The Clinicians’ Guide to Differential Diagnosis of ADHD is a clinical compendium from Medscape, MDEdge, and ADDitude designed to guide health care providers through the difficult, important decisions they face when evaluating pediatric and adult patients for ADHD and its comorbid conditions. This guided email course will cover the following topics:

• DECISION 1: How can I better understand ADHD, its causes, and its manifestations?
• DECISION 2: What do I need to understand about ADHD that is not represented in the DSM?
• DECISION 3: How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
• DECISION 4: How can I best consider psychiatric comorbidities when evaluating for ADHD?
• DECISION 5: How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
• DECISION 6: How can I best consider trauma and personality disorders through the lens of ADHD?
• DECISION 7: What diagnostic criteria and tests should I perform as part of a differential diagnosis for ADHD?

NOTE: This resource is for personal use only.

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Adults with ADHD are up to six times more likely than are their neurotypical peers to have Major Depressive Disorder (MDD), which is characterized by extreme sadness, loss of interest, and mania. Not only is MDD more prevalent in adults with ADHD, but the disorder can have an outsized effect on women and girls who have both conditions. MDD is associated with an earlier age of onset, a longer duration, more severe impairment, a higher rate of suicidality, and a greater likelihood of requiring psychiatric hospitalization in girls with ADHD.

When treating depression in patients with ADHD, it is critical for clinicians to recognize a patient’s feelings of worthlessness, which, as one study points out, were directly related to suicidal thoughts and planning in adolescents.

In this webinar, you will learn:

• About MDD and other mood disorders that are highly comorbid with ADHD, including bipolar disorder, disruptive mood dysregulation disorder, and emotional dysregulation
• About symptoms of mood disorders and how they co-exist with ADHD
• About new and alternative treatments for MDD, including medication, neurofeedback, and neuromodulation therapy, trans-cranial magnetic stimulation (TMS), and esketamine treatments
• Which therapies are in clinical trials that may hold promise
• About strategies to help people with depression and mood disorders

Have a question for our expert? There will be an opportunity to post questions for the presenter during the live webinar.

Meet the Expert Speaker:

Nelson Handal, M.D., DFAPA, is the Founder, Chairman, and Medical Director for Dothan Behavioral Medicine Clinic (DBMC) & Harmonex Neuroscience Research (HRX). As a practicing Board Certified Child, Adolescent and Adult Psychiatrist, Dr. Handal has dedicated much of his career to developing and implementing technologies that elevate the quality of patient care.

Dr. Handal participates in extensive clinical research and has been primary investigator in over 85 clinical trials. In the late 1980s, Dr. Handal was president of one of the first telemedicine referral services in the world. This system was featured in Business Week. CliniCom® is an online psychiatric assessment tool Dr. Handal has been developing for the past 10 years and which has been used by over 54,000 patients. In May 2009 Dr. Handal was invited to testify before the United States House Committee on Veterans’ Affairs regarding innovative technologies and treatments for veterans; he spoke about CliniCom®.

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A further complication: youth with ADHD are at higher risk for developing mood disorders, such as disruptive mood dysregulation disorder (DMDD) or oppositional defiant disorder.

During a recent ADDitude webinar on irritability, we asked nearly 1,000 attendees, “What is the most challenging aspect of emotion regulation for your child or patient?” Here are the answers they gave:

• Dysregulation of emotions in the moment (e.g., feelings often subjugate thinking): 37.8%
• Intensity of felt emotions (e.g., sudden, violent outbursts): 34%
• Unrelenting nature of irritability (e.g., always angry, bristly, mean): 14%
• Poor recognition of other people’s feelings (e.g., apparent and/or real lack of empathy): 7.1%
• Frequency of mood changes (e.g., dizzying emotional lability): 6.7%

Comments and questions submitted during the webinar, titled “Emotion Regulation Difficulties in Youth: ADHD Irritability vs. DMDD vs. Bipolar Disorder” provided deeper insight into how ERD impacts youth with ADHD.

Emotion Regulation Manifestation #1: Explosive Outbursts

“My child screams and breaks down over issues with friends.”

“My son is verbally aggressive and used to destroy doors and walls. It is truly hard for me to cope with his crisis.”

“My 11-year-old son’s physical and verbal aggression seems to be reserved for home. He controls himself at school but not at home, where he is very argumentative and defiant. He is easily triggered when he does not get his way (e.g., he pushes, hits, and calls us names).”

“My 14-year-old daughter keeps it together at school but is defensive, aggressive, and explosive with her 11-year-old sister and us (her parents) when we intervene.”

[Self Test: Does My Child Have Disruptive Mood Dysregulation Disorder?]

Explosive Outbursts: Next Steps

• Download: 9 Truths About ADHD and Intense Emotions
• Read: Why Is My Child So Angry?!
• Read: What Is Intermittent Explosive Disorder? 

Emotion Regulation Manifestation #2: Rejection Sensitive Dysphoria

“It is hard for my child with ADHD to not respond in a passive-aggressive, irritating way toward people she feels have rejected her. This might look like getting into others’ personal space by doing things she knows bothers them. This has gotten her in trouble with peers whom she feels are her bullies.”

“My son is 16 and has had explosive emotional outbursts due to environmental factors since he was 18 months old. The emotional outbursts have lessened substantially, but they still happen when he is super frustrated, upset, or gets his feelings hurt by his friends.”

RSD: Next Steps

• Download: Understanding Rejection Sensitive Dysphoria
• Read: How ADHD Ignites Rejection Sensitive Dysphoria
• Self-Test: Could It Be Rejection Sensitive Dysphoria? Symptom Test for ADHD Brains

Emotion Regulation Manifestation #3: Extreme Irritability

“Irritability occurs when there is a change in the child’s expectations of a situation. For example, it is not going to happen or not happening soon enough according to the child’s understanding or expectation.”

“My kid seems to be frequently irritable and grouchy and has angry outbursts.”

“I’ve noticed a big increase in irritability for my 13-year-old son with ADHD.”

“My 12-year-old wants to buy things or have things bought for her. Telling her ‘no’ results in irritability and a major tantrum.”

Extreme Irritability: Next Steps

• Download: 10 Ways to Neutralize Your Child’s Anger
• Read: New Insights Into Emotional Dysregulation and Treatment Considerations
• Read: “My Child’s In a Bad Mood Every Morning!”

Emotion Regulation Manifestation #4: Lack of Flexibility

“My granddaughter is often agitated and gets things stuck in her head, and there is no working around it. Screen time is about all that keeps her focused and calm. Everything is a challenge — routines, grooming, sitting down to dinner. Everything”

“My son is very rigid and has no ability to cope when he doesn’t get his way.”

“I struggle with my daughter’s need to be in control of everything and everyone. So much so, even making doctor’s appointments are hard to do.”

Lack of Flexibility: Next Steps

• Download: Why Is My Child so Defiant?
• Read: What’s Really Behind Your Child’s Bad Behavior?
• Read: Exaggerated Emotions: How and Why ADHD Triggers Intense Feelings

[Self-Test: Does My Child Have ADHD? Symptom Test for ADHD]

Emotion Regulation Manifestation #5: Self-Harm

“I have an 11-year-old daughter who has had explosive outbursts and big highs and lows since age 4. She began expressing suicidal ideation and was self-harming and experiencing intrusive thoughts.”

“During fits, my child makes comments about ‘not wanting to live,’ and ‘can’t take it anymore.'”

Self-Harm: Next Steps

• Download: Easy Mindfulness Exercises for Kids with ADHD
• Read: ADHD & Self-Harm: How to Help the Girls Who Suffer Most
• Read: How Is Your Emotional Resilience? Learning to Cope with Intense ADHD Feelings

Emotion Regulation Manifestation #6: Overly Emotional

“We’re struggling with my son because he’s not combative, just EXTREMELY emotional. He has crying episodes or extended periods of being upset where he cannot regroup for up to an hour.”

“My son does OK in most environments, but at home, he displays a lot more irritability and dysregulation, anger, frustration, and sadness.”

“My son is explosive at times. I remain calm with few words spoken, but he escalates quickly by yelling and running out of the house. This creates a very stressful environment for everyone in the house. I don’t know how to get him out of his terrible moods, where he fixates on ‘small’ things that bother him.”

Overly Emotional: Next Steps

• Download: Evaluate Your Teen’s Emotional Control
• Read: Q: How Do I Teach My Teen to Manage Emotions?
• Read: Calm Starts at Home: How to Teach Emotional Regulation Skills

Emotion Regulation Manifestation #7: Physical Aggression

“My 8-year-old son with ADHD cannot focus or keep still long enough to finish his schoolwork. Then he gets frustrated, which ends with him hitting his peers or teachers.”

“My daughter has a very hard time with aggressive behavior and has had to have the ‘room cleared’ twice this month, along with three in-school suspensions.”

“So often parenting advice recommends setting firm boundaries with kids, such as saying, ‘you can be mad, but I won’t let you throw things/ damage furniture/ etc.” However, with my kid with ADHD, when his lid is flipped, and he’s having a rage outburst, any attempt to say those things seem to ‘feed the fire.’ He just escalates more, often becoming physically aggressive with us.”

Physical Aggression: Next Step

• Download: Free Guide to Ending Confrontations and Defiance
• Read: Anger Is Important — But Only When It’s Managed
• Read: When “Keep Your Hands to Yourself” Doesn’t Work: Fixes for Hitting

More on Emotion Regulation and ADHD

• Free Download: 15 Ways to Disarm (and Understand) Explosive ADHD Emotions
• Read: How Dysregulated Emotions Hijack the Teen ADHD Brain
• Read: ADHD and Emotional Regulation: A Parent’s Guide

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Irritability, moodiness, temper tantrums, or other mood states commonly occur alongside ADHD in youth, but sometimes emotion regulation difficulties (ERD) indicate something more. Caregivers observing frequent mood issues may worry that their child has a mood-related pediatric psychiatric disorder, like DMDD or bipolar disorder, in addition to ADHD. And in fact, youth with ADHD are at elevated risk, compared to unaffected youth, for developing a mood disorder at some point in their lives.

That said, irritability is a non-specific emotional state that can be observed in healthy youth and those who have ADHD or other behavioral challenges, in addition to youth with diagnosed mood disorders. Understanding the significance of irritability in a child with ADHD, consequently, can be quite challenging, even for seasoned clinicians. So it is no surprise that many parents of youth with ADHD and ERD, feel anxious and uncertain about their child’s diagnoses.

In this webinar, caregivers will learn:

• How ERD in youth with ADHD may constitute a diagnostic subtype of the broader ADHD population
• How to view the typical features of pediatric psychiatry disorders associated with irritability in a way that can help caregivers better differentiate the likely source of emotional disturbance they are observing in their child
• Important next steps they can take to help their children experiencing irritability, and other ERD, both from a parenting intervention perspective and through seeking out appropriate clinical expertise

Watch the Video Replay

Enter your email address in the box above labeled “Video Replay + Slide Access” to watch the video replay (closed captions available) and download the slide presentation.

Download or Stream the Podcast Audio

Click the play button below to listen to this episode directly in your browser, click the symbol to download to listen later, or open in your podcasts app: Apple Podcasts; Google Podcasts; Stitcher; Spotify; Amazon Music; iHeartRADIO.

More on Emotion Regulation Difficulties and ADHD

• Download: Get a Grip on Tough Emotions
• Read: Early Signs of ADD and Emotional Dysregulation
• Read: When a Mood Disorder Looks Like ADHD — and Vice Versa

Obtain a Certificate of Attendance

If you attended the live webinar on December 14, 2022, watched the video replay, or listened to the podcast, you may purchase a certificate of attendance option (cost: $10). Note: ADDitude does not offer CEU credits. Click here to purchase the certificate of attendance option »

Meet the Expert Speaker:

William French, MD, DFAACAP, is a board-certified child and adolescent psychiatrist in the Pediatric Clinic at Harborview, Seattle Children’s Hospital, and Odessa Brown Children’s Clinic in the Division of Psychiatry and Behavioral Medicine. He also is an associate professor at the University of Washington.

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However, emotional dysregulation is not exclusive to attention deficit hyperactivity disorder (ADHD or ADD). Chronic moodiness is also a central component of mood disorders like bipolar disorder, which may complicate the evaluation, diagnosis, and treatment process, particularly for adult patients. Differentiating moodiness as it appears in ADHD, bipolar disorder, and similar disorders is critically important — and not always straightforward.

Emotional Dysregulation Across Disorders

Emotional dysregulation, while present in many conditions, shows up in different ways and in different grades of severity. Making the distinction between characteristics of moodiness in ADHD, ODD, DMDD, and other disorders often requires studying the mood’s intensity and the degree to which it disrupts the individual’s functioning.

ADHD

Chronic Irritability

Many individuals with ADHD report feeling easily irritated and frustrated. Minor frustrations at home, work, and/or school, can cause substantial irritability. (Social pressures outside of the home may keep individuals from lashing out in these settings.) A scenario warranting a 2 on a 10-point scale, for example, can often feel like a 7 or 9 to a person with ADHD. They can be quick to anger, as a result, and may lash out with angry outbursts or through passive-aggressive behaviors. Frustrations, however, are often over quickly. Some may feel upset or regretful later, once the emotional overreaction has subsided.

Oppositional Defiant Disorder (ODD)

ODD is one of the most common comorbidities seen with ADHD. Roughly one-third to one-half of children with ADHD also have ODD, characterized by disruptive, defiant, and irritable behavior. Children with ODD can be quick and impulsive, or sullen and sustained, with their oppositional behaviors toward authority figures. ODD usually becomes apparent around age 12 and lasts until the start of adulthood. Most patients outgrow ODD, but for some, it may turn into conduct disorder, which typically involves delinquent activity, physical aggression, violence, theft, and/or destruction of property.

[ODD vs. ADHD: The Facts About Oppositional Defiant Disorder and Attention Deficit]

Disruptive Mood Dysregulation Disorder (DMDD)

DMDD is a relatively new diagnostic category reserved for children over age 6. It is characterized by steady, persistent problems with mood dysregulation. A child with DMDD experiences severe and recurrent temper outbursts, either verbal or behavioral, that are grossly out of proportion and inconsistent with what is typically expected for a child their age. These outbursts typically occur three or more times a week. Between outbursts, children with DMDD are often persistently irritable or angry. To merit a diagnosis, these symptoms need to be chronically present for at least a year.

DMDD is a way of categorizing major mood problems in children without the bipolar label.

Bipolar Disorder

Bipolar I Disorder

A main feature of bipolar I disorder is a distinct period of abnormally and persistently elevated, expansive, or irritable mood. Bipolar I may also be characterized by a period of “hypomania,” or out-of-the-ordinary, increased activity or energy lasting persistently for at least a week. Depressive moods may also occur concurrently or at other times. These moods are severe enough to cause marked impairment in social or occupational functioning, and often warrant psychiatric hospitalization. There may also be increased risk of suicide or suicide attempts.

To merit diagnosis, at least three of the following symptoms must be present:

• Inflated self-esteem or grandiosity
• Decreased need for sleep
• Pressured speech, racing thoughts
• Extreme distractibility (beyond what is associated with ADHD)
• Increase in agitation (restlessness) or goal-directed activity
• Excessive involvement in risky activity, including over-spending, sexual indiscretions, and/or heavy drinking (the latter often done in an attempt to calm down)

Bipolar I disorder is typically diagnosed around age 18, when a first episode occurs. Many but not all patients go on to experience more episodes.

[Read: Solving the ADHD-Bipolar Puzzle]

Bipolar II Disorder

Bipolar II disorder is usually less severe than bipolar type I, but it can be more complicated to diagnose and significantly impairing. With bipolar type II, there’s at least one hypomanic episode lasting at least four full consecutive days, as well as three or more of the symptoms outlined for bipolar I disorder. These episodes are usually not accompanied by psychotic symptoms; they are not severe enough to cause marked impairment in functioning or to require hospitalization.

Patients with bipolar type II will also meet the criteria for a current or past episode of major depression (MDD). With bipolar I, patients may or may not have accompanying MDD. A major depressive episode is marked by at least 5 of the following symptoms:

• Persistently depressed mood
• Markedly diminished interest or pleasure
• Significant increase or decrease in appetite
• Increased restlessness or slowing down
• Fatigue, loss of energy
• Feelings of guilt or worthlessness
• Diminished ability to think or concentrate
• Recurrent thoughts of death or suicide

Bipolar Disorder vs. ADHD

Bipolar disorder and ADHD do share some characteristics of moodiness, irritability, and other aspects of emotionality. The chart below differentiates these characteristics as they usually appear.

• + = presence
• – = absence
• ++ = more present
• +/– = may be present
• +++ = most present

Bipolar Disorder in Children

Bipolar disorder in children is not always marked by clearly defined episodes of severe moods. Another factor complicating diagnosis is that about 80 percent of children and adolescents with bipolar disorder will also have ADHD, ODD, and/or major depressive episodes. This makes it difficult to tell whether a patient with ADHD and serious mood problems has severe ADHD, bipolar disorder, or both.

But aiding diagnosis is the fact that ADHD and bipolar disorder are highly familial. (ADHD has a heritability index of .76; bipolar disorder is between .6 to .85.) Assessing  for history of mood problems can help determine the diagnosis.

Mood Disorders and ADHD: Treatments and Considerations

Emotional dysregulation and severe moodiness in ADHD and bipolar disorder are often treated with medication. This intervention alone, however, is usually not sufficient. Through psychotherapy, patients and families can receive essential support around understanding and addressing problems with mood and emotional dysregulation, including:

• Identifying triggers to episodes involving family systems
• Using strategies to avoid worsening episodes
• Understanding family history of mood problems
• The limitations of medication

Clinicians should also consider that patients with bipolar type II may not warrant or choose to follow the treatments prescribed for bipolar I. In a hypomanic episode, for example, some patients may want to “tap in to” this energy for work or creative projects. In this case, it’s important to have a conversation with patients about recognizing the signs of an episode.

ADHD and Bipolar Medication Options

The first course of action for treating bipolar disorder with ADHD is to stabilize mood, which can be addressed with medications like Lamictal, Abilify, Risperidone, Zyprexa, or Lithium.

Stimulant Medications

Though not explicitly approved to do so, stimulant medications for ADHD often improve moodiness in patients without a mood disorder. A patient’s effective dose is not based on their age, weight, or severity of symptoms, but rather how sensitive the patient’s body chemistry is to a particular medication. This requires monitoring and fine-tuning dosing to fit individual sensitivity as well as the patient’s lifestyle to ensure the medication is active when they most need it.

For patients with ADHD and bipolar disorder, however, stimulants may exacerbate symptoms of emotional dysregulation. If levels of irritability or agitation are made worse on this medication, the clinician should instead prescribe a mood stabilizer to treat and reduce these issues. When the patient’s mood has stabilized but ADHD symptoms persist, stimulants can be added to treatment, but cautiously. The most prescribed stimulants are Vyvanse and Adderall XR.

“Stimulant rebound” is also important factor for clinicians and patients to consider. Patients who report feeling or acting excessively wired and irritable, or who lose their “sparkle” while the stimulant is active, may be taking a dose that is too high or taking medication that does not work for them. But if these effects are occurring as the medication is wearing off, that’s a different issue of “stimulant rebound”, meaning that the medication is dropping off too fast. Usually, this issue can be fixed by administering a small dose of the short-acting version of the medicine, which smoothes its “exit ramp” and avoids these difficulties.

Nonstimulant Medications

Guanfacine-XR (Intuniv) is a nonstimulant approved for ADHD treatment that may help improve restlessness, impulsivity, and hyperactivity in patients with both ADHD and mood problems. This medication dosage needs to be increased slowly to a maximum of 4 mg per day.

SSRIs

Many prescribers are hesitant to add SSRIs to a bipolar treatment plan, as they can increase the risk of a hypomanic or manic episode and cause suicidal thoughts. But if a patient’s mood is stabilized and symptoms of depression persist, an SSRI like fluoxetine may help improve their mood to baseline. SSRIs should be monitored carefully, especially in the first several weeks of administration.

The Role of the Family

Parent Emotional Dysregulation

How families respond to moodiness and emotional outbursts can make a big difference. Should patients, especially children and adolescents, pursue therapy, it is also important to address parental temper and moods as well. Assessing interactions at home can reveal triggers and sensitive scenarios that contribute to mood instability.

Parental Polarization

A patient’s parents may not share the same approach to addressing irritability and moodiness. One parent may insist on patience and support, while the other adopts a “crackdown” approach. Often, each parent ends up taking a more extreme view over time. Both may fail to see how either approach could be right depending on the situation, to the detriment of the child. Therapy can be an appropriate setting for working through these issues.

Mood Disorders: Next Steps

• Read: The ADHD-Anger Connection: New Insights into Emotional Dysregulation and Treatment Considerations
• Guide: Where ADHD and Bipolar Disorder Overlap
• Download: Bipolar Disorder and ADHD: How to Tell the Difference

The Clinicians’ Guide to Differential Diagnosis of ADHD from Medscape and ADDitude

• How can I better understand ADHD, its causes, and its manifestations?
• What do I need to understand about ADHD that is not fully represented in the DSM?
• How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
• How can I best consider psychiatric comorbidities when evaluating a patient for ADHD?
  • What comorbidities are associated with ADHD?
  • How can diagnosticians differentiate symptoms of anxiety, depression, and ADHD?
  • What are the key distinctions between ADHD and depression?
  • How are the symptoms of ADHD and bipolar disorder often conflated?
  • What are the shared and distinct characteristics of obsessive compulsive disorder (OCD) and ADHD?
  • How can diagnosing clinicians differentiate between rejection sensitive dysphoria (RSD) – the emotional highs and lows associated with ADHD – and the similar ups and downs of bipolar disorder?
  • Free Webinar: Treating Anxiety and Depression Alongside ADHD
  • Free Webinar: ADHD Irritability vs. DMDD vs. Bipolar Disorder
  • Free Webinar: Why ADHD Is Mistaken for Bipolar Disorder in Women
• How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
• How can I best consider trauma and personality disorders through the lens of ADHD?
• What diagnostic criteria and tests are recommended for performing a differential diagnosis of ADHD?

The content for this article was derived from the ADDitude Expert Webinar “Is It Bipolar Disorder or ADHD Moodiness? A Guide to Getting the Right Diagnosis and Treatment” [Video Replay & Podcast #347] with Thomas E. Brown. Ph.D., and Ryan J. Kennedy, DNP, which was broadcast live on March 10, 2021.

SUPPORT ADDITUDE
Thank you for reading ADDitude. To support our mission of providing ADHD education and support, please consider subscribing. Your readership and support help make our content and outreach possible. Thank you.

Attention deficit hyperactivity disorder (ADHD or ADD) is three times more common in people with mood disorders compared to those without, according to a meta-analysis published in Acta Psychiatrica Scandinavica.¹ ADHD was also found to be 1.7 times more common in patients with bipolar disorder (BP) compared to those with major depressive disorder (MDD). Bipolar disorder is a serious mental illness that is characterized by extreme mood swings, abrupt changes in energy levels, and distorted decision making. Major depressive disorder is a serious condition that’s symptoms interfere with all aspects of life, such as sleep, work, school, and eating.

A systematic review was conducted on 92 studies including 17,089 individuals. The studies came from PsycInfo and PubMed, published before September 21, 2020. Random‐effect meta‐analyses were used to gauge the prevalence of ADHD by developmental period and disorder.

Researchers found prevalence of ADHD in individuals with BP was 73% (95% CI 66‐79) in childhood, 43% (95% CI 35‐50) in adolescence, and 17% (95% CI 14‐20) in adulthood. Researchers used 52 studies including 16,897 individuals to demonstrate that the prevalence of ADHD in individuals with MDD was 28% (95% CI 19‐39) in childhood, 17% (95% CI 12‐24) in adolescence, and 7% (95% CI 4‐11) in adulthood.

The significant risk for ADHD among individuals with mood disorders led researchers to conclude that individuals with BP and MDD should be routinely assessed for ADHD, which may require the development of additional comprehensive assessment strategies to aide diagnosing ADHD alongside mood disorders.

Sources

¹Sandstrom, Andrea, et al. Prevalence of attention‐deficit/hyperactivity disorder in people with mood disorders: A systematic review and meta‐analysis. Acta Psychiatrica Scandinavica (Feb. 2021) https://onlinelibrary.wiley.com/doi/10.1111/acps.13283

ADHD walks hand-in-hand with emotional dysregulation. Many children, teens, and adults experience persistent moodiness, out-sized frustrations with daily life, protracted sadness, and/or irritability over seemingly minor disappointments.

It’s often unclear whether such emotionality is part of a patient’s personality or current developmental stage, an aspect of their ADHD, a reaction to medication, or a sign of a more serious mood problem like bipolar disorder.

Diagnostic criteria for ADHD don’t mention problems with emotions, though low frustration tolerance, irritability, or moodiness is listed in the DSM-5 as possible associated features of an ADHD diagnosis. When excessive moodiness is persistent and problematic in someone with ADHD, it may be best to talk with your clinician to consider possible causes and treatment options.

In this webinar you will learn:

• How to differentiate moodiness associated with ADHD from that of bipolar disorder
• Why so many with ADHD are misdiagnosed with bipolar disorder
• When moodiness may indicate a need to evaluate for bipolar disorder
• How medications for ADHD can sometimes cause “rebound moodiness”
• How family dynamics can increase or reduce excessive moodiness
• How medication for bipolar disorder alone may not help ADHD symptoms
• Which medications may be helpful for excessive moodiness with ADHD

Watch the Video Replay

Enter your email address in the box above labeled “Video Replay + Slide Access” to watch the video replay (closed captions available) and download the slide presentation.

Download or Stream the Podcast Audio

Click the play button below to listen to this episode directly in your browser, click the symbol to download to listen later, or open in your podcasts app: Apple Podcasts; Google Podcasts; Stitcher; Spotify; iHeartRADIO.

Read More on Bipolar Disorder and ADHD

• The Physician’s Guide for Distinguishing Bipolar Disorder and ADHD
• Where ADHD and Bipolar Disorder Overlap
• When a Mood Disorder Looks Like ADHD — and Vice Versa: Differentiating Signs of Emotional Dysregulation

Obtain a Certificate of Attendance

If you attended the live webinar on March 10, 2021, watched the video replay, or listened to the podcast, you may purchase a certificate of attendance option (cost: $10). Note: ADDitude does not offer CEU credits. Click here to purchase the certificate of attendance option »

Meet the Expert Speakers

Thomas E. Brown, Ph.D., is a clinical psychologist who earned his Ph.D. at Yale University and served on the clinical faculty of the Dept. of Psychiatry at Yale School of Medicine for 21 years while operating a clinic in CT for children and adults with ADHD and related problems. In 2017 he relocated to California where he sees patients and directs the Brown Clinic for Attention and Related Disorders in Manhattan Beach, California. Dr. Brown’s most recent books are Smart, but Stuck: Emotions in Teens and Adults with ADHD; and Outside the Box: Rethinking ADD/ADHD in Children and Adults-A Practical Guide. | See expert’s full bio »

Ryan J. Kennedy is a Nurse Practitioner who earned his Doctor of Nursing Practice at Quinnipiac University. For nine years he has collaborated with Dr. Brown for research, publications, and in clinical practice. He is Assistant Director of the Brown Clinic for Attention and Related Disorders where he specializes in assessment, behavioral, and psychopharmacological treatments for children and adults. The clinic website is: www.BrownADHDClinic.com. | See expert’s full bio »

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“Both presenters did an excellent job explaining the diagnoses. This information is so helpful and practical for me as a therapist.”

“Presenters were very knowledgeable and broke down the complex topic of Bipolar and ADHD into easy to understand chunks.”

“The speakers were articulate and had a very caring attitude toward their patient group as human beings.”

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Ultimately, emotional dysregulation is one major reason that ADHD is subjectively difficult to manage, and why it also poses such a high risk for other problems like depression, anxiety, or negative self-medication. Scientific and clinical attention are now increasingly turning to correct the past neglect of this integral aspect of ADHD.

Recognizing this inherent relationship between emotional dysregulation and ADHD is also important when discerning between related and similar conditions, like disruptive mood dysregulation disorder (DMDD), bipolar disorder, intermittent explosive disorder (IED), depression, anxiety disorders, and oppositional defiant disorder (ODD). In all, paying mind to anger issues and emotionality in patients with ADHD is crucial for successful treatment and symptom management in the long term.

Anger Issues and ADHD: Theories & Research

Though separated from ADHD in official nomenclature today, emotional dysregulation and anger were connected to ADHD in the mid-20th century before current diagnostic norms were created, and have continued to form part of personal and clinical experiences. Decades ago, when ADHD was known as “minimal brain dysfunction,” criteria for diagnosis actually included aspects of negative emotionality.

Anger problems and emotional dysregulation in individuals with ADHD are sometimes explained by co-occurring mood disorders, such as anxiety or depression. However, these associated disorders do not explain the near universal anger and emotional issues that ADHD individuals experience.

A critical aspect to consider, then, is ADHD’s nature as a disorder of self-regulation across behavior, attention, and emotion. In other words, any difficulties in regulating our thoughts, emotions, and actions – as is common with ADHD – may explain the irritability, tantrums, and anger regulation issues these individuals experience. And the majority do.

About 70 percent of adults with ADHD report problems with emotional dysregulation¹, going up to 80 percent in children with ADHD². In clinical terms¹, these problem areas include:

• Irritability: issues with anger dysregulation – “tantrum” episodes as well as chronic or generally negative feelings in between episodes.
• Lability: frequent, reactive mood changes during the day. .
• Recognition: the ability to accurately recognize other people’s feelings. Individuals with ADHD may tend to not notice other people’s emotions until pointed out.
• Affective intensity: felt intensity – how strongly an emotion is experienced. People with ADHD tend to feel emotions very intensely.
• Emotional dysregulation: global difficulty adapting emotional intensity or state to situation.

Explaining ADHD and Anger via Emotional Profiles

Emotional dysregulation remains a constant in ADHD even when analyzing personality traits, making the case for emotional profiles or subtypes around ADHD.

[Get This Free Download: Emotional Regulation & Anger Management Scripts]

Our own study of children with ADHD that used computational methods to identify consistent temperament profiles found that about 30 percent of kids with ADHD clearly fit a profile strongly characterized by irritability and anger². These children have very high levels of anger, and low levels of rebound back to baseline – when they get angry, they can’t get over it.

Another 40% had extreme dysregulation around so-called positive affect or hyperactive traits — like excitability and sensation-seeking. Children with this profile also had above-average levels of anger, but not as high as those with the irritable profile.

Thinking of ADHD in terms of temperament profiles also becomes meaningful when considering the role of brain imaging in diagnosing ADHD. Brain scans and other physiological measures are not diagnostic for ADHD because of wide variation in results among individuals with ADHD. However, if we consider brain scans based on temperament profiles, the situation may become clearer. Data from brainwave recordings makes the case that there is distinct brain functioning among children who fall under our proposed irritable and exuberant ADHD profiles².

In eye-tracking tests among the participants, for example, children in this irritable subgroup struggled more than those in any other identified subgroup to take their attention off negative, unhappy faces shown to them. Their brains would activate in the same areas when they saw negative emotions; this did not happen when they saw positive emotions.

Genetic Basis for ADHD and Anger Issues

From a genetics standpoint, it appears that emotional dysregulation is strongly associated with ADHD. Our recent findings suggest that genetic liability for ADHD is related directly to most traits under emotional dysregulation, like irritability, anger, tantrums, and overly exuberant sensation-seeking³. What’s more, irritability appears to have the biggest overlap with ADHD versus other traits, like excessive impulsivity and excitement, in children.

These findings refute the idea that mood problems in ADHD are necessarily part of an undetected depression — even though they do indicate higher future risk for depression as well as higher possibility of depression being present.

Anger Issues: DMDD, Bipolar Disorder & ADHD

ADHD, DMDD, and bipolar disorder are all associated in different ways with anger and irritability. Understanding how they relate (and don’t) is critical to ensuring proper diagnosis and targeted treatment for anger issues in patients.

Anger Issues and Disruptive Mood Dysregulation Disorder (DMDD)

DMDD is a new disorder in the DSM-5 primarily characterized by:

• Severe tantrums, either verbal or behavioral, that are grossly out of proportion to the situation
• A baseline mood of persistent grumpiness, irritability, and/or anger

DMDD was established in DSM-5 after a crisis in child mental health in the 1990s in which rates of bipolar disorder diagnoses and associated treatment with psychotropic mediation in children skyrocketed – inaccurately. Clinicians at that time assumed, in error, that irritability in children could be substituted for actual mania, a symptom of bipolar disorder. We now know from further epidemiological work that, in the absence of mania, irritability is not a symptom of hidden bipolar disorder in children. When mania is present, irritability can also emerge as a side feature of the mania. But mania is the primary feature of bipolar disorder.

Mania means a notable change from normal in which a child (or adult) has unusually high energy, less need for sleep, and grandiose or elevated mood, sustained for at least a couple of days — not just a few hours. True bipolar disorder remains very rare in pre-adolescent children. The average age of onset for bipolar disorder is 18 to 20 years.

Thus, DMDD was created to give a place for children older than 6 years of age with severe, chronic temper tantrums who also do not have elevated risk for bipolar disorder in their family or in the long run. It opens the door for research on new treatments targeted these children, most of whom meet criteria for severe ADHD, often with associated oppositional defiant disorder.

DMDD is also somewhat similar to intermittent explosive disorder (IED). The difference is that a baseline negative mood is absent in the latter. IED is also usually reserved for adults.

As far as ADHD, it is important to recognize that most patients who meet criteria for DMDD actually have severe ADHD, sometimes with comorbid anxiety disorder or ODD. This diagnosis, however, is given to help avoid a bipolar disorder diagnosis and take advantage of new treatment insights.

[Self-Test: Could Your Child Have DMDD?]

Anger Issues and ADHD: Treatment Approaches

Most treatment studies for ADHD look at how core symptoms of ADHD change. Treating anger problems in individuals with ADHD has only recently become a major research focus, with useful insights revealed for patient care. Alternative and experimental approaches are also increasingly showing promise for patients with emotional dysregulation and anger issues.

Interventions for Children with Anger Issues

1. Behavioral Therapy⁴

• Cognitive Behavioral Therapy (CBT): Some children with anger issues have a tendency to over-perceive threat – they over-react to an unclear or ambiguous situation (someone accidentally bumps you in line) when no threat is actually present. For these children, CBT can help the child with understanding that something ambiguous isn’t necessarily threatening.
• Counseling: Anger problems can also be caused by difficulties with tolerating frustration. Counseling can help children learn how to tolerate normal frustrations and develop better coping mechanisms.
• Parent Counseling: Parents have a role in how a child’s anger manifests. A parent’s angry reaction can lead to negative and mutual escalation, such that parents and kids both start to lose their balance. This can form a negative loop. With counseling, parents can learn to react differently to their child’s tantrums, which can help reduce them over time.

2. Medication:

Regular stimulant medication for ADHD helps ADHD symptoms much of the time, but is only about half as helpful with anger problems. Selective Serotonin Reuptake Inhibitors (SSRIs) may be next for treating severe anger problems. A recent double-blind study, for example found that children with severe tantrums, DMDD, and ADHD who were on stimulants saw a reduction in irritability and tantrums only after being given Citalopram (Celexa, an SSRI antidepressant) as a second medication⁵. While only one study, these findings do suggest that when mainline stimulant medications are not working, and severe anger problems are a core issue, then adding an SSRI may be a reasonable step.

Interventions for Adults with Anger Issues

Behavioral counseling (as in CBT) has clear evidence pointing to its benefits in treating emotional regulation problems for adults with ADHD. Specifically, these therapies improve skills in the following:

• Interior regulation: refers to what individuals can do within themselves to manage out-of-control anger. The key element here is learning coping skills, practicing them, and checking back with a counselor for refining. Important for patients to understand is that learning about coping skills without practice, or trying some self-help without professional consultation is generally not as effective. Some examples of coping skills include:
  • anticipatory coping, or devising an exit plan to the triggering situation – “I know I’m going to get angry next time this happens. What am I going to plan ahead of time to avoid that situation?”
  • appraisals and self-talk to keep temper under control (“Maybe that was an accident, or they’re having a bad day.”)
  • shifting attention to focus elsewhere instead of on the upsetting situation.
• Exterior supports
  • Social connections – talking to others and having their support –are tremendously beneficial for adults struggling with ADHD and anger
  • Exercise, stress reduction, and other self-care strategies can help.

Strategies with Limited Benefits

• Typical ADHD medication helps with core symptoms, but has only modest benefits on emotional dysregulation for adults with ADHD⁶
• Meditation classes offer some benefits⁷ for managing ADHD symptoms and emotional dysregulation for teens and adults (and for children if parents join in the practice too), but most studies on this intervention tend to be of low quality so it is difficult to draw strong conclusions.
• High-dose micronutrients may help adults with ADHD emotionality, based on a small but robust study⁸. Omega-3 supplementation also appears to have a small effect in bettering emotional control in children with ADHD⁹.

Problems with emotional dysregulation, in particular with anger reactivity, are very common in people with ADHD. You are not alone in struggling in this area. Anger may indicate an associated mood problem but often is just part of the ADHD. Either way, changes in traditional ADHD treatment can be very helpful.

Anger Issues and ADHD: Next Steps

• Read: Why Is My Child So Angry?!
• Learn: Mapping the ADHD Brain – MRI Scans May Unlock Better Treatment and Even Symptom Prevention
• For Clinicians: Comorbid Considerations Q&A – Treating Bipolar Disorder, Depression, Anxiety, or Autism Alongside ADHD

The Clinicians’ Guide to Differential Diagnosis of ADHD from Medscape and ADDitude

• How can I better understand ADHD, its causes, and its manifestations?
• What do I need to understand about ADHD that is not fully represented in the DSM?
  • How does ADHD impair the areas of the brain responsible for executive function?
  • Is emotional dysregulation an ADHD trait? How does it affect diagnosis and treatment? (ADHD)?
  • Why does ADHD impact a patient’s sleep?
  • What is complex ADHD?
  • Is rejection sensitive dysphoria a symptom of ADHD?
  • How can clinicians address the stigma around ADHD in Black communities to ensure better healthcare?
  • Free Webinar: Deficient Emotional Self-Regulation (DESR) and ADHD?
  • Free Webinar: Understanding Complex ADHD
  • Free Webinar: How ADHD Shapes Your Perceptions, Emotions & Motivation

• How can I avoid the barriers and biases that impair ADHD diagnosis for underserved populations?
• How can I best consider psychiatric comorbidities when evaluating a patient for ADHD?
• How can I differentiate ADHD from the comorbidities most likely to present at school and/or work?
• How can I best consider trauma and personality disorders through the lens of ADHD?
• What diagnostic criteria and tests are recommended for performing a differential diagnosis of ADHD?

The content for this webinar was derived from the ADDitude Expert Webinar “You’re So Emotional: Why ADHD Brains Wrestle with Emotional Regulation” by Joel Nigg, Ph.D., which was broadcast live on July 28, 2020.

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Sources

¹ Beheshti, A., Chavanon, M. & Christiansen, H. (2020). Emotion dysregulation in adults with attention deficit hyperactivity disorder: a meta-analysis. BMC Psychiatry 20, 120. https://doi.org/10.1186/s12888-020-2442-7

² Karalunas, S. L., Gustafsson, H. C., Fair, D., Musser, E. D., & Nigg, J. T. (2019). Do we need an irritable subtype of ADHD? Replication and extension of a promising temperament profile approach to ADHD subtyping. Psychological Assessment, 31(2), 236–247. https://doi.org/10.1037/pas0000664

³ Nigg, J., et. al. (2019). Evaluating chronic emotional dysregulation and irritability in relation to ADHD and depression genetic risk in children with ADHD. Journal of Child Psychology and Psychiatry 61, 2. https://doi.org/10.1111/jcpp.13132

⁴ Stringaris, A., Vidal-Ribas, P., et. al. (2017). Practitioner Review: Definition, recognition, and treatment challenges of irritability in young people. Journal of Child Psychology and Psychiatry, 59 (7). https://doi.org/10.1111/jcpp.12823

⁵ Towbin, K., Vidal-Ribas, P., et. al. (2020). A Double-Blind Randomized Placebo-Controlled Trial of Citalopram Adjunctive to Stimulant Medication in Youth With Chronic Severe Irritability. Journal of the American Academy of Child & Adolescent Psychiatry, 59(3). https://doi.org/10.1016/j.jaac.2019.05.015

⁶ Lenzi, F., Cortese, S. et. al. (2018). Pharmacotherapy of emotional dysregulation in adults with ADHD: A systematic review and meta-analysis. Neuroscience and Biobehavioral Reviews, 84, 359-367. https://doi.org/10.1016/j.neubiorev.2017.08.010

⁷ Xue, J et. al. (2019). A meta-analytic investigation of the impact of mindfulness-based interventions on ADHD symptoms. Medicine 98(23). 10.1097/MD.0000000000015957

⁸ Rucklidge, J., Frampton, C., Gorman, B., & Boggis, A. (2014). Vitamin–mineral treatment of attention-deficit hyperactivity disorder in adults: Double-blind randomised placebo-controlled trial. British Journal of Psychiatry, 204(4), 306-315. doi:10.1192/bjp.bp.113.132126

⁹ Cooper, R., Tye, C. et.al. (2016). The effect of omega-3 polyunsaturated fatty acid supplementation on emotional dysregulation, oppositional behaviour and conduct problems in ADHD: A systematic review and meta-analysis. Journal of Affective Disorders 190, 474-482. https://doi.org/10.1016/j.jad.2015.09.053

Perhaps it’s the innate hyperfocus. Or the adrenaline rush. Or the years we’ve spent working hard to ignore buzzing, beeping, unimportant distractions. For maybe all of these reasons, and many others, ADHD brains tend to shine in times of emergency.

We hear this anecdotally from our readers. There was the woman who kicked into high gear as a hurricane approached, able to coordinate supplies, family members, and contingency plans while the world around her panicked. There was the Army aviator who coordinated an emergency rescue mission requiring hours upon hours of life-or-death air traffic control. And many ADDitude readers are feeling it now — during this pandemic that lacks the heart-pumping thrills but none of the dire consequences of a true emergency.

In a survey of ADDitude readers fielded last week, 39.9% of 1,977 respondents said they view their ADHD as an advantage right now. Some cite their ADHD brains’ uncanny ability to shift from first gear straight into fifth with the slightest injection of dopamine. When news of the pandemic’s severity first broke, they responded swiftly and decisively while neurotypical brains struggled to come to terms with a new, changing reality.

“In the initial crisis, I was able to act quickly and aggregate a huge amount of information in order to advocate for us to close/move to online gatherings before the general public did,” wrote one parent of a young child. “Being activated by a sense of urgency and my capacity to hyperfocus served me well. In the following weeks, my ADHD has been a disadvantage as I struggle to maintain the routines and support that I previously used to treat my ADHD. However, even here, I have advantages in adapting to working remotely over my colleagues, because (of necessity) I had already built myself systems of accountability, collaboration, and support with fellow ADHD folk and now these serve me well.”

This theme of using hyperfocus for good emerged time and time again in the survey comments.

[Free Download: 3 Defining Features of ADHD That Everyone Overlooks]

“Hyperfocus lets me absorb a lot of information about things like viruses, the immune system, and epidemiology,” wrote another reader with ADHD and PTSD. “Some folks might find that daunting, but for me, connecting all these dots gives me greater understanding about our situation, and that keeps me more grounded and calm.”

Though hyperfocus and adaptability may seem strange bedfellows, many ADDitude readers also heralded their ability to shift and modify strategies quickly and nimbly as new information unfolded during this crisis. The energy, creativity, and resilience associated with ADHD, it seems, has proven invaluable.

“I can adapt and modify ‘on the fly;’ I’m open to change,” wrote one reader with ADHD, anxiety, and depression. “The typical daily grind is exhausting, but this ever-changing Corona-world is less exhausting. I’m not sure why.”

“I love that we have had to come up with new ways to do things,” wrote another. “Change doesn’t bother me, I adapt. But, honestly, it seems that the world is now more suited to me and I don’t have to work so hard to fit in, or cope.”

[The Benefits of ADHD: Learning to Love It (and Yourself!)]

This theme of finding peace and calm amid the pandemic surprised us as we encountered it time and time again in the survey comments. Many readers expressed gratitude for the opportunity to slow down and engage in the self-reflection and self-care that is so commonly postponed in ‘real life.’

“The rest of the world has come to a stop, so I can now focus on my world without guilt,” wrote one middle-aged woman with ADHD. “I am learning a lot about myself. It’s as though I’ve been able to take a learning workshop on me.”

Others are using their energy and time to pursue joy inside the hyperfocus that their brains crave — but could rarely enjoy with so many daily responsibilities lying in wait prior to the pandemic.

“For the first time in my life, I don’t feel like an outcast, I don’t feel so alone, and I feel like the world is now moving and experiencing the same slowness that I’ve been stuck in for 2 years,” wrote one women with ADHD, bipolar disorder, and PTSD. “I am a part of the new normal and, for once, I am allowed to just be me. I feel like I don’t have to catch up to the rest of society anymore. My distractibility used to take up so much time, but now we’re in limbo and time doesn’t exist. I get to relax while I am in a hyper-focused creative state – there is no more rush… it feels glorious some days – I feel free.”

Indeed, half of the adult survey respondents said they are using “unstructured time” to pursue hobbies, explore creativity, and tackle long-standing projects. This was true for adults both with and without children at home with them.

“I’m free to be creative, working on artistic projects long delayed, without distractions or pressure of any kind,” wrote an older woman with ADHD and anxiety. “For an ADD creative, with no concept of what it’s like to be bored, this is all weirdly ideal. As an artist, I’m blossoming.”

The majority of survey respondents said they are keeping busy with household projects they’ve long avoided; the most common one is clearing clutter to make sheltering in place more calming (and roomy). These organization projects are not easy by any stretch of the imagination; nor are they neatly tied up with a bow. Almost all respondents who reported tackling home projects said these projects are largely unfinished or in a state of flux; they chip away at them slowly and try to feel good about the daily steps in the right direction.

“Organizing spaces is helping me find calm in the storm,” wrote one mother with three young children at home. “I have to focus on one small space at a time or I get overwhelmed. And I can’t do it every day or it’s too much. I’m learning to show myself a lot of grace right now.”

“I got a good start on two areas (with my husband’s help), but can’t get them finished,” wrote a mother at home with two teens. “Some of the challenge is there’s nowhere to take the things to get rid of them. Also, I cannot get motivated to work on any home projects by myself even though there literally has been no other time in my life, and never will be again, that’s better suited to getting home projects, house cleaning done.”

That sense of guilt — over knowing you should be completing home projects right now, but just can’t get it done due to the distractions, the stress, and the work-life rebalancing going on earnest right now — was also a prevailing theme of the ADDitude survey. More than 11% of respondents said they just don’t have time to take on new projects right now; 10% said they are prioritizing self-care and emotional health over productivity; and nearly 28% said they haven’t embarked on any new projects and they feel guilty about it.

“I keep saying I want to get so much done around the house, but then my panic, extreme stress, and lack of sleep do not help,” wrote one parent of elementary and middle school students with ADHD and autism, respectively.

“I feel overwhelmed by how much I have to do in the home, so I focus on other things, even though I want to organize, and I feel guilty for not doing so,” wrote a young adult with ADHD.

The theme of overwhelm was — well, overwhelming, in the answers shared by the 55.77% of survey respondents who called their ADHD a disadvantage during the pandemic. Overwhelmed with all of the change. Overwhelmed with the myriad daily work and parenting responsibilities being constantly interrupted. Overwhelmed with the choices about what to do with unstructured time. All of it resulting in a feeling a paralysis that drives readers to spend too much time on social media or watching mindless shows (the Hallmark channel was cited a lot) or nervously reading the news.

It’s interesting to note that parents with children at home who were also newly working from home were the most likely to call their ADHD a disadvantage right now.

“This is a new experience, so it has placed a strain on the techniques I use to manage my ADHD,” wrote one middle-aged woman. “The sheer amount of information has been overwhelming to the point that I am immobilized by the overwhelm.”

“I finally have all this free time to do all the things I have been neglecting around the house, and yet at the same time, there is so much to do that it is overwhelming, so I find myself defaulting each day to reading and other enjoyable tasks so that I do not have to deal with it — not good,” wrote one parent of teens living in a big city.

“I often feel paralyzed and find it difficult to move forward with projects or tasks,” wrote one mother. “I’m able to make sure my 7th and 9th graders get schoolwork done, which typically does not take up more than 2-3 hours of their days… I’m doing more numbing activities, reading or streaming programs. I read too many daily updates.”

Filling unstructured time with productive, healthy tasks is another common challenge among the respondents struggling to manage their ADHD right now. Many told us they find it difficult to structure their days without the anchors of external obligations like meetings, classes, and social events. They recognize the importance and benefits of structure but feel wholly incapable of creating that structure out of the gaping void in front of them.

“Seemingly unlimited, unstructured time means I veer off into too many rabbit holes and before I know it the day is over, and I haven’t completed any of the professional or personal projects on my to-do list!” wrote one reader.

“Home life is totally unstructured, distracting, and overwhelming,” wrote a woman with ADHD, anxiety, and depression in Seattle. “I try to make a to-do list and get going on it, but it’s so long. Prioritizing and managing it is really difficult. It tends to shut my brain down with overwhelm. I go into some kind of procrastination mode… I usually end up bouncing back & forth between many different tasks that I come across in my path. The end of the day always comes too fast. Then I realize that I still hadn’t started on my to-do list.”

Distractions remain a daunting opponent for many ADHD brains trying to work at home. Some readers report being pulled away from work by children and spouses who need their attention during the day. Others struggle to self-regulate their technology use during the day — having social media and YouTube and news just a click away at all times is sucking up a lot of time. Still others report exhaustion from poor sleep and from feeling compelled to work all the time since the office is just down the hallway.

“Distractibility is having a more severe impact, as I can’t change my environment (e.g. by going to the library) and I have to work in the same room with my partner, usually at the same time,” wrote one readers. “Work never seems to end and is “everywhere” — clear starts and ends are very difficult to maintain — and I don’t have less work than before.”

Routine and boundaries are difficult for parents as well, but in a different way. Three-quarters of parents report that their family’s morning and/or evening routine is less stressful than it was before schools closed. But nearly 25% of parents surveyed said they continue to face hardship with the following:

• Getting a child to adhere to a set class schedule on Zoom or other video learning platform, especially when classes begin early in the day
• Getting kids out of bed and organized for a day of learning before leaving the house for work
• Managing pent-up energy and aggravation at the end of the day, which leads to dysregulation and poor sleep
• Children who think they’re on spring or summer break and fight relentless against bedtimes

“It’s impossible to get my child out of bed to sign in for a virtual class – he does not see the point,” wrote one parent. “After signing in, he claims – that’s it for that class and does not do the work. Nighttime is not any easier. My son is reveling in the combo of not having outside activities and unrestrained screen time. If we cut the screen time off, he threatens to leave the house at very late hours (He is a teen). As a result, he is staying up later than he was before.”

“Humbly, I share that the only reason that there is less stress is because I lower the bar, which is not good,” wrote another parent. “As an adult, now understanding that I have ADHD, I know how incredibly important structure and/or routine is to my and my children’s success in developing competence and confidence. I am not currently successful at this with them. The external structure of school was helpful, and I am struggling now.”

So what is helping? Empathy, support, and community.

“I just like to know I’m not alone in my feelings and struggles in our ‘new norm.’”

So thank you for sharing your unfiltered emotions, struggles, and strategies, ADDitude readers. Your voices matter.

[Read This Next: Results from ADDitude’s First Pandemic Survey]

THIS ARTICLE IS PART OF ADDITUDE’S FREE PANDEMIC COVERAGE
To support our team as it pursues helpful and timely content throughout this pandemic, please join us as a subscriber. Your readership and support help make this possible. Thank you.

“My parents were worried about me being a ‘real boy,’ because I loved playing with Barbies. One day the dolls all disappeared. Dad said I was too old to play with Barbies.”

“Then I discovered G.I. Joes! Here’s a doll that is hot, muscular, and bearded — like that guy,” I say enthusiastically pointing to a handsome audience member, who couldn’t help but crack up. I’m gay, so the joke makes fun of contrasting assumptions (that I must be gay) with GI Joes (Yup, I really am gay).

So began my first-ever Stand Up for Mental Health (SMH) comedy routine.

During college, more than three decades ago, I was diagnosed with attention deficit hyperactivity disorder (ADHD) and bipolar disorder. Both have wreaked havoc in all areas of my life. Let’s just say, it’s been a long, strange trip that’s provided me with no shortage of humorous material.

[Could You Have Bipolar Disorder? Take This Symptom Test]

Through it all, humor has been a common thread. Sometimes I bounce back quickly from painful experiences; sometimes it takes years. Humor has always helped me get through challenges at school and in life. Through bullies who targeted me for my “differences,” breakups with friends and lovers, job loss, rejection by my family, working through pain in therapy, and dealing with medication side effects — I’ve used laughter as a coping tool.

Born This Way

During childhood, my best friend and I constantly bounced ideas and jokes back and forth (during classes no less!) and laughed so hard it sometimes physically hurt. Our teachers put up with us — to a certain point — because we weren’t harming anyone (unlike the bullies) and the other kids found us funny. Apart from that, laughter generates a positive mood and everyone knows that feeling good helps kids (and adults) learn.

Humor is a way to challenge my negative experiences. I typically use it to diffuse awkwardness and respond to painful experiences like being hurt by family members and others who desperately want me to conform. I’m often asked why I write jokes involving family and friends, and I say because it’s easy. I honestly couldn’t invent better material myself.

I never make fun of anyone; my comedy is about what I personally experienced and how it affected me. Comedy helps me turn it around. The Barbie joke could be used in a generic way to denote the experience of anyone wanting me to “conform,” but it’s funnier because it involves my parents.

So much comedy material comes from the well-meaning yet ignorant questions I get about ADHD:

• When did you know you had ADHD?
• Can’t you just try not being distracted?
• Isn’t ADHD a lifestyle choice?
• Isn’t ADHD just a phase like puberty?
• You don’t look like you have ADHD!
• Can you still have kids?
• Do you know my friend Tom? He has ADHD, too!

[You Might Also Like: How Humor Can Reduce Stress at Home]

Learning to Laugh Through the Tears

I never thought about writing and performing comedy until I saw an SMH performance at a mental health clubhouse I belonged to in Vancouver. The year 2018 was a challenging one for me; I spent most of it spiraling in and out of depression. Seeing the SMH performance was a revelation. The comedians used their painful experiences (usually involving mental illness) to make jokes. They were genuinely funny, and their jokes were as good as any professional comedy I’ve seen.

David Granirer, a mental health counselor and stand-up comedian who struggles with depression, founded SMH as a way to reduce the stigma and discrimination around mental illness. He believes that laughing at setbacks helps people rise above them. The group holds classes and training sessions with the goal of helping each participant develop six really good jokes.

In January 2019, I signed up for the class even though I didn’t know anyone else in it. I was feeling down and stuck and performing comedy somehow seemed like it might be good for me. I knew that being onstage would be intimidating, but I didn’t care. I’ve gotten through other scary and intimidating things; this would just be one more. The class turned out to be a lifesaver for me.

From January through June, as a class we listened to each other’s material and gave feedback, which is essential to narrow down the joke to its “nugget” — the most impactful part. To prepare for “graduation” — performing at a professional comedy club — we practiced in class with a stand and microphone and performed at local community clubs and neighborhood events.

The Big Reveal

About 175 people bought tickets to see our final performances. (The audience knew they’d be seeing performances about mental health by people struggling with mental health.)

In spite of my nerves, I find the experience of performing humor on stage to be amazingly empowering. It means that my life — my story — is worth telling. It means I can give the gift of laughter; that I’ve accomplished something new, challenging; and worthwhile.

When I tell others I’m doing stand-up comedy, they usually say “Oh, I could never do that.” But it’s my way of contributing to society. Instead of just being a person struggling with ADHD and bipolar disorder, I’m out there giving voice to the struggle and destroying misconceptions about the conditions.

There’s no doubt my ADHD and bipolar disorders have changed me, for better and for worse. I’ve lost a significant amount of my life to mental illness and trying to conform to other people’s expectations, but comedy and other creative endeavors have given me a reboot and helped me to rediscover myself. That’s one of the strongest validations I’ve ever had.

[Read This Next: You Know You Have ADD When…]

For many people with attention deficit disorder (ADHD or ADD), understanding a single diagnosis isn’t enough. Many present with symptoms of two or more conditions. We call this “co-occurrence.” Great. Just when you thought nothing else could be wrong, you realize (or find out) you may have another psychiatric diagnosis.

While many disorders can co-occur with ADHD, six show up most often:

• Generalized anxiety disorder
• Depression
• Bipolar disorder
• Autism spectrum disorder
• Borderline personality disorder
• Antisocial personality disorder

Each of these conditions can radically affect the approach to medication and therapy for people with ADHD. Here we’ll examine the first four in depth and show how each intertwines with ADHD.

To learn more about these conditions, check out our forthcoming book, ADD and Zombies: Fearless Medication Management for ADD and ADHD.

[Read: When It’s Not Just ADHD – Symptoms of Comorbid Conditions]

This short guide doesn’t supply enough information to set up your own co-occurring diagnosis shop. But it will let you see the complex interplay of several conditions that often intersect with ADHD, and to be a better consumer of those diagnoses and to partner with the providers who give them. This will make all the difference when you or someone you love is up for a diagnostic label.

Anxiety: Is It Primary or Secondary?

We like to think of ADHD and anxiety as being on a continuum. Anxious people care too much about the details of life, and people with ADHD care too little. When ADHD and anxiety appear in the same person, treatment is complicated.

The complication appears in one of three ways. Most commonly, a client who qualifies as having both ADD and anxiety is treated with an SSRI (selective serotonin reuptake inhibitor) or an SNRI (serotonin and norepinephrine reuptake inhibitor) before starting stimulants. This is because stimulants will reduce procrastination and improve on-task behavior by raising anxiety. For clients with both ADHD and anxiety, being prescribed stimulants first can push that anxiety to unproductive levels. Occasionally, we only realize a client has a mixed condition after trying stimulants and seeing this result, in which case we temporarily stop the stimulants and treat the anxiety first.

Sometimes, a client presents ADHD symptoms but is experiencing so much anxiety that he or she has problems concentrating and managing daily affairs. The client’s mind never stops running, in rare cases, to the point of obsessions and compulsions. This preoccupation prevents a person from getting anything done. We refer to this as “anxiety-primary.” However, even when we hypothesize this condition, it is tough to prove without a medication trial. If taking an SSRI or an SNRI reduces both anxiety and the ADHD symptoms, this is the best conceptualization.

[Click to Read: “I Feel Like I’m Losing My Grip.”]

Conversely, we may see a client whose anxiety is the result of ADHD. We call these cases “ADHD-primary.” Such individuals are so overwhelmed by managing ADHD symptoms that they are constantly on edge and fearful. By reducing their ADHD symptoms, their anxiety drops to a tolerable level. The quickest way to find out if this will happen with a given client is to initiate stimulant medication. If anxiety drops, we’ve nailed it. If it rises or remains the same, we’re back to the ADHD-anxious diagnosis. In that case, we typically add an SSRI or SNRI to the medication regimen.

Any differences in symptom presentation following a stimulant trial are critical for your prescriber to know about and understand. Unfortunately, we see many clients who started a stimulant trial with a previous prescriber, had poor results, and then had the prescriber errantly ignore the ADHD diagnosis and eschew a valuable course of treatment. Getting it right matters. Understanding how your anxiety and ADHD interact will make all the difference in successfully treating both conditions.

Bipolar Disorder: Tricky to Treat

Many bipolar disorder symptoms are overlooked because they closely resemble those of ADHD-combined inattentive/hyperactive type. Both disorders are marked by inattention, excessive energy, poor judgment, impulsivity, hyperkinesis, disconnected thoughts, irritability, mood dysregulation, sleep problems, racing and/or jumbled thoughts.

[Self-Test: Bipolar Disorder in Adults]

Bipolar disorder, however, typically brings broader and more severe changes in mood, excessive self-esteem, revved-up energy, impulsive or self-destructive behaviors, and even psychotic behavior. When people with ADHD and co-occurring bipolar disorder have a depressive episode, they may still be agitated or even grandiose, but this may be attributed to their ADHD, not to mania. Thus, they may be misdiagnosed as having unipolar depression rather than bipolar disorder.

Treating co-occurring ADHD and bipolar disorder is tricky because stimulants have the potential to trigger mania. While stimulant-related anxiety is often tolerable and quickly fixed, stimulant-induced mania can create serious trouble. Prescribers are aware of these dangers, so bipolar clients may be under-treated for ADHD symptoms.

The knack in ADHD-bipolar cases is to tightly integrate medication management and psychotherapy to keep up with and respond to the changes in personality, emotional state, and brain chemistry that come with any serious mood disorder. Staying attuned to those tides is the most important job for client, therapist, prescriber, and family. Whenever we use a stimulant in such cases, we start off with low doses, and see the client weekly for medication evaluation and therapy during the first month or two of treatment, then adjust the protocol slowly. We carefully increase the dosage, and introduce, or alter, mood-stabilizing medications as necessary.

Autism Spectrum Disorder: Closely Correlated with ADHD

Autism exists on a broad spectrum — from oddly helpful to debilitating — making it hard to compare one case to another. However, what these cases have in common, in varying degrees of severity, is difficulty with communication and interaction with others. Clients have restricted interests and repetitive behaviors, and impairment in the client’s functioning in school, at work, and in areas of life that involve human interplay.

[Self-Test: Autism Spectrum Disorder in Adults]

Rarely is ASD a differential diagnosis to ADHD because the two are so closely correlated. When a person has both, the diagnoses are especially tricky to treat. Stimulants can help people with ASD-ADD learn social rules and pay attention to the details that underlie them, but no medication can make them more socially adroit or disengage them from their interior worlds. Some patients with ASD-ADD have significant mood fluctuation and emotional breakdowns, particularly when external events overwhelm them. Some providers mistake mood swings for anxiety, and treat them as such, which serves to increase, rather than decrease, irritability.

Mood dysregulation can be as problematic for those with ASD as it is for those with bipolar disorder. In fact, stimulants can be so irritating to people with ASD that, at one time, it was recommended that doctors forgo them. Yet we find, time and again, that the correct combination of stimulants and mood stabilizers improves client functioning. Like bipolar clients, ASD-ADD clients may do well with mood stabilizers plus a slow, careful, and well-integrated treatment plan.

Depression and ADHD: Chicken and Egg

For many individuals, depression and ADHD go hand in hand. Their dual symptoms include a persistent, sad, or irritable mood, loss of interest in previously enjoyable activities, changes in appetite or weight, sleep problems (too much or too little), low energy, feelings of worthlessness, or inappropriate guilt. Some clients experience thoughts or acts of self-harm.

As with anxiety, there are three ways ADHD-depression present together. Most commonly, depression follows the ADHD. Managing ADHD symptoms is tough, so a person with ADHD may feel hopeless and ineffective, leading to diagnosable depression. Even with a good evaluation, the only way to test this is to address the ADHD with stimulants and cognitive behavioral therapy, and see if the depressive symptoms lessen. Frequently, they will.

In other cases, clients respond favorably to stimulants at first, only to have a quick drop-off in their impact. Stimulants raise energy and alertness, and increase productivity, which helps people feel better. However, that improvement may mask underlying depressive symptoms that exist in tandem with ADHD, and may last only as long as the stimulant is working, usually eight to 12 hours. Fortunately, these clients tend to be good candidates for adding an SNRI. Treating co-occurring depression and ADHD in this way allows the prescriber to try lower stimulant doses while maintaining treatment satisfaction.

Similarly, we may see a client presenting with symptoms of depression, treat that condition successfully, and then later realize that, despite improvements in mood, the client is still struggling in school, relationships, or career. The client is feeling better but not doing much better.

In a small number of cases, depression, and not ADHD, is the primary issue. These clients become so sad that they can’t focus. For them, depression management, usually with an SNRI (like Effexor or Cymbalta), or a norepinephrine–dopamine reuptake inhibitor (NDRI) (like Wellbutrin), may manage the ADHD symptoms well without a stimulant.

[Free Expert Resource: Is It ADHD or a Misdiagnosis?]

Wes Crenshaw, Ph.D., ABPP, s a licensed psychologist and coauthor of the forthcoming books Consent-Based Sex Education: Parenting Teens for Sexual Competence and ADD and Zombies: Fearless Medication Management for ADD and ADHD. Kelsey Daugherty, DNP, is licensed to prescribe psychopharmaceuticals, including stimulant medication, under protocol. She works with Dr. Crenshaw at Family Psychological Services LLC, in Lawrence, Kansas.

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Data from a recent clinical trial suggests that a low Body Mass Index (BMI) and an anti-inflammatory diet may promote a positive response to add-on nutraceutical treatment for bipolar disorder.

Bipolar disorder is historically difficult to treat because it comprises two diametrically different sets of symptoms. Current medications are more effective for manic symptoms than they are for depressive ones. The diet tested in the study had a positive impact on both sets of bipolar symptoms.

“If we can confirm these results, then it’s good news for people with bipolar disorder, as there is a great need for better treatments for the depressive phase,” said Melanie Ashton of Deakin University in Australia, lead researcher.

In the study, 133 participants were randomly assigned either a combination of nutraceutical treatments that included the anti-inflammatory amino acid n-acetylcysteine (NAC), NAC alone, or a placebo. This treatment was received for 16 weeks, in addition to any stable treatments participants were already receiving. Depression and ability to function in day-to-day life were measured at the beginning of the study, as were eating habits. Researchers used the eating habits results to calculate a diet quality score for each participant and categorize their diet as either anti-inflammatory or pro-inflammatory. BMI was also measured.

Researchers rated participants’ improvement over the course of 16 weeks of treatment or placebo, plus 4 subsequent weeks. They found that those with anti-inflammatory diets or low BMIs demonstrated a better response to add-on nutraceutical treatment than did those with low-quality or pro-inflammatory diets, and those who were overweight.

The results were presented at the 2018 European College of Neuropsychopharmacology (ENCP) conference in Barcelona, in a presentation entitled “Diet quality, dietary inflammatory index and body composition as predictors of N-acetylcysteine and mitochondrial agents efficacy in bipolar disorder.”

“What this means, if these results can be repeated in a larger trial, is that treatment for bipolar disorder would need to take into account what a person eats and their weight,” explained Ashton, a doctoral candidate at Deakin’s School of Medicine.

She went on to note that, though the study was a randomized, controlled trial, the outcomes were only exploratory. “Our result is statistically significant, but because the study wasn’t specifically designed to test the effect of diet quality, inflammatory diets, and BMI on drug response in general, it is necessary to see the work replicated in a larger study before any firm conclusions can be found.”

Should the results be successfully replicated in a larger trial, it could mean that the treatment of certain mood disorders would be accompanied by the inclusion of dietary advice.

A comorbid condition is a separate condition that exists alongside ADHD, compounding an individual’s cognitive, psychological, and social impairment. These conditions, when found alongside ADHD, warrant special consideration and a unique treatment plan.

This reference chart names the 9 conditions most commonly found in individuals with ADHD, plus the symptoms, common treatments, and recommended resources for each.

NOTE: This resource is for personal use only.

Perhaps more common, however, are feelings of fear, confusion, and apprehension. What treatment plan will work best? Will you need to go on meds? Is therapy an option? Is anything even going to work? It can feel overwhelming.

Fortunately, treatment for bipolar disorder is fairly straightforward, and has been proven highly effective in most cases. The best treatment plans usually involve a combination of medication and therapy — particularly a specific branch of psychotherapy known as cognitive behavioral therapy, or CBT.

[Self-Test: Bipolar Disorder in Adults]

Treating Bipolar Disorder with Medication

Medication is the most universally effective treatment option, and likely will be the first and most important step in your therapy. Medications used to treat bipolar disorder work by stabilizing your moods — untangling you from the dramatic ups and downs of mania and depression — and, if you respond well to them, allowing you to function more or less normally.

If you’re nervous about possible side effects, or angry that you have to take medications just to be “normal,” you’re not alone — most (if not all) recently diagnosed bipolar patients feel this way. But medication is nothing to be ashamed of and, in most cases, nothing to worry about. Untreated bipolar disorder is far more detrimental to your life than are the medications used to treat it, and proper dosage shouldn’t alter your personality — it just works to stabilize your mood and help you avoid frightening extremes that can have drastic consequences.

The most commonly prescribed medication is lithium, a mood stabilizer that’s been used to treat bipolar disorder for more than 60 years. Experts know that lithium works with the central nervous system and spinal cord — primarily with certain neurotransmitters in your brain that seem to contribute to both mania and depression — but it’s exact mode of action is still unclear. About 75 percent of patients respond positively to lithium, making it the most effective option for treating bipolar disorder — but about the same percent of patients experience at least minor side effects.

Anticonvulsants — normally used to treat epilepsy — have also proven effective in treating bipolar disorder. If a patient doesn’t respond well to lithium, anticonvulsants are usually the next step, since they’ve been shown to be as effective as lithium in some cases.

[Free Resource: Is It Bipolar or ADHD?]

Antipsychotics are another option, usually given to patients who experience hallucinations or delusions during extreme periods of mania. In particular, a newer atypical neuroleptic, lurasidone, has been the first medication to demonstrate significant ability to treat the depressed phase of bipolar.

Benzodiazepines are also used, primarily to treat bipolar patients who are severely anxious in both the depressed and manic phases. Benzodiazepines can produce a physical and psychological dependence if used for long periods of time, so they’re best for short-term treatment.

Most bipolar medications, and particularly lithium, need time to build up in the body to a therapeutic blood level — a few weeks, in most cases. Your doctor will ask you to get blood drawn at regular intervals to be sure that the level is neither too low nor too high. If you don’t see results right away, be patient. Be sure you talk to your doctor frequently about changes in your mood, or if you’re worried that the medication isn’t effective.

As with most psychiatric prescriptions, side effects do exist with bipolar medications, but in most cases, they’re mild. Common ones include changes in weight, feeling “dull” or unfocused, drowsiness, reduced libido, dry mouth, and shifts in appetite. Some more serious side effects have also been reported — including comas and kidney failure — but they’re extremely rare. Working with your doctor, start at a low dosage and increase it slowly to find the right balance of meds that works most effectively with the least side effects.

[Where ADHD and Bipolar Disorder Overlap]

If you feel “zombie-like” on medication, you’re likely taking too high a dose — talk to your doctor about reducing it, or switching to a different class of medications.

Treating Bipolar Disorder with Therapy

Many people taking medication for bipolar disorder still suffer from shame and anger related to being bipolar — particularly if they have spent years undiagnosed — and medication alone is often not enough to repair the relationships damaged by symptoms. This is where therapy comes in — to fill in the gaps and boost the overall effectiveness of your treatment plan.

While traditional psychotherapy is used occasionally, cognitive behavioral therapy (CBT) is the most common form of therapy for patients with bipolar disorder. Working together with a trained CBT therapist, bipolar patients examine possible triggers for mania or depression, and talk through their thinking processes to identify distortions that may be negatively impacting their view of a situation. Patients also learn coping mechanisms and relaxation techniques to — ideally — stop episodes in their tracks. When applied effectively, CBT can help patients improve social and romantic relationships, and greatly reduces their chance of relapse.

The first topic you’ll need to address is the shame and resentment associated with finding out that you have a major mental illness that is going to affect you for the rest of your life — one that may be passed on to your children. This is never easy. It will likely take work — with an experienced counselor you trust — to sort through this drastic change in your life and your future.

Luckily, CBT can help a lot with these areas, plus it has the added benefit of empowering patients to take control of their treatment process. Since CBT is interactive and can be highly cathartic, patients report feeling like active participants in their fight against bipolar — not just spectators to a medication.

In some cases, the entire family will need to be involved in therapy. Probably the single biggest factor in achieving a good outcome is having the support, understanding, and acceptance of the important people in your life. In this same vein, bipolar support groups can be invaluable. Being able to talk with and gain support from people who “really know what it’s like” provides a new level of support and understanding that can’t be found anywhere else.

In order for CBT to properly work, however, the patient’s bipolar disorder should be relatively stable and under control when therapy begins. If someone is in the grips of a dramatic episode of mania, CBT won’t be of much help.

Treating Bipolar Disorder with Dietary Changes

It’s true that medication and therapy are the most effective treatment options for bipolar disorder. But they can take weeks to reach their full effect, and they are certainly not the only solutions for managing your symptoms and keeping your moods in line. Eating certain foods — and avoiding others that have been linked to exacerbated symptoms — is one way you can take control of your treatment (as well as your overall health).

A healthy bipolar diet includes the following:

Omega-3s: Multiple studies have shown that Omega-3 fatty acids like the kinds found in fish and fish oil supplements can help decrease the feelings of depression so common in bipolar patients. Vegetarian? Try getting your Omega-3s from eggs or nuts instead.

Magnesium: Magnesium — found in whole grains, beans, and dark leafy vegetables like spinach — has been shown to have an effect similar to lithium, the most common bipolar medication. Upping your intake of magnesium, a natural mood stabilizer, may decrease your need for medication. (It should be noted, however, that magnesium cannot and should not replace lithium entirely.)

Salt: Seems counterintuitive, right? Many people who are trying to “eat healthy” try to dramatically lower their salt intake, but this isn’t necessarily the best idea — especially if you have bipolar disorder. Once you start treatment, don’t let your salt intake get too low, and definitely don’t cut out salt entirely — salt is very necessary to regulate the levels of bipolar medication in your bloodstream.

Healthy Fats: Healthy fats like those found in avocados and olive oil won’t have any effect on your bipolar symptoms themselves, but they can help keep you feeling full longer and decrease your cravings for the “foods to avoid” listed below.

Individuals with bipolar disorder should cut back on the following:

Caffeine: Caffeine and other stimulants can kick mania up a notch. When experiencing a manic phase, avoid coffee, soda, and energy drinks. Try herbal teas or infused water instead — the herbs can give you a natural energy boost to overcome slumps.

Sugar: Sugar highs and lows can make an already unbalanced mood even more erratic, and sugar crashes can make a depressive phase much worse. If you really need something sweet, reach for fruit — the natural sugars won’t cause such a drastic blood sugar spike.

Refined Carbohydrates: Bipolar patients may be more prone to obesity, since imbalances of seratonin in their brains may lead them to crave more unhealthy carbohydrates. Ditch the processed junk and get your carbs from whole grains, fruits, and vegetables instead.

Alcohol: Alcohol and bipolar disorder just don’t mix. Not only can alcohol interact poorly with psychiatric medications, it can also disrupt sleep — bad news for an already high-strung bipolar person. Bipolar patients are also more likely than neurotypical people to develop drug or alcohol addictions. In other words, alcohol is not worth the risk.

Grapefruit: Talk to your doctor about your specific situation, but some bipolar medications — particularly anticonvulsants — interact poorly with grapefruit and grapefruit juice.

Food can’t cure your bipolar disorder, and it’s always best to talk to your doctor about the best treatment plan for you. But proper diet can, in some cases, help keep your symptoms stabilized.

Treating Bipolar Disorder with Lifestyle Changes

Though there is little hard data behind it, anecdotal evidence suggest that getting regular exercise and following a proper sleep schedule can have positive effects on bipolar symptoms, too — at least during a depressive phase. At the very least, one study found a correlation between a sedentary lifestyle and an increased risk of bipolar episodes, indicating there may be some connection between low activity levels and difficult bipolar symptoms.

Since exercise boosts endorphins, it seems to have the most positive effects during depressive phases, helping patients who are not being treated with medication lift their moods. For the same reason, however, some patients find that it tends to exacerbate their manic phases — meaning a dangerous high can go from bad to worse thanks to a big rush of endorphins.

For patients who are being treated with medications, regular exercise can help combat the weight gain that can be an unwelcome side effect. Patients taking lithium, however, should talk to their doctor before embarking on an exercise plan — the medication can affect your salt levels and potentially dehydrate you if proper precautions aren’t taken. Make sure you eat a healthy level of salt and drink a lot of water if you plan to exercise while taking lithium.

Since sleep disturbance is a common symptom of untreated bipolar disorder, it can be a chicken-egg situation — are you not getting enough sleep because escalating symptoms are keeping you up, or are your symptoms getting worse because you’re not getting enough sleep? Regardless, working toward restoring a normal sleep cycle can help you manage symptoms and feel more in control during a manic phase. CBT can — and often does — help with this, but there are at-home solutions you can try on your own:

Keep a sleep diary: Track when you go to sleep, how long it takes you to fall asleep, how well you slept, and what time you wake up. This will help you notice patterns and identify triggers for poor sleep — and if you’re tracking your moods as well, can help you identify whether sleep problems preceded a mood swing, or vice versa.

Avoid alcohol and caffeine: As mentioned above, alcohol and caffeine can affect your sleep cycle in a negative way — even more than they would a neurotypical person.

Create a perfect sleep environment: Make your room as dark as possible, and keep the room cool. Try to go to bed at the same time every night, even on the weekend. Visualization and relaxation exercises can also help someone with bipolar disorder quiet a racing mind and fall asleep.

Since proper diagnosis is the golden ticket to receiving proper — and, in many cases, lifesaving — treatment, it’s important that you know what bipolar disorder looks like in everyday life. Though terms like “mania” are easy for most of us to understand in the abstract, it can be hard to identify when we see it in ourselves or a loved one. Here are some examples of what bipolar disorder might look like in the real world, both at home and at work.

Symptoms at Home

Bipolar disorder affects patients’ relationships, use of substances, and sleep. During a manic phase, you might notice:

• High sex drive — engaging in promiscuous sex with strangers, desiring or demanding sex with a partner more frequently than normal, or masturbating excessively
• Increased pornography use
• Little or no satisfaction with sex, despite the higher frequency; always feeling like you “need more”
• Other risky behaviors, like drug use, excessive drinking, or gambling
• Spending more money than normal; making impulsive and extravagant purchases like jewelry, cars, or other luxury items outside of your normal budget
• Bursts of “creative energy” — might embark on ambitious art projects, often bouncing between several at once or leaving others unfinished
• Feelings of intense optimism or invincibility; feeling like you can and should do anything your heart desires
• Anger with friends or family for discouraging or not understanding your ideas and impulses
• Impatience with your spouse for things like “talking slowly” or “wanting to stay in”
• Talking over others more than normal; most conversations becoming wholly “one-sided” after a few minutes
• Sleeping little or not at all

[Self-Test: Do I Have Bipolar Disorder?]

During a depressive phase, you might notice:

• Little or no interest in sex, even with a loving partner
• For men, erectile dysfunction may occur
• Sleeping too much, or feeling like you never want to get out of bed; in some cases, experiencing insomnia
• Feeling tired all the time, no matter how much (or how little) you slept
• Feeling guilty, hopeless, or full of despair
• Drastically reduced energy for everyday activities, like preparing food or interacting with friends
• Uninterested in normal hobbies, particularly those that tend to go into overdrive during a manic phase
• Dramatic changes in appetite, either eating too much or too little
• Suicidal thoughts; may attempt suicide

Symptoms at Work

Bipolar disorder at the workplace will appear similar to the symptoms listed above, but the nature of your relationship with your coworkers and boss may change its outward appearance a little. While working during a manic phase, you might notice:

• Jumping in during meetings more often than normal, talking over coworkers, or talking so fast that no one can understand you
• Laughing or joking more frequently and more exuberantly than usual; turning into the “office clown”
• Arguing with your boss over even the tiniest criticisms, or blowing up at coworkers over perceived slights
• Impulsively taking on more work or agreeing to lead new projects, often failing to complete them

[How to Treat Bipolar Disorder]

During a depressive phase, you might notice:

• Trouble concentrating on daily tasks; mindlessly browsing the Internet instead of writing a report, for example
• Unable to meet deadlines or juggle multiple assignments at once
• Calling out of work more than normal; making up excuses for not finishing tasks or maintaining regular attendance
• Feeling hopeless about your career, your future at the company, or your life in general while at work
• Getting frequently irritated with coworkers for normal behavior
• Unusually anxious about day-to-day interactions; assuming every email from your boss will be a reprimand, for example

Doctors call bipolar disorder a “kindling” illness — meaning that it gets progressively worse as time goes on. Without treatment, episodes are longer and more impairing, and the time between episodes is shorter. This is why physicians strongly encourage people to stay on their medications, even when they feel well. It is vital, in the long run, to prevent episodes rather than treat them.