Solving the ADHD-Bipolar Puzzle
Dealing with ADHD is a challenge. Bipolar disorder? Even harder. And when the two of them occur together, it can be downright dangerous. Here’s how to sort out symptoms and get adequate treatment now.
Richard, 31, had been diagnosed with ADHD at 12, but he felt that the diagnosis did not explain some of his disabling symptoms. He suffered from terrible depressive episodes and had weeks when he was consistently restless, agitated, and unable to sleep.
His therapist said that people with ADHD often had mood fluctuations. Richard did not find the ADHD stimulants that his doctor prescribed to be helpful, and he began to feel worthless and socially isolated.
Jack, 17, was diagnosed with ADHD and Oppositional Defiant Disorder at age four. His mother said that on some days “he would wake up on the destructive side of the bed.” Instead of tantrums, she endured rages over things that, on other days, didn’t anger him. He attempted suicide at 16, after reporting that he couldn’t live in a world that was “too loud” for him.
Richard and Jack had ADHD, but they also suffered from Bipolar Disorder (BD), characterized by episodes of depression and of elevated mood states, referred to as hypomanic or manic episodes.
Approximately 10 million people in the United States have BD. Bipolar disorder often co-occurs with ADHD in adults, with comorbidity rates estimated between 5.1 and 47.1 percent1. Recent research, however, suggests that about 1 in 13 patients with ADHD has comorbid BD, and up to 1 in 6 patients with BD has comorbid ADHD2. The tragedy is that, when the disorders co-occur, the diagnoses are often missed. It can take up to 17 years for patients to receive a diagnosis of BD. As with any co-occurring disorder, it is important to receive the right diagnosis as early as possible to treat the condition effectively.
Tristan had struggled with BD for 12 years. “I had been told I had something called ‘Limbic and Ring of Fire ADHD,’ which could be treated with supplements. After the treatment, I still couldn’t get my life together, so I figured I was a loser.” After a bout of alcoholism and two suicide attempts, he was assessed by a specialist who understood both conditions and was diagnosed with ADHD and BD. Tristan is now happier than ever before.
It is understandable that doctors confuse bipolar symptoms for those of ADHD. Both conditions involve impulsivity, irritability, hyperactivity, emotional dysregulation, sleep problems, a racing brain, and problems with maintaining attention. But on deeper examination, there are ways to distinguish one condition from the other.
Depressive Episodes: One Side of BD
1. Persistent, sad, or irritable mood. Francis, 14, would wake up feeling “completely gray. I knew that meant the beginning of what I call one of my ‘doomdays.’ I never knew why I felt that way, and it lasted for two or three days sometimes.” This is a classic depressive episode commonly seen with BD.
Lilia, diagnosed with ADHD, could always pinpoint the reason for her moods — a break-up, a poor grade on a test, or a fight with a friend. She saw that her depressive moods were caused by external events. In BD, the mood shifts, which can be rapid and intense, seem to come from the inside, regardless of what is happening externally.
2. Loss of interest in previously enjoyable activities. One of the first signs of depression for Indigo, 17, was not wanting to play the guitar. “With ADHD, I get bored quickly and lose interest in something. But with BD depression, I lose interest in everything.”
3. Significant changes in appetite, body weight, and sleep patterns. The key here is context. Those with ADHD have weight fluctuations or periods when they are sleeping too much or too little. These are often caused by the activities people participate in. When Mario is engaged in periods of hyperfocus (due to procrastination), he works 10-12 hours straight, and feels he cannot stop to eat for fear that he will lose momentum. Kate, 19, who had BD, lost her appetite and couldn’t sleep for six or seven days at a time.
4. Low energy and concentration. Many people with ADHD become fatigued, particularly in situations when their executive functions are taxed. Trouble in focusing and paying attention comes with situations that are boring and not stimulating to them. Vincenzo, 28, who has both ADHD and BD, has learned the signs of an oncoming depressive episode. “It is as if I am walking in molasses through life, even in situations where the day before I was dancing. My ability to focus is completely shot in a way that makes ADHD look like a cakewalk.”
5. Feelings of worthlessness, inappropriate guilt, and recurrent thoughts of death and suicide. One of the major distinctions between ADHD and a depressive episode is feeling worthless, which can lead to suicidal thoughts and behaviors. Fifty percent of people with BD attempt suicide, and 20 percent eventually kill themselves.
Manic Episodes: The Other Side of BD
1. Severe changes in mood. The hallmark of a manic or hypomanic (a less intense but still potentially disabling) episode is a severe shift in mood, in which someone becomes extremely irritable or inappropriately elated without any external reason. These mood states last for hours (as do mixed manic episodes), days, or weeks. With ADHD, irritability is often the result of boredom, sleep deprivation, a stressful situation, or heavy demands on executive functioning. A person having a manic episode feels irritable, regardless of what is going on.
2. Inflated self-esteem and grandiosity. When patients are in the throes of a manic episode, their sense of themselves can become grandiose or narcissistic. Sometimes it is subtle (“I am a better driver than anyone I know”), and other times it can be detached from reality (“I have an amazing ability to do everything”).
3. Increased, revved-up energy. Kathleen, 30, described her manic episodes as “a flurry of uncontrolled energy.” With ADHD, people can feel excited and energetic; manic energy, however, feels scary, uncontrolled, and uncontained.
4. Impulsive or self-destructive behaviors. Hypersexuality, substance abuse, reckless driving, and conflict with others are common in mania. With ADHD, impulsive acts are driven by something someone wants to do. With BD, people having a manic episode feel driven to do acts that, when not manic, they would have no desire to do.
5. Psychosis. Having thoughts that are detached from reality is not a symptom of ADHD, but that is a symptom of a severe depression or mania. Jeff, 36, believed he was Jesus Christ when manic, while Kelly, 14, heard “angels talking.”
Although ADHD and BD are characterized by emotional dysregulation, the mood experiences associated with BD tend to be longer, more chronic in nature, more cyclical, and triggered more easily than in ADHD.
BD runs in families, so someone is at increased risk if he or she has a family member who has been diagnosed with it. Many times BD goes undiagnosed, so it is a good idea for clinicians to ask if anyone in the family has attempted or committed suicide, has had electroconvulsive shock therapy, or has been involuntarily committed to a psychiatric hospital.
BD and ADHD: A Bad Combination
It is essential that a clinician evaluate a patient for ADHD when BD is part of the picture. The debilitating and tormenting nature of this illness cannot be overestimated, especially in someone who also has ADHD. Since the comorbidity rates are high, any time someone is diagnosed with one, the presence of the other should always be looked for.
Studies of people who have both ADHD and BD demonstrate that they have more severe ADHD symptoms, have an earlier age of onset for BD, and have more psychiatric disorders than those with ADHD alone. When compared to patients with BD only, patients with both ADHD and BD tend to be male, and most of them have been diagnosed with conduct disorder or ODD.
Keep in mind that these studies involved many people who were not identified early and suffered for years without the proper diagnoses. Early diagnosis and treatment — which is different for each disorder — are essential in changing the prognosis. With proper medication, therapy, and life management, a patient can live a full, healthy life.
1 Katzman, M. A., Bilkey, T. S., Chokka, P. R., Fallu, A., & Klassen, L. J. (2017). Adult ADHD and comorbid disorders: clinical implications of a dimensional approach. BMC psychiatry, 17(1), 302. https://doi.org/10.1186/s12888-017-1463-3
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