The Bipolar-ADD/ADHD Connection, Part V - Managing the Situation
This is the fifth (the sixth counting last week’s piece on diagnostic labels) in our conversation on the overlap between bipolar and ADD (or ADHD). If you are like me, you are probably a lot more confused than you were at the beginning of this series. Trust me, this is a good thing. There are no easy answers. We need to be asking questions.
My friend Gina Pera devotes a good portion of "Is It You, Me, or Adult ADD" to helping loved ones break through the lack of insight and denial in their partners. A good many of us know the denial factor. It took me, for instance, until age 49 to own up to the truth about my bipolar. For ADD, we may find ourselves back at the very same crossroads, having to own up - yet again - to some very unpleasant realities.
Our doctors and therapists may be more in denial about ADD than we are. Until fairly recently, ADD was regarded as a school behavior problem and was rarely recognized in adults. Not much has changed. The condition is thought to affect three to five percent of adults, but 90 percent go undiagnosed. Loosen the criteria a bit and we’re probably talking about a much larger population.
When a child acts up, the default diagnostic call is ADD/ADHD. Bipolar in kids tends to go unrecognized. With adults, the situation appears to be reversed. We get hit with the bipolar diagnosis and too many of us then endure years of heartache and frustration as our doctors tweak meds cocktails many of us have no business being on. Too often, doctors are blind to the obvious overlap. According to ADD expert Charles Parker in his book, "ADHD Medication Rules":
In my practice we find very few patients with either/or, and many with yes/and: both bipolar and ADHD … Many biologically based challenges can look quite mood disordered, and often don’t become either cognitively or emotionally functional with typical bipolar medication fare.
Stimulants (such as Ritalin and Adderall) are the first line of treatment for ADD, and the resulting improvement can be spectacular. I am taking a wild guess here, but it appears these meds work for ADD much better than antidepressants for depression or mood stabilizers for bipolar. Gina Pera’s book documents numerous accounts of loved ones reporting the overnight improvement in their partner’s ability to concentrate, get through the day with far less drama, and connect with others.
Nevertheless, Ms Pera cautions that if you think "you will enjoy substantive changes by simply taking a pill, that is delusional."
You know the drill: diet, exercise, sleep, stress management, mindfulness, support, every coping trick you can think of. Fortunately, you won’t be rolling out these tools for the first time. Same skills, new situations. With mindfulness, for instance, the emphasis may be on paying attention to paying attention. Your stress management may focus on getting through a major project in one piece.
A cautionary word about ADD meds: Stimulants can be very problematic for those with bipolar. Thus, in co-occurring bipolar-ADD, Dr Parker recommends addressing the mood disorder first. According to Dr Parker:
If stimulants and antidepressants can dysregulate the bipolar brain, start by correcting the cracks in the bipolar foundation first. … Address ADHD only in sequence, after significant moods are successfully managed. Think emotions first, cognition last.
Dr Parker also cautions that a number of mood stabilizers (he specifically mentions Depakote) block the 2D6 metabolic pathway traveled by amphetamines. The backed-up stimulants may result in unpredictable moods.
Finally, the black box warning: I am not a medical doctor or a clinician, and I cannot claim to have even lay knowledge of ADD. Moreover - as this series has made abundantly clear - true expert knowledge regarding the bipolar-ADD overlap is sorely lacking. Accordingly, the best expert about yourself is yourself. So, from one "expert" to another:
- Read up on ADD. Gina Pera’s book offers very descriptive non-clinical real-world accounts. Eileen Bailey here at HealthCentral is also required reading. along with her book, "The Complete Idiot’s Guide to Adult ADHD."
- Feel free to consult the DSM as a rough guide. Also, a commonly used six-question self-screening test can be found online. Keep in mind, you are simply asking yourself questions, not performing a do-it-yourself diagnosis
- Consult with friends, family, loved ones. The people around you have far better awareness of what makes you drive others nuts than you do. Resist your natural urge to throw up your shield walls, and listen with an open mind.
- When consulting a psychiatrist: Beware of their tendency to default to the bipolar diagnosis. You may have to shop around before you find someone who is proficient in recognizing and treating both bipolar and ADD.
- If you are in family therapy: Gina Pera cautions that family therapists are notorious for failing to recognize ADD as the third party in the room. Blame is rampant, progress is nonexistent. The ADD - if you have it - needs to be addressed in relationships.
- Your bipolar recovery tools will be helpful for ADD, but expect to make modifications and adjustments. New challenges demand new strategies.
- Recovery is possible. Your brain is plastic and is changing as you are reading this. We may not have been born with optimal thinking machines, but with effort we can make our own.
Be wise, live well …
This concludes (for now) our series on the bipolar-ADD/ADHD overlap. Many thanks to community member David, who, in a comment, pointed me to Dr Parker. Also, many thanks all those who commented, which helped me enormously.
John is an author and advocate for Mental Health. He wrote for HealthCentral as a patient expert for Depression and Bipolar Disorder.