ODD,ADHD or Mood
Moody, Nasty, Mean, Can’t Sit Still and Concentrate!
ADHD, ODD, Mood Disorder, Which is it?
From the series” I want you to know what I know.”
Mental Health Problems that Shouldn’t be Missed and their Treatments
The primary focus of this series is on common biologically based mental health problems, that should not be missed, because adequate treatment at the earliest age offers the most hope for symptom relief, remission, and prevention of relapses and complications. Being biologically based medication may be needed, perhaps essential, but should be used with appropriate education and psychosocial interventions. The greatest obstacles to evaluation and treatment are fears of what it means to have a mental health problem and fears about negative effects of medication. The goals of this series is to dispel these fears by teaching you what I know. As you begin to know what I know about these problems the unknowns will be made known and inaccurate information will be corrected. Modern psychiatric medications can be remarkable treatments. The right medication at the right dose for the right diagnoses, should be safe, effective, helping sometimes amazingly quickly with minimal to no side effects. On medicine you should be your normal self with symptom relief and now in control of your problem emotions and thoughts. Medications should not make one feel medicated, drugged, numbed, zombied out , high, low or control you. If this occurs either the diagnosis is wrong , or the medicine needs to be adjusted or stopped. One should not have to suffer through excessive negative effects to get the positive effects. The series “I want you to know what I know.” Is only a guide to help you understand, not a substitute for seeking help for yourself or others with qualified health care practitioners.
Why is this an important problem in diagnosis?
1. The non specific behavioral cluster of high energy, poor concentration, impulsivity, nasty, mean, with temper outbursts , mood swings, negativity, defiance, refusing to comply to rules and requests may be caused by ODD, ADHD, or certain Mood Disorders, or all three. This differential in diagnosis is one of the most common presentations and can be seen in any age group, the preschooler, the older child and adolescent and is seen in adults with the ODD being manifested as personality traits or a disorder.
What is ODD?
2. The ODD or Oppositional Defiant Disorder is a descriptive label, no biological cause implied, with the oppositional ,defiant, negativistic , non compliant problems , having some mood symptoms being nasty, mean and hostile behaviors that may be part of temperament, learned, and or conditioned and should be treated with behavior social treatments. Therefore in non biologically based ODD the basic treatment is using the right rewards and punishments. Only if the symptoms are caused by the biology of ADHD or a Mood Disorder will they respond to medication and should medication be the treatment of choice. For ADHD this would be stimulant medication and for Mood Disorders some mood stabilizing medication either an atypical neuroleptic, mood stabilizing anti convulsant, or lithium carbonate. If the causation is mixed, that is having aspects of biology and non biology, both treatments that is medication and psychosocial will be needed.
What are the brain chemistry differences between these?
3. It is crucial to tell the difference between ADHD and a Mood disorder because the medications used are based on different brain chemistry, and meds use for one may make the others worse though not initially.
4. The biology of ADHD is relatively simple caused by too little dopamine/norepinephrine in certain parts of the brain, with often only one medicine is needed working by building up these brain hormones so one can slow down stop and think and concentrate better.
5. The biology of Mood Disorders involves not only dopamine/norepinephrine, but also serotonin, and many other brain chemicals working together causing a complex chemical imbalance, requiring complex and multiple medications to control the symptoms, re establish & maintain the chemical balance, to address [1]the over excitable brain with mood swings,[2] the high energy, nasty, mean, angry, excitable manic pole of the bipolar , and [3]the low energy, sad, depressed, hopeless, major depression pole, and [4] when the highs and lows are extreme there is a disorganization and disconnection of thinking, feelings and behavior and a treatment that “glues” these back together is also needed.
How do you tell these apart?
4. There is no specific test to tell these apart, this can only done by understanding and evaluating three basic things over and over, a. the history, b. the presenting problems and c. the treatment response. Symptoms that are very similar to a Bipolar Disorder its high energy manic state is most often confused with ADHD, and one must understand how they are similar and how they are different.
Are the symptoms different? Yes this is major problem confusing symptoms with diagnosis!
5. The major difference is based on the actual defining characteristics of ADHD and Mood Disorders.
ADHD by definition does not have any significant disturbance of mood, feeling, thinking, and perception. It is a primary disturbance in concentration, not mood, with secondary impulsivity and hyperactivity based on information processing problems related to this core defect in concentration or focus. Mood Disorders by definition have as their core symptoms a 1 or 2 week period of depressed, elevated, expansive irritable or very excitable mood or feeling state, or a cycling between these mood states. The hyperactivity and impulsivity is usually present but is driven by mood changes and better explained by mood changes
Is the course different? Yes again one is occurs in episodes and one is much more consistent and stable!
6. Another big difference is ADHD core symptoms of poor concentration, impulsivity, hyperactivity are persistent, sustained, with no lapses or episodes, they do not come or go, or get appreciably better or worse. In a Bipolar type of mood state by definition symptoms are not sustained but cycle and occur in episodes, and so get better & worse, including over activity , poor concentration and impulsivity.
Are there more differences? Yes in how the symptoms show and are driven by moods and relationships!
7. The third difference is in the actual symptom presentation. Here the confusion is in that the two disorders share the core ADHD symptoms of poor concentration, impulsivity and hyperactivity. But the mood disorder also has 4 other core symptoms, that are sleep disturbance, grandiosity [“I am the boss” or having too big ideas or over involvement in high risk activities or continued involvement in pleasurable activities that have a high likely hood of having negative effects, like gambling, sexual adventures, drugs and alcohol, video games, etc.] or elevated sense of self, subjective sense that ideas are moving too fast, and very rapid speech often mildly illogical going off on tangents. All 7 of these symptom cluster occur episodically while being in the midst of the disorder and most importantly are and driven by and better explained by changing mood states rather than a simple core deficit in concentration only.
Is family history different also?
8. Family history and personal history of the two disorders are different. . History of Mood Disorder is much more complex and dramatic both in the individual and through the family The personal history of a Mood Disorder may filled with many problems like, extreme Colic as an Infant, sever Temper Tantrums, with Rage Attacks, mood swings, mean, nasty, irritable, overly affectionate, severe impulsivity, risk taking behaviors, severe and persistent Separation Anxiety, Migraine headaches, sleep difficulties from an early age, even form infancy, including Sleep Walking/Talking, Night Terrors, Night Mares, fears, Phobias, rituals, overeating with Carbohydrate craving, wont follow rules, needing to be the boss, in control, in charge from an early age. All of these marked by too much too frequent too emotional, all driven by high emotional states, and moods., often very changeable and unpredictable.
9. The family history of Mood Disorder may include Bipolar and Unipolar Depression, Drug and Alcohol problems, Anxiety, Panic, Phobias, Obsessive Compulsive Disorder, ADHD, ODD, Domestic violence, legal issues, poor school, work, relationship performance.
10. The personal & family history of ADHD usually has few or no family members with other psychiatric diagnoses, especially mood, anxiety, drug & alcohol problems. The history should be positive for other having ADHD, and possible Learning Disorders, again uncomplicated by other psychiatric disorders.
What is the least appreciated diagnostic tool after history and more history? Treatment response!
11. The last crucial difference and the one most often ignored in making the diagnosis is medication treatment & responses. Uncomplicated ADHD combined type, often responds rapidly, safely, with sustained effectiveness with a neurostimulant [Dexedrine, Adderal, Ritalin, Concertta, Metadate, Focalin, Daytrana, Vyvanse] medication, often alone, with no major side effects. If this doesn’t occur with the right medication and dose the diagnosis is suspect and there needs to be another evaluation to determine is the diagnosis correct or are there other diagnoses, and then a new treatment trial.
How are mood disorders treated?
12. The choice of medication in a mood disorder depends on the specific subtype, the Unipolar type i.e. major depression, vs. bipolar type i.e. Manic Depression. If one is very sure that is a Unipolar presentation not excessive anger nastiness, mood swings, rapid thinking and speech, etc, then the medications of first choice are one of the SSRI [Prozac, Zoloft, Paxil, Luvox, Celexa, Lexapro,], SNRI [Effexor, Cymbalta ]meds, or Welbutrin. If one is not sure it is best to err on the side of this uncertainty and safety and start treatment with a mood stabilizing medication.
13. If it is clearly a mood disorder that has bipolar features, or if one is not sure, then mood stabilizers are the treatment of choice for both the high energy Manic Pole, including the ADHD symptoms, and the low energy Depressed pole. SSRI meds should be avoided, and the mood stabilizer will treat the depression. There are three types of mood stabilizers, the neuroleptic group[ Risperdal, Zyprexa, Abilify, Seroquel, Geodon, Thorazine, Trilafon, Haldol, etc], mood stabilizing anticonvulsants [ Depakote, Tegretol, Lamictal], and in a class by itself is Lithium Carbonate.
Why should one be careful with anti depressant medications?
14. The reason to avoid as SSRI or other traditional antidepressant[ though Welbutrin may be a relative exception] in a bipolar type may initially work, some times to well and too quickly, which may be omen, and then actually stop working, and whether the dose is increased or not as it is often may be, it will actually start making matters worse, and rapidly and sometime relatively irreversibly fuel the cycling of the bipolar process. The most serious effect is worsening of the three aspects of the bipolar process, that is more mood instability, increased depression and increased anger, excitability, ultimately may reach homicidal and suicidal proportions. Symptoms may include increased of intensity, frequency and duration of the cycling, with increased depression, increased mood swings with increasing and escalating irritability, excitability, anger, rage, and explosiveness and impulsivity. This is a very dangerous combination of symptoms. Much of the bad press about SSRI is based on this problem.
Can you summarize all of this ?
15. In summary, ODD is a label for describing oppositional, defiant, negativistic, moody behavioral cluster with no specific biological cause and is treated with counseling. ADHD is a very specific neurological syndrome with the biological deficit in paying attention, and concentrating, with resulting impulsivity and hyperactivity of various degrees, responding specifically to neurostimulant medication. By definition ADHD should be free of significant anxiety, mood, emotional, perceptual, and thinking disturbance, if these are present another diagnosis is likely present, and treatment of that disorder will take precedence. A common error is mistaking the poor concentration , over activity, and impulsivity of a Bipolar type or more accurately an Unstable Disorder of Mood with Uncomplicated ADHD and treating with a stimulant, rather than a mood stabilizing medication. Failure to distinguish in Mood Disorder of the Bipolar spectrum and treating with an antidepressant rather then a mood stabilizer is equally common error with potentially disastrous outcomes.