Making a Differential Diagnosis for Patients With Bipolar Disorder
At Psych Congress 2023 in Nashville, Tennessee, Julie A. Carbray, PhD, PMHNP-BC, PMHCNS-BC, APRN, clinical professor at the University of Illinois at Chicago, and Jim Phelps, MD, emeritus psychiatrist at Samaritan Mental Health, sat down to explore the challenges of differentiating conditions like PTSD, ADHD, and generalized anxiety disorder when intertwined with depression and bipolar mixed states.
Join Drs Phelps and Carbray in an insightful discussion on the complexities of diagnosing and treating mood disorders and delve into their strategies for unraveling these diagnostic dilemmas and crafting informed treatment plans.
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Read the Transcript:
Jim Phelps, MD: So Julie, you can think about children and adults. The question I would have for you is, do you think there's any way to accurately differentiate things like PTSD, ADHD, and generalized anxiety disorder when they're co-occurring with depression from bipolar mixed states?
Julie Carbray, PhD: That can be so murky. And comorbidity with those disorders, as you know Jim, is very high. And so the challenge is really trying to pull out those mood dysregulation symptoms that in and of themselves might meet criteria for bipolar spectrum disorder from those that would be very characteristic and an overlap of other disorders. PTSD and ADHD are particularly relevant across all our populations. But in children, ADHD probably is more predominant. So we can do things like use screening tools, get collateral information, look at the timeline of illness, and try to determine if we have comorbidity or if their bipolarity index might be higher due to some significant factors we know well, family history, age of onset course of illness, and if there's any cycling features as well. So taking a look at your criteria, taking a look at the mood spectrum and then using screeners collateral information, what do you think?
Dr Phelps: Well, it sounds like you wouldn't be making this diagnosis on the first visit.
Dr Carbray: Absolutely not.
Dr Phelps: And then in the adult world, especially when someone sees me for a consultation, there's often some pressure to come up with a treatment plan on that visit.
Dr Carbray: Right away.
Dr Phelps: So under those circumstances, basically I would answer my own question by saying I don't think it actually is possible to differentiate these things and reminding myself that these things aren't really things—that they're DSM criteria that are designed to help us differentiate extremes, but most patients don't present with those extremes. They present with these combinations of things. So at the end, I'm going to say, well, which of the treatments that I might consider really require calling this one way or another? And can I hedge? Is there any way to stay in the middle with the treatments that I might recommend, at least for the ones that one begins with? And then only at the end, are we going to go with an antidepressant or a mood stabilizer with antidepressant effects? That's the big division. I imagine you face the same one.
Dr Carbray: Absolutely. And I'll talk with families about that. 'What we're thinking here is there's something in the mood arena that's really challenging your child's ability to be themselves. And we're trying to figure out together what that looks like. So we'll have you keep answering some questions, monitoring mood over time. We'll continue to have these discussions. But what's most important is that we figure out where we want to go with treatment and to do that together in an informed way where we continue to see what this will look like, these murky waters. Hopefully we'll get clearer.
Julie A. Carbray, PhD, PMHNP-BC, PMHCNS-BC, APRN, is a clinical professor of psychiatry and nursing at the University of Illinois at Chicago. Dr Carbray holds her PhD (93) and Master of Science (88) degrees from Rush University, Chicago, and her Bachelor of Science (87) degree from Purdue University in West Lafayette, Indiana.
James (Jim) Phelps, MD, has worked in inpatient, outpatient, and primary care consultation and liaison programs for over 25 years, including private practice, while supporting a closet-academic’s habit of following the psychiatric literature. He is the author of A Spectrum Approach to Mood Disorders for professionals, and has written 2 other books on bipolar disorders for patients and families.