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

ADHD clinician career pathway

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

The “Specialist” Adult ADHD Psychiatrist..

A recent referral… “I am writing to refer this 44 year old patient who is concerned that she has some signs of ADHD. She has had symptoms for some time but only considered this diagnosis recently when her daughter was being assessed for the condition. She noticed that she was also answering all the questions in the same way as her daughter.

We have completely the self-assessment questionnaire from the Leeds health pathways website and she does answer as agree or strongly agree to almost all of the questions and statements.

In terms of past history, she has been diagnosed with bipolar disorder and has previous issues with alcohol dependence although is now in remission. She also has a diagnosis of fibromyalgia and struggles with chronic pain. She currently takes codeine, diazepam, aripiprazole and vensir XL.”

The “Specialist” Adult ADHD Psychiatrist..

A recent referral… “I am writing to refer this 44 year old patient who is concerned that she has some signs of ADHD. She has had symptoms for some time but only considered this diagnosis recently when her daughter was being assessed for the condition. She noticed that she was also answering all the questions in the same way as her daughter.

We have completely the self-assessment questionnaire from the Leeds health pathways website and she does answer as agree or strongly agree to almost all of the questions and statements.

In terms of past history, she has been diagnosed with bipolar disorder and has previous issues with alcohol dependence although is now in remission. She also has a diagnosis of fibromyalgia and struggles with chronic pain. She currently takes codeine, diazepam, aripiprazole and vensir XL.”

The “Specialist” Adult ADHD Psychiatrist..

A recent referral… “I am writing to refer this 44 year old patient who is concerned that she has some signs of ADHD. She has had symptoms for some time but only considered this diagnosis recently when her daughter was being assessed for the condition. She noticed that she was also answering all the questions in the same way as her daughter.

We have completely the self-assessment questionnaire from the Leeds health pathways website and she does answer as agree or strongly agree to almost all of the questions and statements.

In terms of past history, she has been diagnosed with bipolar disorder and has previous issues with alcohol dependence although is now in remission. She also has a diagnosis of fibromyalgia and struggles with chronic pain. She currently takes codeine, diazepam, aripiprazole and vensir XL.”

The “Specialist” Adult ADHD Psychiatrist..

A recent referral… “I am writing to refer this patient who is concerned that she has some signs of ADHD. She has had symptoms for some time but only considered this diagnosis recently when her daughter was being assessed for the condition. She noticed that she was also answering all the questions in the same way as her daughter.

We have completely the self-assessment questionnaire from the Leeds health pathways website and she does answer as agree or strongly agree to almost all of the questions and statements.

In terms of past history, she has been diagnosed with bipolar disorder and has previous issues with alcohol dependence although is now in remission. She also has a diagnosis of fibromyalgia and struggles with chronic pain. She currently takes codeine, diazepam, aripiprazole and vensir XL.”

Getting an ADHD assessment (and therefore the right diagnosis) (More often than not)

You have to ask for it ADHD Untreated ADHD may lead to…

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

Is it so bizarre to “think” ADHD?

Prevalence of 2.5% (+)

Rapid, effective and robust treatment responses

Adult ADHD = Comorbidity

• Low self-esteem • Depression (20-50%) • (20-50%) • OCD (5-10%) • Personality disorder (10-50%) • Substance misuse (20% have ADHD) • Bipolar Disorder (5-20%) • Obesity • Psychosis

Differentiating ADHD from other mental disorders

Depression • Chronic Mood instability • Trait-like low mood rather than episodic state-like depression • An absence of somatic symptoms (newly disturbed sleep, appetite, diminished energy levels)

Bipolar Disorder • A lack of distinct periods of abnormal and extreme mood states with corresponding periods of normal baseline functioning in between • Tiredness due to lack of sleep rather than a reduced need for sleep • A lack of grandiosity or psychotic features • Ceaseless unfocused thoughts rather than episodic thought disorder (eg. Flight of ideas)

Anxiety • Ceaseless unfocused thoughts, as opposed to exaggerated apprehension and generalized worry • An absence of somatic symptoms • Situation avoidance due to with own behaviors rather than phobic avoidance common to anxiety disorders • Forgetfulness rather than hypervigilance

Personality Disorder • An absence of psychological disturbances, such as feelings of abandonment and chronic feelings of emptiness • Chronic inattention symptoms Prevalence of ADHD in nonpsychotic adult psychiatric care (ADPSYC): A multinational cross-sectional study in Europe

• Almost 2000 patients

• 15-17% met ADHD diagnostic criteria

• Depression most common

How much is the co-morbidity masking the ADHD? So why is ADHD not being “picked up”? • Multifactorial

• Organisational

• Clinician

• Patient factors Organisational • Funding and provision

• “Other” priorities

• Lack of training (requirements)

• Stigma

Breaking down barriers – the challenge of improving mental health outcomes (BMA, 2017)

• Inadequate funding at a time of increasing demand • Access problems and lack of integration and prevention • Inadequate provision and quality of services • Understaffed workforce and insufficient training

Accessing mental health services • Often strict criteria • At severe end of spectrum • Severe and enduring MH problem – Bipolar Disorder – Psychosis – Resistant depressive disorder – Severe anxiety / OCD – Personality disorder – Eating disorders • “In crisis” (Risk) Clinician factors • Poor knowledge • Clinical skills • Stigma • Clinical and time pressures • Lack of continuity with same patients • Missing red flags • Not considering “underlying” diagnoses’ • Intolerance and misinterpretation of behaviours • Helplessness Use of stimulants leads to and addiction

Its normal. We all have these symptoms. Why the diagnosis? They just need to try harder. Presenting complaints and contexts

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

• Keeping it “hidden”

• Barriers to seeking help

• Psychological impact of ADHD

Barriers to mental health seeking (Salaheddin et al, 2016)

• of stigma • Perceiving problem as not serious enough • Reliance on self • Difficulty accessing help • Fear of negative outcome • Difficulty identifying or expressing concerns

continuous self underneath all that reflection left me exterior was “me” exhausted life kept repeating itself.. wanting to be a young girl stuck accepted but ironically in constant self A PATIENT’S distancing myself from Always labelled the gypsy people as they bored blame for her spiritREFLECTIONS or Tasmanian Devil inadequacies and me or left me overwhelmed. stupidity

all the time I tried I was always reminded I I made daily harder yet won’t succeed unless I pledges to repeating buckle down and you’re conform identical not in primary school behaviours ‘act your age’. All the time telling myself; it’s ok to feel bored, it’s normal to switch off when people I had heard too many comments, I never gave up trying to talk at you noted too many requests to calm be like everyone else; and shouted out too many traveling through life random times in meetings. I felt aspiring to be the girl who vulnerable, scared and no had achieved awareness where to turn for support increases in life expectations did overspill Work colleagues mentioned ADHD causing spirals into numerous times over 15 years but depression and I always laughed it off. Surely anxiety…my constant that’s what ‘naughty boys’ have? stream of internal chatter surely that wouldn’t account for my now filled with negativity sleep problems and my quirks? and endless ‘what if’s Having ADHD leaves patients feeling..

• Different • Mentally and physically exhausted • Hopeless • Frustrated • Overwhelmed • Incompetent in all areas of life • “stupid” • Burnt out • Not trusting own behaviour • Needing to please

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

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

DSM-5 symptoms of ADHD

Inattention Hyperactive-impulsive Lack of attention to details Difficulties to keep still

Difficulty sustaining attention Unable to stay seated when expected

Does not listen when directly spoken to Feeling physically and/or mentally restless

Lack of follow-through on tasks Being loud and difficulty regulating volume of voice

Difficulty organising tasks and activities On the go as if “driven by a motor”

Avoids tasks requiring sustained mental effort Talks excessively

Often loses things necessary for tasks or activities Blurts out before questions completed

Easily distracted by external stimuli Difficulties awaiting turn

Forgetful in daily activities Interrupts or intrudes on others DSM-5 symptoms of ADHD

Inattention Hyperactive-impulsive Lack of attention to details Difficulties to keep still

Difficulty sustaining attention Unable to stay seated when expected

Does not listen when directly spoken to Feeling physically and/or mentally restless

Lack of follow-through on tasks Being loud and difficulty regulating volume of voice

Difficulty organising tasks and activities On the go as if “driven by a motor”

Avoids tasks requiring sustained mental effort Talks excessively

Often loses things necessary for tasks or activities Blurts out before questions completed

Easily distracted by external stimuli Difficulties awaiting turn

Forgetful in daily activities Interrupts or intrudes on others DSM-5 symptoms of ADHD

Inattention Hyperactive-impulsive Lack of attention to details Difficulties to keep still

Difficulty sustaining attention Unable to stay seated when expected

Does not listen when directly spoken to Feeling physically and/or mentally restless

Lack of follow-through on tasks Being loud and difficulty regulating volume of voice

Difficulty organising tasks and activities On the go as if “driven by a motor”

Avoids tasks requiring sustained mental effort Talks excessively

Often loses things necessary for tasks or activities Blurts out before questions completed

Easily distracted by external stimuli Difficulties awaiting turn

Forgetful in daily activities Interrupts or intrudes on others DSM-5 symptoms of ADHD

Inattention Hyperactive-impulsive Lack of attention to details Difficulties to keep still

Difficulty sustaining attention Unable to stay seated when expected

Does not listen when directly spoken to Feeling physically and/or mentally restless

Lack of follow-through on tasks Being loud and difficulty regulating volume of voice

Difficulty organising tasks and activities On the go as if “driven by a motor”

Avoids tasks requiring sustained mental effort Talks excessively

Often loses things necessary for tasks or activities Blurts out before questions completed

Easily distracted by external stimuli Difficulties awaiting turn

Forgetful in daily activities Interrupts or intrudes on others DSM-5 symptoms of ADHD

Inattention Hyperactive-impulsive Lack of attention to details Difficulties to keep still

Difficulty sustaining attention Unable to stay seated when expected

Does not listen when directly spoken to Feeling physically and/or mentally restless

Lack of follow-through on tasks Being loud and difficulty regulating volume of voice

Difficulty organising tasks and activities On the go as if “driven by a motor”

Avoids tasks requiring sustained mental effort Talks excessively

Often loses things necessary for tasks or activities Blurts out before questions completed

Easily distracted by external stimuli Difficulties awaiting turn

Forgetful in daily activities Interrupts or intrudes on others DSM-5 symptoms of ADHD

Inattention Hyperactive-impulsive Lack of attention to details Difficulties to keep still

Difficulty sustaining attention Unable to stay seated when expected

Does not listen when directly spoken to Feeling physically and/or mentally restless

Lack of follow-through on tasks Being loud and difficulty regulating volume of voice

Difficulty organising tasks and activities On the go as if “driven by a motor”

Avoids tasks requiring sustained mental effort Talks excessively

Often loses things necessary for tasks or activities Blurts out before questions completed

Easily distracted by external stimuli Difficulties awaiting turn

Forgetful in daily activities Interrupts or intrudes on others Increasing (internal) Hidden struggle

The (Back to) “Functioning” New demand “functioning” and self- and pressure cycle of resilience (missed) ADHD

Different GP Mental / Crisis Health assessment deterioration Why is ADHD missed/misdiagnosed? • Multifactorial

• Organisational

• Clinician

• Patient factors Steps for change….

• Lobbying

• Media Awareness

• Education/Training

• Clinicians “exposure” to successful outcomes

• Simple clinical guideline for identification in primary and secondary health care

The good news…

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

untreated symptoms of ADHD

A starter.. simple but effective? Presentation of Mood instability, Depression or Anxiety

Screen for ADHD Screen positive Referral for assessment and trial of ADHD treatment as appropriate (unless evidence of acute mania/ severe depression/suicidal risk)

If depression / anxiety persists then treat co- morbidity 4 questions to screen and identify red flags Do you feel that you get bored and restless more easily than most people?

Are you more forgetful or disorganised than the average person?

Do you feel you are consistently failing to achieve your own potential?

And if any “yes” answers, then..

As a child, did you have problems with: • paying attention and distractibility? • doing impulsive, dangerous, or disobedient things? Thank you for listening

Any Questions?

@robbask