It is common to see opioid dependent persons who are depressed, irritable, moody, grandiose, impulsive, and easily distracted. They may be on their fifth try at methadone maintenance. They commonly report a history of child abuse and neglect, poor school performance, perhaps a history of disordered conduct, and a history of ineffective psychiatric care. These are difficult cases that challenge you to sort out the presence of complex PTSD due to the child abuse, ADHD spectrum, the chaos of borderline personality symptoms, narcissistic symptomatology, or the psychiatric storms of bipolar symptoms. Take heart; the following steps will help.

  • The PSSU may show elevations in CAAN, depression and anxiety, ADHD, and PTSD. Is the borderline scale elevated? Lastly, is the bipolar II depression scale elevated? Look at the questions endorsed “3.” Further inquiry can help.
  • Inquire about a history of episodes of mania, where the person is on highs not drug-related, grandiose, loquacious, spendthrift, and requiring little sleep, lasting weeks or months, only to lapse into depression. Here you have a diagnosis of bipolar I disorder. Refer to a psychiatrist.
  • Inquire about a history of hypomania, periods of positive self-esteem, energized activity and irritable mood associated with racing thoughts. Inquire about history of depression that can extend into the childhood, coupled with agitation, racing mind, and leaden paralysis, a depression made worse by SSRIs; and ADHD symptoms in which distractibility is due to the racing mind, rather than attention to outer events. You likely have the diagnosis of bipolar II depression. Again, refer to a psychiatrist. Medications, especially the anticonvulsant Lamotrigine, can help immensely.
  • Give the Mood Disorder Questionnaire (MDQ). It can be found in the VTOC portal: click on a patient, click on clinical forms, click on mood disorder questionnaire. The MDQ is a self-administered test for the likelihood of a bipolar condition; it can be helpful in the discernment process.

If a patient demonstrates a continuous activation of a grandiose self, without any history of depression, he/she most likely has a narcissistic condition. If there is a long history of difficulty in school due to distractibility and impulsivity without hypomania or mania, then an ADHD condition is most likely present. See Synopsis for the Recognition and Management of ADHD Conditions.

Read the post on dualdiagnosis.blog titled Sorting Out Bipolar Disorder, Complex PTSD, Borderline Personality Disorder, and ADHD in Severe Substance Users for a comprehensive in-depth discussion of these issues.