Is It ADHD or Bipolar Disorder?
The symptoms and treatments of these two conditions are often confused thanks to overlapping symptoms, and ADHD and bipolar disorder commonly occur together.
The diagnosis of all mental disorders is largely based on a carefully taken history designed to bring out signs and symptoms that, when grouped together, constitute a recognizable condition. The problem of diagnosis in mental health arises from the remarkable overlap of symptoms among conditions.
To complicate matters further, ADHD is highly comorbid; that is, it is commonly found co-existing with other mental and physical disorders. Therefore, the diagnostic question is not, “Is it one or the other?” but rather “Is it both?”
Perhaps the most difficult differential diagnosis to make is that of ADHD versus bipolar disorder. Both of these disorders share primary features:
- Mood instability
- Bursts of energy and restlessness
- Talkativeness
- “Racing thoughts”
- Impulsivity
- Impatience
- Impaired judgment
- Irritability
- A chronic course
- Lifelong impairment
- A strong genetic clustering
In adults the two disorders commonly occur together. One review found that one in thirteen adults with ADHD was also diagnosed with bipolar disorder. Unless care is taken during the diagnostic assessment there is a substantial risk of either misdiagnosis or of a missed diagnosis. Nonetheless, a few key pieces of history can guide us to an accurate diagnosis.
[Take This Self-Test: Bipolar Disorder in Adults]
Affective Disorders
Affect is a technical term that means the level or intensity of mood. By definition then an affective or mood disorder is a disorder of the level or intensity of an individual’s mood. The quality of mood (happy, sad, irritable, hopeless) is readily recognizable by everyone. What makes it a disorder are two other factors.
First, the moods are intense, either high energy (called mania) or low energy (depressed moods). Secondly, the moods take on a life of their own unrelated to the events of the person’s life and outside their conscious will and control. Although some environmental triggers have been identified for episodes of mood disorders, usually the abnormal moods gradually shift for no apparent reason over a period of days to weeks and persist for weeks to months. Commonly, there are periods of months to years during which the individual is essentially back to normal and experiences no impairment. Although we now are doing a much better job of recognizing that children can and do have all types of mood disorders, the majority of people develop their first episode of affective illness after the age of 18.
The ADHD-Bipolar Disorder Overlap
This is a highly genetic neuro-psychiatric disorder characterized by high levels of inattention/distractibility and/or high impulsivity/physical restlessness that are significantly greater than would be expected in a person of similar age and developmental attainment. To make the diagnosis of ADHD this triad of distractibility, impulsivity and (sometimes) restlessness must be consistently present and impairing throughout the lifespan.
The two disorders can be distinguished from one another on the basis of six factors:
[Read: Solving the ADHD-Bipolar Puzzle]
1. Age of Onset: ADHD symptoms are present lifelong. The current nomenclature requires that the symptoms must be present (although not necessarily impairing) by seven years of age. Bipolar disorder can be present in prepubertal children but this is so rare that some investigators say it does not occur.
2. Consistency of Impairment and Symptoms: ADHD is always present. Bipolar disorder comes in episodes that ultimately remit to more or less normal mood levels.
3. Triggered Mood instability: People with ADHD are passionate people who have strong emotional reactions to the events of their lives. However, it is precisely this clear triggering of mood shifts that distinguishes ADHD from bipolar mood shifts that come and go without any connection to life events. In addition, there is mood congruency in ADHD, that is, the mood reaction is appropriate in kind to the trigger. Happy events in the lives of ADHD individuals result in intensely happy and excited states of mood. Unhappy events and especially the experience of being rejected, criticized or teased elicit intense dysphoric states. This “rejection sensitive dysphoria” is one of the causes, in my view, for the misdiagnosis of “borderline personality disorder.”
4. Rapidity of Mood Shift: Because ADHD mood shifts are almost always triggered, the shifts themselves are often experienced as being instantaneous complete shifts from one state to another. Typically they are described as “crashes” or “snaps” which emphasize this sudden quality. By contrast, the untriggered mood shifts of bipolar disorder take hours or days to move from one state to another.
5. Duration of Mood Shifts: People with ADHD report that their moods shift rapidly according to what is going on in their lives. The response to severe losses and rejections may last weeks but typically mood shifts are much shorter and are usually measured in hours. The mood shifts of bipolar disorder are usually sustained. For instance, to get the designation of “rapid cycling” bipolar disorder the person need only experience four shifts of mood from high to low or low to high in a 12 month period of time. Many people with ADHD experience that many mood shifts in a single day.
6. Family History: Both disorders run in families but people with bipolar disorder usually have a family history of bipolar disorder while individuals with ADHD have a family tree with multiple cases of ADHD.
Treatment of Combined ADHD and Bipolar Disorder
From my own experience with patients, co-existing ADHD and bipolar disorder can be treated very well and with extraordinarily good outcomes. The mood disorder MUST be stabilized first. This can be done with any of the standard mood stabilizing agents like like Lamictal, Abilify, Risperidone, Zyprexa, or Lithium.
Mood stabilizers are necessary even when the bipolar patient is without symptoms between episodes of illness. Otherwise there is a significant risk of triggering a manic episode. Once the mood has stabilized and any psychotic level symptoms have resolved the first-line stimulant class of medications can be used without significant risk of triggering either a mania or a return of psychotic symptoms.
ADHD or Bipolar Disorder: Next Steps
- Read: When a Mood Disorder Looks Like ADHD — and Vice Versa
- Read: How to Distinguish ADHD’s Rejection Sensitive Dysphoria (RSD) from Bipolar Disorder
- Read: Differential Diagnosis of Bipolar and ADHD: Taking a Phenomenological Approach
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