Special Clinical Topics

ADHD: DIAGNOSIS

DIFFICULTY PAYING ATTENTION AND/OR SITTING STILL
Adult-onset ADHD does not exist, only residual childhood ADHD Treatment of childhood ADHD decreases risk of adult pathology
*Evaluation:* 5 components which may take 2-3 visits
Medical Psychiatric Educational Records Testing	Screen for anemia, thyroid, cardiac, or seizure risk Mood, anxiety, psychosis, substance, sleep, family To identify school, work, and social difficulties From previous evaluations, providers, prescribers Neuropsychologist > computer > scales > self-report
SYMPTOMS	DIAGNOSIS	Minimum Criteria
*Difficulty paying attention*	Inattentive	6 problems (6 months) Attention, listening, follow-through, organizing, distraction, memory, losing things, sustained mental effort Adults only require 5 symptoms
*Difficulty sitting still*	Hyperactive-impulsive	6 problems (6 months) Running about, playing quietly, talking too much, waiting turn, blurting out answers, interrupting or intruding, feeling “driven by a motor” Adults only require 5 symptoms
*Both*	Combined	6 of each type (6 months) Adults only require 5 symptoms
Symptoms must occur in 2 settings and be present by 12 years of age
ASRS^a	Adult Symptom Rating Scale 4 in the shaded area of part A (part B is additional info)
VADRS^a	Vanderbilt ADHD Diagnostic Rating Scale Includes parent and teacher assessments ≥6 often/very often scores on inattentive/hyperactive + ≥4 on any impairment in performance scale
Additional Neurodevelopmental Disorders
Intellectual disability		Intellectual and adaptive deficits
Communication disorder		Language, speech, stuttering, social
Specific learning disorder		Reading, written, math
Motor disorder		Coordination, stereotypic, tic
Autism spectrum disorder		Social/communication/relationships
^aValidated: but not listed in AIMS/SAMHSA/AHRQ recommendations

ADHD: TREATMENT

Simple ADHD
Titrate stimulants and add alpha-blockers as needed for augmentation
Inattentive	1) Stimulant 10-60 div daily-TID 2) If SUD/cardiac concerns: atomoxetine 40-80
Hyperactive or combined	1) Stimulant 10-60 div daily-TID 2) If SUD/cardiac concerns: atomoxetine 40-80 3) Add/use clonidine^a 0.05-0.2 BID or ER 0.05-0.4 HS or less sedating guanfacine^a 0.5-2 BID or ER 1-4
Amphetamine-related stimulants: weakest to strongest in effect and side effects: methylphenidate < amphetamine < dextroamphetamine Side effects: anxiety, tremor, insomnia, ▼ appetite, rare seizure EKG: only needed if cardiac history in patient or first-degree relative
ADHD and a Co-occurring Disorder
Treat severe co-occurring disorders first or simultaneously with ADHD
MDD	1) Bupropion ER-24 150-450 2) Bupropion/SSRI/SNRI + ADHD meds
Anxiety	1) Buspirone 10-30 BID or SSRI/SNRI, + ADHD meds 2) Guanfacine^a or clonidine^a ± other ADHD meds
Tic	1) If MDD/anxiety also present: SSRI^a + ADHD meds 2) Guanfacine^a or clonidine^a ± other ADHD meds 3) Tetrabenazine^a 12.5-25 BID or SGA,^a + ADHD meds
Insomnia	Avoid long-acting meds or add clonidine^a 0.05-0.2 HS
History SUD	1) Bupropion ER-24^a 150-450 or atomoxetine 40-80 2) Methylphenidate ≤30 mg (with SUD monitoring)
PSYCHOTHERAPY & RESOURCES
Education, study skills, CBT (anxiety/depression), and HRT (tics)
Delivered from Distraction—Hallowell/Ratey Mindful Parenting for ADHD—Bertin The ADHD Workbook for Kids—Shapiro
ADHD and Me—Taylor
Chadd.org—Children and Adults with ADHD
CONTRAINDICATIONS & MONITORING
Stimulants, bupropion, SGAs, tetrabenazine
See safety and monitoring in appendix for additional information
^aOff-label: evidence-based but no FDA indication

SUICIDE & VIOLENCE

SUICIDE ASSESSMENT
Suicidal risk escalation: ideation-plan-intent-means-attempt
1) Determine non-modifiable risk factors
Sex is male Age over 65 years Depression history Past attempt Etoh history	Rational thought loss Social support lacking Organized plan No spouse Sickness	Caucasian Native American Unemployed Childhood abuse Family suicide
2) Determine modifiable risk factors
Depression Anxiety	Access to lethal means Suicidal ideation/plan	Hopelessness Alcohol use
3) Determine protective factors
Children Social network	Religion/cultural beliefs Therapeutic alliance	Positive affect Hope for future
4) Intervene & document
Determine risk level for imminent harm (high/intermediate/low)
Compare scores to gut feeling balancing objective/subjective, then document clear reasons for risk level and treatment choices
C-SSRS	Columbia-Suicide Severity Rating Scale The *Screen Version* is a 6-question triage scale Yes on 1 or 2 = refer for routine treatment Yes on 3 = nonemergency consult Yes on 4 or 5 (<30 days) = emergency consult Yes on 6 (<90 days) = emergency consult
VIOLENCE ASSESSMENT
1) Determine individual risk factors
Past violence	Recent aggression	Substance history
2) Look for imminent risk factors
Agitation/threats Failing alliance	Acute psychosis Intense staring	Angry affect Attacks on objects
3) Deescalate violence
Recognize escalation Read the situation Connect Empathize and validate Depersonalize situation Give choices	Verbal abuse, agitation, hostility, staring Frustration about feeling disrespected Approach cautiously and speak calmly Apologize and agree with frustration Explain the situation Offer water, a walk, or to reschedule

SUICIDE & VIOLENCE

INFORMED CONSENT
For specific treatment provider must present RRR
Reason	For test or treatment
R/B/A	Risks, benefits, and alternatives
Refusal	Consequences
CAPACITY
For specific treatment patient must show that they CURV
Choose	Able to express their choice consistently
Understand	The basic facts of informed consent
Reason	Demonstrated by explaining situation in own words
Values	Verified/documented and consistent with decision
EMERGENCY HOLDS
*A patient can be held* against their will if they are…**
Mental	Imminently a danger to self/others or gravely disabled
Medical	Expected to imminently die^a if released + lack capacity
Pregnant	Pregnant and the fetus is expected to imminently die^a if released + any question of patient’s capacity
Legal	Represented by a legal decision-maker/parent (with capacity) or court that has already agreed to the hold
EMERGENCY TREATMENT
*A patient can be treated* against their will if they are…**
Mental	Immediately a danger to self/others
Medical	Expected to immediately die^b without it + lack capacity
Pregnant	Pregnant and the fetus is expected to immediately die^b without it + any question of patient’s capacity
Legal	Represented by a legal decision-maker/parent (with capacity) or court that has already agreed to the treatment
RESOURCES
1-800-SUICIDE or 1-800-273-TALK (8255) www.suicidepreventionlifeline.org—National Suicide Prevention Lifeline
^aEvidence supports permanent/significant injury or death within 1 day^bEvidence supports permanent/significant injury or death within 1 hour

SOMATIC & PAIN: DIAGNOSIS

EXAGGERATED FOCUS ON PHYSICAL SYMPTOMS
In factitious disorder* and malingering the patient is intentionally exaggerating or creating symptoms (for primary/secondary gain)* In somatic symptom* and conversion disorders the patient believes that the symptoms are real and experiences them fully*
SYMPTOMS	DIAGNOSIS	MINIMUM CRITERIA
*General medical or pain*	Somatic symptom disorder	Physical symptoms (6 months) With excessive thoughts, feelings, or behaviors around symptoms
		Mild/moderate/severe, with prominent pain, persistent
*Only neuro symptoms*	Conversion disorder	Neuro symptoms (6 months) Unexplainable voluntary motor or sensory deficits
		With [symptom], acute/persistent, with/without stressor
*Only fear of illness*	Illness anxiety disorder	Fear of illness (6 months) Preoccupation with having or acquiring a serious medical condition
		With [symptom], acute/persistent, with/without stressor
*Mental factors worsening medical care*	Psychological factors affecting other medical conditions	Psychological factors Which worsen a condition or conflict with medical care
		Mild/moderate/severe/extreme
*Faked*	Factitious disorder	Intentional falsification of illness To assume the sick role
	Malingering	Intentional falsification of illness For personal gain
PHQ-15	Patient Health Questionnaire-15 Score all symptoms (with/without identified causes) 10-14 medium, 15-30 high level of severity
FPS^a	Functional Pain Scale 5 intolerable, 6 severe, 8 very severe, 10 worst possible
^aValidated: but not listed in AIMS/SAMHSA/AHRQ recommendations