296 vs 314

 

This brief paper will attempt to succinctly review HOW TO DETERMINE THE DIFFERENCES between Bipolar Disorders (296.‑‑) and 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.

 

SUMMARY:

 

1 ‑ 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. (see accompanying graph.)

 

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.

 

Corydon G. Clark, M.D.

Medical Director A.D.D. Clinic, Inc.