ADHD or Bipolar Disorder? How to Tell the Difference

This is one of the distinctions with heavy consequences when it is made wrongly. So let me say it at the very start: this is not a distinction to be made on your own, and this article does not help you make it.

So why am I writing it? Because knowing what is looked at lets you tell the doctor the right things. What I noticed most in my own assessment process is this: giving the right information is a skill too, and in every meeting I went into unprepared I told the wrong things.

Why they get confused

The overlapping sides are real:

• Impulsivity and making decisions without thinking
• Fast-moving thoughts
• Talking a lot
• Disturbance in sleep routine
• Emotional fluctuation
• Risky behavior and impulsive spending

The review by Shaw and colleagues (2014) argues that emotion regulation difficulties may be a central part of ADHD. So emotional fluctuation is expected in ADHD, and this makes it easy to confuse with bipolar disorder.

In me this fluctuation is very pronounced. In the morning I get carried away with an idea and give the whole day to it, in the evening I feel nothing about the same idea. The first time I told someone about this, the person in front of me said "you are not bipolar, are you?" I am not, but I understand why they asked.

The three criteria that separate them

1. Continuity or episodes.

This is the most decisive one.

ADHD is continuous. The symptoms have been there since childhood. They fluctuate through the day but are always there; even on a good day the basic pattern stays the same.

Bipolar disorder is episodic. There are mood episodes lasting days or weeks that clearly depart from the person's usual state. In the periods in between, the person can return to their usual self.

The question to ask is this: has it always been like this, or are there episodes that begin and end?

2. Sleep.

A very distinguishing sign, and the easiest to observe.

In a manic or hypomanic episode the need for sleep decreases: the person sleeps three hours, feels rested and stays energetic all day.

In ADHD sleep is delayed but the need continues: you go to bed late, you are tired the next day and that tiredness goes on all day. The details are in the article on ADHD and sleep.

It is easy to check this difference on yourself: on the days after the mornings when you slept little, were you tired or not?

3. The duration and trigger of the emotional change.

In ADHD the emotional reaction generally comes tied to an event, comes hard and can pass within hours. A message, a look, a piece of feedback is enough. The name and details of this reaction are in the article on rejection sensitive dysphoria.

In bipolar disorder the mood lasts for days and can run independently of events.

In ADHD "I was very low this afternoon" is usual. In bipolar disorder "I have been like this for three weeks" is more typical.

Hyperfocus is not mania

I want to write this separately, because it is very often confused.

In ADHD it is possible to sink into a subject for hours, forget to eat, lose track of time. This is called hyperfocus and from the outside it can look like an excess.

The difference lies here: in hyperfocus mood is not elevated, the need for sleep does not disappear and the person does not change their assessment of themselves. When you come out of the subject you sank into, you are exhausted, not exuberant.

There is one more distinction: hyperfocus sticks to a single subject and when that subject is over only tiredness is left. What is described in a manic episode is a restlessness that spreads across several areas: in the same week a new job, a new plan, a new expense.

I explained how hyperfocus works in the article on what hyperfocus is.

Why it so often goes wrong

Part of the difficulty of this distinction comes not from the pictures but from the interview itself.

The remembering problem. It is hard to remember how long an episode lasted. The sentence "I was like that for a while" can describe both three days and three months, and the two mean entirely different things.

Good periods not being told. People go to the doctor because they feel bad and do not describe the periods when they felt good. Yet the information that makes the distinction is exactly there.

A shifted presentation. In someone with ADHD, low mood added to years of struggling can make the picture look completely different. I dealt with this part in the article on ADHD and depression.

Looking only at the last month. In a single interview the story of the last few weeks is told and that story does not represent the whole of a life. The glossary entry on the developmental history explains why the assessment goes backwards.

Additional signs

Some things are described in manic and hypomanic episodes that are not expected in ADHD:

• An unusually elevated, expansive or extremely irritable mood
• The person making an assessment of their own abilities that is very different from usual
• A marked increase in goal-directed activity: taking on many big projects at once
• People close to them saying "they were not themselves"

If you find yourself in this description, be sure to tell your doctor. Not saying it opens the way to a wrong treatment plan.

The two can be together

This is possible too and not rare. The review by Katzman and colleagues (2017) emphasizes that in adult ADHD the presence of another accompanying condition is almost the rule.

If the two are together, the treatment plan changes and the order becomes important.

Why this distinction matters so much. Starting a stimulant medication in the presence of bipolar disorder, without a plan that takes the picture into account, can affect mood negatively. The European consensus statement (Kooij et al., 2019) recommends that the order of treatment be carefully determined in accompanying conditions. This is something to talk through with your doctor; it is not something to decide on your own.

What to take to the interview

What makes this distinction easier is information about time, and time is the area where someone with ADHD is weakest. That is why the preparation needs to be written.

• A timeline. What happened in which period, how long it lasted. A few lines year by year is enough.
• A sleep record. In the periods when you slept little, were you tired or not? This single question says a lot.
• An observation from someone close. The information "you were very different in that period" from family or a close friend is strong data. A person is the last one to notice their own episodes.
• Family history. Is there a diagnosis of bipolar disorder in the family?
• Substance and medication information. Alcohol, substance use and some medications can produce similar pictures too. Hiding this serves no purpose other than prolonging the process.

Closing note

ADHD is continuous, bipolar disorder is episodic. The most distinguishing sign is sleep: in a manic episode the need for sleep decreases; in ADHD, although sleep is delayed, the need continues.

The two can also be together, and this distinction needs to be made by a specialist.

If you notice a serious change in your mood, especially if there are thoughts of harming yourself, do not carry it alone. In Turkey you can call 112 Emergency, and you can ask for referral from the ALO 183 Social Support Line.