Archive for February, 2011



Anxiety is a common complaint in a psychiatrist’s office.

When that is the case one needs to first rule out medical causes, drugs of all kinds (illegal and prescribed all together), and of course Axis I culprits such as generalized anxiety disorder, panic disorder, OCD, etc. Cluster C comes next as avoidant, OCPD and dependent people tend to be quite anxious.

And then there is the special kind of anxiety, concern, worrying about real issues: external (finances, work or relationship related etc) or INTERNAL (not liking oneself because of laziness, a bad temper, impulsivity, etc.). This is perhaps a good kind of anxiety – as long as it doesn’t reach an overwhelming intensity – and as such it should be supported.

In fact, invariably, therapeutic interventions, when successful, come with a good deal of anxiety. Nothing wrong with it as such ego dystonic states of discomfort are great motivators for completing the work.

When “good” anxiety presents itself for evaluation it should be seen as a good prognostic sign and an ally that one should value and co-opt when designing an intervention strategy.

Avoid the common mistake of labeling all anxiety as “bad”. The result is an universal goal of zapping anxiety off whenever, wherever you see it.

Not good. When it comes to anxiety nuances matter.

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1. Course: ADHD is chronic versus bipolar: episodic. Which also means that you should see ADHD signs during exam, while we might or might not see signs of bipolar on presentation.

2. Long time prognosis: ADHD might get better with time while bipolar tends to get worse with time.

3. Drugs of abuse: ADHD: “cocaine (in general uppers) slow me down”. Bipolar: “I use uppers when I am down, downers when I am hyper”.

4. Family history: bipolar patients have more of a loaded fam hx in terms of affective and psychotic disorders.

5. When in doubt, safety comes first: assume and treat as bipolar (i.e. mood stabilizer) as while this will help a bipolar patient; at the same time, it might not help it would also not harm an ADHD patient. Stimulant first when in doubt is a risky choice: while it would help an ADHD patient, it will also hurt a bipolar patient who will escalade straight into severe mania.

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