Neurodevelopmental Disorders

Facing The Diagnostic Challenge of Comorbid Bipolar Disorder and ADHD

Rakesh Jain, MD, MPH;Shailesh Jain, MD, MPH
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Facing The Diagnostic Challenge of Comorbid Bipolar Disorder and ADHD
Facing The Diagnostic Challenge of Comorbid Bipolar Disorder and ADHD
Overlap in the clinical presentation of the two disorders can result in inaccurate diagnoses and treatment delays.

Bipolar disorder and attention-deficit hyperactivity disorder (ADHD) have overlapping clinical symptoms. Think about it. Don’t both disorders often present with impulsivity, physical over-activity, mood reactivity, and so on?

This overlap in clinical presentation often causes treatment delays as well as an inaccurate diagnosis, leading to negative implications.

The treatment modalities are quite different for the two conditions. In addition, the use of stimulants in bipolar patients can cause exacerbation of mania. This situation is compounded by the fact that both disorders start early in life and often are confused for one another.

Adding to the difficulties, adult ADHD is often missed during clinical evaluation. Concurrence of the two illnesses causes further confusion and elevates risk of a missed or inaccurate diagnosis.

In community samples, almost 60% of pediatric ADHD patients have been found to have an affective illness.1 On the other hand, nearly 10% of bipolar patients are found to have comorbid ADHD.2

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Studies indicate bipolar disorder should be treated first. ADHD symptoms tend not to ideally respond unless comorbid bipolar disorder is first treated optimally.3

It is also been noted that mood symptom age of onset is earlier (average age 13 vs. 18 years) when bipolar disorder is comorbid with ADHD. Therefore, younger patients who have ‘simple’ ADHD should receive periodic assessment for the potential emergence of bipolar disorder through their late adolescence and early adulthood.

Bipolar patients are almost three times less likely to remain well in the preceding two years if they have comorbid ADHD, which is one more reason not to miss a comorbid diagnosis.3

Symptoms that overlap in both bipolar and ADHD include distractibility, impulsivity, increased talkativeness, increased motor activity, physical restlessness, and deficiency in expected degree of social inhibitions.4 However, mood dysregulation in bipolar disorder is more likely to be episodic and cyclic in nature.

Family history is more significant for mood disorders in bipolar disorder, and inattention and distractibility predominates in family history for ADHD patients. Patients with bipolar disorder experience less need for sleep compared to variable and less disruptive sleep in ADHD. Psychosis, euphoria and grandiosity, when present, is predominantly seen in bipolar disorder.5

Treatment of ADHD and Comorbid Bipolar Disorder
  • Treat bipolar symptoms first and if ADHD symptoms persist, titrate ADHD medications carefully
  • It may be safe to use stimulants if bipolar symptoms respond well to a mood-stabilizing agent
  • Some evidence suggests that atomoxetine can be used safely and effectively in combination with mood stabilizers
  • Stimulant use requires ongoing monitoring as it may destabilize the mood disorder
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    A good practice is that when attention and impulsivity issues are the prominent symptoms in someone with bipolar disorder, a thorough assessment for ADHD is warranted, no matter what the age of the individual.

    The reverse is equally true. In patients with known ADHD, presence of repeated and chronic mood dysregulation should prompt a full investigation for the absence or presence of a mood disorder. 

    Suspicion for the presence of bipolar disorder is further elevated when there is presence of a first degree family relative with bipolar disorder, and onset of mood symptoms occurred early in life.4

    Similarly, episodic aggressive behavior with episodic mood liability, particularly when combined with psychotic features (presence of delusions/hallucinations during mood episode) with decreased need for sleep coinciding with maintenance of high energy is consistent with bipolar disorders.

    Shailesh Jain, MD, MPH, is regional chair of the Department of Psychiatry at Texas Tech Health Sciences Center Medical School in Midland, Texas. Rakesh Jain, MD, MPH, is a clinical professor in the same department. Dr. Rakesh Jain will be presenting on this topic at the 2014 U.S. Psychiatric & Mental Health Congress on September 21 in Orlando, Florida.

    References

    1. Dilsaver SC, et al. “Occult mood disorders in 104 consecutively presenting children referred for the treatment of attention-deficit/hyperactivity disorder disorder in a community mental health clinic.” J Clin Psychiatry. 2003; 64(10):1170–1176; 1274–1276.
    2. Nierenberg AA, et al. “Clinical and diagnostic implications of lifetime attention-deficit/hyperactivity disorder comorbidity in adults with bipolar disorder: data from the first 1000 STEP-BD participants.” Biol Psychiatry. 2005; 57(11):1467-73.
    3. Robertson HA, et al. “No evidence of attentional deficits in stabilized bipolar youth relative to unipolar and control comparators.” Bipolar Disord. 2003; 5(5):330–339
    4. Duffy A, et al. “The nature of the association between childhood ADHD and the developmen of bipolar disorder: preview of prospective high-risk studies.” Am J Psychiatry. 2012; 69 (1): 1247-55.
    5. McIntyre RS, et al. A 3-week, randomized, placebo-controlled trial of asenapine in the treatment of acute mania in bipolar mania and mixed states. Bipolar Disord.  2012; 11(7):673-86.