How to Distinguish ADHD’s Rejection Sensitive Dysphoria (RSD) from Bipolar Disorder
Forty percent of individuals with bipolar disorder also have ADHD. The conditions’ symptoms typically overlap, however clinicians can successfully distinguish between them according to patients’ experience of emotions. Patients with ADHD — and, specifically, rejection sensitive dysphoria (RSD) — get triggered by a distinct event and then experience an intense but fleeting mood. People with bipolar disorder experience the random onset of a mood that lasts for weeks or months.
Q: “How can diagnosing clinicians differentiate between rejection sensitive dysphoria (RSD) – the emotional highs and lows associated with ADHD – and the similar ups and downs of bipolar disorder?”
A: Bipolar disorder and attention deficit hyperactivity hyperactivity disorder (ADHD or ADD) share 14 features in common, so even a well-trained clinician could easily misdiagnose ADHD as bipolar, vice versa, or miss that both disorders are present. Two studies, the STAR*D program and the STEP-BD program, both found a tremendous overlap between the disorders; if you have bipolar disorder, you have a 40% chance of having ADHD as well. So, the question is: Could it be ADHD, bipolar disorder, or both?
Unlike ADHD, bipolar is a classic mood disorder that has a life of its own separate from the events of a person’s life, outside of the person’s conscious will and control. Bipolar moods aren’t necessarily triggered by something; they just come and they stay. Usually, the onset is very gradual over a period of weeks to months. To meet the bipolar definition, the mood must be continuously present for at least two weeks and then its offset or resolution must be gradual over a period of weeks to months.
With adult ADHD, you see a very different pattern; the moods of an individual with ADHD are clearly triggered. The ADHD symptom of rejection sensitive dysphoria, for example, is triggered by the perception that a person has been rejected, teased, or criticized. An observer might not be able to point out the trigger, but the individual with ADHD can say, “When my mood shifts, I can always see a trigger. My mood matches my perception of the trigger.” In technical terms, ADHD moods are “congruent.”
Mood changes are instantaneous and intense in individuals with ADHD, much more so than in a neuro-typical person.
ADHD moods rarely persist for more than a few hours. It is extremely rare for them to last two weeks. Typically, the mood can be altered by the person with ADHD finding a new interest or occupation that captures their interest and distracts them from the intense emotion. Distinguishing between these mood presentations is how I separate out mood disorders of all types from ADHD.
[Self-Test: Could You Have Rejection Sensitive Dysphoria?]
The above information is from William Dodson, M.D.’s webinar titled “All the Feels: An ADHD Guide to Emotional Dysregulation and Rejection Sensitive Dysphoria (RSD).” That webinar is available for free replay here. William Dodson, M.D., is a member of ADDitude’s ADHD Medical Review Panel.
The Clinicians’ Guide to Differential Diagnosis of ADHD from Medscape and ADDitude
- How can I better understand ADHD, its causes, and its manifestations?
- What do I need to understand about ADHD that is not fully represented in the DSM?
- How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
- How can I best consider psychiatric comorbidities when evaluating a patient for ADHD?
- How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
- How can I best consider trauma and personality disorders through the lens of ADHD?
- What diagnostic criteria and tests are recommended for performing a differential diagnosis of ADHD?