E55: ADHD: Diagnosis, Comorbidities, and Differential

(upbeat music) - Hello, this is your brand of drugs in this project, it's like I addressed. So, we're looking back over to ADHD today. Covered a lot of the basics last time and kind of talked about background, ideology, acknowledged that this is very controversial. I even read an article just before this episode is recording that said that there was no change in brain imaging with ADHD individuals. And I told you there there was, and I've read several places there is. So, like I said, there's a lot of controversy. We're gonna go over the DSM criteria today. We're gonna talk about diagnosis. And then we're gonna talk about comorbidities and differentials. So, that's what we're gonna cover today. And yeah, I was looking at like, what's the, you know, I learned under DSM4TR. So, I was like, you know, to kind of flesh out those differences between DSM4 and 5. And then there was the 5TR that came out a few years ago. And there were a few changes there. One of them I guess was that you can now be given a diagnosis of ADHD and ASD. I'm pretty sure people have been doing that, but apparently DSM gave its blessing for that. It was moved into like, disorders of childhood and to neurodevelopmental disorders. And this paper was kind of talking about how there was no evidence that it was a neurodevelopmental disorder. And I was talking about on the last episode that that's what it is. And I still agree with that. And then they were saying that even when I was mentioning how the genetics was 70 to 80% heritability and they said, "Well, that's just in twin studies." And, you know, you can't really separate environment from that. And, you know, I mean, that's the case with a lot of things. There's a lot of hate on ADHD. A lot of hate people really have a lot of opinions. And there's a lot of love for ADHD. I mean, there is a love-hate relationship that, I know Americans, I don't know about other countries, but like Americans have a love-hate relationship with ADHD. Some people, they hold on to their ADHD diagnosis for everything it's worth and they will not let go. There are people that think they have it that probably don't, that, you know, really want the stimulants and feel like those help them. And then you've got other people that are just like, this is not a real diagnosis. This is nonsense. These people just want to take drugs legally and we're concerned that this is causing problems. So, like, it's such a controversial thing. And so, like I said, I'm going to talk about the controversy a little bit, but like, this is mainly a Med podcast. I'm giving you the background. And I'm going to talk mostly about, you know, the main plan is to tell you about the medications, how they work, how to use them safely. And so, with that, let's go ahead and get started. When you're diagnosing ADHD, it can be a little bit challenging. Like I said, because people that are kind of, they're a lot of the time they are fishing for the diagnosis. And I'll tell you what I do. I, like, when someone is coming in saying, I think I have ADHD, I'm actually a lot more hesitant to make the diagnosis. And I'm, there's a lot more cautious. And when people come in and they don't talk about ADHD at all, but I'm getting the hint that maybe they have it. And then I bring it up. I'm way more likely to be less thorough. Because I'm like, well, they're not trying to gain me. They're not coming in here with this diagnosis. It's my idea. Like, it sounds like they might have something like this. And I'll tell you what's interesting is, a lot of the time when that case happens, I'm like, you know, I think you might have ADHD. Have you ever been diagnosed? They'll be like, yeah, I have that. Some of them will be like, yeah, I think I took something like. Some of them are kind of like unaware. They're just like, yeah, I think I had that. And my parents had me on meds for like a year. I don't really remember. And then other people will be like, yeah, I've been wondering about that. But like, they didn't actually come in with that as their concern. And I don't think they're trying to pull one over on me. And so where it comes out like more organically like that, like with a lot of other diagnoses. But yeah, the one that bothers me is the people they come in, they're like, yeah, I have ADHD. You know, if you do, if it's in your record, and you've been treated for it, or you know, you've got a long history of it, that's one thing. But if it's like you've never been treated, and you're like wanting me to make the diagnosis, be the first person to make the diagnosis, and you have no evidence for it. And you're basically just saying, I'm here because I think I have ADHD. You're probably going to have more of an uphill climb with me. Because I'm going to be a little more suspicious that, you know, maybe you're just coming here to get stimulants, right? So, and I'll probably follow a different path. I'll probably not give you a stimulant as soon as I would have. I will be looking for collateral information a little bit more. So how the patient presents for me, personally, that's how I do it. I don't, I wasn't taught that, but it's just kind of something, like I said, in the military, we have so many patients that like present with these symptoms and like have histories of these symptoms. I think, I'd let, I mean, I'd like to see if there's numbers on this, but I would say that probably there is a higher prevalence of ADHD amongst people who join the military than people who don't. Maybe there is, maybe there isn't. I don't know, but I saw a lot of it. So your interview, I mean, here are your diagnostic techniques. It's a hard diagnosis to make. And that's because, it's because people are fishing for it. If they're not fishing for it, it's easier to make, okay? But you're gonna use a lot of the same stuff you use for everything, the interview, right? So the interview in the history, you wanna find out what their life is like, you wanna find out what they're struggling with, why they think they're struggling, what their, you know, what their past history is like, what their lives are like, you get a general sense, this is how I make all diagnoses. I don't make them based on DSM criteria. I make them based on the story I hear from the patient and the symptoms that I collect from that. 'Cause the thing is, everyone's gonna have symptoms present in a different way. And like just because the DSM lists it in a certain way, doesn't mean that that person is gonna experience this problem with that certain thing. And I think that's why they try to say, well, you don't need all the criteria, but like it does its best. Like if I were to write the DSM, I'm not sure that I could really do much of a better job to be honest. So like, I think it's a necessary evil, but it's, I don't think that, I think it should probably like have like a forward in it that says, hey, don't take this too seriously. Like this is just a guy, this is just the best we could do. We know that it has faults, but if it qualified itself as like what it actually is, I would not criticize it. But I think those that wrote it and approved it, like take it too seriously. Like, no, no, this is like, this is evidence. This is like real. This is, yeah, everyone should use this. No, it's like, yeah, we need something like this until we can get biomarkers and scans and more objective tools. Yeah, we need something like this, right? But like that's, like what I said, I use interview. I get a general sense of how I think the patient's doing. I think about how the meds work and I try to think about how a med that works different ways would fit with the kinds of symptoms that they have. If this is the picture of someone who I think lithium would be helpful for, I give them lithium. If this is kind of person that has a symptoms I think would respond to a SSRI, I give them SSRI. And of course, these people generally are gonna be people that have the diagnosis of bipolar MDD or something close to it, right? But I don't follow it to the letter. So yeah, you're gonna do an interview, you're gonna find out all about them, find about their history. Their childhood history is gonna be super important here. Like, how did they do in school? How did they do with their friends, their parents, right? If you can get records from that, they always say that, but this is super hard to do. And like, I mean, doctors have such a little time with patients as it is, do they have time to dig all this stuff up? Sometimes you do it, sometimes it's necessary on inpatient units. You have a little bit more time. I mean, I did anyway, but if you can get, the more collateral you can get, if you've got a spouse that can come in with the patient and you can get their story, those can all be useful. But at the end of the day, if I wanna try and met on the patient, we try it, we see what happens, they feel better, we keep it. That's kind of my philosophy. But you wanna be very cautious about giving people controlled substances. Now, we'll talk about the controlled substances in detail in the future. Of course, the stimulants are scheduled to, which is super high. I'm hearing in the news that a cannabis might possibly go from schedule one, which means no medical use down to schedule three, which is kind of interesting, that we could go from saying, "This isn't a legal substance that states aren't even supposed to authorize for use even though they're doing it." We're not even going to lower it to two, we're lower it to three. And then these meds like Adderall and these stimulants, they're scheduled to. So we're going to basically say that, "Go from saying that cannabis is more dangerous than these two less dangerous and not even go through the step of, oh it's the same." It's so arbitrary. It's just so opinion oriented and not like factually oriented or decided. It's like political, it's opinion based, it's just kind of ridiculous. And of course I have my own opinions. And so do you. And that's what you use to guide your care. And you get more information so that your opinions can change. I read every day. You're listening to this podcast. You're getting more information. Hopefully your opinions will be changed. Sometimes a little, sometimes a lot, but that's what it's all about. Getting more information, honing your opinions so that you can do the best job. All right, so we get the interview, the history. And then there's standard assessment measures. Sometimes there is an adult ADHD scale that I will give to patients that I'm kind of like. A lot of the time I'm just like, "Yeah, I'm pretty dang sure you have this." But when I'm on the fence, I might give them the scale. The thing is that people are fishing for a diagnosis. They're going to answer the questions in a way that's obviously, you know, it's like, "Oh, this is what someone with ADHD would say. I'm going to check this box." So I mean, there can be a little bit of problem with that. The one they use for children is a little bit better because the children are not the ones. The children don't want to take these meds. They don't like them. I think that's my experience. The children like tend not to like taking these medications. It's the parents and the teachers that want the kids on the meds. So I think it's a little bit easier to do this for children because we have the corners. We have the parents' addition. We have the teachers' addition. There are other scales available. You send, you know, it's something that you purchase. You have in your office, you're a child psychiatrist or a pediatrician or whatever. You give the parents, you get, I mean, the other good thing is you always have collateral because the parents are always there. And then you get more collateral because you have the patients fill out these forms when they go home, they give it to the teacher, the teacher fills it out. You come back, you have like a little bit more objective information. And then you can assess whether you start a stimulant on this child or not. With adults, I mean, there are no teachers. There are no parents and then there's just this person who might be trying to gain you for meds that's going to basically answer whatever the questions, however the heck they want to try and get it. So the standard assessments for adults, and like I'm mainly going to talk about adults because I'm an adult psychiatrist. But the meds are the same. I mean, there's some meds that we'll talk about. The stimulants are approved for adults and children of different ages. So I'll mention that like this might be, oh, this is approved for six and up or this is only approved for seven, you know, six to 17. And this one's, you know, only approved for 15 and up. And yeah, we'll talk about that. So we will differentiate the difference between pediatric and adults when we talk about like which medications can be used, which ones are approved. We'll talk about, you know, off-label stuff that like you might use with one population versus another. But yeah, the most of our discussion will just be like, in the way you dose meds will be different for kids and adults. And I'll talk about that. But as far as assessing children for this, like that's how it's done. They come in, someone is, you know, the someone has concern. You send the form, send with the parents and the teachers. You evaluate them and then you pick a med and you start the kid on it. It's pretty straightforward. And then the next episode on ADHD that we have, I'm going to go into a lot of detail on how to assess all that stuff out for adults. For today, we're going to talk about more of the formal standardized stuff, right? And then physical and neurological exams. So you're going to want to do your physical and neurological exam because you're going to want to rule out other stuff because that's the other thing. And especially in kids, there's a lot of neurodevelopmental disorders in children that we're not going to go into because that's not my specialty that could look like ADHD. I mean, these are things like tuberous chlerosis, you know, stuff like this that an adult is either going to know they have it or it's going to be something where they're like very impaired by this or dead by that. So there's a whole bunch of disorders like this that, you know, all these childhood neurological and physical disorders and genetic disorders, which can look like ADHD, right? They have the symptoms of ADHD, but you're going to want to make sure it's not one of these other things. I don't have the experience to kind of go through that with you, but for adults, there's a lot less, right? Because by the time someone's an adult, all those things that children could have had that would have looked like ADHD, we now know they have it or don't have it. And if they have it, they're not coming in for an ADHD evaluation. And if they don't have it, then we don't need to worry about it, right? We're not making new diagnoses of these things as adults. There's just a little bit there, but really for adults, not a big deal. So that's another thing to kind of keep in mind, especially if you're looking at pediatrics that they're maybe a handful of disorders. And here's the other thing you have to think about with pediatrics. And we're going to talk about the differential a little bit later, but like just kind of say now, like I said, not a pediatric psychiatrist. However, I have, of course, I did a six month rotation in it and I trained and I've treated some children. And sometimes it's not like you can't treat children as an adult, right? As an adult psychiatrist, you can treat children, especially if you're in an area where there's no options for them, right? So it's something I did a few times in the military. We would get children coming into our emergency room. So mainly I'm doing safety evaluations, but I had a couple that just happened to land in my lab for one reason or another that I ended up treating for ADHD and I think one for ADHD and one for depression. So I just, a couple of kids I treated just now, patient kind of as a favor, that there weren't other good options for them or they were refusing the other options that they had for whatever reason. So yeah, I've got a little bit of experience there, but what I can say on kids is that a lot of the disorders we talk about as for adults like anxiety disorders, OCD, bipolar, schizophrenia, depression, a lot of that stuff can like present as ADHD when it's first starting to pop up, right? And you may think that that's weird, but like yeah, that's often how it happens. Is the brain is developing things fit the picture of ADHD and then later kind of morph into something else and it's like, oh wait, maybe this wasn't ADHD, this was bipolar disorder. So that's something to keep in mind with children, not something to really worry about adults. Of course, you're still going to want to make the same differential, but this kind of idea that like they start out looking like ADHD. I was told at one point that almost everything looks like ADHD when it first presents in children and then turns into something else. I'm sure there was ones that actually do look like what they are, but like that does happen a lot. So with kids, it's a lot, you know, to make these kind of rule out can be more important. All right, so let's look at the DSM criteria, right? And so one thing you need to know is DS basically, with DSM 4, they changed to this. You can have inattentive type, you can have impulse of hyperactive type and you can have combined type. And for whatever reason, DSM 5 changed type to presentation. And to be honest with you, I didn't know that until like 30 minutes ago because I could care less, like this semantic stuff to me is just stupid. Like these, it's like changing autism to autism spectrum disorder and getting rid of ass burgers. And it's like, like, so these people don't exist anymore. And now they're just, now we have to call them autistic or we don't call them autism, we call them autism spectrum disorder. It's like, these words, I think they take themselves too seriously. Okay, so they changed type to presentation, which I think is silly. I've continued to call it type. I didn't like, I'm not even sure that I realized that the sever even happened. But regardless, it's still the same three things. You can be either the inattentive presentation or the hyperactive impulsive presentation or a component or it's in it's like predominantly that or a combined presentation. So. Let's just kind of list these off. This is the other thing, so you've got a list of symptoms here. Another thing that changed with DSM5 was that before it was like you need six or more of these symptoms to have the disorder. For those 17 and up they changed it to five. So they're like, well, you know, we know these symptoms kind of can go away as people get older and we don't want to say that they don't meet the criteria just because they're older like I can of course, you know me, I don't care. I'm not like making my list and checking it twice and like, oh, sorry, there's only five. We can't make the diagnosis. I'm not going to treat what you have. You don't have it. You don't have it because you don't have this other thing. I mean, whatever. But that is something that you should know, especially if you're taking tests and so forth, and that you have to have the criteria for at least six months in two settings. Schoolwork, friends, etc. And then the other thing they changed between DSM4 and five was if we're diagnosing this at a later age, you have to have like in DSM4, it was like you had to have had several symptoms by the age of seven or no, it wasn't several. They changed the word just several in DSM5, but in DSM4, they called it like, I don't know, it was some other word like many ors. It wasn't they changed the word to several in DSM5, but they also changed the age in DSM4. It was by seven years old and then they increased it to 12. So when they say several symptoms, that doesn't mean that you need to have met criteria. So basically, you could have had like three or four criteria. I don't know. How do you want to just how do you want to describe the word several? When you're talking about a number up to six, because I mean, I think I always think several is seven. I think there's some people that think the word several means seven. It doesn't. It just means like many. But like I always think of two is not many. Three is like a few. So a few is not many. Four, which you need at least four. I mean, they don't even say how many. So it's like completely up to your own interpretation. How many several is so basically when they say, well, you didn't you didn't have this diagnosis when you were 11 years old, so you don't have it now. Well, the thing is you can manipulate this to make it however you want it. You can be like, well, it says several symptoms. You had three of them. You had three. I'll call that several. All the fine three is several. Now you have five in your adult, because I mean, honestly, if you only need five, but it's basically saying you didn't have to meet criteria, you just need several. Three is more than half of five. That sounds like several to me. If the max number is five, three sounds like a big number compared to five. So we'll call three several. So like someone else might be like, well, no, I think several means you need all five before it. And someone else might be like, well, three is enough. But it doesn't really say. So you can kind of like, this is where you can kind of make the diagnosis you want and still follow DSM. It gives you all this flexibility. I mean, the other thing is just like the list of symptoms, like someone might say as an example, first symptom, in attention to detail. Someone might say, yeah, I think you had it in attention to detail. And someone else could say, I don't think you had it in attention to detail. It's kind of like, well, it's an opinion, right? That's not a fact. It's not a fact whether someone had an attention to detail or not, right? Because the fact is everyone has had an attention to detail. That's a fact. You can't say that someone does not have an attention to detail. There is not a single person out there that has not had an attention to detail. So if you want to have the opinion that someone had that symptom and it meets the criteria to be a symptom of ADHD, you can have that. It's an opinion. And if you want to say, I know you had an attention to detail, but I don't think it met the rigor of the symptom to meet the criteria for the DSM, five criteria for ADHD, then you can say that. And so it is an opinion because all these symptoms are things that everyone has experienced. And so, but it's the varying degrees, but where's the cutoff? It's a spectrum. How bad does it have to be for you to decide that you think that this symptom is critical enough to give someone the diagnosis? I'll tell you a secret. You don't pay attention to it at all. You talk to the patient. You see if an attention has been a major factor in their life. And it's led to functional impairment and it's causing a lot of problems in their life. And you say, you know what? Sounds like you have ADHD. Here's a med, let's see if it works. You see them back. They say, oh man, everything's better. I'm getting stuff done. I'm not making mistakes. I'm on task. I'm not getting in fights with my spouse as much anymore. And it's like, Boo-ya, then we're keeping this, right? That's how I do it. It might sound a little reckless in Cal way, but the thing is, I've been doing this for a really long time and I don't have any bad outcomes doing it. So that's the way it is. And it might sound like, I'm just going to really really get these meds out. I deny them to tons of people. It's like, no, I don't think you have this. I think you're just want to perform this in answer. You're not actually suffering. You're just, and here's the case with a lot of people. A lot of people are just low functioning. If you're a low functioning person, that doesn't mean you have ADHD. It might mean that you're just lower intelligence level. And that's okay. But that doesn't mean you have ADHD just because you're not interested in learning science. And you can't pay attention to science when it's being taught in school. Doesn't mean you have ADHD. Do you know how much stuff I can't pay attention to? I can't pay attention to meetings. If I'm in a meeting, I don't hear anything. I absolutely despise meetings. And so if I'm in a meeting, and people are talking about blah, blah, blah, this is how our office works. This is the processes and procedures we're going to go to. I am zoned completely out. I'm in La Lalle. This is meaningless to me. You know, but put me in a calculus class or a science class or a history class or something interesting to me. I will be all ears. I will hear everything you have to say. I will be completely tuned in. All right. And that is where making the diagnosis of ADHD can be difficult. Because some people might say that if you can be interested in some things, then that means you don't have ADHD. Other people would say that people with ADHD focus really well on the things that they're interested in, but not in the things that they're not interested in. So it's like if you love wood carving, you might wood carve, you know, like nobody's business. And you can just, man, you can hone in on that. But you can't focus on anything else in your life at all, right? That could be one individual. And do they have ADHD? Do they not have ADHD? They've got the symptoms in every other aspect other than the wood carving. Do they have ADHD? I don't know. But like, I can tell you one thing, wood carving is not paying the bills and driving the car and getting stuff done and keeping you safe and getting your work done. And so yeah, maybe if you can't focus on any of these other aspects, you might need a stimulant to get that stuff taken care of. Okay. So these are all things you have to take. This is why this is a complicated diagnosis. And I can't just like teach you how I do this. And the way I do it is not the way everyone does it. We're just having a discussion today about diagnoses. And everyone has their own kind of thoughts on this. And hopefully you're gleaning something from my thoughts and taking something away from that that helps improve your knowledge. All right. So let's talk about an attention, right? So here, I'm just going to read them off. Inattention to detail, difficulty to sustain attention seems not to listen, fails to finish tasks, difficulty organizing, avoids tasks that require sustained attention, loses things, easily distracted, forgetful. You know what I find interesting about this? Those all sound like synonyms to me, right? It says, oh, you must have five, if you're over 17 or greater and six, if you're pediatric. I mean, I'd have to say that like if you have one of those, you probably have five or six of them because they kind of go together. Don't they? Like, if you can't sustain attention, you probably don't seem like you're listening. Right? If you lose things, you're probably also forgetful. So like you basically get two check marks. Oh, I'm forgetful. I mean, it's slightly different. But if you're the kind of person that loses things, you probably forget things, you know? And if you have difficulty sustaining attention, you probably avoid tasks that require sustained attention. I avoid meetings at all costs. Any chance I get to not go to a meeting, I'm not going to do it because I know I can't sustain attention and I'm born out of my mind, right? So, oh, I have difficulty sustaining attention in meetings. I also avoid tasks that require sustained attention. require to stay in attention meetings. And so I nailed two of them. Oh, seems not to listen. Yeah, I'm not listening in that meeting. I got three so far. Let's see, difficulty organizing. No, I don't have that problem. Fail is to finish-- I'm actually a great organizer. If you can't tell by my presentations, I think I'm pretty organized. Fail is to finish tasks. Yeah, that doesn't really have to do with the meeting thing. In addition to detail, it depends. So is this the detail of writing a standard operating procedure? Yeah, I'm not going to be like sloppy as heck on that, because I just don't care. But you can see, my distaste for meetings has already-- just that one thing has gotten me three symptoms. And I only need five. And guess what? I am forgetful. And I do lose things easily. So boom, I have five. I've already met criteria for ADHD right there. Despite the fact that I am very organized, I very much have-- I finish things all the way through. Easily distracted, not when I got my mindset on things. In attention to detail, no, I'm very detail-oriented. So you've got someone like me that half of these symptoms-- yeah, I totally do. And then half of them, I totally don't do. Like polar opposites of me. So like, you know, and someone could be the exact opposite of that. And that's why you kind of have to look at the whole picture. You can't just go through these symptoms, because I just diagnosed myself with ADHD with like very little thought whatsoever. And yeah, do I have it? Do I not have it? Maybe I do. But I don't think I'd really need to be treated. So I think that I function just fine. I have a little bit of impairment. And I think a lot of people could probably say that. And so you're looking for people here that their lives are significantly impacted and they're finding themselves in real binds because of it. Like if you're getting in car accidents because of your attention frequently, we should probably treat you. If you are like mechanically fixing things and you're making mistakes and the machines are breaking and that's causing safety problems, we should probably treat you. OK, even if you only have like two symptoms, you should probably still be treated. So you have to take the whole picture into mind. And that is, like I said, that's something that you're going to do. And maybe these examples that I brought up give you new light to think about that. And as I mostly treat adults, an attention is the symptom that we're most focused on. Also with girls, they say girls are much more likely to be inattentive than hyperactive. And boys are the ones that are primarily hyperactive. I don't know if they're more hyperactive than they are inattentive. But when compared to girls, boys are more hyperactive than girls, whether they have ADHD or not. And then adults tend not to be hyperactive. Some are. Some are. But inattention becomes the problem later. So that's what I'm dealing with. Let's talk about impulsivity and hyperactivity. Everything else is the same. And you need five for 17 and up, six for pediatrics. And remember, you can meet the criteria for inattentive, but not impulsive hyperactive or vice versa and still get an ADHD. If you do meet it for both, that's combined. So you don't need-- if you have six symptoms across both categories, like three of each, then that's not ADHD for kids. So I'll talk about adults. Five. So if you have-- you have to have five inattentive or five impulsive hyperactive to have the diagnosis. And if you have five of each, that's combined. All right. So it's clear. And it's also-- it says you have to have that many or more symptoms manifested often. This is another vague word. What someone considers often is not the same as what someone else considers often. So like I said, I kind of get in my own mind, decided someone has ADHD. And I can then decide that it's often and that they meet this criteria and whatever. It's not-- like I said, you cannot make an argument that almost anyone has this. And I think that's why a lot of people think the diagnosis is kind of ridiculous. But a lot of people are very impaired by this type of stuff, and you treat them, and their lives are completely turned around. And so that's why I'm in favor of treating it. And like, one thing I like is that like, wow, they get better. When it comes to a psychiatric diagnosis and giving someone a treatment, wow, do they get better from this? And that's often a bad sign. So like, say our other controlled substances would be binzos, and they're class four. So stimulants, class two-- I find that people get more addiction tolerance problems with the binzos than they do with the stimulants. I haven't really seen the problem with the stimulants. I know it's out there. But to me, I see it very often with binzos. It's just very common. So I see those as more dangerous. I would flip these. I would put those in category two and these in category four. But that's just me, because I do see more problems with the binzos. And I also noticed that people that take binzos long-term, it just-- it doesn't work. It's just not good to take them long-term. I see people take these long-term and continue to function. Sometimes you need to up the dose a little bit. But for the most part, it's OK. All right. So let's talk about, like I said, this is all the same thing. Impulsive hyperactive symptoms. Five for 17 up, six symptoms for pediatrics. Often, must be met six months, at least two settings, homeschool work, friends, et cetera, and have to have several symptoms by the age of 12. All right. So that's all the same. The symptoms are different. So they list what the impulsive symptoms are and the hyperactive symptoms. But you just need the five or six from both of those lists combined. So the impulsive list is blurt's out answer before finished, difficulty, waiting, turn, interrupts, or intrudes on others. I can tell you that when I was a kid, I definitely did all three of those things. But at the same time, I wouldn't describe myself as an impulsive child. Like, did I blurt out answers before finished? Yes. Like, these are things that you do in school. That was just more like, I wanted people to know that I knew the answer because I was a brat, right? Or difficulty, waiting, turn, like, I still have that. I'm not going to cut or cheat. But like, I don't like to wait. So yeah, I would not want to wait my turn, even though I would because it's fair, I just would hate it. And then interrupts or intrudes on others, sure. Someone else is talking too long, and I want to say my piece. I might butt in and then feel bad about it. So those type of impulsivity things, I would say I do. Do they list other kind of impulsive things? Do they say like, there's lots of impulsive behavior. Like, if you wanted to buy a watch, you just bought it, without thinking, or you just waste something, which is something I absolutely would not do, right? Like, the impulsive spending, or impulsively, like, if you're upset about someone, just getting mad at them, like, out of nowhere, without hearing their side to the story, that's something that I would not do, right? So I just find it interesting that they've listed these examples of impulsive behavior, but they haven't listed a lot of other types of impulsive behavior. Now, I would say that that's because these are the type of behaviors that is more common in childhood. And this diagnosis was designed for kids. And this is probably why it can be more difficult to make the diagnosis in adults, because a lot of these, especially the impulsive hyperactivity symptoms, are things that are kind of things that adults don't do. Adults don't blur it out, answers before they're finished. I mean, yeah, they do, but much less often, right? But there's a lot of other impulsive behaviors, and that's why I'm gonna talk about adult ADHD later outside of the DSM in our next episode. And then we've got the hyperactive symptoms. Fidgets, unable to stay seated, runs about, or climbs in inappropriate situations on the go, unable to relax, talks excessively. I mean, a lot of that stuff sounds like bipolar manic stuff, and we'll talk about that in a minute. And so in adults, it's like, wow, if you have someone doing that as an adult, do they have bipolar disorder? Do they have ADHD? 'Cause adults tend not to do those type of behaviors. But children, for sure. Like, you can tell that this list, impulsive hyperactivity was definitely designed for children. And that's why the intention, those things could be. easily applied to children or adults. So this diagnosis was never thought to be adults from a more vast time we mentioned that they didn't even like it was like the 1990s that they even were open to the idea that adults could have this. All right. And then I've got a list here for diagnosis of ADHD and adolescents. A lot of this is the same, but there is you know as you go through the life stages your symptoms are going to change. Okay. So distractibility lack of focus that's pretty much the same disorganization forgetfulness. Yeah that's it. That already said that self-focused behavior. So that's something that might be a little bit different. So I guess self-focused behavior is something that might be a little more seen in adolescents. I don't really know is that really ADHD. You know I think that's just something adolescents do. Hyperactivity, infigiting, heightened emotionality and rejection. Okay that's that's something definitely you might see in adolescence. It's not mentioned in the day that criteria that we just talked about. So this heightened emotionality and rejection. I mean that's something that a lot of teenagers are experiencing, but like if it's like extreme you might want to think about could this be a part of an ADHD picture. If that's the only thing you have then no. But if there's other stuff kind of going on it might be like well let's think about that. A sensitive dysphoria so that's kind of like they get really sad if they're criticized. Once again very teenager thing but like if it's severe you know I'd be thinking about depression but I'd also maybe be thinking about ADHD. Impulsivity, poor decision making. See care we're pulling in more the poor decision making that was not listed in the criteria where you're like kind of impulsively doing stupid things that like are reckless for you. Right? Like this could be like maybe jumping off of a high place when it wasn't safe to do so kind of adrenaline rush type of thing or like you know taking your bite down a path that's like really challenging. I'd also be thinking about mania with something like that but like poor decision making if that's like a big problem that might be leading us towards an ADHD diagnosis but it could be something else of course. Poor concentration and difficulty finishing tasks get a lot of those are just like overlapping. I don't even know why it's listed separately there. But let's talk about comorbidities and differentials and then we'll finish this episode up. So I've got this like kind of vent diagram for comorbidities and ADHD in children and so it's got ADHD kind of big circle and then like things that can overlap with it. Right? So it's saying basically like and that this is this is old this is from 1996. Saying that like basically 49% of ADHD is just ADHD there is no comorbidities but then like these other ones like depression 11% people have depression and ADHD 11% have anxiety and ADHD 7% have conduct disorder and ADHD and then it's got some overlaps there it's like 5% with conduct disorder anxiety disorder and ADHD 9% with depression anxiety and ADHD 4% with conduct disorder depression ADHD and then 6% with with all four. So basically it's saying that like ADHD depression anxiety conduct disorder can kind of all go together and then here's one it's got children too but like I want to focus on the adults one. So it's we've got I mean this is also kind of old this is from 1993 this study here but it's I think I think it's relevant it's adult common comorbid mental health diagnoses so it's it's got four columns one um referred adults with ADHD so I guess this is people who like came for an appointment that like thought they might have it or someone thought they had it and then we have non-referred adult relatives with ADHD so um I think this so these are people that weren't referred but they're like relatives maybe relatives of them um and then we've got referred children and then we've got comparison adults without ADHD. So let's look at the refer this is compared they refer to adults in the uh adults without ADHD and the percent that had something so like oppositional disorder. I mean that's not an adult disorder but maybe they had it as a kid um 2% that didn't have ADHD had it 29% that did conduct disorder once again that's a childhood disorder. 4% adults without ADHD 20% with anti-social personality 3% without 12 with but here's your press disorder 5 without 31 with alcohol use 8 without 25 with alcohol dependence um this 13 without 27 with drug abuse 6 without 20 with and then I'll just read through the rest of these like drug dependence multiple anxiety disorders over anxious disorder separate which that's not even a disorder because it's from 93 but I don't I've never heard of over anxious disorder um that wasn't DSM4 but I think DSM4 wasn't that time separation anxiety disorder that's another shot of disorder. Acorophobia is social phobia in your esis and that's like wedding the bed at night um speech language disorder is stuttering. I think it's interesting that they like mentioned this for adults so like maybe they're looking back at their past history um but you basically have most of these with like like between like three to five times increased risk of all of those disorders and I think the ones that like are the most interesting to me would be like the depression anxiety and substance abuse stuff right and then just like a lot of the developmental stuff like speech language disorders stuttering like a lot of stuff like that like learning disorder stuff so folks that have um these kinds of disorders often have ADHD or is it just a manifestation of that disorder. I think what the substance abuse can make sense right you've got impulsivity disorder you know impulsivity problems you've got intention problems and you know you make bad decisions and you abuse substances right so that makes a lot of sense to me we're going to have a whole episode way down the line where we talk about the overlap between this idea of like when you take a stimulant that it might cause you to abuse substances versus prevent you from using it because it's like because of the ADHD not being controlled you like are more likely to abuse a substance and if it's controlled with a stimulant then you don't then you're not going to go abuse the substance which is I'm most think of that camp of course every individual is different um but I think that's definitely something to keep in mind right so a lot of folks I think it could go either way right so let's take a major depressive disorder for example like somebody may meet the criteria for major depressive disorder but they don't really have major depressive disorder they have ADHD which is causing depression you treat their ADHD and now we don't have the depression problem could be the other way around we actually do have major depressive disorder and then they meet the criteria for ADHD because of the because the symptoms overlap but they don't actually have ADHD they have major depressive disorder let's treat the major depressive disorder now both of them go away so this is why I think it's important with these to like kind of suss out what's the root problem because do we want to give this person any impressive doing a stimulant do we want to give him a mood stabilizer you know do we want to give him treatment for alcohol and drugs like what's the root problem and in some cases it will be both right but where this is saying they're comorbid I'm more in the camp that like they have one of these disorders we treat the right one it relieves them both rather than doubling up and double treating two disorders some people do need that but I'm always going to like I'm going to try and suss out which one I think is the major problem that which may be causing the other one treat that one first see how they respond if they don't at all get rid of that man right because I you know I and then try the other treatment if it did work and it did relieve those symptoms but they still have the residual symptoms of the other disorder then I might go ahead and treat them both right so that would be my protocol like which one do I think's the root go with that one first see how we do if we clear everything out great if we don't add on if we don't fix anything switch that's that that that's how I would approach pretty much everything but yeah let's so that kind of gave us some figures there but yeah when when you when you're looking at differential diagnosis and I mentioned a lot of this you know it well that was the comorbidities right but we also have the differential right is it this or this is it ADHD or is it a mood disorder right so a lot of there's a lot of overlap so we're going to want to be ruling out mood disorders anxiety disorders PTSD substance abuse sleep disorders personality disorder um oppositional defiant disorder Autism, Spectrum Disorder, Learning Disorders, so pretty much the gamut of MiddleHealth can present as ADHD, right? Because I mean, just think about it. If you've got any one of these conditions and you're suffering from it, are you going to not be paying attention so well? Are you going to be forgetting things? Are you going to be, let's go back and look at this stuff. Are you going to be losing things, easily distracted, have difficulty organizing, if you have like other MiddleHealth disorders? Yeah, that doesn't mean you have ADHD, all right? And this is one argument that people make the ADHD doesn't exist. The argument is kind of that one of these other disorders is the answer and you just have to figure out which one it is. I disagree. I think that's definitely, definitely true that someone could have one of these other disorders and if we treat it, then we don't need to give them a stimulant for ADHD. But I definitely think there are people that have ADHD and if the stimulant does treat them the best rather than something else. So that's where I would disagree. But yeah, you definitely want to get their diagnosis right. And then medical disorders too, right? And especially once again for kids here, like hearing and vision impairment. If someone has hearing or vision problems, they're going to look like they have ADHD. Especially a kid they may not be able to articulate. They may not know that their hearing is poor or their vision is poor. You need to have that checked. And you can do a quick check in the office. And if everything seems good to go and the parents are like, no, no concerns there. And you're like, you do an eye chart, you do a quick hearing test. You don't need to send them further testing. If there's something questionable, send them further testing. There's formal hearing tests. Hyperthyroid, something else that could cause these symptoms. And I want to check a thyroid if they have other symptoms of that. These are disorders can look like ADHD. Especially like obscenes. People might think that they're not paying attention, but they're having an obscenes seizure. I know someone who's their child was basically having, like, and I thought of obscenes seizures, which we used to call petite mall, which means a little bit bad. It really like damaged this child's brain. And no one seemed to believe her. And they didn't think that these were seizures he was having, but they were mostly obscenes kind of seizures or ones where they weren't obvious. And you could easily think someone like that has ADHD. So you may think a lot of people think seizures, that's jerking around on the ground and stuff. How could you mistake that? There's so many different kinds of seizures. And the obscenes, that's where you, like, obscenes means absence in French, petite mall is French. I guess it was a Frenchman that figured this out, but it's just kind of like where you zone out for not that long, but you're not zoned out. You're having a seizure, and that's why you're not paying attention. It's not because you have ADHD. So you definitely want to make sure that that's not going on as well. And toxicity can cause ADHD symptoms. The adverse effects of certain medications. So like anytime you do a history, you're definitely wanting to see what meds they are taking and think about whether this could be affecting them. You know, and I'm particularly thinking about sedating meds, right? So things that slow you down, slow down your cognitive functioning, even if you took them at night, could be causing symptoms that make it hard to concentrate. And you know, we don't want to get in the whole like prescribing cascade where it's like when you stimulate in the morning and the sedative at night, right? We're just like basically like batting things back and forth between the two. It's like, well, I need the stimulant because I can't sleep because of the sedative. And then I need the sedative because the stimulant's still working and I can't sleep, right? And then there's a lot of other medical stuff, but those are the big ones I just wanted to mention. And then the last, or not the last thing, but just about the last thing, I want to talk about bipolar disorder. And this is actually one of the few papers I've had published was I did a case series on ADHD bipolar disorder, where, and I think a lot of people disagree with me with this. And this is why I post a paper. I had a couple of patients that seemed to clearly meet criteria for bipolar disorder, but they just didn't respond to antidepressants. And one of them was he kept getting treated with antidepressants, but the weird thing was the antidepressants made him less manic, incident more manic, and made him more depressed instead of happier. So like the antidepressants were having some weird effect on him. And I was like, and his mania was like more of a hypomania, and it was just weird that the antidepressant was like having, he was like, "Well, if he had bipolar disorder, you would affect." You wouldn't expect him to get like eliminated. It like eliminated his hypomanic episodes, but it did not eliminate his depressive episodes, which was like really bizarre to me. And so I know I came up with this theory that he had some sort of ADHD and I gave him a stimulant and it like fixed everything. He also didn't have the hypomanic episodes, and he didn't have the depressive episodes. And I mean, the focus was, interestingly, the focus was not as big of a problem for him. There was a little bit of that, but it was more like he would only have the focus issues during the episodes. And I mean, this is like a big no-no. It's like, "Oh no, ADHD is there all the time." And my polar depression symptoms are episodic, but you know what? Nothing worked for this guy, except for the stimulant. And so there was, there's somebody that had written a paper out there that had basically proposed that ADHD and bipolar were kind of one and the same. And it might be that like ADHD is a subtype of bipolar or something like that. I found it really curious. And he ran this study where he gave people methylphenidate that were manic on the ward. He had some case studies where he gave the stimulant to people who came onto the unit, the impatient unit, manic, and like it calmed them down immediately, whereas you would think it would have like the opposite effect. But then he ran a randomized control trial on it and had to stop it early because it was like not working at all. But I still thought, and this is what I always think of moments, you can't apply the same rules to everyone. If everything's been tried, it's time to go outside the box. And with this guy, I was like, "Let's go outside the box. Let's say, hey, maybe this is one of those guys that would have been responsive to something like this, like this guy had had a couple of cases on it." And guess what? It worked. Someone might say, "Well, stimulants just make everyone better." But it just, I think it's also odd that he didn't have the hypomanic episodes either. And that's something that he would assume would happen. Right? And then the other patient was, she had had like a 20-year history and she had been on like a lot of different meds. And a lot of them worked for bipolar disorder, but like she just didn't tolerate them for one reason or another. And I just started to say, you know, she definitely had ADHD. And so my thought was, and this is completely against what the guidance out there, anytime you read guidance, it's like, "Oh, there's this big overlap of bipolar ADHD, but you have to treat the bipolar first. Give them a mood stabilizer, get them stable, then put them on a stimulant." I kind of threw that out. The window was like, you know what? She's already trying all these mood stabilizers. Let's just go straight to stabilizer. And it wasn't straight. This was 20-year history of taking any depressants and you can read the published paper. You can look me up and read it if you want to get the details on it. And yeah, so I just gave her a stimulant and it like relieved everything. Like her ADHD symptoms went away, her depression went away, her mania, hypomania went away, it just fixed everything. And then down the line, she ended up getting some depression and I had it less a pro. And once again, if she had bipolar disorder, you would think stimulant and anti-depressant and no mood stabilizer. And this is a person with very clear history of bipolar disorder. You're thinking this is nuts. Nope, work great. So you know, you can't follow the algorithm once you get it. When you get a challenging case and everything's been tried, you have to start thinking outside the box. So let's talk about what I said in my paper other than the one I just explained there. So ADHD bipolar often commorded up to 85% of children with bipolar disorder have ADHD up to 22% of children with ADHD have bipolar disorder. So a lot of people with bipolar disorder have ADHD. I mean, I would say that maybe they have ADHD and it's not bipolar disorder. You know, maybe, you know, so maybe it's one or the other. And some people with this type of bipolar disorder, maybe a bipolar, you know, we already talked about type three and four and three and a half. Maybe we call this bipolar type five. It's a type of bipolar that looks like ADHD that is not your standard ADHD and you give a stimulant as the treatment. I don't know. Or maybe we call this like an ADHD type three that is like a bipolar looking ADHD. I don't know, but there are definitely people out there who are the spits because I've found a couple of them. So there's a lot of overlapping symptoms between bipolar and ADHD, talktiveness, distract second-water agitation, impulsivity, pork concentration, mood instability, impairments in social and familiar relationships, school performance. The key differences are typically the episodic nature bipolar versus chronic nature ADHD. I mentioned that a second ago. You know, bipolar manic and depressive symptoms tend to happen for short periods of time and then there's like no symptoms. They're not gonna live their entire existence, manic or depressive. And ADHD, if someone has ADHD, is always an attentive, you know, more or less yes. And then elevated mood and decreased need for sleep are symptoms of bipolar disorder that tend not. People with ADHD tend not to have the elevated mood, the kind of manic, elevated mood that you would see or decreased need for sleep. So, those are the couple of differences, but it can be difficult to tell them apart. Like I said, some may have both disorders and then these are my ideas. Some may have only one with the symptoms of the other. And like I said, there's a theory that exists that they are a singular disorder on a continuum. And I like that, you know, what we talked about before that in the last episode of depression, that depression and mania are on a continuum, I think there's something to it that ADHD and bipolar could be on a continuum. I know a lot of people are yelling for that and I don't care. Treatment. So the recommendation, like I said, to treat bipolar disorder, if we just stabilize our first, then add stimulant, that would be the standard course. However, there is mixed evidence for a risk reduction of induction of mania psychosis with stimulant alone. Basically, they're saying, don't just use a stimulant because it can induce mania psychosis, but there is mixed evidence of that. It doesn't always happen. I've done it, it didn't happen. And then I have my case series of two patients with both successfully treated with mood stabilizer or stimulant without mood stabilizer. So read that paper. I was very proud of that. One of my, I think I published, I'm first author on four papers. One of them you will never find because it was in like a resident journal, three of them. And then I was interviewed for a newspaper based on one of my articles I wrote. I'm Dixon with Thorough Fan. You might find that. And then I'm like fourth author on another paper. So that's all I've got out there. It's not a whole lot. And then lastly, let's talk about medical cooperatives. People with ADHD are increased risk for mild cognitive impairment dementia. Something that the stimulants may actually increase the likelihood of that. I worked with an neurologist to, you know, this guy had been, he was being evaluated for that. He's like, you know, this guy's been treated for ADHD forever. We don't know him. Maybe that caused it. So there's, that could be going on increased risk for obesity. And think about it. If you have like, impulsivity problems, you may have impulsivity problems with eating. So that's why the obesity is in there. Cardiovascular disease. And this is like not necessarily even treated ADHD with the stimulants causing this, but just ADHD by itself is a risk factor for cardiovascular disease. And we'll talk a lot about cardiovascular disease as we get to these ADHD episodes. Diabetes. So these metabolic disorders are also associated with mild cognitive impairment and dementia. So like these are, this is all kind of like metabolic stuff. And like my theory would probably be like the obesity picture. Like, cause like cardiovascular disease, diabetes. And then like a lot of the stuff with mild cognitive impairment can be caused from cardiovascular disease, many strokes around many strokes, but like vascular strokes, things like that. But like, and you don't necessarily have to be obese. And remember, if you're following my obesity series that we're doing in tandem, 40% of people in the United States are obese and approaching 50. And you don't necessarily have to be obese to have a really crappy diet. And really crappy diets can cause diabetes and cardiovascular disease as well, even if you aren't obese. So I don't know, my theory here, this just me throwing out, you know, my own ideas, but like, I would say like if you have untreated ADHD that you're probably like just not as able to make good informed stable decisions with what you eat and exercise and things. Like, if you get bored easily and you can distract it easily, are you gonna be able to maintain an exercise regimen? Probably not. If you have organ, if you have difficulty with organizing things, are you gonna be able to eat a consistently healthy diet and have good exercise and good sleep and all this stuff? No, all these lifestyle stuff we're gonna talk about in the obesity series. You're probably gonna be an increased risk for not being able to do it as well. If you have unmanaged ADHD, which might be a good reason to treat it. And guess what? Five ants, Liz Dexanthetamine, an estimate that's used for ADHD is also a proofs for binge eating disorder. And if you look at the criteria for binge eating disorder, you will see that like it is not difficult to meet that. Probably the majority of people that are obese probably meet the criteria for binge eating disorder. All right, so, and look at that. A stimulant is the treatment. And I guess it's the stimulant in treatment because it likes suppresses appetite. Probably that was the theory. But it might also help you focus better so that you don't do this in pulse of stuff. So maybe it's treating an underlying ADHD. That's probably a piece of it as well, right? In addition to appetite suppression. So, when people with obesity don't have suppressed appetites and people with ADHD probably don't have suppressed appetites either and maybe that's part of why the stimulants work. It's probably all connected, right? So I feel like it's important to treat ADHD with not only medication, but also lifestyle factors. And we'll be talking about all those lifestyle factors in the obesity series, which I'm flipping back and forth between. So I hope you guys learned a lot about ADHD. You know, you learned all of, you know, you got my opinions on how to diagnose it. Maybe you got some new tips on that. I'll be throwing these things out throughout this entire series. You heard my land just ideas about bipolar disorder and ADHD being on a continuum and using stimulant-only and select patients. And maybe that's, you know, maybe you've got a patient and you're like, you know what? Maybe that would work. And you're like, yeah, try it, read the paper. I don't make any money off that. I just, you know, I put it out there because I want people to like, you know, think, hmm, maybe I should study this or maybe this is something I should try with a patient that like kind of fits these same pictures. Those two patients were completely different and they both responded to this treatment better than I could have imagined. I love stimulants. Like I love when they work and people don't abuse them. And so like, 'cause they just work so well. Like you're gonna get a quicker response, you're gonna get like a better response. And if you can find the right patient that this is the meant for them, man, you feel good about like helping that person out and they feel good and they're grateful, right? So I want today's song, let's see. Let's end, I'm doing motivation by some 41. I think this is a, this song makes sense to me for ADHD, right? A lot of the stuff with ADHD, it's like, it's hard to get the motivation to do something because of the difficulty focusing, difficulty concentrating, right? So to me that just makes sense. And I want to thank you so much for tuning in today. I hope you will continue to listen. Things are just gonna get better and better. And I hope you also listen to the obesity series because I don't know, it's super interesting. And it's just like super like relevant to like everything. And like if anything, listen, I haven't got to them yet, but listen to those lifestyle things because the lifestyle stuff will just like, that'll change your life. That'll help you treat anything. So thank you so much for listening and I'll see you in a minute. (upbeat music) [BLANK_AUDIO]