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ADHD vs. Bipolar Disorder

Approximately 20 percent of people with ADHD also suffer from bipolar disorder, a serious mental illness characterized by depressive and manic episodes. Since both conditions share symptoms, but ADHD is more common, bipolar disorder is often missed or misdiagnosed. 

ADHD’s high rates of comorbidity with other neurobiological disorders are well researched and documented. The majority of people with ADHD 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 disorder; they are astronomical for patients with bipolar disorder plus ADHD.

“What Is Causing My Racing Thoughts?” Bipolar Disorder and ADHD
Approximately 60 to 70 percent of people with bipolar disorder also have ADHD. What’s more, 20 percent of people with ADHD have bipolar disorder. This comorbidity rate is significant enough to justify dual evaluations for virtually every patient; a physician should virtually never assess for one condition in isolation, as ADHD and OCD rarely walk alone.

Yet holistic neurobiological assessments are not happening. 70 percent of bipolar patients are misdiagnosed at least once. On average, patients with bipolar disorder wait a whopping 17 years before receiving an accurate diagnosis. That’s 17 years of missed treatment opportunities, of poor symptom management, and of patient stress and anxiety. And it’s simply unacceptable, if not at least somewhat understandable.

Why is bipolar disorder missed or misdiagnosed with such regularity?

  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. (Up to 11 percent of all children in the U.S. have symptoms of ADHD; roughly 60 percent of those children grow up to become adults with ADHD. Bipolar disorder, in contrast, impacts just 2.6 percent of the population.) 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.

Whatever the reasons, undiagnosed and/or untreated bipolar disorder can have deadly consequences. One in five people with the condition will commit suicide. Studies show that at least one in three, or even one in two will attempt it — 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.

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.

About 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.

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

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.

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.

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

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.

Bipolar II/Hypomanic Symptoms
  • Hypomanic episodes marked by anxiety
  • Rejection sensitivity
  • Personality disorders
  • Significant risk of suicide

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.

Differential Diagnosis: Bipolar Disorder vs. ADHD
  • 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 committed 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 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.

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.”
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.

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
  • 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.

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. Meditation, exercise and mindfulness are shown to be beneficial.

Finding support and understanding from family and friends universally benefits patients, and when not an option, finding that support and understanding from a supportive therapist who is experienced with ADHD can be very of great benefit.

This information was adapted from a guide from clinical instructor at Harvard Medical School, Roberto Olivardia, Ph.D. and ADDitude.com.

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