Evidence-Based Reviews

ADHD: Only half the diagnosis in an adult with inattention?

Current Psychiatry. 2007 June;6(6):46-61

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Mood symptoms first

A diagnostic hierarchy is implicit in DSM-IV-TR; anxiety disorders are not diagnosed during an active major depressive or manic episode, and schizophrenia is not diagnosed on the basis of psychotic symptoms during an active major depressive or manic episode. Mood disorders sit atop this implied diagnostic hierarchy and must be ruled out before psychotic or anxiety disorders are diagnosed. Similarly, most personality disorders are not diagnosed during an active mood or psychotic episode.

Clinical Point

Inattentiveness in adult ADHD may manifest as neglect, poor time management, motivational deficits, or forgetfulness

Diagnosing adult ADHD when a patient is actively depressed or manic is inconsistent with this hierarchy and conflicts with extensive nosologic literature.¹³ We suggest that ADHD—a cognitive-behavioral problem—not be diagnosed solely on symptoms observed when a patient is experiencing a mood episode or psychotic illness.

Bipolar disorder. Two useful mnemonics (Table 3) assist in screening for DSM-IV-TR symptoms of BD type I:

Pure mania consists of euphoric mood and ≥3 of 7 DIGFAST criteria, or irritable mood and ≥4 of 7 DIGFAST criteria
Mixed mania consists of depressed mood with ≥4 of 7 DIGFAST criteria and ≥4 of 8 SIGECAPS criteria.

To be diagnostic, these symptoms must cause substantial social or occupational dysfunction and be present at least 1 week. Diagnose BD type I if a patient has experienced a single pure or mixed manic episode at any time, unless the episode had a medical cause such as hyperthyroidism or antidepressant use. Because patients with mixed episodes experience depressed mood, assess any patient with clinical depression for manic symptoms. Otherwise, a patient with a mixed episode could be misdiagnosed as having unipolar depression instead of BD type I.¹⁴

BD type II also has been observed in patients with comorbid adult ADHD/BD.^4,6 The main difference between BD types I and II is that manic symptoms in type II are not severe enough to cause functional impairment or psychotic symptoms.¹⁵

Adult ADHD. The clinical interview seeking evidence of inattention and hyperactivity/impulsivity remains the basis of adult ADHD diagnosis (Table 2). Key areas are:

the patient’s past and current functional impairment
whether substantial impairment occurs in at least 2 areas of life (such as school, work, or home).

Clinical Point

Impulsivity in adult ADHD may manifest as low tolerance for frustration, leading to frequent job changes or unstable relationships

Take medical, educational, social, psychological, and vocational histories, and rule out other conditions before concluding that adult ADHD is the appropriate diagnosis.¹⁶ In adult ADHD, inattentive symptoms become far more prominent, about twice as common as hyperactive symptoms.¹⁷ Inattentive symptoms may manifest as neglect, poor time management, motivational deficits, or poor concentration that results in forgetfulness, distractibility, item misplacement, or excessive mistakes in paperwork.¹⁸ When impulsive symptoms persist in adults, they may manifest as automobile accidents or low tolerance for frustration, which may lead to frequent job changes and unstable, interrupted interpersonal relationships.¹⁸

Neuropsychological testing is not required to make an adult ADHD diagnosis but can help establish the breadth of symptoms or comorbidity.¹⁷ Rating scales can screen, gather data (including presence and severity of symptoms), and measure treatment response.¹⁶ Commonly used rating scales include:

Conners’ Adult ADHD Rating Scales¹⁹
Brown Attention Deficit Disorder Rating Scale for Adults²⁰
Adult ADHD Self-Report Scale.²¹

When using rating scales, remember that adult psychopathology can distort perceptions, and some self-report scales have questionable reliability.¹⁶

Table 3

Mnemonics for diagnostic symptoms of pure and mixed bipolar mania

*DIGFAST for bipolar mania symptoms**	SIGECAPS^† bipolar depression symptoms
Distractibility Insomnia Grandiosity Flight of ideas Activities Speech Thoughtlessness	Sleep Interest Guilt Energy Concentration Appetite Psychomotor Suicide
Pure mania: Euphoric mood with ≥3 DIGFAST criteria or irritable mood with ≥4 DIGFAST criteria.
Mixed mania: Depressed mood with ≥4 DIGFAST criteria and ≥4 SIGECAPS criteria.
* Developed by William Falk, MD
^†Developed by Carey Gross, MD
Source: Adapted from Ghaemi SN. Mood disorders. New York: Lippincott, Williams, & Wilkins; 2003

Treatment recommendations

Limited data. We found only 1 study on adult ADHD/BD treatment. In this open trial,²² 36 adults with comorbid ADHD and BD received bupropion SR, up to 200 mg bid, for ADHD symptoms while maintained on mood stabilizers, antipsychotics, or both. Improvement was defined as ≥30% reduction in ADHD Symptom Checklist Scale scores, without concurrent mania. After 6 weeks, 82% of patients had improved; 1 dropped out at week 2 because of hypomanic activation. Methodologic limitations included trial design (non-randomized, nonblinded, short duration) and patient selection (90% of subjects had BD type II).

Clinical Point

For acute bipolar depression, adding an antidepressant is no more effective than using a mood stabilizer alone