Links Between Bipolar & ADHD
- Nov 9, 2024
- 6 min read
Updated: Jun 16
A presentation on Bipolar and ADHD by Dr. Ferguson from Edinburgh Adult Psychiatry.
November Meeting Summary: Bipolar & ADHD
At our recent all ages meeting, Dr. Ferguson from Edinburgh Adult Psychiatry delivered a very well-received talk on ADHD and the connections with Bipolar Disorder. An East Lothian NHS Consultant Psychiatrist since 2009, Dr. Ferguson has a special interest in the experience of Bipolar with ADHD (and to some extent Autistic Spectrum Disorder ASD) and shared with us his insights.
What is ADHD?
In short - a poorly focussing brain. It is relatively common, with a prevalence rate of around 5% in children and around 2.5% in adults (compared to around a 1-2% prevalence rate of bipolar in adults).
ADHD starts to manifest itself in childhood. There is a wide degree of severity (from mild, moderate to severe) and, rather like shortsightedness in children, it is very easy to overlook.
ADHD has a high degree of heritability - around 80% of cases are thought to have a genetic component. The malfunctioning of the prefrontal cortex part of the brain, where executive functioning or executive control are thought to be centred, gives rise to a number of clinical features.
Clinical Features of ADHD
A. Attention
Lack of Focus
The inability to focus thoughts can create a very busy brain for people with ADHD, described it as 'ceaseless mental activity' or 'thoughts are constantly on the go'. It can be a challenge in social settings, feeling like 'I can't focus when people talk' or 'too many conversations in my mind all at once'. A mind constantly wandering can make it difficult to read a book or watch a movie and cause sleep problems.
Hyperfocus
Those living with ADHD can get totally immersed in a task (like playing a video game, or doing a creative project). People with the condition frequently lose track of time. It is not unknown for those hyperfocused on something to forget to go to the loo, or are frequently late for (or entirely miss) appointments.
B. Executive Functioning
Time Blindness
Those with ADHD are often said to be "time blind" because they struggle with accurately estimating how much time has passed or predicting how much time something takes. Their internal awareness of time is impacted by challenges with attention, whether hyperfocused or easily distracted. This means people with ADHD are often late or rushing to events or appointments, or not doing anything else because they are afraid of losing track of time.
Productivity
There are frequently productivity issues for those with ADHD, especially around getting started on a task. Dr. Ferguson likened it to a person trying to get up and going on a Penny Farthing bicycle, whereas those without ADHD may easily get on and off a step-through bike.
It seems like those with ADHD need a sense of urgency to get started. If someone has three months to complete a thesis or dissertation, they will often leave it until the last week when they begin to feel the pressure of the deadline. In work environments, having someone who manages or oversees their work may be beneficial by providing a little pressure and creating that sense of urgency. Following Covid, the surge of adults seeking ADHD assessments is considered related to the transition from a structured work environment to working from home, as people with undiagnosed ADHD experienced a collapse in work effectiveness without someone supervising and keeping them on-task.
If starting a task is difficult with ADHD, so is finishing one. Someone who moves into a new flat and is still surrounded by boxes six months later, or takes everything out of a closet to reorganise but ends up with a pile of clothes everywhere instead may be dealing with the condition.
Disorganisation
Those with ADHD may struggle with organisation such as not remembering to pay bills, missing important deadlines, or putting thins in random places and forgetting where they are forgetting where they put things, often later found in random places (phone in the pantry, etc.).Planning (such as a holiday) left too late when flights have booked up, difficulty filling in forms etc. All are symptoms of difficulties with organisation.
C. Impulsivity and Hyperactivity
Fidgetiness
Those with ADHD often display signs of being fidgets. Toying with their rings, finger tapping, bouncing their leg, twirling their hair or pen clicking and twirling. Pulling hair from eyebrows or beard. Picking their skin or lips. All these signs can be indicative of a mind with ADHD.
Impatience
Finding it intolerable to be waiting in a queue, getting overly-frustrated being stuck in traffic, walking very fast, talking quickly or driving at inappropriate speeds. Signs, too, of possible ADHD.
Impulse Control
Features of difficulty with impulse control include: Rash spending, ill-considered decisions (such as getting a tattoo that's later regretted, getting into relationships/ having sex without much consideration, ending relationships, quitting jobs, binge eating or drinking or self-harming.
D. Emotional Regulation
Emotional Volatility
Those with ADHD can easily become frustrated, irritated, angry, overwhelmed, excited, or suddenly sad. This sudden reactivity and dysregulation plays a role in people with ADHD suffering burn out, as it takes significant energy to re-regulate emotions, in addition to the effort many people with ADHD are already exerting to navigate daily life.
Rejection Sensitive Dysphoria
Rejection or response to criticism both seem to affect those with ADHD more deeply than people without. Rejection or criticism feel bad for everyone, but somehow the negative feelings are often felt more acutely by those with ADHD.
The Consequences of ADHD.
Life with ADHD can feel like you are always swimming against the current. Experiencing academic or career failure is common and the launch into adulthood can be difficult. These challenges can have a negative impact on self-esteem, often with thoughts like "Why can't I just do this, like everyone else?"
Impulsivity, difficulty coping, and other challenges with ADHD can lead to self-destructive behaviors or create unhealthy environments. 30% of young prisoners in Scotland have an ADHD diagnosis. In addition, those with ADHD have increased rates of obesity, suffer from problem gambling, performance issues at work, and have stress in their relationships.
For those with ADHD, there is also a higher chance of experiencing additional mental health problems, such as ADHD and Bipolar.
ADHD and Bipolar
Comorbidity
Only around 30% of people with ADHD have it as a single condition without any other diagnosis. Comorbidity is when there is an overlap of mental or physical conditions. The statistics of comorbidity with ADHD shows approximately 21.2% of those of us with bipolar also have an ADHD diagnosis, and conversely, 19.4% of people with ADHD also have bipolar.
Misdiagnosis and missed diagnoses.
Some of the signs and symptoms of bipolar and ADHD can be very similar, and it's often possible that a psychiatrist may have a special interest in, say, mood disorders (such as bipolar), but have limited knowledge of ADHD and vice-versa. It often takes a psychiatrist who has experience and knowledge of both to spot the subtle differences.
Missed diagnoses are common. It is very easy for a physician to quickly zero-in on a diagnosis where the features of one illness are very apparent (such as hypomania) but miss the subtle signs that something else might be going on in the background.
This has of course a significant impact on the effectiveness of treatments, as bipolar and ADHD respond very differently to differing medications.
Treatments
ADHD generally responds well to medication which are most often stimulants. Although the number of drugs that are prescribed for ADHD might be limited in number, they are often very effective as treatments:
Methylphenidate (brand names: Ritalin, Concerta, Delmosart, Equasym, Medikinet).
Lisdexamfetamine (Elvanse)
Dexamfetamine (Amfexa)
Atomoxetine (Strattera)
Quanfacine (Tenex for immediate-release, Intuniv for extended-release)
However, for someone who also has bipolar, the order in which treatment is carried out can be really important. Whereas whether you put the milk in your teacup first or after you pour the tea doesn't really matter, it absolutely does for someone receiving treatment for both bipolar and ADHD. Also important to note that strong stimulants such as Ritalin can induce mania in someone with bipolar unless that person's mood has been stabilised by medication first.
Further Information
If you find you relate to the experience and challenges of ADHD and would like to learn more, Dr. Ferguson supplied us with self-report questionnaires that you and/or a family member can fill out prior to seeing a medical professional.
Should you wish to consult privately about bipolar and ADHD, you can reach out to Dr. Ferguson's private practice Edinburgh Adult Psychiatry.
Our community members had a very active Q&A session following Dr. Ferguson's presentation and demonstrates the significance of this topic for people with bipolar. We'd like to thank Dr. Ferguson again for sharing his expertise with us.
