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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 7 of 7. This is the beginning of the thread.
Posted by Libby on June 21, 2000, at 13:52:30
Has anyone out there been through the differential diagnosis of bipolar and ADD? I'd appreciate hearing your experience. How did you finally decide which
diagnosis was correct? Also, does anyone out there have BOTH these disorders? Are they coincident often?Thanks...
Libbby
Posted by Janice on June 22, 2000, at 0:03:25
In reply to Differential Diagnosis: ADD - Bipolar II, posted by Libby on June 21, 2000, at 13:52:30
hi Libby,
yes, lucky me, I have both. It's not uncommon at all to have both disorders. I am going to go to find an article about how to differentiate between ADD and bipolar. In case I don't come back, this would mean I didn't find it. From my personal experience, bipolar has alot more anger than ADHD. ADD people may flip out, but from what I experience from my family (who all have ADD but no bipolar), they very quickly get over it. But bipolar people--well I could stop talking to livin boyfriends for 3 days over nothing. The rage was incredible.anyway, I'll go look for the article, Janice
Posted by Janice on June 22, 2000, at 0:07:39
In reply to Differential Diagnosis: ADD - Bipolar II, posted by Libby on June 21, 2000, at 13:52:30
Bipolar Disorders (296) vs. Attention Deficit Disorders (314)
Superficially, individuals with 296 often are Hyperactive, Impulsive, and Inattentive; of course, individuals with 314 are also often Hyperactive, Impulsive, and Inattentive! During the course of an interview of any such individual it may be in fact impossible to determine the difference simply on the basis of their mental status features at that time.
Further confounding the matter is - often - the Family History. While Bipolar Disorder, under it's old name "Manic Depressive Disorder," was frequently applied to adults/parents in the past, A.D.D. is a relative newcomer to the adult diagnostic field, and so will very rarely have been previously diagnosed in an older relative. In fact most commonly one finds the next older generation, if diagnosed at all, considered Bipolar despite symptoms which sound precisely like A.D.D.
Another problem is emerging evidence that some individuals have BOTH! By the age of 35-40, as many as 85-90% of all people with A.D.D. have some clear mood disorder, and of that group about 5-7% appear to have Bipolar I or Bipolar II. Of course some people with clear Bipolar I or II also have A.D.D. These are not mutually exclusive diagnoses!
It is of considerable importance to do our very best to tease out which is which whenever possible, since treatment for the wrong condition OFTEN aggravates symptoms of the primary disorder.
In certain areas, "proponents" of 296 have circled wagons and are now in "camps" which reject any or all concept of A.D.D. as a viable/valid condition. We also see emerging some 314 circles denying the existence of Bipolar or at least arguing most people carrying the diagnosis are actually A.D.D.!
Please review the following guidelines with great care, and in every case consider yourself a neutral clinician whose only mission is to be careful and accurate in diagnosis! We do not want to make mistaken diagnoses of either condition! In fact we work in a Clinic which treats people with 296, 314, and BOTH 296/314. The idea is to do it right!
Onset of Symptoms
In ADHD, this is typically very young: ages 2-6. When a child has been regarded as "Hyperactive" during the years 2-6 by Grandparents and Day Care staff, then ADHD is a primary diagnosis until proven otherwise.
In Bipolar Disorder, it is indeed possible to see symptom development in very young children, BUT THIS IS VERY UNUSUAL. Most individuals with 296 are described as relatively "normal" in mood and activity level (especially) until early adolescence.
Extreme Reactions to Frustration
In general, the earlier the onset of VERY EXTREME temperamental reactions to even minute frustration, the more likely Bipolar is a major diagnostic consideration. This is a very consistent feature in the history of many adults with clear 296, but inconsistent in children with ADHD.Exceptional Overactivity Early In School
This is in fact rather uncommon in the history of people with 296. It is common in people with ADHD. Restlessness, in and out of seat, up and down, disorganization, inattention, and disruptive behaviors are typical of ADHD children, but not Bipolar children, whose symptoms at that age (5-10) typically are far more emotional and temperamental.Difficulty with Transitions vs. Changes
A child who reacts with emotional difficulty to any "transition" tends to be one with ADHD. A "transition" is defined as going from one reasonably expected activity to another, e.g from one class to another. A "change" is a MAJOR stress, such as from one school or area to another. Individuals with 296 consistently experience aggravation of symptoms when sleep-deprived, or when confronted with unusual stress/changes. Children and adults with ADHD usually have aggravated symptoms during almost any transition period, no matter how minor. Remarkable overreaction to a major change may be symptomatic of 296.The Mood Disorder is Different
Individuals with ADHD have "mood swings" as they age which vary from High to Low, Euphoric to Depressed, by the HOUR (even the MINUTE!) or by the DAY. These "mood swings" are responsive to external events. While they are also "internal," the defining characteristics of mood swings in people with ADHD is an exaggerated response to external stimuli, and extreme rapidity of changes in
these moods - from hour to hour or day to day. When "down in the dumps" /depressed, a typical individual with an ADHD related mood disorder called by a friend to go bowling that night and maybe meet some interesting people tends to say "Yeah, cool!" and feel better right away. A person with true 296-driven depression tends to say "I don't feel up to it".
In effect, people with 314 have what we call "mood lability" which is very rapid and variable from hour to hour and substantially influenced by external influences. People with 296 have much less rapid mood cycles which are much less influenced by external events or stimuli: when "up" they tend to stay "up" for days or even weeks despite many failures, and when "down" even exciting and typically interesting things no longer appeal to them.296 Has A Cyclic Character
A defining feature of Bipolar Disorder is, of course, a pattern of cycles of mood changes over time, over years, and with little or no influence by external events apart from sleeplessness or major change tending to precipitate a "manic phase." The same exact events in a person with ADHD, on the contrary, usually leads to what we call ADHD "shutdown:" withdrawal, hypersomnia, sloth, indolence, and lethargy.
314 never by itself has a cyclic character; in fact spouses of people with 314 report the "mood swings" are almost completely unpredictable, except when the ADHD individual is faced with an extraordinary frustration, whereupon he/she (usually he) "explodes," going from minor frustration (molehill) to the top of Mt. Everest in a microsecond.
An exceptionally important difference between the mood swings in ADHD vs Bipolar is this: within minutes, the individual with ADHD is again ranting and raving and blaming others but calmer, i.e. heading back toward the base of the mountain, while the patient with Bipolar is still up there and sailing from one peak of irrational thought and behavior to another. In people with 296 this kind of mania is sustained and perpetuated, while in people with 314 it is momentary, brief, and in many cases followed by an apology: "Sorry, Honey, I kinda flipped out."
Typically, the individual with 314 acknowledges (grudgingly) he/she just might have - shall we say - kinda "overreacted." On the other hand, the individual with 296 typically never displays any such insight and usually continues their out-of control behavior with very clear manic and grandiose overtones over hours, days, even weeks. People with ADHD can usually "calm down" and recognize their overreaction, while this insight is usually unavailable to people with Bipolar Disorder.
Mood "Elevations" in 314 Rarely Include Real Euphoria
In fact while acting "high" a person with A.D.D., although being very grandiose, bragging, intense, and intrusive rarely sustains a "high" mood of this kind for long, usually for minutes rather than hours, and hardly ever for more than a few hours: in Bipolar Disorder these periods of excitement and euphoria are usually sustained for several days, and sometimes for weeks.
In patients with A.D.D. these "highs" usually lack the wild, "over the edge" and/or "driven" excitement and hyper-intense projections of a patient with Bipolar Disorder. Usually one may detect very logical patterns in the train of thought of people with A.D.D., while during an interview with people with Bipolar/Manic stage it is difficult or even impossible to follow their logic, and the ideas and plans usually sound much more grandiose, far more illogical and impractical, and sometimes clearly psychotic.
"Lows" Are Briefer in 314
This is incredibly important! In terms of symptom description, these episodes of "Depression" may be precisely similar to those seen in other patients with Bipolar and/or Major Depression, but in patients with A.D.D. they are brief, often in response to external stress, and while intense usually limited to a few minutes or hours: almost never to days. People with A.D.D. are "just as moody," but far more responsive to external stimuli (frustrations and disappointments) than they are to internal cycles. In effect, "life seems worthless" to people with both conditions, but in those with A.D.D. these episodes are brief (minutes or hours) and in patients with Bipolar Disorder sustained over many days or weeks.
In most adolescents and adults with A.D.D., the level of depression is much less, and the condition tends to look more like Dysthymia than full-blown Major Depression. The "down" episodes are not so severe, and are more influenced by external events (in both ways -"depressed" because a boyfriend cancels a date; happy and excited again a few hours later because another boy calls and asks for a date!).
The mood disorder is usually, in adolescents and adults with A.D.D., relatively chronic, sustained over months or even years! extremely variable and often predictable given external events. In adolescents and adults with Bipolar Disorder there is much less response to external stimuli, much less day-to-day variability, and episodes of depression tend to be deeper and much longer. The pattern over time of these mood changes is usually very significantly different.
When confronted with an answer of "no," people with A.D.D. tend to argue and object. People with Bipolar Disorder buy the company which is denying cooperation, insist upon getting their way, stay up all night developing new schemes, and keep insisting upon more and even more elaborate schemes to develop alternatives.
Typically an adult with A.D.D. forgets what she/he was so intense about by the next morning, while an individual with Bipolar Disorder in a manic phase may be up all night developing new ways to promote his/her scheme and be even more hyperintense about it the following morning.
The Sleep Disorder Is Different
Adults with A.D.D. typically are like the Hare in a race with the Tortoise: they "go" at full speed in "bursts" of four, six, or 12 hours, then "crash." They may act very "manicky" and driven during this time, but their history reveals this is a very well - established pattern, has gone on for many years with only minor variations, and is a daily routine. The very intense effort and activity is then, in adults with A.D.D., followed by a "crash" that evening (very much like the Hare). People with A.D.D. alternate between speeds of 100 and zero EVERY DAY!
Consequently their daily sleep pattern tends to be fairly regular and predictable, especially to their spouse, and it does not vary much from month to month or year to year. At least 40% of individuals with A.D.D. have, since late childhood, difficulty falling asleep and lethargy upon awakening. Many have sought remedies for "insomnia" for years. In their case the complaint consistently refers to difficulty getting to sleep because of the myriad "thoughts" they have in the evening.
People with Bipolar Disorder tend to have prolonged periods of hypersomnia when depressed, and of course repeated episodes of extreme energy seemingly eliminating a need for sleep for periods of many days, or reduced sleep for weeks, when in a manic phase. While it is very uncommon for an adult with A.D.D. to experience intense excitement lasting for more than 6-12 hours, these episodes in adults with Bipolar Disorder may last for well in excess of 48-72 hours.
In effect, the sleep pattern is usually markedly different in people with A.D.D. vs Bipolar. It is very rare for any patient with A.D.D. to experience sustained hyperarousal over a period of days, and it is unusual for a patient with Bipolar Disorder to report a regular - over years - pattern of intense hyperfocus and effort during the day and long episodes of nocturnal sleep. In most individuals, the sleep/arousal pattern alone suggests a diagnosis of 314 vs 296.
Summary1. OBSERVABLE SYMPTOMS: Often identical: Hyperactive, hyperfocused, intense, grandiose, temperamental. In 296: psychotic projections are common and grandiosity is usually substantial. In 314: psychotic projections are rare, grandiosity minimal.
2. AGE OF ONSET: In 314: ADHD evident by ages 3-6. In 296: rarely evident before mid-late adolescence.
3. EARLY SYMPTOMS: In 314: Hyperactivity, inattention, severe impulsivity. In 296: Fierce, extreme reactions to even minor frustration more commonly confused with oppositional Defiant Disorder. Violence is more common also.
4. HYPERACTIVITY IN SCHOOL during ages 5-10: 314: a very common complaint. 296: rare.
5. TRANSITIONS and CHANGES: 314: difficulty with any transition is common in history. 296: intense symptom onset after a MAJOR change is common, but rarely related to routine transitions.
6. MOOD DISORDER: 314: "Highs" and "Lows" tend to occur hourly or daily, usually influenced by external events. "Highs" are very rarely really euphoric, and are brief - rarely more than a few minutes or hours. "Lows if are also brief. 296: A defining characteristic is the persistence of an intense, "High" mood over a period of at least several days, and many would argue at least a week. This is very, very uncommon in 314.
7. SLEEP DISORDER: 314: daily variation between hypersomnia and insomnia. Problems getting to sleep followed by difficulty in arising. 296: persisting insomnia with accompanying excitement and intense hyperfocus often over days or even a week or more with little sleep. When this phase is over, individuals with 296 may have periods of hypersomnia and reported depression lasting for many days or weeks. Cycles of this kind are very rare in 314.
8. MEDICATION RESPONSE: usually, an individual with 314 feels more "relaxed" upon being given a stimulant medication. This is very rarely the case in anyone with 296. Lithium or Depakote may, of course, help the mood disorder in anyone - regardless of diagnosis. Stimulants may improve concentration and focus in anyone; positive response does not make a diagnosis!
Individuals with 296 will very rarely feel more relaxed and able to cope with stress when given a psychostimulant, while this is almost universally true of adults with 314.
Posted by Libby on June 22, 2000, at 9:00:22
In reply to Differential Diagnosis: ADD - Bipolar II, posted by Libby on June 21, 2000, at 13:52:30
Thanks Janice. I don't have the kinds of rages they describe as Bipolar. I tend to build up, explode, then realize I flipped out and apologize. Given a short time to calm down, I always realize how out of proportion my response was and feel ashamed I got so out of control.
On the other hand, I don't have a history of school problems, which seems to be one of the major ADD criteria. However, I do have a history of problems at work, which have gotten progressively worse over the years, due to my extreme impulsivity and inattention. I have a reputation as unreliable to both my family and my coworkers.Could I ask how long you have had both diagnoses,
what meds you are on, and if you wouldn't mind
answering... what quality of life are you looking forward to with treatment? Also, are you rapid cycling? Both ADD & Bipolar diagnoses are new to me. I'm really afraid of the Bipolar label.
ADD seems more "acceptable" to me. Did you ever
feel like that?Thanks, L.
Posted by Janice on June 22, 2000, at 23:05:10
In reply to Re: Differential Diagnosis: ADD - Bipolar II, posted by Libby on June 22, 2000, at 9:00:22
>Hi Libby,
I notice when I read those descriptions of ADD, they still tend to concentrate on the aggressive little boy version of ADD. I never had a history of problems in school. In fact I was in the gifted class, daydreamed my time away, very rarely did homework, worked hard to be invisible and succeeded.
I've had the bipolar diagnosis for 7 years and have been treated for the ADHD for about 2 years. I currently take 900mg of lithium and Topamax for the bipolar, and Dexedrine (as needed) for the ADHD. The only thing I am afraid of is never finding treatment for the depression, as I do have the rapid cycling type of bipolar which is very difficult to treat. So quality of my life in the future = amount of depression I'll experience.
like you Libby, I'd pick the ADD over bipolar. But ADD with depression would be a pretty fierce competitor to misery. Actually, I'd pick anything that could be successfully treated.
Perhaps you have ADD, and it has become worse with depression.
If you have anymore questions, please ask, Janice
a good way to help discern which disorder you could have would be to examine the medications you've tried and to look at the reactions you've had with them.
Posted by Libby on June 27, 2000, at 14:09:25
In reply to Re: Differential Diagnosis: ADD - Bipolar II, posted by Janice on June 22, 2000, at 23:05:10
Hey Janice...
>The only thing I am afraid of is never finding >treatment for the depression, as I do have the
>rapid cycling type of bipolar which is very
>difficult to treat. So quality of my life in
>the future = amount of depression I'll
>experience.I'm taking a TOVA on Monday, which should tell me about the ADD. He's already begun treating me as Bipolar II - Rapid Cycling. Depakote and a lower dose of Effexor XR. The only change I feel is the depression closing in again. I can't tell the Depakote has improved a thing I'm not sure I understand the philosophy behind medicating me so my moods don't "cycle" when NOT cycling leaves me so depressed. I am depressed, to some degree, every single day.
I think that no matter what my doc says, I am going to do a trial with Wellbutrin, the lower dose of Effexor, and perhaps the Depakote. The studies I've found say that stimulants will improve anyone's ability to focus and since Wellbutrin is a stimulating AD and I have an old supply onhand, I figure it's worth a try.
It may not be ideal to try it myself, but if it works, I may be able to take Wellbutrin instead of Depakote. If the Wellbutrin worsens my symptoms, then it strengthens the case for hypomania & Bipolar II. I discussed this idea with my doc and he said it was "intriguing"
then prescribed the Depakote.Wellbutrin and see if that helps than be on Depakote for the rest of my life, especially if I don't need it.
>Perhaps you have ADD, and it has become worse >with depression.
Maybe so. This has been my third major depressive episode, but the first two weren't like this. A little Prozac, a little therapy,
& no more problem. This time, no matter what I try, there are side effects that leave me non-functional. I don't want to start battling Bipolar II unless I'm pretty convinced that's what I have because more drugs => more side effects.> If you have anymore questions, please ask, Janice
>
> a good way to help discern which disorder you could have would be to examine the medications you've tried and to look at the reactions you've had with them.This is the hard part because I don't know what happy is "supposed" to feel like.
Posted by Janice on June 29, 2000, at 23:31:36
In reply to Re: ADD - Bipolar IIJanice, posted by Libby on June 27, 2000, at 14:09:25
Hello Libby,
Great to see how busy you've been. I have to say I admire your spirit and facing all of this head on.
I'm taking a TOVA on Monday, which should tell me about the ADD.
•Sometimes it seems like it's just a matter of listening to and adding up all the clues…the Tova test, the medications to see what you have
He's already begun treating me as Bipolar II - Rapid Cycling. Depakote and a lower dose of Effexor XR. The only change I feel is the depression closing in again. I
can't tell the Depakote has improved a thing I'm not sure I understand the philosophy behind medicating me so my moods don't "cycle" when NOT cycling leaves me so depressed. I am depressed, to some degree, every single day.•that is often the catch 22 with treating bipolar II - you flatten the mood and sometimes you get a depressed person, sometimes worse off than before. Treatment can become complicated for some people when they try to get their moods above depression without cycling.
Generally speaking rapid cyclers don't always do well on anti-depressants, some do very, very poorly on them. I am a bit surprised he put you on Effexor.
Libby, it sounds like you have alot of plans and some hope for getting better. I would love it if you would keep me up to date with how you are doing. Maybe if the results of the Tova tests suggest ADD, your psychiatrist could let you try some medications for ADD.
Take very good care Libby,
Your friend, Jance
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