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ADHD and Bipolar: Controversy Explored at CorePsych Radio

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ADHD and Bipolar Disorder may at times ‘look’ similar, but the differences can spell big trouble for treatment strategies. Tune in to  the link at  CorePsych Radio to listen to this program on Thursday 4PM EDT, 1 PDT to tease apart the specifics.

The Diagnostic Challenge: Biology More than Psychology

Bipolar Overview:

  1. Remember Bipolar is a *Mood Disorder,*
  2. ‘Not’ Primarily *Cognition* ‘Not’ Primarily *Impulsivity*
  3. But often does demonstrate Cognitive Changes
  4. Can occur with ADHD

Consider these Biologic Contributions: All can look ‘bipolar’ until corrected or directly addressed

  1. Sleep
  2. Stress
  3. Drug Reactions: Stimulants used with Depression
  4. Substance abuse
  5. Malnutrition
  6. Immune conditions: Gluten/Corn
  7. PTSD
  8. Estrogen Dominance
  9. Industrial toxins, paints
  10. Thyroid
  11. Brain Injury

Bipolar I: Are these symptoms Mania or Depression?

  1. >Shopping - Differential from Depression
  2. Manic Shopping Objective: Shopping for the neighborhood
  3. Art Buchwald in Martha’s Vineyard
  4. Depression Objective: Shopping to fill the hole in my heart
  5. >Sex – Differential from Depression Impulsivity becomes cyclic and repetitive
  6. Manic: I will make everyone happy they need me and will remember me
  7. Depressed: I need them, I don’t care what it takes.
  8. >Sleep – Impulsivity and sleep disturbance often connected to both Bipolar and ADHD
  9. Marked sleep disorder does not absolutely mean Bipolar
  10. Can be associated with ADHD
  11. >Stress - Cortisol – Adrenal dysfunction

Bipolar II: The Refractory Depression: Cormbidity the key – Some frequent examples

  1. Comorbid ADHD
  2. Drugs and ETOH
  3. Watch for *Clint Eastwood Depression:* More Explosive
  4. Sleep Deprivation and Paranoia
  5. Post Partum Depression – Estrogen Dominance
  6. Differentiate from ADHD, but May Include ADHD

ADHD Differential: Always Consider ADHD

  1. Predominantly cognitive
  2. ADHD More contextual [related to the reality], but can deteriorate with stress and sleep issues to non contextual
  3. Bipolar Moods more explosive and dangerous
  4. Both Can have Associated Sleep problems
  5. School History
  6. Bipolar is less contextual, more out of the blue
  7. Bipolar moods often last longer
  8. Bipolar less apologetic
  9. ADHD and Bipolar Both Often associated with TBI

The Meds: We will Review Some Mood Disorder Med Details

See ya Thursday – outline in pdf at the CorePsych Radio link

cp

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15 Comments
  1. I have seasonal manic episodes in the summer and am also hyper the rest of the year. This started in my toddler years though. Before Lamictal, I would have to stop the Dexedrine and that would make the manias escalate faster and worse. I have skills to practice as well as klonopin for thunderstorm induced panic attacks and can take that or in the case of almost to the 72-hour hold point, I have Ativan and Haldol to knock me down. Benzodiazepines are useful for 6 weeks with me. I think they are excellent short term but are the worst long term. The irony is that since I have been on and off Dexedrine, post lamictal, it calms me down more and helps slow my thinking better, maybe because I am hyper. With those two, I only need klonopin before a thunderstorm.

    Now antidepressants landed me in the hospital numerous times because the megadoses of xanax, trilafon, lithium and dexedrine made them think I was depressed. The fact is that my diagnosis could be called “seasonal affective disorder” because since I was young, I had manic moods begin every summer, often off the dexedrine because the school year was over. I don’t deal with depression and it annoys me that the new DSM didn’t come out with a unipolar mania diagnosis. There are numerous journals that indicate that it is common.

    • Mat,
      With the complexity of issues you document here it’s easy to see how many facets accompany your mind challenges. Without a full on evaluation it seems quite trivial to shoot out a comment in the context of this complexity. It is quite safe to say, however, that you should do more biomedical testing, and consider serious IgG testing in addition to looking at D3 and seasonal change patterns.

      The hard part is reading through this brief summary and understanding – separating – “hyper” from “manic.” Generally speaking manic implies a mood elevation, hyper is associated more cognitively with decreased executive function.
      cp

      • I fully agree… I am glad that you specified that because that is exactly the difference. With mania, it is more like I am possessed or something and I even will go into full on psychotic episodes in that state and I feel omnipotent and every now and then paranoid, my last one was in 2007. That mood is literally a beast that takes you over and it feels like a drug,

        Hyperactive is my main state, without meds I mean… I tend to say things without thinking, I talk a lot and go on tangents but unlike when I am manic, I have breaks and I am not screaming. I lose my voice from mania after awhile. I also just do everything spur of the moment. I argue about everything just because it seems to be something that makes me feel a settled. Always in a rush, no patience etc. That is in no way anything like mania at all.

        I am definitely looking into that biological testing because I have been like this since I was five and almost every psychiatrist I have been to has said there is no way they could fathom giving this medication combination with what I describe (Bipolar I Disorder, always most recent episode manic, with psychotic features and ADHD hyperactive/impulsive type). I have had meds changed by some doctors that felt it was unethical but I flew into mania and even when that stabilized, my hyperactive and impulsive behavior at appointments would drive them nuts and when I went back to the usual combination, I was lucid, rational, mature and calm.

        • I will also note that I recall as a kid having EEG testing frequently during the evaluation and some other testing I forgot. I don’t consume a lot of gluten these days and I am glad something works for me. My hang up is taking short acting meds because I metabolize fast and had a liver enzyme test CYP I think. It verified that I burn through meds fast. I used to feel bad about having to get prior authorizations over and over for lower amounts of long acting meds so I assumed it was because they thought I was a druggie. That was part of why I had that liver enzyme test because my med doses have needed to be high and pharmacists feel odd giving out almost twice the recommended dose so she received a lot of calls so she had that test done to verify it. She told my pharmacy and they are polite and seem much less standoffish than before. I tried to get one of those local college eeg test studies for some ADHD thing where they pay you for your time and the head of the study said that he didn’t want someone on dexedrine in the study because it is more potent and the other participants were on Concerta, Adderall XR or Vyvanse and apparently Vyvanse has a much lower amount of the drug in it.

          • Mat,
            Those doing the study were significantly uninformed – and it shows how gossip can effect studies. Yes AMP is more efficacious than MPH for several important psychopharm reasons, but that exclusion makes no sense to me at this distance. Why take a good med out of a comprehensive study unless they were only studying MPH?

            That “druggie thing” is going on all over the world. Good care is completely denigrated while managed care collects dollars from you and me to keep the screws tightened down based upon the absurd, completely absurd idea, that all stimulant meds are the same with the same outcomes. A further point that “research” has little to do w real office experience. They perpetuate the denial dream. One “favorable” study can save them thousands of dollars and create havoc for those same unrepresented thousands of human beings. If that disparity were on our side, in medicine, we’d be sued for neglect.
            cp

        • Mat,
          Treating Bipolar comorbid w ADHD is, as you so accurately point out, a serious balancing act. So often overlooked are those contributory biomedical challenges – and if they aren’t corrected you can chase your tail for a lifetime. Not good. Nothing in medicine offers 100% guarantee, and biomedical testing fall under that cautionary umbrella. On the other hand some information is better than no information and complete denial.
          cp

  2. i havejust been to a conference on adhd and was told by a nurse practitioner (in uk ) that adhd can be treated before bipolar but psych that dx me said bipolar (2) needs to be treated first, who is correct?

    • Janette,
      With serious mood disorder it needs to be addressed first as the stim meds can seriously dysregulate thinking. But the NP is right, they certainly can be treated together… and if the moods are just that: moods, they may not be bipolar but a derivative of ADHD [even more common than bipolar] and treated first, successfully. Treatment failure means you got it wrong, it was bipolar – reverse the priority process and stay very close to the evolution to avoid catastrophic results.
      cp

  3. I would like to actually hear your presentation- but I can’t find a way through the website to where the individual podcasts are kept. I am quite happy to pay the purchase price – but dont want to join the site as amember for this one item.Can you provide a direct link? Is there something I missed?
    I dowant to push this on a little. My psych is very open to new ideas- and as I am a family paractitioner myself we are having some very valuable discussions on this point.
    Thanks
    Andrew

    • Andrew -
      The bipolar controversy is a big one, and those of us in the field, down in the trenches uniformly disagree with polemic encouraged by the research crowd… don’t give bipolar stimulants or antidepressants… those admonitions are such old news – confirmed by thousands of corrected folks who are grateful we took the higher road based on office evidence.

      I did drop you an off-line note indicating to you [and here to others] that we will have the CD available ASAP, just drop a line to use at CorePsych on the About page and we will keep you posted on the completion date. – It will be 10 solid hours of the latest on meds and differential dx with ADHD,
      Tnx
      Chuck

  4. Your point 2 fascinates me. As an adult who had 2 frankly manic episodes in early adulthood I found my underlying problem of ADHD completely missed because of preconceptions re my status as bipolar. My latest psychiatrist who picked the ADHD observes the association between bipolar and ADHD-but is struggling with my instinctive suspicion that my mania did evolve as a result of the challenges I faced with my ADHD.It appears that our enjoyable debate will continue for some time, courtesy of your material.

    • Andrew,
      Thanks for the confirmation from your personal experience.

      Again, as always, it’s important to not feel compelled to make it an ‘either/or’ dispute with polarized thinking. For your doc, if he/she only considered the possible comorbid condition of ADHD as causal with sleep disturbances and unrelenting cognitive anxiety, they could treat both for awhile and watch, as I have many times, the outcome over time. Many more times than not, it’s simply treating the unmanageable cognitive abundance – and the appearance of moods is gone, or at the least one needs an antidepressant with the stimulant and some sleep insurance.

      Do tune into CorePsych Radio for the next program on Sleep and ADHD – the program outline is there in the program notes page.

      Too bad this presentation is considered heresy by the Bipolar Believers – thrown out without a moments consideration.
      Tnx
      cp

  5. Many have defined Bipolar Disorder (manic-depressive illness) has been defined as a major affective mood disorder in which one alternates between the mental states of deep and brutal depression and embellished elation.
    These mental states can last for months in some bipolar disorder patients. These cyclical episodes are a catalyst for noticeable psychosocial impairment. Also, the episodes of both manic phases as well as depressive ones can last anywhere from weeks to months.
    Bipolar Disorder also affect’s one’s cognition, emotions, perceptions, and behavior- along with psychosomatic presentations (such as pain with depressive episodes, for example). It is thought to be due to a physiological dysfunctional brain in one affected with bipolar by many.
    The etiology for bipolar disorder is unknown. As many as half of those suspected as having a bipolar are thought to have at least one parent with some sort of mood disorder similar to bipolar disorder, which suggests a genetic predisposition may be present.
    Because of the complexity associated with bipolar disorder, greater than 50 percent of those afflicted are misdiagnosed as major depression, or perhaps schizophrenia.
    It is also believed that bipolar presents itself with symptoms associated with the definition of bipolar when one is between the ages of 15 and 25 years old. The disorder was entered in the psychiatrists’ bible, the DSM, in 1980, although bipolar disorder is thought to have existed for quite some time.
    Also, those with bipolar are thought to be in possession of heightened creativity during their manic phases, as well as they have accelerated growth of their neurons. This is not necessarily a bad thing, it seems. Conversely, those with bipolar disorder experience up to 3 times the number of depressive episodes as manic ones.
    Research has determined that as many as 15 to over 30 percent of bipolar patients commit suicide if they are left untreated, or undertreated. Also, as many as half of those affected with bipolar also have at times severe substance abuse issues along with their bipolar as well. Co-morbid medical conditions should be taken into consideration when evaluating one suspect of, or having bipolar disorder.
    Bipolar patients are also often experiencing anxiety issues that vary, and are treated often as a result of these medical issues. The disorder varies as far as severity goes- with some bipolar patients being more severely affected than others. In fact, there are at least 6 classifications of bipolar, according to the DSM.
    Bipolar patients are thought to be symptomatic half of their lives. As stated previously, the depressive episodes occur more frequently than manic ones. When symptomatic, bipolar patients are thought to be rather disabled, according to some, when in their depressive state in particular. The diagnosis has become more frequent recently. In one decade, the assigned diagnosis of bipolar rose from being about 25 per 100 thousand people to being 1000 per 100,000 people.
    Most diagnosed with bipolar are not diagnosed based on solid, comprehensive, or psychiatric review that is often absent of valid or standard diagnostic methods. Some believe as many as 5 percent of the human population may be affected by bipolar disorder- which may include as many as 12 million people in the United States. This is if the diagnostic criteria developed by others were to be fully utilized. An emphasis should be implemented by the health care provider to utilize available clinical evidence, and review this scientific literature.
    A subjective questionnaire called the Mental Status Examination is often utilized when diagnosing one suspected has having bipolar disorder. Many believe the diagnosis has increased recently due to the progressive treatment options now available. It is an argument of increased awareness versus over-diagnosis.
    Yet the diagnosis is vague, as children and adolescents are often absent in research with bipolar. Also, there is not any objective diagnostic testing to rely upon for bipolar. There is also a mental diagnosis of what is called mixed depressive disorder, which is one with depression who also has minimal manic episodes.
    Many younger than 18 years of age are prescribed atypical anti-psychotics as first line treatment, which is largely not recommended as treatment options. In fact, close to half a million of those younger than 18 years of age are prescribed the atypical anti-psychotic Risperdal alone, it has been determined. The class of medications overall is thought to be prescribed to about 10 percent of those non-adults thought to have bipolar.
    While not recommended, about a half of all those assessed as being bipolar are prescribed antidepressants, such as SSRIs, as first line treatment. It has been suggested that this class of drugs has decreased the risk of suicide attempts compared with other classes of antidepressants for close to 20 years.
    Yet tricyclic antidepressants have been determined to be efficacious in over half of those diagnosed with bipolar – with a greater amount of research behind this class of drugs. Furthermore, therapy with any antidepressants has been associated with what is known as treatment-emergent mania. This is when a bipolar disorder that is in a depressive state rapidly enters a manic phase. This occurrence can be unmanageable by the bipolar disorder patient.
    The most recognized treatments for bipolar long term are lithium (Ekalith or Lamictal- along with an anti-convulsant. Sugar intake is thought to vex the symptoms of one with a bipolar disorder as well.
    Atypical anti-psychotics have been prescribed for bipolar, which change some aspects of the brain, physiologically, as does the disease itself. In fact, one may argue the brain becomes more efficient due to both the disorder and the treatment with the atypical anti-psychotics. Yet many recommend the utilization of this class of drugs with bipolar disorder only if psychosis is present as well.
    As many as 15 percent of bipolar disorder patients diagnosed as such are prescribed an atypical presently. This class of medications may be particularly beneficial for those women who are diagnosed with bipolar who are pregnant, however.
    Lithium, which is essentially a very light metal with low density in which the salts are obtained for medicinal treatment, and an anti-convulsant are believed to be standard bipolar treatment, pharmacologically, studies have shown. This is due to Dr. John Cade and his examination with lithium and its benefits with those who have psychotic excitement close to 60 years ago.
    Ekalith is believed to be both neuro-protective as well as having an anti-suicidal affect in those believed to be bipolar- and is viewed as a mainstay as far as treatment for bipolar goes with many who treat the disorder. Lithium is thought to regulate the calcium molecule in the brain, so this and valporate are historically the medicinal treatment options preferred for those with bipolar disorder.
    Bipolar is difficult to detect, and is often diagnosed as major depression with many affected by this disorder. There is no objective criteria protocol available to utilize when assessing any patient believed to be suffering from any mental disorder. So such mental disorders that are diagnosed are ambiguous, yet that does not conclude that such disorders do not exist, such as the case with bipolar disorder.
    Yet perhaps a health care provider should be very thorough and knowledgeable when assessing a patient believed to have a mental condition such as bipolar. As should the health care provider keep in mind that the ultimate goal with this disorder is to stabilize the mood of the one affected.
    http://www.dbsalliance.org
    Dan Abshear
    Author’s note: What has been annotated is based upon information and belief.

    • Dan,
      I am leaving your lengthy note to underwrite the point of my presentation: much is know about Bipolar, but much is unknown. These postings are about dialogue, and while this is a bit of a ramble, you do have some good points. BTW I went in and corrected some of the spellings on the meds. I leave it here because it serves as a good example of the progress and pervasive challenges that continue with Bipolar.

      I do disagree with several points:
      1. Most importantly is the oversight, tho new information, that bipolar is downstream from many metabolic issues from toxins, drug reactions, sleep, ADHD, chronic depression, Immune dysfunction – most traditional docs don’t know this because they simply have not been introduced to it – thus this blog.
      2. ADHD is frequently called Bipolar when it truly simply ADHD. Why? Because, as Russell Barkley has so regularly commented on in excellent his writings on ADHD, the anger, irritation and affective impulsivity is so often coded out as ‘not appropriately identified under the rubric of ADHD.’ Said an easier way, anger is not in the current criteria for ADHD.
      3. Comorbidity and the various biologic challenges, [including Traumatic Brain Injury which you did not mention, but is quite frequently comorbid with mood swings] as noted in several posts on this site.

      Thanks,
      cp
      3.

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