The Bipolar-ADD/ADHD Connection, Part II - Lack of Impulse Control or Hypomania?

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This is the second in our conversation on the overlap between bipolar and ADD (or ADHD). The condition is not so much about attention deficit (as the name implies) as a failure in directing that attention. On one extreme, the brain may hyper-focus, say on a project, at the expense of awareness of the immediate world. On the other, the brain may under-focus, bouncing from one distraction to the next, failing to stay on task.

Either way, the consequences can be devastating - busted relationships, broken dreams, financial ruin - but throw bipolar into the mix and we find ourselves living extremely dangerously. Hyper-focusing on a project, for instance, may lead to losing a night's sleep, which may trigger mania. Under-focus, meanwhile, may lead to frustration and a sense of learned helplessness, which is an open invitation to depression.

Back when I was facilitating a DBSA support group, I was struck by the number of individuals reporting co-occurring ADD. According to data from the International Mood Disorders Collaborative Project, nearly one in five individuals with bipolar experience ADD. What we really need to be aware of, though, is that we don't have to have a full-blown ADD diagnosis to complicate our lives. Virtually all of us ("normal" people included) have attention problems of some sort. Thus, we all need to be paying attention - to attention.

Another element of ADD concerns lack of ability to rein in impulses. It works something like this: Attention is a function of the thinking parts of the brain. If you're not thinking right, the front end of your brain is perpetually engaged in a losing battle with the back end of the brain. The back of your brain may tell you that now would be a good time to belt out "There's No Business Like Show Business" in your best Ethel Merman voice. The front end of your brain neglects to remind you that you happen to be in the middle of a business meeting right now.

This is where hyperactivity enters the picture, a failure to apply the brakes. You almost automatically act on your distracting thought. No red tape, no delay. Next thing, you're out of your chair and on the table ...

But wait, I hear you protesting. Isn't this hypomania? Funny you should ask. Check out this DSM-IV symptom for hypomania:

Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed.

Now compare it to this symptom for ADD:

Is often easily distracted by extraneous stimuli.

The interchangeability doesn't stop there. Can you tell which of the symptoms below belongs to which diagnosis?

  • "Is often 'on the go' or often acts as if 'driven by a motor.'"
  • "... persistently increased activity or energy ..." (from the DSM-5 proposed revision).
  • "Increase in goal-directed activity ..."
  • "Flight of ideas or subjective experience that thoughts are racing."
  • "... subjective feelings of restlessness."
  • "Often talks excessively."
  • "More talkative than usual or pressure to keep talking."
  • "Excessive involvement in pleasurable activities."
  • "... makes careless mistakes ..."

So here you are, singing your heart out, doing your best Ethel Merman, unfortunately during an important business meeting with no regard for the other people in the room. Is it hypomania or is it ADD? Your boss is unlikely to take the time to make a differential diagnosis. It's all the same to him or her - you're fired.

And now you are out of work, needing to control your behavior. If it's hypomania, we know the brain is running too hard, so we tend to slow it down with mood stabilizers or (in some cases) antipsychotics. But with ADD, the meds treatment of choice are stimulants that nominally speed up the brain. What is going on?

To vastly oversimplify, over-active dopamine signaling may drive a lot of mania and hypomania (not to mention psychosis). The opposite is the case with ADD, where executive function - which controls a range of vital cognitive processes such as working memory and attention - is decidedly underpowered. Stimulants, which enhance dopamine-signaling, act to boot up the brain's capacity to focus and process information. Chaotic thinking becomes organized. Of all things, in certain brains, stimulants exert a paradoxical calming effect, sometimes even aiding in sleep.

Dopamine is also involved in arousal and pleasure and reward. Maybe you can see where this is going: Low arousal and no sense of pleasure creates a need to self-stimulate and seek out novelty, typically by acting on a distracting thought. The result (not surprisingly) is socially inappropriate behavior. A drug that delivers the requisite dopamine power surge may reduce the need to self-stimulate and engage in risky behavior. Again, the calming effect.

Unfortunately, too many with ADD self-medicate with dopamine-enhancing street drugs such as meth and cocaine (as many as 30 percent, according to an article in the Dec, 2006 American Journal of Psychiatry). Much safer are prescription stimulants such as Ritalin or Adderall, which - when used correctly - deliver neither the instant high of street drugs nor create a dependency. But when bipolar is also going on, stimulants - with their risk of inducing mania - can be a major issue, but that is a topic for a future post.

In the meantime: Is it hypomania or is it ADD? Do you need to settle your brain down or wake it up? In the final analysis, only you can answer that question.

Much more to come ...

For the ADD side of the equation in this series of posts, I am relying very heavily on my friend Gina Pera's highly original book, "Is It You or Me or Adult ADD?" Please check out her exceptionally provocative and riveting blog, ADHD Roller Coaster.

I am also working off of Eileen Bailey and Donald Haupt's very informative and straightforward "The Complete Idiot's Guide to Adult ADHD." Eileen is a fellow Health Guide here at HealthCentral, with extremely useful  posts on ADHD.

For the bipolar side of the equation, I am largely connecting my own dots based on my research into how the brain processes information, focuses attention, modulates impulses, and responds to dopamine. I am also guided by the comments of my readers in response to a recent  Question of the Week.