This is the third in our conversation on the overlap between bipolar and ADD (or ADHD). Last week, we asked the question, Is it hypomania or is it ADD? This begs the obvious follow-up: Is it depression or is it ADD? For starters, check out this DSM-IV symptom for depression:

Diminished ability to think or concentrate, or indecisiveness ...

Now compare that to this symptom for ADHD:

Often has difficulty sustaining attention in tasks ...

“Fighting through the fog” is how those with ADD describe their attempts to achieve some form of mental clarity.  All of us (even those with “normal”) know what this is like. We experience it every morning, prior to our coffee, which I jokingly refer to as my “neuro-cognitive starter.”

Gulp-gulp-ahh! The fog lifts. But what if it doesn’t? What if, in effect, you don’t fully awaken? Is this depression or is this ADD? Maybe chronic fatigue?  Perhaps all of the above? Consider this DSM-IV symptom for depression:

Fatigue or loss of energy ...

Pair fatigue with other symptoms, such as “psychomotor retardation,” and we are talking about anergic (low energy) depressions, very common to bipolar. Meanwhile, ADD experts refer to “low arousal,” where the reception - so to speak - fails to come in loud and clear. In both cases, under-active dopamine circuits are the primary suspect. According to an editorial in the April 2007 American Journal of Psychiatry, entitled, "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.

In 2007, at an American Psychiatric Association symposium entitled, “Hypersomnia in Psychiatry,” I heard Stephen Stahl of UCSD mention that the neurotransmitters of arousal are also the neurotransmitters of concentration. Dr Stahl went on to outline an “arousal-concentration” or “hypersomnia-cognitive” spectrum that is shared by depression, anxiety, sleep disorders, and - drumroll - ADD. 

Sleep-deprived individuals require more brain activation in order to process mental tasks. At the same symposium, Christopher Drake of Wayne State University explained that a sleep loss of four hours equates to five to six beers, or blood alcohol of 0.095, over the legal limit.

A stimulant is the obvious answer, right? But wait, we have the bipolar brain to consider:

In 2004, Deborah Yurgelun-Todd of Harvard discovered, among other things, that stable bipolar test subjects had to work their brains harder than those in the control group to come up with the correct answers to a cognitive task. Ramp up the degree of difficulty, and stress and outside distractions enter the picture. As I heard Stephen Strakowski of the University of Cincinnati explain at the 20011 9th International Bipolar Conference, when the heat is on cognitively speaking, those with bipolar, among other things, have difficulty suppressing signaling from the amygdala (which mediates fight or flight) and filtering out background noise.