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Attention Deficit Hyperactivity Disorder

ADHD or Bipolar

03/14/1999

Question:

How much overlap is there between ADHD and Bipolar Disorder? My caseworker says it is hard to tell which one I have, and I am not pushing for an ADHD diagnosis since I am on wellbutrin for co-morbid depression anyway and it helps me focus. I have tried many of the other tri-cyclics and SSRI's and none of them work as well as the Wellbutrin. My daughter has been diagnosed with ADHD, my brother Joe has it, my brother David is being treated for it along with autism and I am about 98% certain I have it. I don't cycle as if I were bipolar. Also, I just took the WAIS test and was told that I probably have ADHD but am too intelligent to have it cause me any problems, (which I think is a good example of why logic should be taught in our schools)because if it wasn't causing me any problems, I wouldn't seek help for it. I learned to read fluently at 18 months and seldom have academic problems except with math, although I have extreme problems dealing with social situations and have been married 5 times. I am 41 and female and have led the kind of weird life that many people only read about; the only times I have functioned anywhere close to normal was in my truck driver phase when I took amphetamines and now that I am being treated for depression with the Wellbutrin.

Answer:

Interesting questions and concerns. No specific answers since, of course, I do not know your case well enough to comment directly about you. But a few general points are in order.

First, there is no reason why someone must have an "either...or" diagnosis. ADD is sometimes seen with bipolar disorder (BPD). It appears as if, although not yet verified, the genes for ADD, BPD and obsessive compulsive disorder (OCD), as well as for several other psychologic disorders, are often linked. If someone has relatives who have OCD and/or BPD that person is more likely to have ADD themselves compared with someone with a negative family history for those disorders.

Second, in some instances it can be very difficult to define ADD when psychologic disorders like BPD are present. If you have not yet received a second opinion from an expert you might benefit from one, but it may not answer the question. An expert very familiar with ADD can often even set appropriate goals with his/her patient or client, see if they are significantly met with a stimulant trial, and suggest stimulant therapy if they are. However, even people withOUT ADD can sometimes feel "clearer" or "more aware," etc., when they try a stimulant, so it is inappropriate to give an ADD diagnosis using a trial of stimulant therapy without appropriate ADD-related assessment.

Third, no one is really "too intelligent to have ADD cause problems," although the higher the inteligence the more one does tend to be able to compensate. If one goes by the "official" criteria that defines ADD (that in the psychiatric manual known as the "DSM IV"), ADD always includes symptoms that have resulted in some impairment of social or occupational functioning. Thus, the term "disorder." And, of course, "impairment" is a relative term.

My personal opinion is that somone with ADD should receive a trial of appropriate stimulant doses IF THERE ARE NO MAJOR CONTRAINDICATIONS. A few coincident psychologic disorders (in the medical literature these are often referred to as "co-morbidities") or medical disorders can be made worse with stimulants. A very small (but significant) number of people are unable to use their stimulants appropriately. Stimulants do have some contraindications.

One final note: on the average, people with ADD have above average intelligence. Some experts even speak anecdotally about having met no one with an IQ above 160 who did not have ADD. However, even if the latter is true, it probably pertains to only specific types of ADD. The DSM IV decribes three forms of ADD (inattentive, hyperactive, and a mixture of the two), however, I think we will likely define many more subcatagories over the next decade or two. Some of those may even do much better with a medication like buproprion (Wellbutrin) than with a stimulant, or, as I often see at The Affinity Center, do very well on both a stimulant and a low dose of buproprion-like medications. In addition, I have seen many people with ADD and BPD do well on a stimulant plus a "mood stabilizer" like depakote.

Best of luck to you. Let me know if you get a different diagnosis, or change to a different therapy, and it makes a significant difference.

For more information:

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Response by:

Susan Louisa Montauk, MD
Formerly Professor of Family Medicine
University of Cincinnati