Can adults with attention-deficit/hyperactivity disorder be distinguished from those with comorbid bipolar disorder? Findings from a sample of clinically referred adults.

BACKGROUND: Despite data describing the overlap of attention deficit hyperactivity disorder (ADHD) and bipolar disorder (BPD) in youth, little is known about adults with these co-occurring disorders. We now evaluate the clinical characteristics of referred adults with (n = 24) and without BPD (n = 27). METHODS: Referred adults to clinical trials of ADHD were evaluated by psychiatric evaluation using DSM-IV criteria. Structured psychiatric interviews were used to systematically assess adult and childhood disorders. RESULTS: The vast majority of patients with ADHD plus BPD had bipolar II disorder (88%). Adults with ADHD plus BPD had higher rates of the combined subtype of ADHD compared to ADHD without BPD (chi(2) = 8.7, p =.003), a greater number of DSM-IV ADHD symptoms (14.8 +/- 2.9 and 11.4 +/- 4.0; t = -3.4, p <.01), more attentional symptoms of ADHD (8.1 +/- 1.4 and 6.8 +/- 2.1; t = -2.5, p <.02; trend), poorer global functioning (47 +/- 5.9 and 52 +/- 7.4, t = 2.6, p <.02; trend), and additional comorbid psychiatric disorders (3.7 +/- 2.5 and 2.0 +/- 1.9; t = -2.9, p <.01). CONCLUSIONS: These results suggest that adults with ADHD plus BPD have prototypic symptoms of both disorders, suggesting that both disorders are present and are distinguishable clinically.     

Further evidence of a bidirectional overlap between juvenile mania and conduct disorder in children

OBJECTIVE: To investigate systematically the overlap between mania and conduct disorder (CD) in a sample of consecutively referred youths. It was hypothesized that neither CD nor manic symptoms were secondary to the other disorder and that children with the 2 disorders would have correlates of both. METHOD: Subjects were consecutively referred children and adolescents meeting DSM-III-R diagnostic criteria on structured diagnostic interview for CD (n = 116), mania (n = 110), and CD + mania (n = 76). RESULTS: Of 186 children and adolescents with mania and of 192 with CD, 76 satisfied criteria for both CD and mania, representing 40% of youths with CD and 41% of youths with mania, respectively. Examination of the clinical features, patterns of psychiatric comorbidity, and functioning in multiple domains showed that children with CD and mania had similar features of each disorder irrespective of the comorbidity with the other disorder. CONCLUSIONS: The data suggest that when mania and CD co-occur in children, both are correctly diagnosed. In these comorbid cases, CD symptoms should not be viewed as secondary to mania and manic symptoms should not be viewed as secondary to CD.     

注意缺陷多动障碍患儿的成人早期精神状况随访研究

目的 了解注意缺陷多动障碍(ADHD)患儿在成人早期罹患精神障碍的状况.方法 采用前瞻性设计方法,对就诊于北京大学精神卫生研究所精神科门诊的300例ADHD患儿进行随访,同意参加随访者116例(随访率38.7%),基线至随访为2.0～13.5年;患儿基线年龄为7.5～17.0岁,随访时年龄为18.0～23.5岁;采用以美国精神障碍诊断与统计手册第4版为诊断标准制订的定式会谈工具确定诊断,包括Conners成人ADHD诊断会谈量表(Conners Adult ADHD Diagnostic Interview for DSM-Ⅳ,CAADID)、DSM-Ⅳ-TR轴Ⅰ障碍定式临床检查(SCID-Ⅰ)和DSM-Ⅳ轴Ⅱ障碍定式临床检查(SCID-Ⅱ)工具.结果 随访时116例中符合成人ADHD诊断者共59例(50.9%),其中单纯符合成人ADHD诊断标准者18例(15.5%),同时符合成人ADHD及精神障碍/人格障碍者41例(35.3%);不符合成人ADHD诊断,但符合精神障碍/人格障碍者17例(14.7%);不符合任何精神疾病诊断者40例(34.5%),其中功能缓解29例(25.0%),功能未缓解11例(9.5%).116例中,40例(34.5%)至少共患1种DSM-Ⅳ轴Ⅰ障碍,其中21例(18.1%)共患情感障碍,12例(10.3%)共患焦虑障碍,6例(5.2%)共患物质滥用;38例(32.8%)符合DSM-Ⅳ轴Ⅱ人格障碍诊断,其中6例(5.2%)符合A组人格障碍诊断,23例(19.8%)符合B组人格障碍诊断,包括20例(17.2%)反社会型人格障碍,18例(15.5%)符合C组人格障碍诊断,6例(6.0%)符合其他人格障碍诊断.结论 ADHD患儿至成人早期预后较差,2/3左右罹患成人ADHD、精神障碍或人格障碍,其中50.9%符合成人ADHD.     

Life events in a prepubertal and early adolescent bipolar disorder phenotype compared to attention-deficit hyperactive and normal controls

OBJECTIVE: To examine life events in subjects with a prepubertal and early adolescent bipolar disorder phenotype (PEA-BP) compared to those in subjects with attention-deficit hyperactivity disorder (ADHD) and normal controls (NC). METHODS: To optimize generalizeability, subjects with PEA-BP (n = 93) and ADHD (n = 81) were consecutively ascertained from pediatric and psychiatric sites. Subjects in the NC group (n = 94) were obtained from a random survey. PEA-BP was defined by Diagnostic and Statistical Manual of Mental Disorders (fourth edition) mania with at least one of the cardinal symptoms of mania (i.e., elation and/or grandiosity) to avoid diagnosing mania only by criteria that overlapped with those for ADHD. All subjects received comprehensive, blind research assessments of mothers about their children and separately of children about themselves. Assessment instruments included the Washington University in St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS) and the Life Events Checklist. Data from the Life Events Checklist were examined by total life events and by subcategories of dependent, independent, or uncertain relationships to the child. RESULTS: Total, independent, dependent, and uncertain life events were all significantly more frequent in the PEA-BP subjects compared to both the ADHD and NC groups. CONCLUSIONS: Because there was no a priori reason to expect significantly more independent life events in the PEA-BP compared to the ADHD and NC groups, these results warrant further research into the role of life events in the onset of PEA-BP.     

Subsyndromal depression is associated with functional impairment in patients with bipolar disorder

BACKGROUND: The purpose of this study was to assess whether a relationship exists between mild depressive symptoms and overall functioning in subjects with bipolar disorder. METHOD: Twenty-five male subjects with bipolar I disorder (DSM-III-R criteria), who had not experienced a DSM-III-R episode of mania, hypomania, or major depression for 3 months as determined using the Structured Clinical Interview for DSM-III-R, were evaluated for degree of depressive symptoms using the Hamilton Rating Scale for Depression (HAM-D) and for overall functional status using the Global Assessment of Functioning (GAF, DSM-IV Axis V). RESULTS: GAF scores were significantly negatively correlated with HAM-D scores (r = -0.61, df = 23, p = .001), despite the fact that no patient had a HAM-D score high enough to be considered clinically depressed. CONCLUSION: The results of this study support a relationship between subsyndromal depressive symptoms and functional impairment in bipolar subjects, despite their not meeting threshold criteria for a major depressive episode. These findings raise the possibility that in some patients with bipolar disorder subsyndromal depressive symptoms might contribute to ongoing functional impairment.     

Attention-deficit hyperactivity disorder as a potentially aggravating factor in borderline personality disorder

BACKGROUND: Clinical experience suggests that people with borderline personality disorder often meet criteria for attention-deficit hyperactivity disorder (ADHD). However, empirical data are sparse. AIMS: To establish the prevalence of childhood and adult ADHD in a group of women with borderline personality disorder and to investigate the psychopathology and childhood experiences of those with and without ADHD. METHOD: We assessed women seeking treatment for borderline personality disorder (n=118) for childhood and adult ADHD, co-occurring Axis I and Axis II disorders, severity of borderline symptomatology and traumatic childhood experiences. RESULTS: Childhood (41.5%) and adult (16.1%) ADHD prevalence was high. Childhood ADHD was associated with emotional abuse in childhood and greater severity of adult borderline symptoms. Adult ADHD was associated with greater risk for co-occurring Axis I and II disorders. CONCLUSIONS: Adults with severe borderline personality disorder frequently show a history of childhood ADHD symptomatology. Persisting ADHD correlates with frequency of co-occurring Axis I and II disorders. Severity of borderline symptomatology in adulthood is associated with emotional abuse in childhood. Further studies are needed to differentiate any potential causal relationship between ADHD and borderline personality disorder.     

DSM-IV mania symptoms in a prepubertal and early adolescent bipolar disorder phenotype compared to attention-deficit hyperactive and normal controls

OBJECTIVE: To compare the prevalence of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) mania symptoms in a prepubertal and early adolescent bipolar disorder phenotype (PEA-BP) to those with attention deficit hyperactivity disorder (ADHD) and normal community controls (CC). METHODS: To optimize generalizeability, subjects with PEA-BP and ADHD were consecutively ascertained from outpatient pediatric and psychiatric sites, and CC subjects were obtained from a random survey. All 268 subjects (93 with PEA-BP, 81 with ADHD, and 94 CC) received comprehensive, blind, baseline research assessments of mothers about their children and of children about themselves. PEA-BP was defined by DSM-IV mania with elation and/or grandiosity as one criterion to ensure that subjects had one of the two cardinal symptoms of mania and to avoid diagnosing mania only by criteria that overlapped with those for ADHD. RESULTS: Five symptoms (i.e., elation, grandiosity, flight of ideas/racing thoughts, decreased need for sleep, and hypersexuality) provided the best discrimination of PEA-BP subjects from ADHD and CC controls. These five symptoms are also mania-specific in DSM-IV (i.e., they do not overlap with DSM-IV symptoms for ADHD). Irritability, hyperactivity, accelerated speech, and distractibility were very frequent in both PEA-BP and ADHD groups and therefore were not useful for differential diagnosis. Concurrent elation and irritability occurred in 87.1% of subjects with PEA-BP. Data on suicidality, psychosis, mixed mania, and continuous rapid cycling were also provided. CONCLUSION: Unlike late teenage/adult onset bipolar disorder, even subjects with PEA-BP selected for DSM-IV mania with cardinal symptoms have high rates of comorbid DSM-IV ADHD. High rates of concurrent elation and irritability were similar to those in adult mania.     

Prevalence and correlates of eating disorder co-morbidity in patients with bipolar disorder

This study was designed to document eating disorder symptoms in a well-defined sample of patients with bipolar disorder and to evaluate the relationship of current loss of control over eating (LOC) to demographic and clinical features hypothesized to characterize bipolar patients at risk for disordered eating. Eighty-one patients enrolled in the Bipolar Disorder Center for Pennsylvanians provided demographic information and completed the Structured Clinical Interview for DSM-IV Axis I Disorders. The Eating Disorder Examination was administered by independent clinicians to evaluate current and lifetime eating disorder symptomatology. Twenty-one percent of participants met DSM-IV criteria for a lifetime eating disorder, and 44% reported a history of LOC. Patients who endorsed weekly LOC during the past six months (n=18) were heavier, had more atypical depressive symptoms, and were more likely to have a lifetime substance use disorder compared to patients in the rest of the sample (n=63). These findings indicate that eating disorder symptoms are prevalent in patients with bipolar disorder and are associated with obesity and other psychiatric morbidity. Screening for eating disorders in bipolar patients is warranted, as intervention may minimize distress and improve treatment outcome.     

A pessimistic attitude towards the future and low psychosocial functioning predict psychiatric diagnosis among treatment-seeking adolescents

OBJECTIVE: The objective was to study factors associated with psychiatric diagnosis among adolescents (n = 164) seeking psychiatric care for mental symptoms. METHOD: Psychiatric diagnosis was confirmed by a structured diagnostic interview. Psychosocial functioning was assessed with the Global Assessment of Functioning Scale, and the Beck Depression Inventory and Offer Self-Image Questionnaire were also used. Background data were gathered. RESULTS: A majority (76%) of the adolescents met DSM-III-R criteria for psychiatric diagnosis. The self-image was more negative and the Beck score was higher among these adolescents than the others. All who had attempted suicide had a psychiatric disorder. Those diagnosed as having a psychiatric disorder consumed alcohol in order to get drunk more often than others. Continual conflicts with parents and smoking were not associated with the existence of a psychiatric disorder. In logistic regression analysis, low psychosocial functioning (OR = 3.9) and an uncertain or pessimistic attitude towards the future (OR = 9.1) proved to be independent risk factors for psychiatric disorders. CONCLUSIONS: Health service staff should be aware of factors associated with psychiatric disorders in adolescents so that they can identify those at high risk.     

Screening psychiatric emergency department patients with major mental illnesses for at-risk drinking

OBJECTIVE: This study determined the prevalence of at-risk drinking in a psychiatric emergency service and compared the characteristics and functioning of at-risk drinkers with schizophrenia or bipolar disorder with those of at-risk drinkers with depression or anxiety disorders. METHODS: Adult patients who entered the psychiatric emergency service and met study criteria were surveyed. RESULTS: A total of 148 participants had schizophrenia or bipolar disorder, and 242 had depression or anxiety. Twenty-three percent of the group with schizophrenia or bipolar disorder and 22 percent of the group with depression or anxiety drank more than the recommended limits. The group with schizophrenia or bipolar disorder reported experiencing significantly more consequences from drinking than the depression or anxiety group. Both groups reported significant depression in the prior few days. CONCLUSIONS: This study demonstrated the importance of assessing alcohol use and depression among all patients in psychiatric emergency services.     

Relationship between psychiatric illness and conduct disorder in adolescents

Ninety-six psychiatrically ill adolescents admitted to an adolescent inpatient service were systematically assessed to determine the morbidity of conduct disorder (CD), with other Axis I psychiatric disorders. Twenty-six (27%) met DSM-111 criteria for CD in addition to other Axis I disorders. A CD diagnosis was significantly associated with substance abuse, and attention deficit disorder with hyperactivity. Although CD was found in 21% of depressives it was more commonly found in patients with psychotic disorders (25%) and bipolar (42%) disorders. These findings suggest that CD may be commonly found in a variety of adolescent psychiatric disorders. The implications of this finding for pharmacologic treatment of CD, the clinical assessment of the CD patient, and possible relationships between CD and adolescent psychiatric disorders are discussed.     

Tourette syndrome in youth with and without obsessive compulsive disorder and attention deficit hyperactivity disorder

Chronic tic disorders (TD) are consistently found to have high rates of comorbidity with obsessive-compulsive disorder (OCD) and attention deficit hyperactivity disorder (ADHD). The purpose of this study is to compare the severity of TD only to TD with comorbid OCD or ADHD based on severity of tics, measures of psychopathology and additional comorbid diagnoses. Baseline data from 158 youth with a chronic TD who participated in two longitudinal studies were examined. Fifty-three percent (N = 85) of the youth also met criteria for a diagnosis of OCD, 38.6 % (n = 61) met criteria for ADHD and 24.1 % (N = 38) met criteria for both. Measures of interest addressed severity of tics, symptoms of anxiety, depression, ADHD, psychosocial stress, global functioning and the presence of comorbid diagnoses. Youth with comorbid TD and OCD were characterized by more severe tics, increased levels of depressive and anxious symptoms, heightened psychosocial stress and poorer global functioning. Youth with comorbid TD and ADHD did not differ from those with TD alone on measures of tic severity, but experienced greater psychosocial stress and poorer global functioning. Subjects with comorbid TD and OCD had more internalizing disorders than those without OCD, while those with comorbid ADHD were more likely to meet criteria for oppositional defiant disorder. TD with OCD is a more severe subtype of TD than TD without OCD. TD with ADHD is associated with higher psychosocial stress and more externalizing behaviors. Further research is needed into the underlying relationships between these closely associated conditions.     

Ages of onset and rates of syndromal and subsyndromal comorbid DSM-IV diagnoses in a prepubertal and early adolescent bipolar disorder phenotype

OBJECTIVE: To study rates and ages of onset of DSM-IV syndromal and subsyndromal comorbidity in a prepubertal and early adolescent bipolar disorder phenotype (PEA-BP) (N = 93) compared to attention-deficit/hyperactivity disorder (ADHD) (N = 81). METHOD: The WASH-U-KSADS was given by raters blinded to subject group separately to mothers about their children and to children about themselves. PEA-BP was defined as DSM-IV mania with at least one cardinal symptom of mania (elation or grandiosity) to avoid diagnosing using only symptoms that overlapped with those for ADHD. Syndromal diagnoses required a CGAS score of 60 or less to ensure severity at a level of definite "caseness." RESULTS: PEA-BP subjects were aged 10.9 (SD = 2.6) at baseline and 6.8 (SD = 3.4) at onset of first mania episode. Rates of oppositional defiant disorder and total number of comorbidities were significantly higher in the PEA-BP group than the ADHD group. In PEA-BP subjects, mean ages of onset of ADHD occurred before the first manic episode, and obsessive compulsive, oppositional defiant, social phobia, generalized anxiety, separation anxiety, and conduct disorders occurred after. CONCLUSIONS: Onsets of ADHD before mania and of oppositional defiant disorder/conduct disorder after mania have clinical and research implications. These include the need to examine for mania symptoms in children with ADHD and/or oppositional defiant disorder/conduct disorder and to develop scales to differentiate preschool mania from ADHD. Comparison with other studies demonstrated the importance of DSM system and severity scales in reporting comorbidity rates.     

重性抑郁障碍或双相障碍患者抑郁发作伴随躁狂症状的临床特征

目的:了解重性抑郁障碍(MDD)或双相障碍抑郁发作患者出现躁狂症状的频率和程度。方法:对52例经简明国际神经精神访谈(MINI)、符合《美国精神障碍诊断与统计手册》第4版(DSMIV)重性抑郁障碍或双相障碍抑郁发作的患者,采用情感障碍评估量表(ADE)评估患者本次抑郁发作中出现的躁狂症状。结果:52例患者中有36例重性抑郁障碍,16例为双相障碍抑郁发作。至少有1条躁狂症状的患者达86.5%(n=45),至少有3条躁狂症状的患者占32.7%(n=17),而没有任何躁狂症状的患者仅占13.5%(n=7)。结论:抑郁发作患者大多存在不同程度的躁狂症状,及时识别这些症状,对诊断与治疗有指导意义。情感障碍评估量表是一个值得应用的评估情感发作的工具。     

Childhood mania,attention deficit hyperactivity disorder and conduct disorder: a critical review of diagnostic dilemmas

Objectives:  Significant debate exists on whether early onset bipolar disorder is mistakenly attributed to attention deficit hyperactivity disorder (ADHD) or conduct disorder (CD), or whether ADHD and CD are frequently misdiagnosed as mania. We review the literature on the extent to which these disorders can be reliably differentiated, and describe the diagnostic confusion that may be the result of features common to both classes of disorders.
Methods:  The review focuses on research studies that have examined whether overlapping symptoms of bipolar disorder, ADHD, and CD contribute to misdiagnosis of the two classes of disorders, the prevalence of early onset bipolar disorder with comorbid ADHD or CD, and theories regarding the origins of this comorbidity.
Results:  Reliable and accurate diagnoses can be made despite the symptom overlap of bipolar disorder with ADHD and CD. Children with bipolar disorder and ADHD may have a distinct familial subtype of bipolar disorder. Some findings suggest that manic symptoms may represent `noise' that indicates the general severity of psychopathology in a child or adolescent.
Conclusions:  Further prospective studies may confirm whether early onset bipolarity can be successfully differentiated from ADHD or CD, whether all three types of disorders can be recognized in comorbid cases, or whether comorbid cases represent a distinct subtype of bipolar disorder.     

Phenomenology and outcome of subjects with early- and adult-onset psychotic mania

OBJECTIVE: This study examined clinical differences between subjects with early-onset and adult-onset psychotic mania. METHOD: Subjects were from an epidemiologically derived, hospitalized sample who met criteria for definite bipolar disorder after 24 months of follow-up and whose index episode had been manic. Information collected regarding demographic characteristics, psychotic and depressive symptoms, childhood behavior problems and school functioning, substance/alcohol use disorders, and episode recurrence for two subgroups were compared: those whose illness first emerged before age 21 (early onset) (N=23) and those whose first episode occurred after age 30 (adult onset) (N=30). RESULTS: A larger proportion of the early-onset subjects were male, had childhood behavior disorders, had substance abuse comorbidity, exhibited paranoia, and experienced complete episode remission less frequently during 24-month follow-up than the adult-onset subjects. CONCLUSIONS: These data add to the body of evidence that has suggested that many subjects with early-onset psychotic mania have a more severe and developmentally complicated subtype of bipolar disorder.     

The specific burden of comorbid anxiety disorders and of substance use disorders in bipolar I disorder

OBJECTIVES: Uncertainty exists regarding whether comorbid substance use disorders (SUDs) in bipolar I disorder are more prevalent among persons with versus without comorbid anxiety disorders. Moreover, the independent contribution of these comorbidities to the burden of bipolar disorder (BD) is unclear. METHODS: The 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions was used to identify respondents with lifetime BD (n = 1,411). Illness severity was compared across four groups based on the presence of lifetime anxiety disorders, lifetime SUDs, neither, or both. Variables included lifetime prevalence of mixed mania, prolonged mood episodes, BD-related health service utilization, and forensic history, 12-month prevalence of mania and depression, and current general mental health functioning. Diagnoses were generated using the National Institute on Alcohol Abuse and Alcoholism Alcohol Use Disorder and Associated Disabilities Interview Schedule, DSM-IV Version. Analyses were computed separately for males and females. RESULTS: For females only, the lifetime prevalence of SUDs was significantly greater among those with lifetime anxiety disorders [odds ratio (OR) = 1.41, 95% confidence interval (CI) = 1.08-1.86]; this was not found among males (OR = 1.15, 95% CI = 0.79-1.68). In multiple logistic regression analyses among both males and females, anxiety disorders were significantly associated with mixed episodes, prolonged depressive episodes, 12-month prevalence of depression, BD-related health service utilization, and poorer current mental health functioning. SUDs were significantly associated with mixed episodes among females, 12-month prevalence of depression among males, and with forensic history among both males and females. CONCLUSIONS: Whereas comorbid anxiety disorders appear to confer increased liability towards poor mental health functioning and greater BD-related health service utilization, comorbid SUDs are associated with positive forensic history. Early identification and treatment of these comorbid conditions are of paramount importance. Further representative prospective studies are needed.     

What symptoms predict the diagnosis of mania in persons with severe/profound intellectual disability in clinical practice?

Background While researchers have attempted to address the difficulties of diagnosing affective disorders in the intellectually disabled population, diagnosing bipolar disorder in an individual with severe intellectual disability (ID) remains a challenge. The aim of this study was to identify what symptoms can predict a diagnosis of mania in the intellectually disabled population. Methods Three groups of persons with ID participated in this study: (1) individuals with a bipolar diagnosis who were currently manic; (2) individuals with an Axis I diagnosis other than bipolar disorder; and (3) individuals without an Axis I diagnosis. Two recognized measures of mania (i.e. Diagnostic Assessment for the Severely Handicapped‐Revised and Parent Version of Young Mania Rating Scale) were used to evaluate symptoms of mania. A logistical regression procedure was conducted on mania items to identify which items correctly identify persons with ID who were currently manic. Results Psychomotor agitation, decreased sleep, changes in mood and aggression were significantly related to the diagnosis of mania. Further, psychomotor agitation and disturbed sleep were significant predictors of a diagnosis of mania. Conclusions Problems of sleep and psychomotor agitation should alert clinicians that further assessment of bipolar symptomatology is warranted. Focusing on observable behaviours based on Diagnostic and Statistical Manual of Mental Disorder‐IV criteria can be useful in formulating a diagnosis of bipolar disorder in persons with ID.