Bipolar disorder (formerly known an manic depression) and ADHD are two distinct mental health conditions that can present with overlapping symptoms, making diagnosis more difficult at times. They can also coexist, which makes both medication and therapy treatments more complex. I have had a number of clients with both bipolar disorder and ADHD where medication and therapy treatments have been very important in managing both issues and having a better quality of life.
This blog post aims to explain more about what bipolar disorder is, how it could be mistaken for, or coexist with ADHD, and how treatment can look different than for ADHD and other mood disorders.
What is Bipolar Disorder?
Bipolar disorder is a mood disorder characterised by significant changes in mood, including episodes of mania (bipolar I) or hypomania and depression (bipolar II).
Bipolar I Disorder is characterised by experiencing at least one manic episode. Most people will also have recurrent depressive episodes, and some will also experience hypomanic episodes. During manic episodes, individuals may experience elevated or irritable mood, increased energy, inflated self-esteem, decreased need for sleep, rapid speech, racing thoughts, distractibility, and may engage in risky behaviours. Manic episodes by definition create significant functional impairment. Psychotic symptoms can also co-occur, such as holding delusional beliefs or experiencing hallucinations. Hospitalisation can sometimes be necessary to treat a manic episode. A mixed features episode can also occur, which is characterised by a mixture of manic/hypomanic and depressive symptoms occuring simultaneously or in rapid succession.
Bipolar II Disorder is characterised by a pattern of depressive episodes and hypomanic episodes, without the full-blown manic episodes seen in Bipolar I disorder. Hypomanic episodes involve elevated or irritable mood, increased energy, enhanced self-confidence, decreased need for sleep, talkativeness, racing thoughts, distractibility, and engaging in pleasurable activities that may have potential negative consequences, but these symptoms are less severe than those in full mania and do not lead to significant impairment in social or occupational functioning. Depressive episodes tend to create more difficulties than hypomania for a person with bipolar II, and may be more numerous than hypomanic episodes.
While it is hard to ignore a manic episode, it is much easier for bipolar II to go undiagnosed. For most people with bipolar II, it is the depressive episodes which are most impairing, and these may well be diagnosed as recurrent major depressive episodes and treated as such without hypomanic being queried or detected. Hypomanic episodes can be periods of enjoyable increased energy which can help make up for some of the the problems caused by depressive episodes, e.g. catching up on work, having creative ideas, and re-engaging socially. Many people will live their whole lives without being diagnosed or treated for bipolar II.
Overlapping Symptoms with ADHD
Both bipolar disorder and ADHD can share certain symptoms, which can make it harder to understand which disorder is present. Some common overlapping symptoms include:
Emotional Dysregulation: Individuals with both bipolar disorder and ADHD often experience intense emotions and difficulty managing them. In bipolar disorder, emotional dysregulation is a core symptom. In ADHD, emotional dysregulation is not a core symptom, but rather an associated feature according to the DSM-5. In practice it is commonly reported by many.
Periods of Increased Energy: Bipolar disorder is characterised by manic or hypomanic episodes where individuals have increased energy, reduced need for sleep, and heightened activity for several days. Similarly, people with ADHD might experience periods of hyperactivity and restlessness, albeit more commonly for hours than days.
Impulsivity: Impulsivity is a core symptom of ADHD, leading to hasty actions without considering consequences. During hypomanic and manic episodes, individuals can also engage in impulsive behaviours such as reckless spending or engaging in risky activities.
Inattention: Difficulty maintaining attention is a core symptom of ADHD but can also appear during depressive episodes in bipolar disorder and in hypomania and mania.
Pressure of speech: People in a manic or hypomanic episode will often be more talkative than usual, or have difficulty stopping talking. This can also be present in some people as part of their ADHD (especially when they are feeling excited).
Distinguishing Between Bipolar Disorder and ADHD
Despite these overlapping symptoms, there are differences that often help differentiate the two disorders:
Mood Cycles: Bipolar disorder involves clear mood cycles of mania/hypomania and depression, lasting several days to weeks, which are noticed by themselves and other people. In contrast, ADHD symptoms are consistent across time in spite of current mood state (mood state will have some influence over symptoms, but they should still be present). The main thing to look for here is if the person ever met criteria for experience a hypomanic or manic episode, as many people with ADHD will have experienced depression so this cannot be used as a way to discrimate between diagnoses.
Sleep Patterns: Individuals with bipolar disorder may experience significant changes in sleep patterns, such as getting significantly less sleep during hypomania or manic phases and hypersomnia during depressive phases. ADHD is often associated with chronic difficulties in falling asleep, often going back to childhood or adolescence, but people will feel tired by their lack of sleep. Not so for mania and hypomania, where the elevated energy persists despite less sleep.
Emotional Dysregulation: In bipolar disorder, emotional dysregulation is more clearly linked to mood state. In ADHD, it tends to be more persistent without huge ebbs and flows unless it is associated with premenstrual dysphoric disorder. In that case, emotional dysregulation should mostly predictably follow the menstrual cycle.
Treatment Pathways
I screen for hypomania and mania in all my potential assessment clients before I will book their assessment. When it appears that bipolar disorder is present, I will not perform an ADHD assessment at that time, but instead will encourage the person to seek assessment for potential bipolar disorder. While ADHD can often be treated first with other co-occurring mental health conditions (provided they are not severe or with high risk issues), this is not the case for bipolar disorder.
Treatment for bipolar disorder typically takes precedence because untreated bipolar symptoms, especially manic episodes, can be more disruptive and potentially dangerous. Stabilising mood with medications is the first-line treatment.
Once bipolar symptoms are better managed, treatment for ADHD can be trialed in many situations. Stimulant medications, commonly used for ADHD, need to be used cautiously as they can potentially trigger manic episodes if mood is not being adequately managed as part of treatment for bipolar. Antidepressants can also trigger hypomania or mania in a person with bipolar, which is another reason why GPs and other health professionals should be mindful of possible bipolar when someone is presenting with depression.
Psychotherapy can be beneficial for both bipolar and ADHD. Therapy can help individuals develop coping strategies, improve emotional regulation, manage impulsivity, process grief, and create strong daily routines that are helpful treatments for both bipolar and ADHD.
Conclusion
Bipolar disorder and ADHD are complex conditions with overlapping symptoms that can sometimes lead to misdiagnosis or diagnosis of one, but not the other. Recognising the differences and understanding the appropriate treatment pathways is crucial for effective management. For individuals with both disorders, prioritising the treatment of bipolar disorder before addressing ADHD symptoms may be the preferred pathway.
ADHD expert psychiatrist Dr William Dodson talks about the commonalities and differences in bipolar and ADHD
This ADDitude article takes a closer look at distinguishing between ADHD and bipolar
Drs Thomas E. Brown and Ryan Kennedy explore "moodiness", or emotional dysregulation, in ADHD and bipolar disorder in this one-hour webinar
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