The Bipolar-ADD/ADHD Connection, Part III - Lack of Focus or Depression or Fatigue?
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":
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.
Sound like a brain with attention difficulties to you? But this time something different seems to be going on, more like a state of high arousal rather than low. Perhaps a stimulant may boot up the brain's executive function to help bring order to the chaos. Or perhaps a stimulant may worsen the chaos, add oil to the fire. It's a crap-shoot. Who knows?
In my research for this series, I came across no shortage of hard data and expert commentary for ADD and likewise for bipolar. For instance, when I did a PubMed search for "bipolar treatment," 26,713 article titles popped up. For "ADHD treatment," the tally was 10,626.
But when I searched for "comorbid bipolar ADHD treatment," the yield was a piddling 124, most of them false positives. What this is telling me is despite the fact that nearly one in five with bipolar also experience ADD, despite the fact that attentional difficulties of some sort are endemic throughout the entire population, and despite the fact that current research has opened up the relatively new field of cognitive deficits in bipolar disorder, precious few are bothering to investigate the obvious overlap between bipolar and ADD.
So, there you are - your morning coffee has just failed you. Now what?
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.