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Evidence-Based Reviews


ADHD: Only half the diagnosis in an adult with inattention?

Adults with ADHD and bipolar disorder often have comorbid agoraphobia, posttraumatic stress disorder, social phobia, or alcohol or drug addiction.

Vol. 6, No. 6 / June 2007

Overlapping symptoms may obscure comorbid bipolar illness

An adult with function-impairing inattention could have attention-deficit/hyperactivity disorder (ADHD), bipolar disorder (BD), or both. Comorbid ADHD and BD often is unrecognized, however, because patients are more likely to report ADHD-related symptoms than manic symptoms.1

To help you recognize comorbid ADHD/BD—and protect adults who might switch into mania if given stimulants or antidepressants—this article describes a hierarchy to diagnose and treat this comorbidity. Based on the evidence and our experience, we:

  • discuss how to differentiate between these disorders with overlapping symptoms
  • provide tools and suggestions to screen for BD and adult ADHD
  • offer 3 algorithms to guide your diagnosis and choice of medications.

Clinical challenges

Prevalence is unclear. Adult ADHD—with an estimated prevalence of 4.4%2—is more common than BD. Lifetime prevalences of BD types I and II are 1.6% and 0.5%, respectively.3 Studies of ADHD/BD comorbidity suggest wide-ranging prevalence rates:

  • 9% to 21% of BD patients may have adult ADHD2,4,5
  • 5% to 47% of adult ADHD patients may have BD.2,6-8

Underdiagnosis. Adult ADHD/BD is a more severe illness than ADHD or BD alone and is highly comorbid with agoraphobia, social phobia, posttraumatic stress disorder, and alcohol or drug addiction. Adults with ADHD/BD have more frequent affective episodes, suicide attempts, violence, and legal problems.4 Diagnosing this comorbidity remains a challenge, however, because:

  • identifying which symptoms are caused by which disorder can be difficult
  • BD tends to be underdiagnosed9
  • patients often misidentify, underreport, or deny manic symptoms1,10,11
  • if a patient presents with active bipolar symptoms, DSM-IV-TR criteria require that ADHD not be diagnosed until mood symptoms are resolved.

Overlapping symptoms. ADHD and bipolar mania share some DSM-IV-TR diagnostic criteria, including talkativeness, distractibility, increased activity or physical restlessness, and loss of social inhibitions (Table 1).12 Overlapping symptoms also are notable within ADHD diagnostic criteria (Table 2). In the inattention category, for example, “easily distracted by extraneous stimuli,” “difficulty sustaining attention in tasks,” and “fails to give close attention to details” are considered 3 separate symptoms. In the hyperactivity category, “often leaves seat,” “often runs about or climbs excessively,” and “often on the go, or often acts as if driven by a motor” are 3 separate symptoms.

Given ADHD’s relatively loose diagnostic criteria and high comorbidity in adults with mood disorders, the question of whether adult ADHD/BD represents comorbidity or diagnostic overlap remains unresolved. For the clinician, the disorders’ nonoverlapping features (Table 1) can assist with the differential diagnosis. For example:

  • ADHD symptoms tend to be chronic and BD symptoms episodic.
  • ADHD patients may have high energy but lack increased productivity seen in BD patients.
  • ADHD patients do not need less sleep or have inflated self-esteem like symptomatic BD patients.
  • Psychotic symptoms such as hallucinations or delusions might be present in severe BD but are absent in ADHD.

Table 1

Overlap between DSM-IV-TR diagnostic criteria for ADHD and bipolar mania

Overlapping symptoms

ADHD

Bipolar mania

Talks excessively

More talkative than usual

Easily distracted/jumps from one activity to the next

Distractibility or constant changes in activity or plans

Fidgets
Difficulty remaining seated
Runs or climbs about inappropriately
Difficulty playing quietly
On the go as if driven by a motor

Increased activity or physical restlessness

Interrupts or butts in uninvited
Blurts out answers

Loss of normal social inhibitions

Nonoverlapping symptoms

ADHD
  Forgetful in daily activities
  Difficulty awaiting turn
  Difficulty organizing self
  Loses things
  Avoids sustained mental effort
  Does not seem to listen
  Difficulty following through on instructions/fails to finish work
  Difficulty sustaining attention
  Fails to give close attention to details/makes careless mistakes

Bipolar mania
  Inflated self-esteem/grandiosity
  Increase in goal-directed activity
  Flight of ideas
  Decreased need for sleep
  Excessive involvement in pleasurable activities with disregard for potential adverse consequences
  Marked sexual energy or sexual indiscretions

ADHD: attention-deficit/hyperactivity disorder

Source: Adapted and reprinted with permission from reference 12

Table 2

DSM-IV-TR diagnostic criteria for attention-deficit/ hyperactivity disorder

Inattention

≥6 symptoms have persisted ≥6 months to a degree that is maladaptive and inconsistent with developmental level. The patient often:

  • fails to give close attention to details or makes careless mistakes
  • has difficulty sustaining attention in tasks
  • does not seem to listen when spoken to directly
  • does not seem to follow through on instructions and fails to finish work
  • has difficulty organizing tasks
  • avoids tasks that require sustained mental effort
  • loses things necessary for activities
  • is easily distracted
  • is forgetful in daily activities

Hyperactivity/impulsivity

≥6 symptoms have persisted ≥6 months to a degree that is maladaptive and inconsistent with developmental level. The patient often:

  • fidgets
  • leaves seat
  • shows excessive movement or feels internal restlessness
  • has difficulty engaging quietly in leisure activities
  • is “on the go” or often acts as if “driven by a motor”
  • talks excessively
  • blurts out answers before questions have been completed
  • has difficulty awaiting turn
  • interrupts or intrudes on others (such as butts into conversations or games)

Diagnosis requires evidence of inattention or hyperactivity/impulsivity or both

Some hyperactive/impulsive or inattentive symptoms that caused impairment were present before age 7

Some impairment from symptoms is present in ≥2 settings (such as at school, work, or home)

Symptoms do not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder and are not better accounted for by another mental disorder (mood disorder, anxiety disorder, dissociative disorder, or a personality disorder)

Source: DSM-IV-TR

Mood symptoms first

A diagnostic hierarchy is implicit in DSM-IV-TR; anxiety disorders are not diagnosed during an active major depressive or manic episode, and schizophrenia is not diagnosed on the basis of psychotic symptoms during an active major depressive or manic episode. Mood disorders sit atop this implied diagnostic hierarchy and must be ruled out before psychotic or anxiety disorders are diagnosed. Similarly, most personality disorders are not diagnosed during an active mood or psychotic episode.

Diagnosing adult ADHD when a patient is actively depressed or manic is inconsistent with this hierarchy and conflicts with extensive nosologic literature.13 We suggest that ADHD—a cognitive-behavioral problem—not be diagnosed solely on symptoms observed when a patient is experiencing a mood episode or psychotic illness.

Bipolar disorder. Two useful mnemonics (Table 3) assist in screening for DSM-IV-TR symptoms of BD type I:

  • Pure mania consists of euphoric mood and ≥3 of 7 DIGFAST criteria, or irritable mood and ≥4 of 7 DIGFAST criteria
  • Mixed mania consists of depressed mood with ≥4 of 7 DIGFAST criteria and ≥4 of 8 SIGECAPS criteria.

To be diagnostic, these symptoms must cause substantial social or occupational dysfunction and be present at least 1 week. Diagnose BD type I if a patient has experienced a single pure or mixed manic episode at any time, unless the episode had a medical cause such as hyperthyroidism or antidepressant use. Because patients with mixed episodes experience depressed mood, assess any patient with clinical depression for manic symptoms. Otherwise, a patient with a mixed episode could be misdiagnosed as having unipolar depression instead of BD type I.14

BD type II also has been observed in patients with comorbid adult ADHD/BD.4,6 The main difference between BD types I and II is that manic symptoms in type II are not severe enough to cause functional impairment or psychotic symptoms.15

Adult ADHD. The clinical interview seeking evidence of inattention and hyperactivity/impulsivity remains the basis of adult ADHD diagnosis (Table 2). Key areas are:

  • the patient’s past and current functional impairment
  • whether substantial impairment occurs in at least 2 areas of life (such as school, work, or home).

Take medical, educational, social, psychological, and vocational histories, and rule out other conditions before concluding that adult ADHD is the appropriate diagnosis.16 In adult ADHD, inattentive symptoms become far more prominent, about twice as common as hyperactive symptoms.17 Inattentive symptoms may manifest as neglect, poor time management, motivational deficits, or poor concentration that results in forgetfulness, distractibility, item misplacement, or excessive mistakes in paperwork.18 When impulsive symptoms persist in adults, they may manifest as automobile accidents or low tolerance for frustration, which may lead to frequent job changes and unstable, interrupted interpersonal relationships.18

Neuropsychological testing is not required to make an adult ADHD diagnosis but can help establish the breadth of symptoms or comorbidity.17 Rating scales can screen, gather data (including presence and severity of symptoms), and measure treatment response.16 Commonly used rating scales include:

  • Conners’ Adult ADHD Rating Scales19
  • Brown Attention Deficit Disorder Rating Scale for Adults20
  • Adult ADHD Self-Report Scale.21

When using rating scales, remember that adult psychopathology can distort perceptions, and some self-report scales have questionable reliability.16

Table 3

Mnemonics for diagnostic symptoms of pure and mixed bipolar mania

DIGFAST* for bipolar mania symptoms

SIGECAPS bipolar depression symptoms

Distractibility
Insomnia
Grandiosity
Flight of ideas
Activities
Speech
Thoughtlessness

Sleep
Interest
Guilt
Energy
Concentration
Appetite
Psychomotor
Suicide

Pure mania: Euphoric mood with ≥3 DIGFAST criteria or irritable mood with ≥4 DIGFAST criteria.

Mixed mania: Depressed mood with ≥4 DIGFAST criteria and ≥4 SIGECAPS criteria.

* Developed by William Falk, MD

Developed by Carey Gross, MD

Source: Adapted from Ghaemi SN. Mood disorders. New York: Lippincott, Williams, & Wilkins; 2003

Treatment recommendations

Limited data. We found only 1 study on adult ADHD/BD treatment. In this open trial,22 36 adults with comorbid ADHD and BD received bupropion SR, up to 200 mg bid, for ADHD symptoms while maintained on mood stabilizers, antipsychotics, or both. Improvement was defined as ≥30% reduction in ADHD Symptom Checklist Scale scores, without concurrent mania. After 6 weeks, 82% of patients had improved; 1 dropped out at week 2 because of hypomanic activation. Methodologic limitations included trial design (non-randomized, nonblinded, short duration) and patient selection (90% of subjects had BD type II).

In the absence of adequate data on adult ADHD/BD, studies in children suggest:

  • stimulants may not be effective for ADHD symptoms in patients with active manic or depressive symptoms
  • mood stabilization is a prerequisite for successful pharmacologic treatment of ADHD in patients with both ADHD and manic or depressive symptoms.23,24

Follow the hierarchy. First treat acute mood symptoms, then reevaluate and possibly treat ADHD symptoms if they persist during euthymia (Algorithm 1). When a patient meets criteria for adult ADHD/BD, first stabilize bipolar manic or depressive symptoms (Algorithm 2). For acute mania, treat with standard mood stabilizers (lithium, valproate, lamotrigine, or carbamazepine) with or without a second-generation antipsychotic.25 Starting stimulants for ADHD when patients have active mood symptoms is sub-optimal and potentially harmful because of the risk of inducing mania. For acute bipolar depression, adjunctive antidepressant treatment has been found to be no more effective than a mood stabilizer alone.26

After bipolar symptoms respond or remit, reassess for adult ADHD. If ADHD symptoms persist during euthymia, additional treatment may be indicated.

Very little evidence exists on treating adult ADHD/BD; as mentioned, bupropion is the only medication studied in this population. For adult ADHD alone, clinical trials have showed varying efficacy with bupropion,27,28 atomoxetine,29 venlafaxine,30,31 desipramine,32 methylphenidate,33 mixed amphetamine salts,34 and guanfacine.35 Whether these treatments can be generalized as safe and efficacious for comorbid adult ADHD/BD is unclear. Nonetheless, we suggest using bupropion first, followed by atomoxetine or guanfacine before you consider amphetamine stimulants (Algorithm 3).

Continued...
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