From Current Psychiatry Online at http://www.currentpsychiatry.com/article_pages.asp?AID=5051&UID=

Vol. 6, No. 6 / June 2007

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

Aliza P. Wingo, MD  Adult psychiatry 3rd-year resident, department of psychiatry and behavioral sciences 

S. Nassir Ghaemi, MD, MPH  Associate professor of psychiatry and public health, director, Bipolar Disorder Research Program, Emory University, Atlanta, GA 

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:

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  discuss how to differentiate between these disorders with overlapping symptoms

  
  
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  provide tools and suggestions to screen for BD and adult ADHD

  
  
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  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:

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  9% to 21% of BD patients may have adult ADHD^2,4,5

  
  
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  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:

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  identifying which symptoms are caused by which disorder can be difficult

  
  
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  BD tends to be underdiagnosed⁹

  
  
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  patients often misidentify, underreport, or deny manic symptoms^1,10,11

  
  
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  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.

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