Are you being treated for the wrong condition?

by John McManamy


NEARLY one in five individuals with bipolar experience ADD (or ADHD). What we really need to be aware of, though, is that we don't have to have a full-blown ADD diagnosis to complicate our lives. Virtually all of us ("normal" people included) have attention problems of some sort. Thus, we all need to be paying attention - to attention.

ADD is not so much about attention deficit (as the name implies) as a failure in directing that attention. On one extreme, the brain may hyper-focus, say on a project, at the expense of awareness of the immediate world. On the other, the brain may under-focus, bouncing from one distraction to the next, failing to stay on task.

Either way, the consequences can be devastating, but throw bipolar into the mix and we find ourselves living extremely dangerously. Hyper-focusing on a project, for instance, may lead to losing a night's sleep, which may trigger mania. Under-focus, meanwhile, may lead to frustration and a sense of learned helplessness, which is an open invitation to depression.

ADD or Hypomania?

As well as a failure in directing attention, ADD (and especially ADHD) concerns a lack of ability to rein in impulses, which can look an awful lot like the dancing-on-tables behavior of hypomania. The twist is that with ADD we seem to be talking about an operational failure in the front, rather than the back, end of the brain, where thinking is engaged in a losing battle with impulse. 
To vastly oversimplify, in the ADD brain, executive function - which controls a range of vital cognitive processes such as working memory and attention - is decidedly underpowered. Stimulants, which enhance dopamine-signaling, act to boot up the brain's capacity to focus and process information. Chaotic thinking becomes organized. Of all things, in certain brains, stimulants exert a paradoxical calming effect, sometimes even aiding in sleep. 
Dopamine is also involved in arousal and pleasure and reward. Thus, low arousal and no sense of pleasure creates a need to self-stimulate and seek out novelty, typically by acting on a distracting thought. The result (not surprisingly) is socially inappropriate behavior. A drug that delivers the requisite dopamine power surge may reduce the need to self-stimulate and engage in risky behavior. Again, the calming effect. 
Unfortunately, too many with ADD self-medicate with dopamine-enhancing street drugs such as meth and cocaine. Much safer (major caveat further down) are prescription stimulants such as Ritalin or Adderall, which - when used correctly - deliver neither the instant high of street drugs nor create a dependency.

ADD or Depression or Fatigue?

"Fighting through the fog" is how those with ADD describe their attempts to achieve some form of mental clarity. ADD experts refer to "low arousal," where the reception - so to speak - fails to come in loud and clear. Whether depressed or fatigued or unable to focus, under-active dopamine circuits are the prime suspect. According to an editorial in the April 2007 American Journal of Psychiatry, titled, "Can't Get Enough of That Dopamine":  



Through their many connections, dopamine neurons participate in the modulation of expectation, reward, memory, activity, attention, drives, and mood - the very substrates of psychiatric illness.

But before you pop a stimulant down the hatch, we have the bipolar brain to consider, where the very opposite - over-arousal - may be going on. Over-arousal may ramp up stress, which in turn may sabotage our efforts in staying on task. Perhaps a stimulant may sufficiently boot up the brain's executive function to help bring order to the chaos. Or perhaps a stimulant may worsen the chaos, add oil to the fire. It's a crap-shoot. Who knows? 

Sorting Through the Mess

Confused?  Good - we need to be asking tough questions. "Is there any ADD going on with me?" is a good start. Over on the blog I used to do for HealthCentral, a number of my readers commented on the diagnostic chaos. For instance, from Joe, who four years earlier was diagnosed with bipolar II:

It was a year ago the psychiatrist and I zeroed in on the ADD. Ritalin came into the picture. It worked like a miracle. The obvious benefits were what it primarily functions as, a concentration aide. However, secondarily it helped immensely with energy, and as a major perk, helped elevate mood!  In other words it was the missing piece of the mood stabilizer. It lifted the lows to normal. Concentration and focus allowed my natural talents to shine and success followed.




Until fairly recently, ADD was regarded as a school behavior problem and was rarely recognized in adults. When a child acts up, the default diagnostic call is ADD or ADHD while bipolar tends to go unnoticed. With adults, the situation appears to be reversed. We get hit with the bipolar diagnosis and too many of us then endure years of heartache and frustration as our doctors tweak meds cocktails many of us have no business being on.

Too often, doctors are blind to the obvious overlap. According to virtually the only doctor who has addressed the issue, Charles Parker in his book, "ADHD Medication Rules":

In my practice we find very few patients with either/or, and many with yes/and: both bipolar and ADHD ... Many biologically based challenges can look quite mood disordered, and often don't become either cognitively or emotionally functional with typical bipolar medication fare.

Where there is co-occurring bipolar-ADD, Dr Parker recommends addressing the mood disorder first. Says Dr Parker: 

If stimulants and antidepressants can dysregulate the bipolar brain, start by correcting the cracks in the bipolar foundation first. ... Address ADHD only in sequence, after significant moods are successfully managed. Think emotions first, cognition last.



Dr Parker also cautions that a number of mood stabilizers (he specifically mentions Depakote) block the 2D6 metabolic pathway traveled by amphetamines. The backed-up stimulants may result in unpredictable moods.
Assuming that your brain can handle a stimulant, the resulting improvement can be spectacular. Gina Pera in her book "Is it You, Me or Adult ADD?" documents numerous accounts of loved ones reporting the overnight improvement in their partner's ability to concentrate, get through the day with far less drama, and connect with others. Nevertheless, Ms Pera cautions that if you think "you will enjoy substantive changes by simply taking a pill, that is delusional."
You know the drill: diet, exercise, sleep, stress management, mindfulness, support, every coping trick you can think of. (See the articles in the Recovery section.) Fortunately, most of you won't be rolling out these tools for the first time. Same skills, new situations.

Paying Attention to Attention

Unrecognized ADD could be what is holding you or your loved one back. A number of possibilities: Perhaps it's not bipolar but actually ADD. Or the two may be co-occurring. Or it could be bipolar with some attention-impulse issues, or, perhaps ADD with some mood-emotions issues.

It could be that successfully getting your bipolar under control has unmasked a whole new set of issues, ones you never even considered back when you spent most of your life depressed and manic. Things like: Being easily distracted, feeling jittery and on edge, not able to focus or stay on task, impulsively and mindlessly acting on the first thought to pop into your head, easily ovewhelmed by projecs, procrastination, difficulties booting up the brain (lack of mental clarity, lack of motivation), novelty-seeking (particularly doing stupid things) to give you a feeling of being alive.

Likewise, if you've been diagnosed with ADD (or suspect you have it), it's also important to watch for bipolar and mood-disorder symptoms.

When it comes to our own brains, we are the true experts. But we also need to be paying attention to our friends and loved ones (or ex-friends and loved ones, as the case may be). These are the true experts in how we drive other people crazy. Resist the natural urge to throw up your shield walls. Pay attention (yes, this part is really hard).

Take home message: In bipolar, if the ADD is not addressed treatment is problematic - frustration with meds, misdirected coping, no recovery. In ADD, if the bipolar is not addressed, same thing.
Be wise, ask questions, pay attention, live well ...

Sept 17, 2012, reviewed June 16, 2016


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