiring sustained mental effort Often loses things necessary for tasks or activities Easily distracted by external stimuli Forgetful in daily activities Hyperactive-impulsive Difficulties to keep still Unable to stay seated when expected Feeling physically and/or mentally restless Being loud and difficulty regulating volume of voice On the go as if driven by a motor Talks excessively Blurts out before questions completed Difficulties awaiting turn Interrupts or intrudes on others

40 Increasing (internal) Hidden struggle The functioning cycle of (missed) ADHD (Back to) Functioning and selfresilience New demand and pressure Different GP / Crisis assessment Mental Health deterioration

41 Why is ADHD missed/misdiagnosed? Multifactorial Organisational Clinician Patient factors

42 Lobbying Steps for change. Media Awareness Education/Training Clinicians exposure to successful outcomes Simple clinical guideline for identification in primary and secondary health care

43 The good news

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46 Mood instability, depression and anxiety features are often the direct result of ADHD and only continue to exist due to untreated symptoms of ADHD

47 A starter.. simple but effective? Presentation of Mood instability, Depression or Anxiety Screen for ADHD Screen positive Referral for assessment and trial of ADHD treatment as appropriate (unless evidence of acute mania/ severe depression/suicidal risk) If depression / anxiety persists then treat comorbidity

48 4 questions to screen and identify red flags Do you feel that you get bored and restless more easily than most people? Are you more forgetful or disorganised than the average person? Do you feel you are consistently failing to achieve your own potential? And if any yes answers, then.. As a child, did you have problems with: paying attention and distractibility? doing impulsive, dangerous, or disobedient things?

49 @robbask Thank you for listening Any Questions?