When a Mood Disorder Looks Like ADHD — and Vice Versa: Differentiating Signs of Emotional Dysregulation
As the name suggests, mood disorders are associated with persistent emotional dysregulation. Moodiness is common with bipolar disorder, but it’s also common with ADHD, ODD, DMDD, and other neurobehavioral conditions. Differentiating one condition’s symptoms of moodiness from another is critical in accurately diagnosing patients and determining a helpful treatment and management route.
Emotional dysregulation and moodiness are not included in the diagnostic criteria for ADHD – a detrimental omission, according to many researchers and clinicians. The reality is that children and adults with ADHD commonly experience irritability, low frustration tolerance, and mood lability – emotional symptoms that have long factored into resulting treatment and management plans.
However, emotional dysregulation is not exclusive to attention deficit hyperactivity disorder (ADHD or ADD). Chronic moodiness is also a central component of mood disorders like bipolar disorder, which may complicate the evaluation, diagnosis, and treatment process, particularly for adult patients. Differentiating moodiness as it appears in ADHD, bipolar disorder, and similar disorders is critically important — and not always straightforward.
Emotional Dysregulation Across Disorders
Emotional dysregulation, while present in many conditions, shows up in different ways and in different grades of severity. Making the distinction between characteristics of moodiness in ADHD, ODD, DMDD, and other disorders often requires studying the mood’s intensity and the degree to which it disrupts the individual’s functioning.
Many individuals with ADHD report feeling easily irritated and frustrated. Minor frustrations at home, work, and/or school, can cause substantial irritability. (Social pressures outside of the home may keep individuals from lashing out in these settings.) A scenario warranting a 2 on a 10-point scale, for example, can often feel like a 7 or 9 to a person with ADHD. They can be quick to anger, as a result, and may lash out with angry outbursts or through passive-aggressive behaviors. Frustrations, however, are often over quickly. Some may feel upset or regretful later, once the emotional overreaction has subsided.
Oppositional Defiant Disorder (ODD)
ODD is one of the most common comorbidities seen with ADHD. Roughly one-third to one-half of children with ADHD also have ODD, characterized by disruptive, defiant, and irritable behavior. Children with ODD can be quick and impulsive, or sullen and sustained, with their oppositional behaviors toward authority figures. ODD usually becomes apparent around age 12 and lasts until the start of adulthood. Most patients outgrow ODD, but for some, it may turn into conduct disorder, which typically involves delinquent activity, physical aggression, violence, theft, and/or destruction of property.
Disruptive Mood Dysregulation Disorder (DMDD)
DMDD is a relatively new diagnostic category reserved for children over age 6. It is characterized by steady, persistent problems with mood dysregulation. A child with DMDD experiences severe and recurrent temper outbursts, either verbal or behavioral, that are grossly out of proportion and inconsistent with what is typically expected for a child their age. These outbursts typically occur three or more times a week. Between outbursts, children with DMDD are often persistently irritable or angry. To merit a diagnosis, these symptoms need to be chronically present for at least a year.
DMDD is a way of categorizing major mood problems in children without the bipolar label.
Bipolar I Disorder
A main feature of bipolar I disorder is a distinct period of abnormally and persistently elevated, expansive, or irritable mood. Bipolar I may also be characterized by a period of “hypomania,” or out-of-the-ordinary, increased activity or energy lasting persistently for at least a week. Depressive moods may also occur concurrently or at other times. These moods are severe enough to cause marked impairment in social or occupational functioning, and often warrant psychiatric hospitalization. There may also be increased risk of suicide or suicide attempts.
To merit diagnosis, at least three of the following symptoms must be present:
- Inflated self-esteem or grandiosity
- Decreased need for sleep
- Pressured speech, racing thoughts
- Extreme distractibility (beyond what is associated with ADHD)
- Increase in agitation (restlessness) or goal-directed activity
- Excessive involvement in risky activity, including over-spending, sexual indiscretions, and/or heavy drinking (the latter often done in an attempt to calm down)
Bipolar I disorder is typically diagnosed around age 18, when a first episode occurs. Many but not all patients go on to experience more episodes.
Bipolar II Disorder
Bipolar II disorder is usually less severe than bipolar type I, but it can be more complicated to diagnose and significantly impairing. With bipolar type II, there’s at least one hypomanic episode lasting at least four full consecutive days, as well as three or more of the symptoms outlined for bipolar I disorder. These episodes are usually not accompanied by psychotic symptoms; they are not severe enough to cause marked impairment in functioning or to require hospitalization.
Patients with bipolar type II will also meet the criteria for a current or past episode of major depression (MDD). With bipolar I, patients may or may not have accompanying MDD. A major depressive episode is marked by at least 5 of the following symptoms:
- Persistently depressed mood
- Markedly diminished interest or pleasure
- Significant increase or decrease in appetite
- Increased restless or slowing down
- Fatigue, loss of energy
- Feelings of guilt or worthlessness
- Diminished ability to think or concentrate
- Recurrent thoughts of death or suicide
Bipolar Disorder vs. ADHD
Bipolar disorder and ADHD do share some characteristics of moodiness, irritability, and other aspects of emotionality. The chart below differentiates these characteristics as they usually appear.
- + = presence
- – = absence
- ++ = more present
- +/– = may be present
- +++ = most present
Bipolar Disorder in Children
Bipolar disorder in children is not always marked by clearly defined episodes of severe moods. Another factor complicating diagnosis is that about 80 percent of children and adolescents with bipolar disorder will also have ADHD, ODD, and/or major depressive episodes. This makes it difficult to tell whether a patient with ADHD and serious mood problems has severe ADHD, bipolar disorder, or both.
But aiding diagnosis is the fact that ADHD and bipolar disorder are highly familial. (ADHD has a heritability index of .76; bipolar disorder is between .6 to .85.) Assessing for history of mood problems can help determine the diagnosis.
Mood Disorders and ADHD: Treatments and Considerations
Emotional dysregulation and severe moodiness in ADHD and bipolar disorder are often treated with medication. This intervention alone, however, is usually not sufficient. Through psychotherapy, patients and families can receive essential support around understanding and addressing problems with mood and emotional dysregulation, including:
- Identifying triggers to episodes involving family systems
- Using strategies to avoid worsening episodes
- Understanding family history of mood problems
- The limitations of medication
Clinicians should also consider that patients with bipolar type II may not warrant or choose to follow the treatments prescribed for bipolar I. In a hypomanic episode, for example, some patients may want to “tap in to” this energy for work or creative projects. In this case, it’s important to have a conversation with patients about recognizing the signs of an episode.
ADHD and Bipolar Medication Options
Though not explicitly approved to do so, stimulant medications for ADHD often improve moodiness in patients without a mood disorder. A patient’s effective dose is not based on their age, weight, or severity of symptoms, but rather how sensitive the patient’s body chemistry is to a particular medication. This requires monitoring and fine-tuning dosing to fit individual sensitivity as well as the patient’s lifestyle to ensure the medication is active when they most need it.
For patients with ADHD and bipolar disorder, however, stimulants may exacerbate symptoms of emotional dysregulation. If levels of irritability or agitation are made worse on this medication, the clinician should instead prescribe a mood stabilizer to treat and reduce these issues. When the patient’s mood has stabilized but ADHD symptoms persist, stimulants can be added to treatment, but cautiously. The most prescribed stimulants are Vyvanse and Adderall XR.
“Stimulant rebound” is also important factor for clinicians and patients to consider. Patients who report feeling or acting excessively wired and irritable, or who lose their “sparkle” while the stimulant is active, may be taking a dose that is too high or taking medication that does not work for them. But if these effects are occurring as the medication is wearing off, that’s a different issue of “stimulant rebound”, meaning that the medication is dropping off too fast. Usually, this issue can be fixed by administering a small dose of the short-acting version of the medicine, which smoothes its “exit ramp” and avoids these difficulties.
Guanfacine-XR (Intuniv) is a nonstimulant approved for ADHD treatment that may help improve restlessness, impulsivity, and hyperactivity in patients with both ADHD and mood problems. This medication dosage needs to be increased slowly to a maximum of 4 mg per day.
Many prescribers are hesitant to add SSRIs to a bipolar treatment plan, as they can increase the risk of a hypomanic or manic episode and cause suicidal thoughts. But if a patient’s mood is stabilized and symptoms of depression persist, an SSRI like fluoxetine may help improve their mood to baseline. SSRIs should be monitored carefully, especially in the first several weeks of administration.
The Role of the Family
Parent Emotional Dysregulation
How families respond to moodiness and emotional outbursts can make a big difference. Should patients, especially children and adolescents, pursue therapy, it is also important to address parental temper and moods as well. Assessing interactions at home can reveal triggers and sensitive scenarios that contribute to mood instability.
A patient’s parents may not share the same approach to addressing irritability and moodiness. One parent may insist on patience and support, while the other adopts a “crackdown” approach. Often, each parent ends up taking a more extreme view over time. Both may fail to see how either approach could be right depending on the situation, to the detriment of the child. Therapy can be an appropriate setting for working through these issues.
Mood Disorders: Next Steps
- Read: The ADHD-Anger Connection: New Insights into Emotional Dysregulation and Treatment Considerations
- Guide: Where ADHD and Bipolar Disorder Overlap
- Download: Bipolar Disorder and ADHD: How to Tell the Difference
The content for this article was derived from the ADDitude Expert Webinar “Is It Bipolar Disorder or ADHD Moodiness? A Guide to Getting the Right Diagnosis and Treatment” [Video Replay & Podcast #347] with Thomas E. Brown. Ph.D., and Ryan J. Kennedy, DNP, which was broadcast live on March 10, 2021.
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