The Physician’s Guide for Distinguishing Bipolar Disorder and ADHD

ADHD’s high rates of comorbidity with other neurobiological disorders are well researched and documented. The majority of people with attention deficit disorder (ADHD or ADD) also have another condition or learning disability. Yet accurate diagnosis rates for co-occurring or stand-alone conditions like obsessive-compulsive disorder, anxiety, and even autism remain discouraging at best. The rates of misdiagnosis and delayed diagnosis are particularly high among patients with bipolar symptoms; they are astronomical for patients with bipolar disorder plus ADHD.

“What Is Causing My Racing Thoughts?” Bipolar Disorder and ADHD

Bipolar disorder often co-occurs with ADHD, with comorbidity figures as high as 20%.¹ Recent research also suggests that about 1 in 13 patients with ADHD has comorbid BD, and up to 1 in 6 patients with BD has comorbid ADHD². This comorbidity rate is significant enough to justify dual evaluations for virtually every patient, yet bipolar disorder is often missed or misdiagnosed in patients for the following reason:

1. Several depressive and manic symptoms of bipolar disorder and ADHD symptoms resemble each other in both children and adults.
2. ADHD is far more common than bipolar disorder. (About 9% of all children in the U.S. have symptoms of ADHD³; many of those children grow up to become adults with ADHD. Bipolar disorder, in contrast, impacts just 2.4 percent of the population.⁴) As such, physicians are more likely to recognize and screen for ADHD.
3. Once considered an adult condition, bipolar disorder does begin in childhood but its symptoms are difficult to diagnose because they so closely mimic other childhood-onset conditions like ADHD and because they are often dismissed as signs of puberty.

[Self-Test: Bipolar Disorder in Adults]

Whatever the reasons, undiagnosed and/or untreated bipolar disorder can have deadly consequences. One in five people with the condition will die by suicide. Studies show that at least one in three⁵, or even one in two⁶ will attempt suicide — that is 15 times greater than the suicide rate in the general population. Suicide occurs often during manic phases, when patients are more impulsive and fearful of falling into another depressive cycle. People with bipolar disorder have a reduced life expectancy of about 10 years. Among undiagnosed and untreated bipolar patients, the rates of suicide — as well as alcohol and drug abuse, unprotected sex, and other risky behaviors — is substantially higher.

To stop this national health crisis, we must first better understand bipolar disorder and how it manifests in different settings at different ages in both its manic and depressive forms. We must also understand how it mimics and overlaps with other neurobiological conditions, and what treatment options exist for patients who suffer from bipolar alone or in combination with a disorder like ADHD.

The biggest obstacle to a good prognosis is an adequate diagnosis. Once you have an adequate diagnosis that is appropriate and you get the right interventions, you can live a wonderful healthy, thriving life with bipolar disorder or bipolar disorder and ADHD.

What is Bipolar Disorder?

Bipolar disorder is a serious mental illness that is characterized by extreme mood swings, abrupt changes in energy levels, and distorted decision making. In most cases, it develops in the late teens or early adulthood — though more and more experts now accept the existence of pediatric bipolar disorder. Bipolar disorder affects men and women at virtually equal rates, and the disorder is found among patients of all races, social classes, and ethnic groups.

[Self-Test: Does My Child Have Bipolar Disorder?]

Bipolar disorder is characterized by high, euphoric, or irritable periods called mania and low periods of depression. The mania stage is sometimes mistaken for hyperactivity and the low states manifest themselves as inattention and lack of motivation, which are common in individuals with ADHD.

Depressive Symptoms of Bipolar Disorder

The depressive symptoms of bipolar disorder include:

• Very low mood state
• A loss of interest in things that previously gave pleasure
• Dysregulation of appetite (either increase or decrease)
• Significant weight loss or gain
• Change in sleeping habits (sleeping much more than normal or sleeping too little)
• Altered physical agitation rate (slowing down or becoming more anxious)
• Feelings of fatigue, worthlessness, or inappropriate guilt
• Difficulty concentrating
• Recurrent thoughts of death or suicide

How Depressive Symptoms Resemble ADHD

The ADHD brain produces an insufficient amount of dopamine, the neurotransmitter that helps control to brain’s reward and pleasure centers. As such, it naturally craves more dopamine, which sugar and carbohydrates deliver in spades. Feeding these cravings may result in the appetite changes, weight gain, and sleep problems described above. In addition, people with ADHD report frequent sleep disturbances and problems falling asleep due to a racing brain. Inattentiveness and difficulty concentrating may cause fatigue, especially among students and full-time employees working long days. Distractibility and poor focus can cause people with ADHD to quickly lose interest in activities or objects that once gave them pleasure as well.

The principle difference is that ADHD symptoms are contextual and situational, whereas bipolar symptoms are not triggered by any external factors. In a stimulating and positive environment, people with ADHD remain in a good internal state. If the environment is not stimulating enough, they can become bored or agitated. People with ADHD always experience life in this manner. Their sensibility and orientation toward the world is the same, even when they move through mood states of different intensities. Patients with ADHD can more often control their feelings by changing their environment and stimuli.

Depressive bipolar symptoms, on the other hand, can feel like a dark cloud emerging from an internal emotional state. No situational reasons trigger these feelings of depression; patients just wake up feeling fundamentally different when depressed and not depressed.

Manic Symptoms of Bipolar Disorder

Mania is a severe change in mood during which a person with bipolar disorder is either extremely irritable or overly silly/elated. Manic symptoms include:

• Overly-inflated self-esteem, grandiosity
• Increased, revved-up energy
• Decreased need for sleep for up to a week without feeling tired
• Extreme random distractibility
• Racing thoughts
• Increased monetary spending
• Extreme irritability/inability to settle down
• Talking too much or too fast, changing topics quickly
• Unusual hypersexuality
• Increased goal-directed activity
• Disregard of risk, excessive involvement in risky behaviors or illegal activities

How Manic Symptoms Resemble ADHD

One hallmark byproduct of ADHD is hyperfocus, or the ability to focus intently on something of great personal interest for an extended period of time, at times mentally drowning out the world around. This may happen on deadline pressure or when wrapped up in a compelling project, book, or video game. Hyperfocus may cause a decreased need for sleep and may look like “increased goal-directed activity,” however this is short-lived in people with ADHD, who often feel exhausted once the hyperfocus fades. A manic episode, on the other hand, is independent of external circumstances. People with bipolar disorder often want to go to sleep or relax, but describe feeling as if there is electricity going through their bodies that they cannot stop or dampen, no matter how desperate they are for sleep. This inability to settle the mind and body can go on for a week. Going without sleep for long periods of time can trigger psychotic episodes or hallucinations.

People with ADHD often interrupt or talk too much without noticing because they miss social cues or because they lose focus on the threads of a conversation. Patients experiencing a manic bipolar episode are often aware they are changing topics quickly and sometimes randomly, but they feel powerless to stop or understand their quickly moving thoughts. This type of behavior is uncharacteristic and does not reflect how they would typically converse.

People with ADHD report racing thoughts, which they can grasp and appreciate but can’t necessarily express or record quickly enough. With mania, the patient’s racing thoughts flash by like a flock of birds overtaking them so fast that their color and type is impossible to discern. These distracting and disconcerting racing thoughts are often mistaken for ADHD, though they are quite different in nature.

During a manic episode, a patient can engage in risky sexual or illegal behavior. They may also become incredibly productive for a few days, before exhaustion causes them to physically and mentally crash.

[ADHD Directory: Find an ADHD Specialist or Clinic Near You]

Bipolar II/Hypomanic Symptoms

Bipolar II affects 1-2 percent of the population and its symptoms include:

• Hypomanic episodes marked by anxiety
• Rejection sensitivity
• Personality disorders
• Significant risk of suicide

The hypomania experienced by people with bipolar II is less intense than other manic episodes, and is easily mistaken for anxiety. During these episodes, patients feel revved up, or like their thinking is different than it normally is, which often resembles regular hyperactivity. People with bipolar II have a high rejection sensitivity, a trait common to people with ADHD as well.

In addition, people with bipolar II experience more depressive episodes than do people with bipolar I disorder. Bipolar II is more common in women, and can be misdiagnosed as major depressive disorder because the mania is less severe.

There is also a type of bipolar spectrum disorder that doesn’t fit neatly into manic or depressive episodes called NOS (not otherwise specified). In the course of a day, people with NOS might experience both mania and depressive symptoms.

Differential Diagnosis: Bipolar Disorder vs. ADHD

Clinicians working to differentiate between ADHD and bipolar disorder should conduct a comprehensive, clinical interview that aims to determine whether the following unique signs of bipolar disorder are present:

• Unlike ADHD, symptoms are seldom apparent at birth, but develop over time
• The impairment is more chronic and delibitating
• Mood dysregulation is random or cyclical, not situational
• Mood is significantly different when not depressed or manic
• Experiences limbic rage, or mood shifts that are rapid, intense, long-lasting, and highly destructive
• Family history of bipolar disorder, or family members who have died by suicide or been institutionalized
• Psychosis, where thinking becomes slippery, delusional, or bizarre
• Destructiveness or violence
• Regressive or primitive behavior
• High trigger sensitivity
• Feelings of grandiosity
• Symptoms respond well to mood stabilizers

Bipolar vs. ADHD in Children

Bipolar disorder does exist in children, though it’s commonly misdiagnosed as ADHD. Parents of children with ADHD describe their babies as colicky, always crying, difficult sleepers, or always moving around. Children are born with ADHD symptoms; bipolar is a condition that develops and even grows in intensity. A teen with bipolar disorder can rage for hours in a destructive, disturbing way that is described as volcanic emotion or limbic rage. The limbic system is the most primitive, emotional part of the brain. With tantrums caused by ADHD, a child may be upset, but will stop if distracted by something else or when he becomes exhausted. The rage goes on much longer in children with bipolar disorder.

Children who develop bipolar disorder are often precocious, gifted, and have night terrors characterized by gore and mutilation. They have an extreme fear of annihilation, and talk about death, murder, and suicide in an obsessive, matter-of-fact way. Some children with bipolar disorder will harm animals, or experience hallucinations and psychotic symptoms of paranoia from a young age. Children diagnosed with conduct disorder or oppositional defiant disorder are at a higher risk of having bipolar disorder.

Most parents seek diagnosis for bipolar disorder when they feel “something is taking over” their child, who doesn’t seem in his or her “right mind.”

ADHD + Bipolar = More Severe Symptoms

Patients with both ADHD and bipolar disorder face a greater risk of suicide and other health threats, in part because the symptoms they experience of both conditions tend to be more intense and severe if left untreated.

Patients with both conditions also tend to demonstrate symptoms of bipolar disorder earlier in life. This early age of onset is often paired with and muddied by a higher incidence of other comorbid psychiatric disorders and poorer overall functioning.

Treatment

Psychopharmacologically, the medications used to treat ADHD and bipolar disorder are completely different.

Three main classes of medication are used to treat bipolar disorder:

• Mood stabilizers
  • Lithium
• Anti-convulsants
  • Divalproex Sodium (Depakote)
  • Carbamazepine (Tegretol)
  • Lamotrigine (Lamictal)
• Anti-psychotics
  • Olanzapine (Zyprexa)
  • Ziprasidone (Geodon)
  • Risperidone (Risperdal)

People with bipolar respond very well to mood stabilizers, which are indicated for classic bipolar I with episodes of week-long depressive symptoms followed by week-long mania. Anti-convulsants and anti-psychotics are the treatment of choice for bipolar II and not otherwise specified bipolar spectrum disorders. These medications help prevent a person’s mood from dropping into depression, and limit the high points of moods before they reach mania. They soften the ‘tops’ and the ‘bottoms’ to even out moods and behaviors.

Antidepressants prescribed for misdiagnosed depression can help with low emotional states, but they do nothing for mania. In fact, the SSRIs used to treat depression can make bipolar disorder much, much worse.

In contrast, ADHD is commonly treated with these two main classes of medication:

• Stimulants
  • Methylphenidate (e.g., Ritalin)
  • Amphetamine/Dextro-amphetamine (e.g., Adderall)
• Non-stimulants
  • Atomoxetine (Strattera)

Not all patients who have both ADHD and bipolar disorder can take a stimulant medication for their ADHD symptoms. Stimulant medications can actually make bipolar symptoms worse, often triggering a manic episode. Other patients may find that their manic episodes are triggered by the chaos of untreated ADHD symptoms and executive dysfunction; for them, a stimulant medication that keeps ADHD in check may lessen the frequency of bipolar mania.

Often more effective are psychological treatments designed to minimize the ADHD symptoms that may trigger a bipolar episode. Cognitive behavioral therapy is a powerful tool for controlling ADHD symptoms, as in maintaining health and wellness with a consistent sleep routine and a low-sugar, high-protein diet. Finding support and understanding from family and friends universally benefits patients.

[Treatment for the Symptoms of Bipolar Disorder]

Roberto Olivardia, Ph.D., is a member of ADDitude’s ADHD Medical Review Panel.

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¹ Salvi, V., Ribuoli, E., Servasi, M., Orsolini, L., & Volpe, U. (2021). ADHD and Bipolar Disorder in Adulthood: Clinical and Treatment Implications. Medicina (Kaunas, Lithuania), 57(5), 466. https://doi.org/10.3390/medicina57050466

²Schiweck C, Arteaga-Henriquez G, Aichholzer M, et al. Comorbidity of ADHD and adult bipolar disorder: a systematic review and meta-analysis. Neuroscience & Biobehavioral Reviews. 2021;124:100-123. https://doi.org/10.1016/j.neubiorev.2021.01.017

³ Melissa L. Danielson, Rebecca H. Bitsko, Reem M. Ghandour, Joseph R. Holbrook, Michael D. Kogan & Stephen J. Blumberg. (Jan. 24, 2018). Prevalence of Parent-Reported ADHD Diagnosis and Associated Treatment Among U.S. Children and Adolescents, 2016. Journal of Clinical Child & Adolescent Psychology, 47:2, 199-212, DOI: 10.1080/15374416.2017.1417860. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5834391/pdf/nihms937906.pdf

⁴Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic advances in psychopharmacology, 8(9), 251–269. https://doi.org/10.1177/2045125318769235

⁵Tondo, L., Pompili, M., Forte, A., & Baldessarini, R. J. “Suicide attempts in bipolar disorders: Comprehensive review of 101 reports.” Acta Psychiatrica Scandinavica (2016) https://onlinelibrary.wiley.com/doi/abs/10.1111/acps.12517

⁶ Pompili, M., Tondo, L., Grispini, A., De Pisa, E., Lester, D., Angeletti, G., & … Tatarelli, R. Suicide attempts in bipolar disorder patients. Clinical Neuropsychiatry: Journal Of Treatment Evaluation (2006) 10.4088/JCP.v64n0503

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