Treatment Resistant Anxiety

[zenman]

I inherited a young fellow who I saw for med management. Dx GAD and panic disorder. He has tried, with no success, clonazepam, alprazolam, bupropion, paroxetine, sertraline, trazodon, venlafaxine, depakote, fluoxetine. I think that's it if I remember correctly. Cannabis helps but he's on parole now. Any suggestions? I'm starting to think an eval for another dx may be in the works, like bipolar maybe.

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[TexasPhysician]

Thorazine helps with anxiety

 

[PETRAN]

rigorous CBT? Behaviour exposure and cognitive restructuring helps tremendously for this type of thing. Nothing helps more than facing your fears. Also i know a lot of people who have felt better with escitalopram, well it wasn't on the list

 

[IAmAUser]

.

 

[Suedehead]

rigorous CBT? Behaviour exposure and cognitive restructuring helps tremendously for this type of thing. Nothing helps more than facing your fears. Also i know a lot of people who have felt better with escitalopram, well it wasn't on the list

i agree. therapy's the way to go for GADish persons (almost more of a temperament thing). a med can help a ton but typically won't cut it alone.

it's a shame when we look at anxiety only as a symptom to be treated instead of a window of opportunity for growth and change.

not saying it should go untreated or that we should avoid meds, but the disease model falls short of addressing 'treatment resistant anxiety.'

 

[tkim]

Thorazine helps with anxiety

 

[nitemagi]

I'd also more closely evaluate "failure" of SSRI's. More commonly when I see this it's too rapid of a titration in those highly sensitive to early akathisia or anxiety. See if they had a real/adequate trial - high dose, good duration.

Therapy is also definitely indicated, as everyone here agrees - CBT. Could also try out hypnosis.

Lesser supported but possibly helpful meds not on your list - vistaril, neurontin, buspar.

 

[Suedehead]

I'd also more closely evaluate "failure" of SSRI's. More commonly when I see this it's too rapid of a titration in those highly sensitive to early akathisia or anxiety. See if they had a real/adequate trial - high dose, good duration.

excellent point

 

[firedoor]

excellent point

I third that. Did he truly fail (or even have) an adequate trial of at least one SSRI?

I'd also very closely comb his history for substance use (both licit and illicit, e.g. benzos, alcohol, marijuana, caffeine, nicotine, pseudoephedrine). Is there a component of use or withdrawal from any of these (perhaps protracted)?

You mentioned the possibility of bipolar. GAD is a highly comorbid condition so I would certainly consider that and other mood disorders (e.g. MDD) as they take precedence over anxiety both diagnostically and therapeutically.

Of course the psychosocial component and therapy are huge as others have mentioned. Remeron and lyrica are also pharmacologic options, but first and foremost I'd verify the veracity of prior med failures (especially as mentioned the reported benzo failure) and also consider malingering (I'm not saying that's the case, just to keep it in the differential as Iamauser suggested). I believe verapamil has been used in panic disorder and there is literature on chromium picolonate in GAD, but I would be reluctant to use that due to the risk of hypoglycemia.

 

[whopper]

I got 4 patients that cannot tolerate SSRIs, benzos are to the point where they feel drunk, and Neurontin did not help.

Here's what little advice I can offer.

B-blockers, try it. Clonidine or guanfacine, they too can relieve anxiety, Buspirone, fish oil, or Lamictal augmentation, gabapentin or Lyrica (yes there are studies backing that it does reduce anxiety, Lyrica in fact is approved in the EU for anxiety), Seroquel when processed by the liver becomes an SNRI.

Also consider the patient may have anxiety secondary to another condition such as ADHD. I've had plenty of patients suffer from things meeting the criteria of panic disorder, but when given a stimulant, their anxiety ironically stopped. Turned out their anxiety was from ADHD not treated.

Although there is no data to back it up I'd consider light therapy since it's supposed to raise serotonin levels.

In one of the cases I had, I actually did consider medical marijuana but it's not legal in the state. That was one of the only cases ever where I thought medical marijuana was appropriate because nothing else seemed to work, the state of the disorder was to the point where the person's GAF was less than 40, and the person did not have a drug abuse history.

 

[PETRAN]

I got 4 patients that cannot tolerate SSRIs, benzos are to the point where they feel drunk, and Neurontin did not help.

Here's what little advice I can offer.

B-blockers, try it.

Yes man, i was gonna say b-blockers. I know it because i see a lot of people getting help with it. Psychotherapy with b-blockers and/or an SSRI


This marijuana thing is strange though because in many people it has a paradoxical increase-of-anxiety and induction of panic attacks. Maybe because cannabis has many active ingredients. I've heard that the anxiety-reduction effect comes from CBD and not from THC so depending on the type of cannabis used and the person you'll get different results.

 

[zenman]

maybe he's looking for a medical marijuana script? new mexico does have this as per a quick google

I bring this up because of the pt's forensic history and claim that benzos do not alleviate the anxiety. I've yet to meet a patient whose anxiety is not at least temporarily reduced with a benzo.

We do have medical marijuana but his dx is not on the list of acceptable ones. Thanks for all the tips, guys. I'll bring him back for extended eval.

 

[OldPsychDoc]

If he's like any of the young fellows I see regularly:

1) When (age) did symptoms start? When did he discover that weed was the cure for them? Or did the sx start AFTER his first experiments?
2) alcohol?
3) DON'T pin "bipolar" on him without clear, chemically free evidence at this stage. I'm really tired of "bipolar" being used as a euphemism for "I can't seem to get this person better yet".
4) May or may not be cluster B, but he could still probably benefit from some good new-fashioned distress-tolerance and emotional-regulation coaching, IMHO.
5) Agree with beta-blocker, gabapentin, and would also consider hydroxyzine prn.

 

[whopper]

If anyone gives out marijuana, be very very careful. Aside from the obvious that several may fake symptoms to get it, there is no real good established standard on when to give it. Therefore, if any bad outcome happened and you are brought to court, you'd have a hard time arguing that you practiced standard of care when there is no standard established.

I would be opening to giving it but I'd cross my t's and dot my i's in these cases and make sure nothing else conventional worked, or use it perhaps if benzos were the only thing that was working because benzos as we know are substances of abuse possibly even more dangerous than marijuana.


With the case of B-blockers, a popular board question suggests use of pindolol because it also works pharmacologically in a manner similar to buspirone.

I mentioned before that Gabapentin does have data showing it is effective in the treatment of anxiety. It's more potent sibling, Lyrica is approved for the treatment of generalized anxiety disorder in the EU. Mentioned it, but here's an actual article.

http://www.medscape.com/viewarticle/529020

The approval was based on a review of data from 5 randomized, double-blind clinical trials in more than 2000 patients showing that pregabalin provided rapid and sustained efficacy in treating GAD, yielding significant relief from psychic and somatic symptoms within the first week of treatment.

I've had a few patients that could not tolerate SSRIs do well on Gabapentin for anxiety.

 

[kugel]

After carefully checking for other diagnoses and reviewing personal/family history, relationship history, and substance use history...

"Well, Mr. Patient, I can certainly imagine your frustratration with how little doctors have been able to help. It sounds like you've been trying for years to get some help but all we've done is give you chemical after another, and leaving you with the same problem, or worse. I think we have to admit that there's very little chance that I'm smart enough to know of a once-a-day pill, that you haven't tried yet, which will magically eliminate all your anxiety.

I do have an idea. But I need to know what you're willing to do to make it work.
What if I had a treatment that has a reasonable chance of reducing your anxiety by half over the next year? And what if I told you that this treatment will require up to two hours per day, during which time you may sweat and get some rapid heartbeat, and could have some residual soreness the first few hours of every day. And that this treatment might mean that during some of the time of your daily treatment, you will have to experience some INCREASED anxiety in exchange for eventually reducing your overall anxiety. And imagine that this treatment will cost you $100-150 per week, and require weekly visits to the doctor for about an hour.

I know all of this would be a big price to pay for reducing your anxiety by half over the next 12 months. Would you be willing to do all that? Are you sure? Because it's a big commitment and it's really not worth starting if you aren't sure you're willing to do it on a regular basis."

If he's willing, I advise starting a daily exercise program and enrolling in CBT (and tell him to expect daily homework). I remind him that chemicals really have not helped, "so let's lay off all the pills and pot and anything else, and come back to see me in 3-4 months after your therapist has mailed me or called me with a progress report. Are you really willing to do all that?

 

[PETRAN]

After carefully checking for other diagnoses and reviewing personal/family history, relationship history, and substance use history...

"Well, Mr. Patient, I can certainly imagine your frustratration with how little doctors have been able to help. It sounds like you've been trying for years to get some help but all we've done is give you chemical after another, and leaving you with the same problem, or worse. I think we have to admit that there's very little chance that I'm smart enough to know of a once-a-day pill, that you haven't tried yet, which will magically eliminate all your anxiety.

I do have an idea. But I need to know what you're willing to do to make it work.
What if I had a treatment that has a reasonable chance of reducing your anxiety by half over the next year? And what if I told you that this treatment will require up to two hours per day, during which time you may sweat and get some rapid heartbeat, and could have some residual soreness the first few hours of every day. And that this treatment might mean that during some of the time of your daily treatment, you will have to experience some INCREASED anxiety in exchange for eventually reducing your overall anxiety. And imagine that this treatment will cost you $100-150 per week, and require weekly visits to the doctor for about an hour.

I know all of this would be a big price to pay for reducing your anxiety by half over the next 12 months. Would you be willing to do all that? Are you sure? Because it's a big commitment and it's really not worth starting if you aren't sure you're willing to do it on a regular basis."

If he's willing, I advise starting a daily exercise program and enrolling in CBT (and tell him to expect daily homework). I remind him that chemicals really have not helped, "so let's lay off all the pills and pot and anything else, and come back to see me in 3-4 months after your therapist has mailed me or called me with a progress report. Are you really willing to do all that?

+1 excellent post

 

[Suedehead]

Also consider the patient may have anxiety secondary to another condition such as ADHD. I've had plenty of patients suffer from things meeting the criteria of panic disorder, but when given a stimulant, their anxiety ironically stopped. Turned out their anxiety was from ADHD not treated.

yes. as this is much much much more likely than bipolar d/o.

 

[Suedehead]

If he's like any of the young fellows I see regularly:

1) When (age) did symptoms start? When did he discover that weed was the cure for them? Or did the sx start AFTER his first experiments?
2) alcohol?
3) DON'T pin "bipolar" on him without clear, chemically free evidence at this stage. I'm really tired of "bipolar" being used as a euphemism for "I can't seem to get this person better yet".
4) May or may not be cluster B, but he could still probably benefit from some good new-fashioned distress-tolerance and emotional-regulation coaching, IMHO.
5) Agree with beta-blocker, gabapentin, and would also consider hydroxyzine prn.

you know, i'm happily married with a couple of cute kids and all, but.... i think I'm in love.....

 

[nitemagi]

I must've missed where anxiety is a diagnostic criteria for ADHD. While others get sick of Bipolar being overdiagnosed, I'm not on the stimulant bandwagon.

My experience has been that those with anxiety and "ADHD" do more on a stimulant, but just more of whatever is dysfunctional. I had a guy with OCPD who cleaned his front door until 4am after being on a stimulant.

I would be particular in pinning down Which symptoms of anxiety he/she is experiencing, and focus on that. Autonomic? Which ones? Motor? Internal dis-ease? Panic attacks? Catastrophic thoughts?

 

[firedoor]

I've had plenty of patients suffer from things meeting the criteria of panic disorder, but when given a stimulant, their anxiety ironically stopped. Turned out their anxiety was from ADHD not treated.

I've seen your posts on this before and do not dismiss this possibility. How, might I ask, do you get to the point where you consider a stimulant trial is appropriate for what may at face value present as anxiety?

 

[SpiritiualDuck]

GAD vs Bipolar II. I've read these links before and I have struggled to make that leap, but here it is.

http://www.psycheducation.org/depression/GAD&BPII.htm
http://www.psycheducation.org/depression/Anxiety.htm

 

[Suedehead]

GAD vs Bipolar II. I've read these links before and I have struggled to make that leap, but here it is.

http://www.psycheducation.org/depression/GAD&BPII.htm
http://www.psycheducation.org/depression/Anxiety.htm

I find akiskal's description of bipolor II to be virtually useless. and your first link provides a chart which demonstrates exactly why. no way to distinguish GAD vs bipolarity with any certainty.

this line from that same link drives me a little bonkers: "When you look at these virtually identical lists, I hope it makes sense to you than anyone with GAD symptoms who has not responded well to antidepressants should consider a trial of mood stabilizers."

The logic is that if anxiety is refractory (i.e. didn't respond to meds) then they may have bipolar disorder..... try, then, a 'mood stabilizer.' ...and treatment response to a mood stabilizer is diagnostic. hooray logic.

many probs with this type of thinking.

one problem is the idea that GAD is refractory if it doesn't respond to meds. Meds can help, but GAD people have a type of temperament or a type of thinking that go beyond meds. therapy's key.

another problem is that 'mood stabilizers' (and we still don't have a good definition of what a mood stabilizer is - anticonvulsants?) are generally sedating. anyone with any condition who takes a 'mood stabilizer' may 'respond.'

now someone with GAD may get some serious help from an anticonvulsant (neurontin, etc). does not mean they are 'bipolar.'

now there may very well be a 'bipolar spectrum.' but akiskal's conceptualization just muddies the water.

 

[Suedehead]

I've seen your posts on this before and do not dismiss this possibility. How, might I ask, do you get to the point where you consider a stimulant trial is appropriate for what may at face value present as anxiety?

great question. i wonder the same thing. how are others handling this?

 

[whopper]

I've seen your posts on this before and do not dismiss this possibility. How, might I ask, do you get to the point where you consider a stimulant trial is appropriate for what may at face value present as anxiety?

It's not easy. I too am not on the stimulant bandwagon and I've posted about that several times.

If someone says they are "anxious" it doesn't necessarily mean they have an anxiety disorder. For example, several people with GAD say they have "racing thoughts" if you ask them prompting several doctors to erroneously assume the person has bipolar disorder. Someone with too much anxiety doesn't know the psychiatric lingo, and indeed, it may seem to them that they do have racing thoughts.

So when I ask a patient about "racing thoughts", instead I'll say "Do you have thoughts that seem to go so fast that they may even be uncomfortable?"

But getting to the anxiety DO vs. ADHD differential, it's not easy because the person may have both or just one. You have to also screen them for ADHD if the person complains of excessive anxiety, and ask for things such as the onset of the disorder, perhaps do psychological testing, and if you cannot clearly rule out one, you have to go over the dilemmas that could happen because of the lack of certainty with the diagnosis.

E.g. the first time this happened to me, I was fearing that a stimulant would make the patient's anxiety worse. I warned her about it, and told her the risks vs. the benefits so she knew what was going on.

Remember, psychologically, anxiety is often a manifestation of one's feeling of having lack of control. If someone has ADHD, to the point where it needs treatment, many of these people will not feel in control over their lives. It's not surprising for someone with ADHD to have anxiety due to it.

 

[nitemagi]

Akiskal has some interesting other "pathognomonic signs" for bipolar if you talk with him in person. Including wearing red shoes, or being married 3 times or more.

While I get the theory behind why stimulants help those with anxiety (when you stimulate the whole brain, you're also stimulating the frontal lobes and thus inhibitory control of many things), it's a slippery line of logic that leads all my meth addicted patients to tell me the only thing that helps them feel better is meth. Yes, but...

 

[whopper]

Mentioned this in other threads but I do not give out stimulants unless a non-stimulant was tried and it didn't work, there's psychological testing that is difficult to malinger highly suggesting ADHD, an EKG, and drug screens.

 

[393656]

Mentioned this in other threads but I do not give out stimulants unless a non-stimulant was tried and it didn't work, there's psychological testing that is difficult to malinger highly suggesting ADHD, an EKG, and drug screens.

Hard to malinger? Have you ever seen or did these tests? It is a piece of cake to malinger. We all tried them for kicks and I could pass or fail based on my will and that was without knowing any "tricks". I do not believe in ADHD in people over 18 and never prescribe stimulants.

First OP patient sounds bipolar to me

 

[nitemagi]

Hard to malinger? Have you ever seen or did these tests? It is a piece of cake to malinger. We all tried them for kicks and I could pass or fail based on my will and that was without knowing any "tricks". I do not believe in ADHD in people over 18 and never prescribe stimulants.

First OP patient sounds bipolar to me

Check it out:

http://www.ncbi.nlm.nih.gov/pubmed/20528060
http://www.ncbi.nlm.nih.gov/pubmed/17507198
http://www.ncbi.nlm.nih.gov/pubmed/19439760

Three studies all showing ADHD is easy to malinger by college students, with a minimum of preparation (5 minutes on google for one study).

 

[393656]

Check it out:

http://www.ncbi.nlm.nih.gov/pubmed/20528060
http://www.ncbi.nlm.nih.gov/pubmed/17507198
http://www.ncbi.nlm.nih.gov/pubmed/19439760

Three studies all showing ADHD is easy to malinger by college students, with a minimum of preparation (5 minutes on google for one study).

That is what I am saying. I think ordering neuropsych testing for adhd is the biggest farse in psychiatry. ADHD is a FUNCTIONAL diagnosis not a pure symptoms based diagnosis. I simply refer for cbt and make sure they are not depressed, anxious or bipolar. After that I tell them to get some help and learn how to study.

If you are using computer testing to evalute adhd dont even waste your time, just gift them the speed.

 

[firedoor]

I simply refer for cbt and make sure they are not depressed, anxious or bipolar. After that I tell them to get some help and learn how to study.

Do you mean that you refer them to CBT for ADHD? What do you mean that you tell them to "get some help"? ADHD is highly comorbid with other Axis I diagnoses...what if this (likely) scenario presents?

 

[zenman]

Hard to malinger? Have you ever seen or did these tests? It is a piece of cake to malinger. We all tried them for kicks and I could pass or fail based on my will and that was without knowing any "tricks". I do not believe in ADHD in people over 18 and never prescribe stimulants.

First OP patient sounds bipolar to me

And I think you're right. Had a cancellation Friday so pulled this fellow in. He was completely different from last visit, very depressed. Turns out his mom is bipolar so I asked him what she thought about him and he said, "That I'm just like her!" He scored moderate probability on Bipolar Spectrum Diagnostic Scale. Someone asked about cannabis. He had a 6 month history of smoking it. Started him on Lamotrigine.

 

[firedoor]

And I think you're right. Had a cancellation Friday so pulled this fellow in. He was completely different from last visit, very depressed. Turns out his mom is bipolar so I asked him what she thought about him and he said, "That I'm just like her!" He scored moderate probability on Bipolar Spectrum Diagnostic Scale. Someone asked about cannabis. He had a 6 month history of smoking it. Started him on Lamotrigine.

Politely, does he have a history of mania, hypomania or a mixed episode? It seems that he initially presented with symptoms of anxiety, and more recently with more of a depressive picture, which could "simply" be MDD with anxiety.

Unless you've personally diagnosed his mother, her history of bipolar disorder is unsubstantiated (though not necessarily irrelevant). Just playing devil's advocate here, but I'm failing to see the bipolarity from what you've thus reported.

 

[393656]

Politely, does he have a history of mania, hypomania or a mixed episode? It seems he initially presented with anxiety, and now more depressive symptoms. Unless you have diagnosed his mother, her history of bipolar disorder is unsubstantiated (though not necessarily irrelevant). Just playing devil's advocate here, I'm failing to see the bipolarity from what you've thus reported.

This is exactly the type of categorical thinking that leads to missed diagnosis of bipolarity. "anxiety" is a word thrown out by individuals with a huge variety of meanings. The internal uneasiness and restlessness, excessive internal stimulation and thoughts that are going through their head non-stop all have been described more often than not to me as "anxiety." People with anxiety are often people with underlying bipolarity, often in a mixed episode that are totally missed. It is sub-clincal bipolar if you will. Just like sub-clinical hypothyroidism or a myriad of other medical diseases that do not fit neatly into categories. It does not mean you do not apply the treatment for the proper disease, whether they meet 3 criteria or 5 or 6 or whatever.

If you do not think outside the box and more dynamically in psychiatry you will do a lot of diservice to patients. If someone had tried that many standard anxiety meds and you keep trying more, who is doing a diservice? Treating for bipolarity in this case would be a no brainer. Tell us more about him--
Childhood depression? more than 4 episodes, seasonal componenet?
-parents with bipolar-yes
-substance co-morbid yes
-atypical features to their depressive episodes?
-resistance to typical SSRI's and depression meds--yes

Those are some other questions but with a mother who has bipolar or any major mood illness, failure of that many meds and a presentation of "anxiety" without response to meds would be a no brainer to treat for BPAD.

Our anti-depressants suck for depression but for anxiety they work really well. If you do not respond after 2 drugs you better be looking for a new diagnosis or drug use.

 

[393656]

I tell them to get a tutor or set them up with a study workship on campus. Also refer for cbt. Most dont go. As I said I do not believe in adult adhd. Not enough experience in kids to give an opinion on it but do think there is a legit adhd out there in a very small population of kids.

 

[9point75]

IMHO, it sounds like you're trying to treat a personality issue with a pharmaceutical. Like Osler said, if you listen close enough to your patients, they will tell you the diagnosis. Here is this guy telling you that he's got legal problems, he's got mood problems, he's got anxiety problems, the meds don't work on him, he's got a messed up mom and probably a messed up childhood. The reason he doesn't fit neatly into a nice axis I is because he probably doesn't have an axis I and it's more Axis II and IV. The last thing this guy needs is a "mood stabilizer" so before you shoot him up with consta, try getting him on the couch at least twice a week. Bipolar my foot. Score another one for nuance.

 

[firedoor]

If you do not think outside the box and more dynamically in psychiatry you will do a lot of diservice to patients. If someone had tried that many standard anxiety meds and you keep trying more, who is doing a diservice? Treating for bipolarity in this case would be a no brainer.

I completely agree with your first statement, and am open to the concept of a bipolar spectrum. Checklist psychiatry is an oxymoron.

Secondly, as you state, it is critical to distinguish between "anxiety" and, as the DSM puts it, "flight of ideas or subjective experience that thoughts are racing". If you look at the criteria for a manic episode, this is really the only one which could potentially be mistaken for anxiety (barring perhaps psychomotor agitation).

"Internal uneasiness and restlessness", as you mention, are not criteria for mania. "Feeling wound up, tense or restless", however, is a criterion for GAD. True "racing thoughts" are quite different from the kind of inner restlessness (a symptom of GAD) which you suggest hints at bipolarity. Often when someone complains of anxiety, they're actually anxious. However, when someone complains of "mood swings" or "racing thoughts", they're typically not referring to the DSM definitions of those experiences.

I believe that what you are espousing is the notion that what has historically been termed "agitated depression" properly falls within the category of bipolarity. That is controversial.

Thirdly, I disagree that a default diagnosis and/or treatment of bipolar is a "no-brainer" here. We simply don't have enough information.

Lastly, though the patient has tried a multitude of different medications, that is almost meaningless if those trials were not actually adequate.

 

[9point75]

Manic episodes and depressive episodes aren't subtle creatures.

 

[nitemagi]

I'm with firedoor on this one. And is there evidence of impairment during a "manic" episode? Hospitalization? Arrest? Or is this just a presume mood disorder "in the bipolar spectrum?"

And I wouldn't put too much faith in the BSDS. Like all self-report measures, heavily prone to bias and over-endorsement.
http://www.psycheducation.org/depression/BSDS.htm

While I can appreciate the possibility of a bipolar diathesis in any mood disorder patient, I wouldn't go so far as to say there's ever any no-brainer bipolar diagnosis in any patient without a clear witnessed manic episode in the absence of substances. Everything else is conjecture, presumption, and has risks (sometimes worthwhile risks).

 

[strangeglove]

Manic episodes and depressive episodes aren't subtle creatures.

Agreed. I think there's a subtext to this whole "bipolar spectrum" concept, which is the idea that only psychiatrists are skilled enough to "catch" this subtle disorder. We start to see ourselves as special only when mood stabilizers and antipsychotics come into the picture, which starts to make the "bipolar spectrum" a little more attractive. Why not just say that there are some kinds of unipolar depression that do not respond to antidepressants alone, and therefore require augmentation with lithium, atypicals, etc.?

 

[Suedehead]

Agreed. I think there's a subtext to this whole "bipolar spectrum" concept, which is the idea that only psychiatrists are skilled enough to "catch" this subtle disorder. We start to see ourselves as special only when mood stabilizers and antipsychotics come into the picture, which starts to make the "bipolar spectrum" a little more attractive. Why not just say that there are some kinds of unipolar depression that do not respond to antidepressants alone, and therefore require augmentation with lithium, atypicals, etc.?

totally. we put WAY too much stock into our meds when we think that their inefficacy must have something to do with the patient.

 

[nitemagi]

totally. we put WAY too much stock into our meds when we think that their inefficacy must have something to do with the patient.

Or with the diagnosis Not that it couldn't be something wrong with the diagnosis, but that isn't the only possibility.

 

[whopper]

http://www.ncbi.nlm.nih.gov/pubmed/20528060
http://www.ncbi.nlm.nih.gov/pubmed/17507198
http://www.ncbi.nlm.nih.gov/pubmed/19439760

Three studies all showing ADHD is easy to malinger by college students, with a minimum of preparation (5 minutes on google for one study).

Sure, but I don't use any of the tests mentioned in those studies. A problem with several ADHD scales is the scales ask the person to gauge the severity of the symptoms. If someone wants meds for abuse, they could just list 4 on every scale. As for acting the role, one could do that too easily just by reading the DSM symptoms.

I use a Wender Utah filled with red-herring questions that are not related to ADHD (so if all of the red herring questions are a 3 or 4 on a Likert scale I will suspect malingering) and a TOVA test.

It's actually interesting because I have several patients I treat for ADHD where on the Wender Utah, all the red herring questions were all a 0 or 1, while the ADHD questions were all a 2-4 with the majority being a 3 or 4.

Despite everything I mentioned above, I agree with the argument that ADHD is easy to fake, especially for a doctor willing to give a stimulant prescription on a first meeting who doesn't take the time to figure out what's really going on.

That is what I am saying. I think ordering neuropsych testing for adhd is the biggest farse in psychiatry. ADHD is a FUNCTIONAL diagnosis not a pure symptoms based diagnosis. I simply refer for cbt and make sure they are not depressed, anxious or bipolar. After that I tell them to get some help and learn how to study.

I don't know if you're referring to the TOVA test since that is on the computer. The test does have a symptom exaggeration index.

If you're not familiar with the TOVA..
http://www.tovatest.com/

Besides, if someone is willing to fake ADHD with me, to go through a regimen of that will be more than 2 months of time, (urine drug screens, a nonstimulant medication, EKG testing, psychological testing, OARRS surveillance) would not be cost-effective, a malingerer would IMHO more likely just go to another doctor.

ADHD is a FUNCTIONAL diagnosis not a pure symptoms based diagnosis. I simply refer for cbt and make sure they are not depressed, anxious or bipolar. After that I tell them to get some help and learn how to study.

There are studies showing that psychotherapy does help for ADHD, in addition to medications, and biofeedback. The problem with medications are that many of them could be abused, but nonetheless, some people do need the medications. I always advise that if stimulants are given, give them under tight control, but do not completely close yourself off to the possibility that someone may need them.

Another problem is that several people, even without ADHD, will show improvements in attention with an ADHD medication. Benefit using an ADHD medication, IMHO, is not proof of ADHD.

An attending I trained under told me he would not treat ADHD at all because of the problems mentioned above, not just from me but everyone on the thread. Personally, IMHO, I find that too closed-minded. I do though think that several doctors, not giving out stimulants at all, is justified given the difficulties with malingering and possible abuse of the medication. Many doctors choose to try non-stimulant treatments but will not give out stimulants. That I understand, especially in several clinical scenarios, in fact I did treat using that method for some time.

IMHO, the entire field needs more research. Well, ahem, everything could use more research, but ADHD treatment is a complicated issue because the mainstay treatment given out by several doctors is something that could be abused. I also am of the opinion that too many children are being medicated due to a diagnosis such as ADHD. Despite this, there are people I do see that I believe do need treatment with ADHD that I can provide.

 

[zenman]

I'm with firedoor on this one. And is there evidence of impairment during a "manic" episode? Hospitalization? Arrest? Or is this just a presume mood disorder "in the bipolar spectrum?"

And I wouldn't put too much faith in the BSDS. Like all self-report measures, heavily prone to bias and over-endorsement.
http://www.psycheducation.org/depression/BSDS.htm

While I can appreciate the possibility of a bipolar diathesis in any mood disorder patient, I wouldn't go so far as to say there's ever any no-brainer bipolar diagnosis in any patient without a clear witnessed manic episode in the absence of substances. Everything else is conjecture, presumption, and has risks (sometimes worthwhile risks).

I agree with you and nothing is written in stone yet. I've only seen him briefly twice now, plus read his previous notes. First time I saw him I thought he was more anxious than hypomanic. The second visit he was notably depressed. I think there some Cluster B here also. There's one note about him being narcissistic and presenting his own differential diagnoses. Then there's a few tattoos and lip rings. He also reports "deep depression" after sex. This is all from him of course but he reports drastic mood swings, work and social impairment, irritability, blowing money, being more talkative, more sex, etc.. We'll see.

 

[firedoor]

I agree with you and nothing is written in stone yet. I've only seen him briefly twice now, plus read his previous notes. First time I saw him I thought he was more anxious than hypomanic. The second visit he was notably depressed. I think there some Cluster B here also. There's one note about him being narcissistic and presenting his own differential diagnoses. Then there's a few tattoos and lip rings. He also reports "deep depression" after sex. This is all from him of course but he reports drastic mood swings, work and social impairment, irritability, blowing money, being more talkative, more sex, etc.. We'll see.

"Mood swings" as colloquially understood are more of a temperamental issue and quite different from the labile affect seen in mania, hypomania and certain neurodegenerative conditions (e.g. pseudobulbar affect).

 

[firedoor]

I agree with you and nothing is written in stone yet. I've only seen him briefly twice now, plus read his previous notes. First time I saw him I thought he was more anxious than hypomanic. The second visit he was notably depressed. I think there some Cluster B here also. There's one note about him being narcissistic and presenting his own differential diagnoses. Then there's a few tattoos and lip rings. He also reports "deep depression" after sex. This is all from him of course but he reports drastic mood swings, work and social impairment, irritability, blowing money, being more talkative, more sex, etc.. We'll see.

Oh wait...he has TATTOOS?? That's virtually pathognomonic for bipolar in my neck of the woods .

 

[nitemagi]

"Mood swings" as colloquially understood are more of a temperamental issue and quite different from the labile affect seen in mania, hypomania and certain neurodegenerative conditions (e.g. pseudobulbar affect).

Agreed. Mood swings need a set duration, intensity, causing impairment, and preferably with witnesses or objective evidence of impairment (hospitalization, arrests, near death, etc). Retrospective and self-reports as a sole basis of information is limited.

 

[zenman]

Oh wait...he has TATTOOS?? That's virtually pathognomonic for bipolar disorder in my neck of the woods .

Where I'm at it's APD/BPD, especially with neck tattoos and the word "crazy" across your forehead.

 

[393656]

Clearly most psychiatrists, evidenced by the rigidity of ideas on this board cannot diagnosis subtle bipolar spectrum disease let alone PCP's. You can have your own opinions but watch them change all of a sudden when dsm 5 and then 6 is out and voila-no more specific rigid checkboxes. "internal restlessness" is what someone wants it to be. The guy who made the GAD checklist describs that as part of GAD which is can be. It doesnt mean that is the only thing it happens in.

Also mania and depression is not clear whoever said that. It masquarades as anxiety and all sorts of things

but to each is own. Keep trying the 6th SSRI and then SNRI then remeron etc and see wehre that gets you.

 

[OldPsychDoc]

Oh wait...he has TATTOOS?? That's virtually pathognomonic for bipolar disorder in my neck of the woods .

Tattoo/tooth ratio >1.0 ===> Methamphetamine dependence.

 

[393656]

Tattoo/tooth ratio >1.0 ===> Methamphetamine dependence.

indeed!