1) SB is a 35-year-old woman with a long history of mental health issues including depression, anxiety, self-harm, and suicide attempts dating back to age 12. She has a complex psychiatric history and comorbid diagnoses. 2) Upon further evaluation, it was discovered that SB likely has undiagnosed ADHD, bipolar disorder, and possibly Asperger's syndrome. Her childhood symptoms and family history were consistent with these disorders. 3) Treatment with stimulant medication for ADHD resulted in a remarkable improvement in SB's mood, reduction in suicidal ideation, and overall functioning. Her accurate diagnosis and treatment of comorbid conditions was key to improving her long-standing mental health

1. Addicted to Chaos
A case presentation with an
unexpected end
DrYasir Hameed (SpR)
Dr Jaap Hamelijnck (Consultant)
Eastern RecoveryTeam
18 March 2014

2. Overview
 The story will flow from present to past.
keep an eye on small details
 How easy to miss the whole picture,
especially in crisis
 Stop, think and then think again, and again

3. “You only see what your eyes want
to see”
In psychiatry, this is exceptionally true….

4. Meet SB
 35 year old single woman, lives alone,
working in a pub, presented with serious
overdose in August 2013 and long history
of mental health problems going back to
12 years of age
 Childhood?

5. Chief complaint
 Low mood for most adult life
 Relationship difficulties
 Poor self esteem
 SUICIDAL

6. HPI 1) Self harm and suicide
 Started to think about suicide since age 12
 Started to superficially cut herself at age
 Gets a “buzz out of it”, hoping someday she
will do it properly
 Overdoses at age 13 and 18. Constant
thoughts of suicide

7. August 2013 overdose
 Overdose was well planned
 Left detailed suicidal note
 66 tablets of venlafaxine XL 150 mg
 Initial referral stated 6 tablets
 ITU: seizures and loss of consciousness

8. Referral to ERT August 20313
 “…an impulsive but deliberate overdose”
 “….was one of several more serious self harm
attempts Susan has made in her adult life”
 “S---- denies any further intent to harm herself
at this time, did not want crisis team support,
but was open to having her medications further
reviewed by a psychiatrist”

9. HPI 2) Mood
 Variable,“moody”
 Easily irritable
 Worrier
 Impulsive (gambling, binge eating, binge
drinking, shoplifting)

10. Substance misuse
 Alcohol
 Cannabis
 Amphetamine
Variable and no dependence

11. Relationship difficulties
 Five short relationships since age 17
 Love/hate relationship with family, friends
and the church
 Poor self esteem
 Feels unloved

12. “I need help but I don’t know how
or what, all I wanted has been
provided for me, therapist, CPN,
and I am still poorly-that is why I
want to kill myself”
SB

13. Any initial thoughts?

14. Past psychiatric history
 Has been know to psychiatric services since
she was 18 years old
 Disturbed as a child, no help sought
 At age of 15-16 treated for depression by
GP, not getting along with her step father
 Comfort eating, overweight, sometime make
herself sick

15. Summary of psychiatric assessments
 Age 18-19 (1997):
◦ Referred by GP for severe depression and
anxiety and suicidal thoughts
◦ Overdose
◦ Relationship ending
◦ Poor engagement and chaotic

16.  April 1999: Consultant clinical
psychologist report
◦ Several patterns of addictive behaviour
◦ Amphetamine gave her confidence and good
feeling about herself
◦ Poor response to antidepressants
◦ Sees suicide as the only escape
◦ Very poor self-image
◦ She wants to get better and work

17.  October 2000
◦ Admitted informally for a week
◦ Suicidal thoughts
◦ Reversed sleep pattern
◦ Poor concentration and motivation
Discharge report:
“discrepancy between her account of her mental
state and the observations made by staff on the
ward.There were no positive signs of any
depressive symptoms during her stay on the ward.
She has become more settled and she was
socialising well with others”

18.  June 2001
◦ Re-referred from GP
◦ “I would be grateful for your help regarding
(S) whose mother, (AS) is a colleague of yours
in Occupation Therapy”
◦ Very depressed
 Nov 2001
◦ Clinical psychologist: Moderately depressed
with moderate-severe anxiety
◦ Main problems: her personality development
has been influenced by her weight and her
perception of her body shape

19. From 2002-2012
 Overdoses and self harm, not meeting the
criteria for acute services (2012)
 Offered psychological input
 Not much information
recorded

20.  Jan 2013:
◦ Completed 16 session of CAT
◦ Difficulty in managing her daily life and how
busy her head is and how impossible it is to
switch off.
◦ “Could not really say that therapy had helped
or that she would be able to use this to
inform her future. However has made some
changes to her life in a positive way and her
relationships have improved with friends and
family. No further input at present. Close”

21. Family history
 All reports from psychiatrists mentioned
no family history of mental illness until I
assessed her in 2013!

22. Medication and allergies
 Treated with fluoxetine, paroxetine,
Temazepam and venlafaxine until 2013
 No allergies
 No significant past medical history

23. Personal history
 6th of five daughters
 Pregnancy was uneventful, mother did not
smoke or drink alcohol
 Normal delivery
 Normal developmental milestones, spoke
early and could not stop talking!

24. Personal history (cont’d)
 Religious upbringing of Mormon parents
 Parents separated when she was 9
 Bullying
 Poor social skills, never said appropriate
things, and never saw it as inappropriate

25. Personal history (cont’d)
 Left school aged 16 with poor grades and
obtained BTEC diploma in Nursery
Nursing
 Few seasonal jobs
 Short term relationships

26. Social history
 Drink socially but binges when low or
anxious
 Smokes 2-3 cigarettes a day
 Cannabis on and off and used speed
 In debt

27. Premorbid personality
 Moody, easily irritable, worrier. Few
friends.
 Feels unloved
 Feels judged by others

28. Diagnosis?

29. My first appointment
 Diagnostic labels she already had:
◦ Adjustment disorder
◦ “Immature personality problem”
◦ Borderline Personality Disorder
◦ Recurrent depression
◦ Generalised anxiety disorder
 Medication:
◦ Venlafaxine 75 mg bd

30. My initial thoughts (Nov 2013)
 Current problems: chronic low mood and
anxiety, unable to sleep, unable to shut
down, very sensitive to comments
 Preoccupation with death, yarning for
death, fantasies about death
 Imp: ? Personality, willing to engage,
medication review, switched venlafaxine
to sertraline

31. Second appointment (Jan 2014)
 Struggled with the switching.
 Reported elation in mood for three to
four days
 Significant mood swings
 Very suicidal
 Christmas was disastrous
 Everybody is avoiding her
 Feels she betrayed her family

33.  Past periods of hypomania lasting about a
week with irritability, hyperactivity, lacking
sleep, much more interested in sex, talk
excessively, overspending, then depressed

34.  Two of her sisters had been treated for
bipolar
 ?mother

35.  She was told that she has manic
depression
 Mood disorder questionnaire: answered
yes to all 13 questions with problems
affecting her life significantly

36. And more…
 Constant difficulty in sustaining her
concentration and attention, since she
was a child
 Had problems at school due to her
hyperactive behaviour
 Can’t remember her childhood
 Used amphetamine during early twenties
for 6 months and had significant calming
effect

37. History from mother
 As an OT, she always suspected that her child had
ADHD
 S never slept well, always on the go, poorly
attentive. No one could cope with her
 Completed an checklist for screening of ADHD
for her daughter and she was positive
 Was embarrassed to bring her forward for
assessment (fear of stigma)

38. Following appointments
 Quetiapine added
 Mood diary suggestive of bipolar disorder
 Moods are general more stable following quetiapine
 Alcohol drinking is part of her job and boredom,
never drinks at home, effect on her medication
 Gained some weight, worried
 Suicidal thoughts are slightly improving

40.  ADHD assessments completed and
confirmed the diagnosis of combined
ADHD (DSM IV) using structured
interview (DIVA®)
 Age of onset: 3 years
 Features of Oppositional Defiant
Disorder and Conduct Disorder as a
child (deliberately destroyed property, lied
to obtain goods, shoplifting)

41. Assessment tools
Current symptoms scale- self report form:
IA 6/9. HI 8/9. Most areas affected. ODD 4/8.
Childhood symptoms scale- self report form:
IA 8/9. HI 8/9. Most areas affected. ODD 4/8. CD 3/15.
Current Symptoms Scale-other:
IA 9/9. HI 8/9. age of onset 3 years.All areas affected.
Childhood Symptoms Scale-other:
IA 8/9. HI 9/9.All areas affected. ODD 8/8.
ASRS-v1.1
Part A 4/6. Part B 10/12.

42. The Conners’ Adult ADHD Rating Scales–Self
Report: LongVersion (CAARS–S:L)
 The Conners' Adult ADHD Rating Scale, a
66-item assessment has a diagnostic
sensitivity of 82%, specificity of 87%, and
PPV of 85%.

43. Self report score

44.  “S did not sleep at night until she was
nearly 4 years old. She never settled to
anything for long. She was a sad child”
 Mother’s comment on assessment
forms

45.  Asperger's assessment is undergoing, high
Autism Quotient (AQ), and Relatives
Questionnaire (RQ) scores suggestive of
Asperger’s

46.  Methylphenidate started with remarkable
results
 Suicidal ideation completely gone
 Mood is much better
 Still long way to go…

50. ADHD/Bipolar/Personality
Disorder?
Incidence rates of bipolar disorder in clinical samples of
adults with ADHD have ranged from 3%-17% (Brown,
2011)
Among children with ADHD estimated incidence of
bipolar disorder has ranged from 2.4% to 21% (Arnold,
et al. 2011)
Overlap between ADHD and BD not only insufficient
ability to manage and modulate emotions but in
addition, two additional executive functions often
impaired a) ability to inhibit and manage actions, and b)
ability to regulate levels of arousal.

51. ADHD and personality disorder:
Miller, Nigg and Faranoe (2007) studies 363 adults with
ADHD and compared them to non-ADHD controls in
relationship to personality disorder.Adults with ADHD
had a higher incidence of both cluster B and C.
Controls % ADHD %
Cluster A No difference
Cluster B 9.5 24.4
Cluster C 4.3 21.0
The most frequent Cluster B personality disorder in
ADHD was Borderline PD
In Cluster C, the most common type was OC PD

52. In the differential diagnostic assessment,
the following criteria are used:
1.The frequency of the mood swing (4–5 times a
day in ADHD and cluster B personality
disorders, a minimum of 2–3 days in a hypomanic
episode)
2.The course (chronic in ADHD and cluster B
personality disorder, episodic in bipolar disorder)
3.The age of onset (childhood in ADHD, usually
later in the bipolar and personality disorders)

55. ADHD and Suicide
The incidence of death from suicide is nearly 5
times higher among adults who had had
childhood ADHD compared with control
participants (N = 367)
Barbaresi et al. Mortality,ADHD, and Psychosocial Adversity in Adults With Childhood
ADHD:A Prospective Study. PEDIATRICSVolume 131,Number 4,April 2013.

56. The chance of suicidal tendencies in
adolescents and adults with ADHD
compared to controls is elevated mainly in
the presence of hyperactivity/impulsivity,
depression or dysthymia, and the antisocial
behavioural disorder
(Barkley and Fischer 2005 ; Semiz et al.
2008 )

57.  In research, among adolescents 36 % of
the patients with ADHD had suicidal
thoughts before the age of 18, versus 22
% of a control group.
 For suicide attempts, these numbers were
16 % versus 3 %.
(Barkley and Fischer 2005 )

58. Young women diagnosed with ADHD, were
three to four times more likely to attempt
suicide and two to three times more likely
to report injuring themselves than
comparable young women in a control
group
Hinshaw et al. Prospective Follow-Up of Girls With Attention-Deficit/Hyperactivity
Disorder Into Early Adulthood: Continuing Impairment Includes Elevated Risk for Suicide
Attempts and Self-Injury. Journal of Consulting and Clinical Psychology.American
Psychological Association. 2012,Vol. 80, No. 6, 1041–105.

59. ADHD and Autistic Spectrum
Disorders (ASD)
 41 % of the children with autistic
spectrum disorders also had many ADHD
characteristics, and 22 % of those with
ADHD characteristics also had the
diagnosis autistic spectrum disorder.
 Suggested a joint genetic influence in both
disorders (Ronald et al. 2008 ) .

60. Conclusion
 Think about ADHD when you see the red
flags
 ADHD is real and treatable
Refer
 Learn more about ADHD

61. Red flags
ADHD in Adults.The latest assessment and treatment strategies. Russel Barkley PhD. 2010
 Self-control
 Responsibilities and restless
 Impulse-control
 Time management and organisation
 Repeated failures in self care programmes
such as weight loss, smoking cessation, or
substance abuse treatment
 Poor educational achievement
 Poor occupational functioning
 Poor satisfaction with interpersonal
relationships
 Substance dependence and abuse