Frequently, I am asked about how to distinguish symptoms of bipolar disorder from those of attention deficit hyperactivity disorder (ADHD). While this question arises more often when seeing children or adolescents, it comes up in the course of evaluating adult patients as well.
One would think that this is a less common problem because the diagnostic criteria for the two conditions seem distinctive enough on first glance. However, I believe that part of the difficulty in distinguishing the two disorders is based on the fact that in both conditions, there is a significant degree of variability of symptom presentation.
As is the case with most psychiatric diagnoses, when attempting to distinguish bipolar disorder from ADHD, the most important tool we have at our disposal is the diagnostic interview and obtaining an adequate history. One of the most important aspects to remember is that bipolar disorders are cyclic mood disorders.
As a result, when patients are describing their symptoms, I always make a point of asking them or their family members, “Are these symptoms episodic in nature? Is the symptom you are describing something that does or can occur during any week of the year, or does the symptom seem to be present for days or weeks, then absent for weeks or months?” This single question will often help to clarify the possible diagnoses.
If a patient or loved one describes symptoms that can occur at virtually any time, on any day, or during any week of the year, then bipolar disorder becomes a less likely diagnosis. The average person with bipolar disorder spends about half or more of his or her time asymptomatic. During the minority of time when patients are symptomatic, they spend significantly more time with some degree of depressive symptoms and a relatively small percentage of time in manic, hypomanic, or mixed states.
Just as not all mood swings are indicative of bipolar disorder, not all inattentiveness and impulsivity are indicative of ADHD. If a patient reports rapid mood changes occurring on an hourly or daily basis, it is usually the case that the person is less likely to meet criteria for bipolar disorder and may be suffering from another mood disorder, an anxiety disorder, a personality disorder, or some other condition. If a person reports that having trouble focusing or concentrating in certain areas, yet they in general have been successful and high achieving in most areas of their life, it is harder to establish a diagnosis of ADHD.
There are a few basic rules I try to keep in mind when evaluating these types of patients:
1. Bipolar disorders are cyclic in nature, but the cycles should not occur over the span of an hour or a day.
2. Bipolar disorders are almost always accompanied by significant changes in sleep patterns and levels of energy.
3. ADHD does not start in adulthood, although it is possible for it to have not been diagnosed when the person was younger.
4. Substance use and sleep problems can create a number of symptoms that patients and clinicians could mistake for bipolar disorder or ADHD.
5. Stimulant medications make most people feel and function better. Taking someone else’s stimulant medication and feeling better, more energetic, happier, and more focused does not constitute a diagnosis of ADHD (any more than driving a friend’s Ferrari and then diagnosing yourself with a Ferrari Deficit Disorder).
6. Correcting poor sleep hygiene and sleep apnea fixes a lot of cases of patient-diagnosed bipolar disorder or ADHD.
7. Objective, computer-based continuous performance tests can be useful tools in helping to establish the presence and severity of symptoms of ADHD, and they can be used to demonstrate the clinical efficacy of treatments. Such testing also provides a “response cost” for patients, which may help to sift out patients who are truly interested in a more thorough evaluation from those who have more of a casual curiosity of what a stimulant may do for them.
What are the ways in which you distinguish these diagnoses in your practice?
Chris Bojrab, MD, is the president of Indiana Health Group, the largest multidisciplinary behavioral health private practice in Indiana, established in 1987. He is a board certified psychiatrist and a Distinguished Fellow of the American Psychiatric Association who treats child, adolescent, adult, and geriatric patients. His areas of interest include psychopharmacology, sleep disorders, and gambling addiction. For more information and disclosures, visit www.chrisbojrabmd.com
The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors.