Some estimates suggest that bipolar disorder occurs in about 1% of the population, with perhaps 4-6% of the population meeting the criteria for a "soft spectrum" bipolar variant. Almost certainly, the uptick we’ve noticed in bipolar diagnoses over the past several years is due to multiple factors. First, we are likely identifying bipolar disorder that we were missing before. Additionally, however, many clinicians suspect that the bipolar disorder diagnosis is being misapplied and over-applied.
Not so long ago, clinicians were hesitant to offer a diagnosis of bipolar disorder in patients younger than 19 or 20 years of age. But it turns out that sixty percent of adults who have been accurately diagnosed with bipolar disorder report that they recall symptoms prior to that, and as many as 40% may recall prodromal symptoms such as hypomania as early as age 13.
One of the most helpful things we can do is to help the young bipolar patient avoid manic episodes or avoid having a second manic episode. On the other hand, we want to avoid inappropriate medication and treatment. So getting this diagnosis right is important! And to confound the issue, many of you have noted the symptom overlap between ADHD and Bipolar Disorder in children. Mood instability, complaints of cognitive inefficiency, and irritability - these may be part of the ADHD presentation, or part of a Bipolar client's experience, or simply a normal part of child and adolescent development. The DSM-IV-TR is the professional manual that guides our diagnostic thinking, but even a careful review of DSM description reveals remarkable overlap. The Manual suggests, for example, that manic experience might be associated with "pressured speech," while the client with ADHD might demonstrate "talking too much." Similarly, manic episodes are marked, according to the DSM,by "psychomotor restlessness" and the diagnostic criteria for ADHD include "runs about or climbs excessively."
For many of our clients and families, reviewing the chief complaint does little to help determine whether this might be a clear bipolar variant or, on the other hand, might more accurately be identified as an ADHD symptom constellation.
Rather than focusing on the frustrating symptom overlap, then, we might look for that clinical presentation which is clearly "non-overlap." That is, can we identify symptoms that appear in only one, not both, clinical conditions? Let’s walk through a mnemonic for looking at the "non-overlap" between bipolar disorder and attention deficit hyperactivity disorder:
ADHD is not FRED-PG13
Yes it looks silly but bear with me here. The "F" and "R" in our mnemonic refer to flight of ideas and racing thoughts. These are experiences fairly specific to the manic or hypomanic client. When it comes to the Bipolar/ADHD diagnostic dilemma, then, these are “non-overlap” symptoms: they occur in one, but not the other, of the two disorders. Folks with ADD/ADHD typically experience their thoughts as moving at about the same speed as the non-ADHD clients. Certainly, these thoughts may "bounce around" from topic to topic, may be tangential, and may be disorganized, but they are not likely experienced as uncomfortable or painful. A way of testing this distinction out in the clinical setting is to gently interrupt your client during conversation. The client with ADHD features will typically tolerate the interruption, regard your comment or question, and continue to move along in the usual fashion. The Bipolar patient, on the other hand, will have some difficulty tolerating interruption. It’s as if by interrupting them you’ve done them harm; as though she can barely keep up with her thoughts as it is, so please don’t interrupt her attempts to manage them or give voice to them!
Let’s move on to the "E" in our mnemonic – referring here to euphoria. ADHD clients typically have the same type of mood variability as the rest of us, with good days and bad days, and do not as a rule demonstrate a "happier than happy" affective experience. Euphoria is fairly specific to mania in clients with euphoric mood, demonstrating symptoms more consistent with a bipolar variant than an ADHD-type symptom constellation.
Decreased need for sleep (that's the "D” in the mnemonic) is fairly specific to the manic phase of bipolar variants. While our clients with ADHD may demonstrate poor sleep hygiene, and may have difficulty honoring a bedtime, and may find multiple interesting and rewarding things to do well past their bedtime, and they will "pay for it" the next day like the rest of us. On the other hand, bipolar patients in a manic or hypomanic state may demonstrate a decreased need for sleep - they actually need less sleep than others of the same age.
And “P” refers to periodicity – having a periodic quality, or cyclical changes over time. ADHD is a fairly steady state disorder which is not associated with cycles. If your client (or his parents) note periods of irritability and impulsivity lasting for several weeks at a time followed by a depressive crash, we can be fairly certain that it is not primarily an ADHD symptom constellation.
Grandiosity is a classic symptom of hypomanic patients. It can be a challenge to determine psychological grandiosity from the "normal grandiosity" associated with children. A 7-year-old, for example, who announces that she plans to be "an actress, an astronaut and a dinosaur" might not be pathologically grandiose. On the other hand, a middle school student who insists that her peers take part in a fantasy football league about which she makes rather excessive and lengthy lists of details, or a student who insists that he has advice and teaching tips that his teacher absolutely needs to review might be perceived by the clinician familiar with students of that age as demonstrating grandiosity.
The number 13 in our mnemonic, obviously, is to call to mind the movie rating system's "PG-13" classification. That's just to make the mnemonic stick. The point of having a number here is to remind ourselves of the age of onset associated with these two very different disorders. Bipolar disorder is classically associated with onset in very early adulthood but may, as is increasingly demonstrated in clinical experience and research literature, have its onset in adolescence and even younger. On the other hand, ADHD is a neurodevelopmental disorder and has, by definition, onset in very early childhood. Features of ADHD can typically be identified between the ages of 5 and 12. When a 35-year-old client reports that he has had symptoms of inattention and distractibility and mood instability for 3 years or so, we can be fairly certain that this is some condition other than the neurodevelopmental condition we refer to as ADHD. In this case, we would be considering not only mood disorder but traumatic brain injury, substance abuse, trauma-related anxiety disorder, Lyme disease or some other condition that might be associated with adult onset rather than childhood onset. The 16 year old who presents for the first time with disorganization, frustration, and difficulty following conversations might well have an ADHD symptom constellation that has flown under the radar – we’ve simply missed it all these years. On the other hand, that age of onset makes us at least raise some questions about other etiologies of inattention and distractibility. Is there marijuana use, for example? Any changes in the home setting or school environment? Any trauma-related anxiety or depression?
Grandiosity is a classic symptom of hypomanic patients. It can be a challenge to determine psychological grandiosity from the "normal grandiosity" associated with children. A 7-year-old, for example, who announces that she plans to be "an actress, an astronaut and a dinosaur" might not be pathologically grandiose. On the other hand, a middle school student who insists that her peers take part in a fantasy football league about which she makes rather excessive and lengthy lists of details, or a student who insists that he has advice and teaching tips that his teacher absolutely needs to review might be perceived by the clinician familiar with students of that age as demonstrating grandiosity.
The number 13 in our mnemonic, obviously, is to call to mind the movie rating system's "PG-13" classification. That's just to make the mnemonic stick. The point of having a number here is to remind ourselves of the age of onset associated with these two very different disorders. Bipolar disorder is classically associated with onset in very early adulthood but may, as is increasingly demonstrated in clinical experience and research literature, have its onset in adolescence and even younger. On the other hand, ADHD is a neurodevelopmental disorder and has, by definition, onset in very early childhood. Features of ADHD can typically be identified between the ages of 5 and 12. When a 35-year-old client reports that he has had symptoms of inattention and distractibility and mood instability for 3 years or so, we can be fairly certain that this is some condition other than the neurodevelopmental condition we refer to as ADHD. In this case, we would be considering not only mood disorder but traumatic brain injury, substance abuse, trauma-related anxiety disorder, Lyme disease or some other condition that might be associated with adult onset rather than childhood onset. The 16 year old who presents for the first time with disorganization, frustration, and difficulty following conversations might well have an ADHD symptom constellation that has flown under the radar – we’ve simply missed it all these years. On the other hand, that age of onset makes us at least raise some questions about other etiologies of inattention and distractibility. Is there marijuana use, for example? Any changes in the home setting or school environment? Any trauma-related anxiety or depression?
So there you go -- FRED-PG13. I'd love to hear your thoughts about the ADHD/Bipolar challenge. Especially those of you who do a lot of work with younger clients identified with a Bipolar variant. Contact me at David@DrNowell.com.