Dr. Bob's Psychopharmacology Tips

Bipolar disorder and ADD

Date: Fri, 27 Oct 1995 13:56:15 -0700 (PDT)
From: Ivan Goldberg <psydoc@psycom.net>
Subject: Bipolar disorder and ADD

Marshall Thomas wrote:

I recently reviewed the case of a woman admitted with mixed manic symptoms. The psychiatrist involved insisted that the patient's Ritalin (methylphenidate) 20 mg tid be continued because of a supposed diagnosis of adult ADD and the clinical impression that the patient had improved (in terms of dysphoria and distratability) with the addition of Ritalin. Simultaneous with this I recently heard a national expert on the diagnosis of bipolar disorder say that he at times recommends Ritalin to treat intractable mania especially if the history is suggestive of adult ADD.

One frequently sees bipolar pts with supposed comorbid ADD or diagnosed solely with ADD. This is becoming increasingly common in adults as well as kids thanks to the popularity of the ADD dx.

The problem is that just about all bipolar pts have a disorder of attention. To differentiate between the two, I look for sx that are seen in bipolar but not ADD, for example:

• racing thoughts
• not needing to sleep or hypersomnia
• changes in energy parallel to the above
• tangential thinking
• overspending, overcommitting
• grandiosity
• grandiose thrill seeking (eg, jumping off of high places)
• psychosis.

Since bipolar disorder does not run in families of ADD pts, I also look at family hx.

If I think the pt is bipolar, I treat that first. If there is an attentional problem left when everything else is remitted, I might treat with a stimulant if clonidine didn't help (which it usually doesn't). Remember that most adult ADD pts aren't hyperactive.

In my view, getting sedated or feeling sharper on stimulants is diagnostic of nothing. Everyone's attention is improved by stimulants. Bipolar people are frequently sedated by stimulants, and I saw a manic pt yesterday who drinks strong cappucino to get to sleep. You can find reports of this going back 30 years (see for example, Chiarello and Cole in the Archives).

From: "M Cevdet Tosyali" <TOSYALIM@child.cpmc.columbia.edu>
Date: Thu, 18 Jul 1996 10:37:16 EST
Subject: Bipolar disorder vs. ADD

It certainly can be confusing at times in children and adults.

Episodic change in behavior, increased drive, and productivity seem more typical of hypomania in adults, while ADHD is more likely to be associated with impairment, distractability, and significant childhood history of problems on a chronic, fairly unremitting basis. Family history as always can help.

Date: Thu, 18 Jul 96 20:40:30 UT
From: "dan steinfink" <dsteinfink@msn.com>
Subject: Bipolar disorder vs. ADD

ADH should be a more constant factor in the patient's life, causing problems with performance and follow through. Bipolar patients may have a more episodic history with more grandiosity.

From: MataKeata@aol.com (Matt Keats)
Date: Sun, 21 Jul 1996 16:40:48 -0400
Subject: Bipolar disorder vs. ADD

Nothing sure fire, but a couple of points to help differentiate:

• Generally one does not see decreased need for sleep in ADHD, as in hypomania.
• Most adults with ADHD have lowered rather than elevated self esteem (ie, lack grandiosity).
• Hypomania tends to be more episodic that ADHD.
• Family hx may give a clue.
• Onset of ADHD, in early childhood, preceeds the usual age of onset of bipolar disorders.

Date: 03 Jan 97 17:48:14 EST
From: "John M. Rathbun" <73162.3513@compuserve.com>
Subject: Bipolar disorder vs. ADD

The boundary between persistent hypomania and ADD is unclear. The usual practice is to treat such cases with stimulants before puberty and with mood-stabilizing agents in adulthood. OTOH, I've seen several youngsters who did much better on mood-stabilizers than on stimulants, and several adults who got the atypical calming effect from stimulants.

In trying to categorize these patients, I pay a lot of attention to their cognition. ADD kids usually look pretty normal in my office, but they're a horror in the classroom. The ones that respond better to mood-stabilizers have more obviously pressured, grandiose, and bizarre thinking. Similarly, adults with residual ADD seem cognitively normal to me, as contrasted with the hypomanics, who seem accelerated and psychotic. Additionally, the stable hypomanic typically appears about 10 years younger than stated age, which resolves remarkably with treatment; this seems to relate to tension in the facial muscles during the hypomanic state -- look at the eyes!

Stable hypomania seems to be an entity in search of a researcher. I've never read about it, but in over twenty years of practice I've seen enough of it to respect its existence. If they are bright, they may have exceptionally productive professional careers, but their personal lives are often shambles. They typically come to me around age 40 when (due to declining cortical predominance?) their moodiness becomes a source of distress to them. They may decompensate into major depression after overreaching themselves, as demonstrated by bankruptcy, reversal of professional reputation, or rupture of an important relationship. I don't often see one go into true mania.

They seem to benefit largely from lithium or other mood-stabilizers. These need to be administered with a light touch because such high-functioning persons are quite sensitive to feeling slowed down. A 12-hour lithium level of 0.5 or 0.6 is often plenty. Note that their complaint about the medicine often takes the following form: "I can't accomplish nearly what I'm accustomed to; after only 10 or 12 hours of work, I'm tired and want to sit down!" It takes a while for them to see that the tortoise-and-hare phenomenon now applies to their career, which may have gone like a jackrabbit previously.

BTW, I've had scant success with Depakote (divalproex) compared to lithium and carbamazepine, and I've seen a lot of people complaining about the jitters and tremors they get. Sometimes the tremors last for weeks after the Depakote is stopped.

From: HRudMD@aol.com (Howard Rudominer, M.D.)
Date: Sat, 15 Mar 1997 16:06:47 -0500 (EST)
Subject: Bipolar disorder and ADD

With bipolar patients comorbid for ADHD it has been my experience that one must treat the bipolarity first before the ADHD, since the psychostimulants by themselves could possibly worsen the condition.

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