April 27, 2023

Is it ADHD? Or Bipolar? Could It Be Both? What. Is. Going. On.

Dr. Kelly Ryan was interviewed for this article that appeared in Mental.

Link to the original article. 

When I cycled through episodes of feeling so depressed and hopeless I could barely get out of bed with periods of euphoria, energy, and super creativity all within the same week, I thought I was going crazy. When my brain felt so cluttered that I couldn’t organize any one thought or bring myself to concentrate on a single task for longer than 10 minutes, I thought it was a failed personality trait I was stuck with for life.

Turns out, I am crazy—I have bipolar 2 and ADHD. I’m on a cocktail of medication that is working, but it took years of trial and error, frustration, tears, and feeling helpless. I finally found a solid mental health care team who helped me reach these diagnoses, but getting here wasn’t easy. Now, I understand why: Bipolar 2 and ADHD share a lot of the same symptoms, and they are often clinically hard to distinguish from each other.

Sure, medical professionals use the Diagnostic and Statistical Manual of Mental Disorders (DSM) to diagnose mental illnesses based on listed criteria and assessments with patients, but, there aren’t hard-and-fast tests or exams to reach a specific diagnosis.

Of ADHD and bipolar 2 specifically, “there’s just so much overlap,” says Kelly Ryan, Ph.D., a clinical neuropsychologist and associate professor of psychiatry at Michigan Medicine. “If you don’t have a psychiatric provider who understands both, it may be harder for them to really flush out. There’s probably a lot of misdiagnosis.”

To complicate things more, these two disorders can exist together in the same person—that’s what experts mean when they say you have “comorbid conditions.”

Treating this combo requires careful evaluation and medication management and, as always, we encourage you to speak with a mental health pro if you’re struggling, since these things are always so individualized. But here, we dug into the commonalities to help you parse between these two mental disorders.

Let’s Start With Definitions

We heart TikTok for blowing open the convo around mental health (and if you’re not following Mental there, give us a watch!), but misinformation is rampant. Self-diagnosing via social media is not a substitute for clinical assessment and treatment, and just because you identify with certain symptoms of ADHD or bipolar, you might have one or the other, none at all, or both!

To understand the nuances, let’s break ‘em down.

ADHD. It stands for attention-deficit hyperactivity disorder, which can be a bit of a misnomer, particularly in women. Yes, one of the key signs is a persistent inability to focus and concentrate in a way that interferes with everyday functioning, but ADHD diagnoses in women have lagged because women’s symptoms are often internal, not external. They can include what appears to be daydreaming, issues with self-confidence, a deep distaste for boredom, intrusive thoughts, and a hard time motivating. There is also growing research that identifies emotional dysregulation—where you have a hard time regulating your emotional responses—as a core component of ADHD, although this isn’t listed as an official diagnostic criteria in the DSM.

Bipolar 2. Bipolar disorder is a class of mental illness that includes bipolar 1, bipolar 2, and cyclothymic disorder. Bipolar disorders involve intense emotional swings, a cycle between depression and mania. While people with bipolar 1 have full-blown mania (you might engage in risky behavior, function on zero sleep, have racing thoughts), bipolar 2 presents with a milder version called hypomania, including elevated moods or feelings of elation—or, as an example, racking up a couple hundred dollars of credit card debt vs a couple thousand.

ADHD and Bipolar Like to Share (Symptoms, That Is)

Blood tests can ID anemia, and an MRI can show brain tumors. But mental disorders have less diagnostic clarity—and the crossover of symptoms between ADHD and bipolar disorder makes that even trickier. A dive into a few traits they’ve got in common…

Mood Changes
The intense emotional states of bipolar disorder and the emotional dysregulation of ADHD are like Taylor Swift and her doppelgänger Ashley Leechin: often mistaken for each other but clearly not the same. Specifically, hypomania can include feeling irritable or quick to anger, which is one way emotional dysregulation presents. About 70 percent of adults with ADHD report symptoms like low frustration tolerance, irritability, and rapid changes in mood, according to a meta-analysis published in BMC Psychiatry.

Hyper Behavior
The hype is real: Both hypomania and hyperactivity can include talking excessively, interrupting others, and being impulsive. When someone is in a hypomanic state, they can feel like they’re running on a motor, one that requires little sleep. It’s easy to confuse that with feeling hyperactive, where you can’t stay still, need constant movement, and fidget repetitively. While the hyperactivity found in ADHD shows up more in kids, it can carry into adulthood.

There’s a reason that old “squirrel—look!” stereotype exists: Easy distraction is a core component of ADHD, particularly with inattentive ADHD, and that can include being forgetful and having trouble listening. Distractibility, as it’s called, is also present in bipolar 2, although it’s less clear-cut.

Every person with bipolar 2 experiences their emotional states differently, and as with other forms of depression and anxiety, it’s hard to pay attention when you’re feeling depressed, hypomanic, or in a mixed state. But generally, people with bipolar 2 report going through stages where they feel like they can’t focus or pin down just one thought.

Genetic Component
Both conditions are highly genetic, and research suggests that ADHD and bipolar disorders are passed down from family members. The American Psychiatric Association states that 80 to 90 percent of people with bipolar disorder have a relative with bipolar disorder or depression, and one small study observed that nearly half of the parents who had kids with ADHD also had ADHD. Personally, I can tie ADHD and bipolar disorder to both sides of my family (tysm, mom and dad!).

3 Things That Set ADHD and Bipolar Apart

Confused yet? Yep, we get it. Another example of why details matter! Check out these nuances.

The biggest difference between the two disorders is that ADHD is persistent, while the mood fluctuations in bipolar 2 are episodic. “ADHD is a chronic, pervasive condition,” explains psychiatrist Po Wang, M.D., a clinical professor of psychiatry and behavioral sciences at Stanford University School of Medicine. “They might [be distracted] more with doing one thing versus doing another thing, but those symptoms are basically present all the time.” This is especially true if you have inattentive ADHD.

Bipolar 2, by nature, is cyclical. Although people with bipolar disorders do have a baseline where they feel “normal,” they experience depressive and manic or hypomanic episodes that can last for up to days at a time. “With bipolar 2, you’ll probably see more difficulties with attention during the depression phases or during those hypomanic [episodes], so it may not be this persistently low attention,” says Dr. Ryan. It’s equally hard to focus when you’re in a depression fog or a hypomanic state with racing thoughts.

Age of Onset
Although some people don’t get diagnosed with ADHD until adulthood—particularly an issue in women, where it gets overlooked in childhood or misdiagnosed as anxiety—ADHD develops when you’re young.

“ADHD is a neurodevelopmental disorder,” Dr. Ryan says. “We see problems with it as a child, and that sort of persists throughout one’s life.” Symptoms include frequent daydreaming, talking impulsively, constant fidgeting, and getting feedback from parents and teachers about being easily distracted or not delivering work on par with your potential.

Although I didn’t get an ADHD diagnosis until I was 32, this clinical label was a lightbulb moment that explained issues I had struggled with for as long as I could remember: my room constantly being a mess, losing important items, having zero time management and always running late, procrastinating, not being able to sit down and hone in to school work for more than 10 minutes, going from all honors classes to barely making Bs and Cs… The list goes on.

In contrast, the average age of bipolar disorder onset is 25, according to the American Psychiatric Association. Bipolar disorders can occur when someone is young, but it’s not super common, and bipolar 2 usually starts to present in the late teens and early 20s, says Dr. Wang. This tracks with the severe mood ebbs and flows I started experiencing in my mid-20s.

The Way Depression Manifests
Depression and anxiety are also common in both disorders (insert face-melting emoji here). The biggest diff is that they’re secondary in ADHD. It makes sense: Regularly feeling inadequate or like you’re failing at work or school thanks to executive function problems can spawn nervousness or “I suck” thoughts.

“When people have inattentional problems because of ADHD, they get frustrated in their life. They get upset,” Dr. Wang says. “And then you can get mood symptoms or anxiety.”

In bipolar 2, however, major depressive states are a core component, not typically tied to a stimulus or explained by a life event. These moods just happen—they’re unpredictable. Whenever I’ve had depressive episodes, I can’t trace it to anything in particular; I just know I feel hopeless and helpless and unclear why I feel that way.

It’s totally normal if you can’t pinpoint exactly when your symptoms started, says Dr. Wang, especially as they progress into adulthood. You may not remember all of the difficulties with attention, hyperactivity, or impulsivity you experienced as a young pup, or when mood changes became noticeable.

That’s the job of your clinician! Providing a thorough-enough assessment to establish a timeline of symptoms so you can then determine what’s causing depression, says Dr. Wang. Is it persistent, ADHD-style—for instance, not feeling productive or like you can’t keep up with peers? Or is it up and down, as it is with bipolar 2? This is why a good psychiatric pro is so essential.

Double Diagnoses

Now that we’ve cleared up a bit of the confusion, time to introduce more! JK, but it’s true that a person can have both mental disorders at the same time (*raises hand*). In fact, some research points to a comorbidity as high as 20 percent for ADHD and bipolar disorder (FYI, this is for all bipolar disorders, not bipolar 2 specifically).

My path to both diagnoses was a long and windy road with many obstacles (seen Olympic hurdle-jumping?). After years of research and trial and error, I suspected I had bipolar 2 rather than the unipolar depression I was diagnosed with at age 14. I had to strongly advocate for myself and visit several psychiatrists until I found someone who believed the complexities of all my symptoms. I started taking medication for bipolar 2 when I was 28 (the mood stabilizer lamotrigine for hypomania, and the atypical antipsychotic Latuda for bipolar depression).

Since I write about mental health for a living and had done plenty of research on ADHD, I slowly started to suspect I had that, too. When my negative symptoms tied to ADHD got so bad that they were nearly destroying my life and causing distress, I knew I needed to get help. I finally found a reliable psychiatrist who performed a full assessment for ADHD, and I was prescribed the stimulant medication Vyvanse at age 32.

Treatment for Two

If ADHD and bipolar 2 do exist comorbidly in your body, too, treatment always requires a careful assessment and often a delicate balance of medication. For ADHD, you may be prescribed a stimulant, such as Adderall, Vyvanse, or Concerta, which increase the levels of neurotransmitters in your brain and help improve attention and executive function and control impulsive behavior. However, these medications can also trigger mania/hypomania in those with bipolar disorder. Yeah.

Bipolar 2 is typically treated with a combination of mood stabilizers and antipsychotics. While antidepressants can help with depressive episodes, they don’t address hypomania and may, in fact, trigger hypomanic episodes. Yeah again.

This is why managing ADHD and bipolar 2 at the same time is highly individualized and depends on your particulars. Some people do well with a stimulant; for others, it can be disastrous.

Still others initially feel good on stimulant medication, but then quickly deteriorate, says Dr. Wang—going from being productive to getting too amped up and overly irritable, their mood fluctuating so quickly that it starts causing problems with daily activities and relationships. This would require changing up the medication and parsing through symptoms again to find a more effective treatment plan.

When I was prescribed a stimulant, my psychiatrist was concerned it would trigger a hypomanic episode, so he closely monitored me and made himself reachable 24/7. Luckily, it didn’t happen, and I’ve been doing well on this medication.

If all of this complexity sounds overwhelming, remember this: While these mental disorders, individually or together, can indeed cause major major life disruptions, treatment is very effective. With the right medication, you can be happy, successful, and productive, even if it doesn’t feel like it right now.

Psychotherapy can also be hugely beneficial; Dr. Ryan recommends cognitive behavioral therapy specifically for bipolar disorder and ADHD, because CBT helps you change negative thought patterns and manage emotional dysregulation.

Beware misinformation on the socials, as always, and know who you’re following: Are they a trusted media source that relies on studies and experts, or a professional themselves? Look for credentials. “Clinicians are not self-trained; we don’t just read a book and go, Oh, I think I know everything about bipolar and ADHD,” Dr. Wang says. “We have to see a lot of patients, we have to see a lot of cases, a lot of different permutations. And those subtleties make a big difference.”

What is helpful from the increased convo on social is the focus on advocating for yourself—something Dr. Wang believes is key. “I think that having an illness that could be treated, and not recognizing it, and not getting treated, is really a disservice,” Dr. Wang says. “Plenty of people struggle. They just sort of suck it up and think it’s some kind of thing they’re just not working hard on. Understanding that maybe you are trying hard enough and there’s something that you need help with, that’s the thing.”