View Full Version : Questions About ADHD vs Bipolar?


ADHDsim
11-13-15, 10:24 PM
Hello,

I ask these questions on behalf of a friend who is dealing with a family member that is currently being treated for Bipolar of whom I suspect as having ADHD.

A bit of background, he is a 25 year old male who had his first "episode" at age 23. The "episode" was extreme anxiety which transpired into deeper depression.

He has no delusions of grandeur etc during his manic episodes which are described as wild mood swings that cause him to do wild acts such as destruction of their family home amongst other violent and aggressive actions.

The man is a born athlete who as a child was constantly and excessively active. His mother tells me that as a child he would do extremely dangerous actions such as riding his bike off the roof onto a trampoline at the age of 9...

Mania as the parents describe can be triggered, (which I found to be exceedingly odd for someone with bipolar?.) Simple life events can "trigger" him. The use of Benzos for anxiety is a known trigger for "mania" as they describe.

His currently medication regime is a mixture of antipsychotics (he's never had a psychotic event IMHO) and lithium. All of which do not control the mans emotions or knee jerk mood swings. He has virtually no ability to control his emotional state.

He also has extremly low self esteem (although a born athlete, tall, good looking) he is a perfectionist, his biggest critic, suffers from insomnia and racing thoughts.

To myself he sounds every bit ADHD and virtually nothing like Bipolar. His biggest enemy is his bipolar medication which by all means has exacerbated his memory issues.

What does everyone think? Please ask any questions and thank you.

ADHDsim
11-13-15, 10:27 PM
No drugs use aside from a temporary bout of alcoholism (which was used for anxiety treatment)

His issues by all means sounds oddly like someone who can not gain control of their life in a directional way. He flickers between hobbies,jobs etc.

aeon
11-14-15, 12:13 AM
I couldn’t say one way or the other. What you describe could be so many things.

I’ll leave this one to the professionals working with him now.


Cheers,
Ian

Abi
11-14-15, 12:16 AM
Agree with aeon,

BellaVita
11-14-15, 12:20 AM
Agree with Abi who agrees with Ian.

dvdnvwls
11-14-15, 01:59 AM
You may have a lot more knowledge of the situation that you haven't mentioned.

But from what you've posted, it sounds as if you're thinking of some of ADHD's comorbidities and some of the possible reactions to having ADHD (depression, anxiety, reckless behaviour) as if they constitute ADHD on their own.

It's also quite possible that he does have ADHD but also has something else going on. (Whether that "something else" is bipolar or not would be an important question.) I would be very very slow to agree with the idea that it might be just ADHD.

My own opinion is that there is so much going wrong for your friend's family member right now, that (a) careful professional diagnosis is essential and (b) he needs to somehow "turn a corner" and make major positive changes in his life. Unfortunately, nobody can really make those changes for him.

ADHDsim
11-14-15, 10:52 AM
Thank you all.

There's only one thing that has got me going with this and that is simply that he himself mentions how even more awful and useless he feels since taking the medication. And how he relates his sudden aggression with how the medicine makes him feel.

Emotions clearly trigger his mood, his frustrations with bipolar medication not fixing some very real ADHD symptoms is startling to say the least and how that all relates back to his behaviour is again amazing.

Polymorphed
11-14-15, 06:54 PM
Regardless of what the underlying cause may be, the symptoms all point towards an over-activated Sympathetic Nervous System (SNS). The risk taking and athletic focus from early childhood could suggest he has been an adrenaline junky for his whole life. Over time, the cumulative effect of bias towards the SNS over the Parasympathetic NS leads to anxiety/panic, being on edge/highly irritable/easily triggerable/emotional labidity/insomia. etc. This is because it is very easy to become overwhelmed by stimulii when you are so revved up as your mind denies you the ability to tune out or be selective about what to focus on. Regardless of whether or not you have ADHD this will occur to a certain extent in any physiology.

Grandiose delusions are a dead give away for a Bipolar diagnosis, but not a prerequisite for diagnosis as everyone is different and it's all a wide grey scale in severity. How frequently are his lithium:plasma levels analysed?

My wife was mistakenly diagnosed with bipolar II and treated for 5 years before I began attending all psych appointments and pushing for more proactive investigation. It was almost as though the medical community threw her in the too hard basket. They just kept playing around with doses of Lithium/Epilum, mixing in other anti-psychotics or SSRIs etc. There wasn't even a placebo effect from the Bipolar specific meds. Just months of "when will this start doing something?" before the Dr would make a minor change. Rinse and repeat. FFWD 5 years.

Ritalin for her = instant relief.

I'm not diagnosing or encouraging anything beyond maintaining an open mind and not losing hope. Keep pushing and advocating. Help him find a new psych if necessary. The controversy of ADHD is still very prevalent and many Psychs completely skip past even contemplating it as a diagnosis.

ADHDsim
11-15-15, 01:11 AM
Thank you polymorph, you have been a guardian angel on these forums.

I don't instintively feel that ADHD is the sole issue with this man but rather is very important peice of the puzzle that has been neglected.

His current medication by all means has made him worse, has made his mind flicker more often. A BIG clue i see is how his mind flickers MORE during depression and the fact that he relates this very problem as the causation of his knee jerk aggression.

He reports that "manic episodes" interferes with his ability to get a good night sleep, that it keeps him awake until the wee hours of the morning. He paces the hallways in a futile attempt to settle himself. Not once has his mania ever reduced his need for sleep.


In the end he's going no where fast and I worried that if they don't at least try another course of action that he will be abandoned by his family members. His problems have only intensified since bipolar treatment.

dvdnvwls
11-15-15, 02:11 AM
ADHDsim - just from my outsider and non-professional point of view - while I share your perception that the bipolar diagnosis might not sound convincing, I don't (yet?) share your other perception that ADHD is the real cause of some of the problems.

ADHDsim
11-15-15, 04:02 AM
Dvdnvwls, neither do I, but I feel ADHD is an important peice of the puzzle going forward with this mans mental well being.

I'm a huge beleiver that many of the garden variety mental illnesses out there are extremly hard to treat adequately If the fog of ADHD is Lingering. What I think many find is that doctors scramble with different medications in some futile attempt to counteract ADHD symptons.

Polymorphed
11-15-15, 04:35 AM
Thanks for the appreciation :) I feel that I have a duty to myself to make the time I spend/waste learning [and/or obsessing about] all this stuff useful beyond just satisfying my own curiosity and keeping myself zoned out/perpetuate my procrastination. It kind of gives it a purpose!

I recommend getting a lithium blood test to see how high his lithium plasma levels are and titrate the dose accordingly. Whether or not he should titrate off it altogether should be explored.

I'd also bring into discussion the possibility of working towards replacing the current antipsychotics with pericyazine (typically brand, Neulactil). Just a tiny dose of 2.5mg daily, which may not require increasing at all. Using Lithium Orotate supplemention as a part of the Lithium phase out titration, if considered, could be beneficial (even if Bipolar is a misdiagnosis).

Pericyazine is an older antipsychotic that kind of got left behind a bit with all the new drugs that found their into pharmacology textbooks, however, it is often successful where Lithium, Epilum and a bunch of other mood-stabilising antipsychotics are not.
It is most known for its affect on bringing someone back down to reality if they have become particularly dissociative or aggressive. It is often used as a backline in treating Bipolar where the other antipsychotics are causing too many side effects, but it can also be used to treat the symptoms specifically and can be of benefit for ongoing use for ADHD with particular comorbitdities like CPTSD or Panic Disorder.

I also wonder if expectation bias is blurring the image of what he is perceiving as mania. I remember staying up many, many nights because I was sucked in by objects of my then hyperfocus obsessions, as well as already having insomnia and just a general anxiety response to "calling it a day", so to speak. As chronic procrastinators, going to sleep is like logging off for the day - all of our failures become absolute realities.

Of course, as we develop better introspection, we learn to identify these dead-end thought patterns (ruminations/worries), interrupt them and choose a more constructive perspective to base our response on. Alas, I digress; the point of all that was, if you tell a man he has Bipolar the chances of him exhibiting the symptoms of Bipolar increase.

Again, I'm not trying to contradict the diagnosis, just demonstrating that going back though some doors that were already closed may be worthwhile. I mean SOMETHING has to change.

I wonder if the med cocktail he has been on has had an impact on cholinergic activity. Short term memory and recall in particular is very closely influenced by choline nueral pathways. Eggs are a great natural source of choline. If he doesn't eat much fish/seafood and eggs aren't a part of his daily diet, then I wouldn't be surprised if having a few eggs a day really helps him. I think by now most doctors accept that eggs negatively affecting cholesterol in an individual with an otherwise healthy diet is a myth.

I got before/after blood testing to prove my point to my GP haha I actually improved my cholesterol profile over the course of 6 months eating 8 eggs a day, every day. I digress again.

Could it really be that risky to give a desperate patient a month's supply of Ritalin to try out? I mean it's diagnostic. Any worthy psychiatrist should have the self confidence to catch out a fraud by a long shot. If the patient doesn't report back with a smile on their face and all the signs that indicate a therapeutic response, then you don't organise a repeat and scratch your head and think of a new angle to try.

Of course, I haven't been present for any of this and you told a brief story, so my comments come with a disclaimer, but best intentions ^^

dvdnvwls
11-15-15, 03:35 PM
Dvdnvwls, neither do I, but I feel ADHD is an important peice of the puzzle going forward with this mans mental well being.

I'm a huge beleiver that many of the garden variety mental illnesses out there are extremly hard to treat adequately If the fog of ADHD is Lingering. What I think many find is that doctors scramble with different medications in some futile attempt to counteract ADHD symptons.
I think you're just assuming he has ADHD. I suggest you take a step back and consider that maybe he doesn't.

ADHDsim
11-16-15, 10:49 AM
I think you're just assuming he has ADHD. I suggest you take a step back and consider that maybe he doesn't.

Granted but when a high dose of lithium does not curtail manic episodes which by all means do not even meet the criteria of mania on a patient who is not improving by any means I start to think an alternative view point is necessary otherwise he may go thru many more years of suffering.

Bipolar, no
ADHD, possible
Depression, yes
Anxiet, yes

Little Missy
11-16-15, 10:54 AM
Maybe he needs to try a different doctor.

Fuzzy12
11-16-15, 11:29 AM
Granted but when a high dose of lithium does not curtail manic episodes which by all means do not even meet the criteria of mania on a patient who is not improving by any means I start to think an alternative view point is necessary otherwise he may go thru many more years of suffering.

Bipolar, no
ADHD, possible
Depression, yes
Anxiet, yes

I dint think how he responds to any medication gives a good reliable indication of what disorder he has. Maybe lithium just isn't the right Med for him for whatever reason.

(Though i do agree that if he doesn't meet enough of the criteria for mania of hypomania it's definitely worth considering alternative explanations)

ADHDsim
11-17-15, 03:47 AM
Exactly right, nothing at all suggests true mania. And anything that even resembles mania ends with in a few hours of its begining with and with out medication. All of which have had emotional triggers.

sarahsweets
11-17-15, 04:12 AM
The interesting thing with bioplar is, most people think of the symptoms that are associated with biopolar I that people often neglect to consider Bipolar II. The symptoms of delusions of grandeur or extreme mood swings and major manic episodes are what gets the most press. Bipolar II is a much more-uh- tricky thing. For me, I have bipolar II and I have had manic episodes that consist of mild risk taking behavior, feeliing really "up" and extreme impulsiiveness, lack of forsight when it comes to consequences, followed by depression in the extreme. More often than not, I have very mild cycles but there are those of us who experience rapid cycling as well. Its a bit of a myth that antipsychotics are used in bipolar to treat psychotic episodes. I take an atypical antipsychotic and its not for anything other than mood stabilization. Antipsychotics can be used for psychosis but thats not the only reason they are used.
It seems like your friends could have BPII going on or alot of other things. I wouldnt jump the gun and go right to adhd though.

ADHDsim
11-17-15, 04:46 AM
Thank you Sarah, as I mentioned earlier I do feel ADHD is a peice of the puzzle. I'm wrong to have said that he does not have bipolar.

Anyway I'm only suggesting to the parents that possibly ADHD is a factor that needs further investigation by a physch.

Pilgrim
11-17-15, 09:00 AM
I don't know if it's over there, go to The Black Dog Institute. There the best.

Polymorphed
11-17-15, 07:44 PM
Very low doses of atypical antipsychotics, in my experience, are the most effective (in terms of efficacy without diminishing returns at the cost of side effects) at treating BPII in conjunction with appropriate monoamine support. In most, this will be an SSRI or SNRI, but care must be taken with the dose and titration phase so as not to force mood polarity into mania/dysphoria cycles.

I also think that a supplementary dose of Lithium Orotate can be helpful if Lithium is NOT being used as a primary approach. The BPII Lithium : plasma therapeutic range accepted by modern psychiatry is generally too high (in my opinion) and will make a lot of patients develop adverse reactions, especially if not carefully and slowly titrated and regularly monitored.

If impulsivity/concentration span/short term memory and recall etc. are all affecting the patient around the clock, then they are most likely in a physiological state of anxiety, regardless of the cause (which could be ADHD).

Pilgrim
11-18-15, 07:25 AM
Very low doses of atypical antipsychotic

I also think that a supplementary dose of Lithium Orotate can be helpful if Lithium is NOT being used as a primary approach. The BPII Lithium : plasma therapeutic range accepted by modern psychiatry is generally too high (in my opinion) and will make a lot of patients develop adverse reactions, especially if not carefully and slowly titrated and regularly monitored.

If impulsivity/concentration span/short term memory and recall etc. are all affecting the patient around the clock, then they are most likely in a physiological state of anxiety, regardless of the cause (which could be ADHD).

So how do you treat that?

Polymorphed
11-22-15, 09:05 PM
So how do you treat that?

In Australia, a typical approach is to combine the stimulant medication with a sympatholytic drug, such as Clonidine (Catapres). Most GPs will think "Blood Pressure Lowering" drug when they hear Clonidine (if they are even familiar with it), but there is literature (http://cd.net.au/files/File/cdn/pdf/MedMaP/Clonidine.pdf)you can supply if you think your Doc will give it due consideration.

In the States, Guanfacine (Intuniv is the suitable SR formula) is available and is generally accepted as superior to Clonidine.

ADHDsim
11-23-15, 10:37 AM
Thank you polymorph. Yes Australian physchs tend to be a little behind the curve at times. Few doctors prescribe clonidine for ADHD in Australia. Only those who specialise in ADHD understand its usefulness.

Anywho Ill give an update, he is now being treated solely with seroquel for bipolar. Unfortunately he recently starting blaming a family member for all of his problems in life and over the course of a day his kept getting angrier and angrier until his physch sedated him in the evening with a very high dose of seroquel. :/

He's been ok for a while now but yesterday he started to lightly talk about his past and it just escalated he got angrier and angrier up until the evening at which point he sort professional help. He was raging badly and just wouldn't let it go.

No chance seeking ADHD testing / diagnosis now :/

Polymorphed
11-23-15, 05:57 PM
Thank you polymorph. Yes Australian physchs tend to be a little behind the curve at times. Few doctors prescribe clonidine for ADHD in Australia. Only those who specialise in ADHD understand its usefulness.

Anywho Ill give an update, he is now being treated solely with seroquel for bipolar. Unfortunately he recently starting blaming a family member for all of his problems in life and over the course of a day his kept getting angrier and angrier until his physch sedated him in the evening with a very high dose of seroquel. :/

He's been ok for a while now but yesterday he started to lightly talk about his past and it just escalated he got angrier and angrier up until the evening at which point he sort professional help. He was raging badly and just wouldn't let it go.

No chance seeking ADHD testing / diagnosis now :/

I'm sorry to read that. Hopefully things change soon. Seroquel is a horrible drug that heavily impacts on quality of life. I see it only as a short term measure for acute problems.

I had tried a very weak 25mg IR of Seroquel to help fall asleep and, yes, it sedated me and helped, but I would be completely unresponsive over night and had extreme difficulty getting up and motivated.

My wife, at one point, was expected to get on with life on 300mg. I wonder why she couldn't get out of bed all day?

Clonidine would be a nice transition from Seroquel. The biggest problem is compliance, as its short half-life dictates a 3x daily dose. I am taking 100mg before bed and it helps me naturally wind down and get sleepy and I still wake up normally. Plus it improves acetylcholine activity overnight, improving REM and memory consolidation.

ADHDsim
11-24-15, 03:11 AM
Yeah I'm on the same path in regards to serequil, whilst stopping short of ever suggesting he stops prescribed treatment the doctor is only keen to see him again in a months time. I'm pushing that he tries to see him sooner and find a more appropriate treatment.

whilst the medicine helped last night he has become even less rational as this morning he suddenly packed his bags and left his caring home. We think he's become really depressive over night and naturally were all worried.

Polymorphed
11-24-15, 10:04 PM
Yeah I'm on the same path in regards to serequil, whilst stopping short of ever suggesting he stops prescribed treatment the doctor is only keen to see him again in a months time. I'm pushing that he tries to see him sooner and find a more appropriate treatment.

whilst the medicine helped last night he has become even less rational as this morning he suddenly packed his bags and left his caring home. We think he's become really depressive over night and naturally were all worried.

Honestly, it never surprises me when patients with psychiatric disorders respond this way to strong sedatives. I'd feel like the world was against me too if everyone's idea of "help" was daily Seroquel.

Anyone who has a modicum of introspection will likely feel trapped while sedated on Seroquel and this sense of an unresponsive mind and body can easily lead to defiance in order to avoid returning to that state.

It may have a good success rate in clinical settings like inpatient mental health wards where professional monitoring and medication dosing is around the clock, but yeah, I don't see too many people overly happy to comply to a daily regime on it while in a more liberal environment, particularly if they are already particularly defensive and irrational.

I'd encourage taking whatever steps are necessary for him to understand you and his family are on his side and that you won't force him to take Seroquel, but instead you'd like to get him back to the Dr to let him know it's not working for him (if that's the true cause of his reaction).

KarmanMonkey
12-10-15, 10:27 AM
I find it unusual that benzos would trigger "mania", as they're often the first choice for immediate relief for a manic episode while waiting for mood stablizers to take effect.

Since the meds don't seem to be helping control his moods, it may not be bipolar. I'd encourage a second opinion, or at least some clarification of what can be expected from the medications. It could be that he does have bipolar and the meds are actually helping, but just not enough.

There also could be a personality disorder in the mix, like emotional disregulation disorder (previously known as borderline personality disorder). The way I'd describe it is where most people have a dial for their emotions, and can have an anger level anywhere in the spectrum of 0-100%, people with emotional disregulation have a switch instead, and have either a 0 or a 100% for any emotion, with very little in between.

In the end, while an accurate diagnosis can lead to effective treatment, what's far more important is how to support this person and their family. Make sure the parents get support for themselves, and do what you can to help the person find healthier responses to their emotions.

daveddd
12-10-15, 01:20 PM
Sounds almost textbook borderline pd

But if you seen any of my posts , I strongly believe that ADHD may be the core to it. It's what current research is saying anyway

So ur intuition may be correct that ADHD is the core But meds plus therapy will likely be the best option

BellaVita
12-10-15, 03:44 PM
Sounds almost textbook borderline pd


I was thinking a similar thing.

Polymorphed
12-14-15, 12:13 AM
ADHD genetic polymorphisms plus childhood developmental arrest plus chronic stress = extremely high predisposition to BPD. The links go deeper than this, but it will be interesting what the next decade reveals.

Polymorphed
12-14-15, 12:18 AM
If you look into early childhood developmental psychology you will see the various qualities that define BPD, such as splitting. People with BPD are adults who have missed out on basic cognitive developmental milestones. The 0-100% describes catastrophic thinking, which is both a quality associated with neuroticsm AND psychosis (thought disorder) - hence borderline (not quite one or the other), but this dramatic simplification really doesn't cut it with modern scientific understanding.