Barden: Hyperactivity or Mania: Overlap of ADHD and Bipolar Spectrum Disorder Scales

Introduction to Overlap of ADHD and Bipolar Spectrum Disorders

• Research Focus: Investigated the intersection of frequently administered psychopathology inventories designed to measure Attention-Deficit/Hyperactivity Disorder (ADHD) and bipolar spectrum symptoms.

• Problem Statement: Individuals with ADHD often exhibit difficulty with concentration and restlessness, symptoms that also appear in other psychiatric disorders, notably bipolar disorder (BD), specifically mania symptoms (e.g., racing thoughts, impulsivity).

  • Consequence: This symptom overlap can lead to miscategorization within assessment tools and potential misdiagnosis, as ADHD and bipolar spectrum disorders have substantially different onset and treatment trajectories.

• Study Aim: To investigate the overlap of self-report psychopathology measures for ADHD and bipolar spectrum symptoms in an adult assessment context.

• Key Findings (Overview):

  • Moderate-to-strong associations among different scales measuring ADHD and bipolar spectrum symptoms.

  • Bipolar spectrum symptom scales accounted for significant variance in global indices of ADHD symptoms.

  • Distinct ADHD symptoms also explained significant variance in bipolar spectrum symptom measures.

• Clinical Impact Statement: The study found substantial overlap between hyperactive ADHD symptoms and mania symptoms, reinforcing the importance of multimodal assessments for enhancing measurement-based care and diagnostic clarity.

Attention-Deficit/Hyperactivity Disorder (ADHD)

• Definition: A neurodevelopmental disorder characterized by inattention and/or hyperactivity/impulsivity, with onset before age $12$ (APA, $2013$).

• Symptoms & Characteristics:

  • Difficulties with concentration and attention.

  • Disorganization.

  • Restlessness.

  • Impulsivity.

  • Associated with deficits in executive functioning and behavioral inhibition.

  • Poor performance on cognitive and attentional tasks (e.g., continuous performance, working memory, set-shifting, fluency).

• Prevalence:

  • Childhood: estimated at $5.27\%$ (Polanczyk et al., $2007$).

  • Adulthood: estimated at $4.4\%$ (Kessler et al., $2005$).

  • Persistence: Historically thought to remit by late adolescence/early adulthood, but now widely understood to persist into adulthood.

• Subtypes (Presentations) (APA, $2013$):

  • Predominantly Inattentive Presentation: Struggles with sustaining attention (e.g., wandering focus).

  • Predominantly Hyperactive/Impulsive Presentation: Struggles with behavioral/motor symptoms (e.g., fidgeting, restlessness, interrupting).

  • Combined Presentation: Struggles substantially with both inattention and behavioral/motor symptoms.

Bipolar Spectrum Disorders and Mania

• Definition of Mania: A feature of bipolar disorder, characterized by a distinct period of abnormally elevated or irritable mood, and increased energy and activity (APA, $2013$).

• Overlap with ADHD Symptoms:

  • Mania-like symptoms commonly observed in individuals with ADHD include distractibility, impulsivity, psychomotor agitation, restlessness, and racing thoughts.

  • Hyperactivity/impulsivity symptoms of ADHD particularly overlap with mania symptoms.

• Importance of Differentiation: Accurately distinguishing between mania/bipolar disorders and ADHD is imperative as they have distinct treatment trajectories.

• Comorbidity:

  • Lifetime prevalence estimates of ADHD in individuals with bipolar spectrum disorders range from $9.5\%$ to $37.8\%$ (Aedo et al., $2018$; Karaahmet et al., $2013$; Sachs et al., $2000$; Schneck et al., $2008$).

  • Prevalence of comorbid bipolar spectrum disorders is substantially higher in individuals with ADHD than in the general population.

  • A recent meta-analysis found approximately $18\%$ of adults with bipolar disorder also have comorbid ADHD (Schiweck et al., $2021$).

Distinguishing Features Between ADHD and Mania

• Despite symptom overlap and potential comorbidity, ADHD and mania are distinct clinical phenomena.

• Symptom Duration/Course:

  • ADHD symptoms tend to be chronic and stable across time (lasting years).

  • Mania symptoms are episodic (lasting days) and associated with greater impairment in functioning.

• Specific Symptoms:

  • Mania frequently manifests as grandiosity and elevated mood, which are not typical in ADHD presentations.

• Other Differentiating Factors:

  • Age of onset.

  • Presence of psychotic symptoms.

  • Symptom trajectory.

  • Prevalence rates.

Assessment Tools and Their Limitations

• Role of Self-Report Measures: Can be beneficial for brief assessment but may decrease diagnostic accuracy, especially in common screening procedures.

  • Assessors may struggle to distinguish diagnoses when relying solely on self-report or during brief initial evaluations.

• Frequently Used Instruments:

  • Behavior Assessment System for Children–Third Edition (BASC-3): Includes scales for ADHD facets (Attention Problems, Hyperactivity) and a Mania content Scale. T-scores of $70$ or above are clinically significant.

  • Millon Clinical Multiaxial Inventory–Fourth Edition (MCMI-IV): Includes a Bipolar Spectrum Scale but not an ADHD-related scale. Base rate scores identify clinically significant elevations (e.g., $85$ or greater for Bipolar Spectrum).

  • Conners’ Adult ADHD Rating Scale Self-Report: Long Version (CAARS-S:L): Measures ADHD symptoms (four factor-derived scales, four composite scales). T-scores of $65$ or above are clinically significant.

• Limitations of Self-Report Measures:

  • Discriminant Validity: Extant literature is mixed regarding their ability to distinguish among individuals with and without ADHD.

  • Sensitivity/Specificity: Screening measures for bipolar disorder may show weak sensitivity and/or specificity, performing poorly in distinguishing individuals with/without BD in community samples.

  • Incongruence with DSM Criteria: Self-report inventories for bipolar symptoms may be inconsistent with diagnostic criteria and can detect personality patterns.

  • Item Similarity: Measures of ADHD and bipolar disorder can exhibit high item similarity (over $20\%$) for overlapping behavioral (e.g., impulsivity, hyperactivity) and cognitive (e.g., racing thoughts, inattention) symptoms.

  • High Correlations: ADHD and mania/bipolar spectrum scales are likely highly correlated in assessment due to measuring similar phenomenology (increased energy, restlessness, racing thoughts, impulsivity, concentration difficulty).

  • Impact on Assessors: High correlations can lead to difficulty distinguishing diagnoses, recognizing spurious elevations, and cause confusion in considering differentials, follow-up steps, and client debriefing.

Consequences of Overlap and Misdiagnosis

• Misdiagnosis Rates:

  • Bipolar disorder: Underdiagnosis at $30\%-50\%$, overdiagnosis at approximately $13\%$ (Rakofsky & Dunlop, $2015$).

  • Children/Adolescents: Bipolar disorder is often underdiagnosed, with prevalent overdiagnosis of ADHD.

• Costly Implications: Misdiagnoses can be financially and medically costly in terms of pharmacological and psychotherapy treatment, potential medication side effects, and failure to treat actual symptoms.

• Ethical Implications: Emphasizes the ethical imperative for accurate diagnosis due to significant impact on patient care and well-being.

Current Study: Method

• Participants: $119$ adult assessment-seeking individuals ($18-64$ years old) with concerns of ADHD, recruited from two outpatient psychological clinics in the Northeast U.S.

  • Demographics:

    • Sex: $57$ male (47.9\%$), 62$female ($52.1\%$).

    • Average Age: $22.24$ years (SD = $5.39$).

    • Average Education: $14.35$ years (SD = $1.77$).

    • Race: White (74.7%), Asian (11.8%), Multi-racial (8.4%), Hispanic or Latinx (3.4%), Black or African American (1.7%).

    • Known Diagnoses in Sample: ADHD inattentive (8.4\%$), ADHD combined (13.4\%$), Bipolar spectrum (5.0\%$), Bipolar and ADHD (0.8\%$), Other (55.5\%$), None (17.6\%$).

• Procedure: Archival data from participants who underwent a clinical interview, completed a personalized psychodiagnostic assessment battery (self-report questionnaires, cognitive tests).

• Measures Used for Analysis:

  • Conners’ Adult ADHD Rating Scale Self-Report: Long Version (CAARS-S:L): $66$ items (0-3 scale). Yields Inattention-Memory, Hyperactive-Restlessness, Impulsivity and Emotional Lability, Problems with Self-Concept, and composite scales (Inattention Symptoms, Hyperactive-Impulsive Symptoms, ADHD Total, ADHD Index). Clinically significant T-scores $\ge 65$.

  • Behavior Assessment System for Children–Third Edition, Self-Report of Personality–College (BASC-3 SRP-COL): $192$ items (true/false, 1-4 Likert scale). Used Attention Problems, Hyperactivity, and Mania content Scales. Clinically significant T-scores $\ge 70$.

  • Millon Clinical Multiaxial Inventory–Fourth Edition (MCMI-IV): $195$ true/false items. Used the Bipolar Spectrum Scale. Clinically significant base rate scores $\ge 85$.

• Data Analytic Plan:

  • Performed using SPSS Version $23$.

  • Calculated T-scores (BASC-3, CAARS-S:L) and Base Rate scores (MCMI-IV).

  • Bivariate Pearson Correlation Analyses: Tested associations among variables. Cohen’s ($1988$) guidelines for $r$ values: $.10-.29$ (weak), $.30-.49$ (moderate), $.50$ and greater (strong).

  • Stepwise Multiple Regression Analyses: Evaluated unique relations, controlling for shared variance. Variables only included if significantly correlated with outcome variables. Variance Inflation Factors (VIFs) ensured to be between $2.0$ and $4.0$.

  • Hierarchical Multiple Regression Analyses: Cross-validated stepwise results; variables entered based on strength of zero-order correlations. Interpretations based on consistencies between regression analyses.

Current Study: Results

• Preliminary Analyses (Descriptive and Correlations):

  • Clinically Significant Elevations in Sample:

    • CAARS-S:L: Inattention-Memory (65.5\%$), Hyperactive-Restlessness (31.1\%$), Impulsivity and Emotional Lability (23.5\%$), Problems with Self-Concept (39.5\%$).

    • CAARS-S:L Composite: DSM-IV Inattention Symptoms (85.7\%$), DSM-IV Hyperactive-Impulsive Symptoms (42.0\%$), DSM-IV ADHD Total (75.6\%$), ADHD Index (42.0\%$).

    • BASC-3: Attention Problems (31.1\%$), Hyperactivity (15.1\%$), Mania (15.1\%$).

    • MCMI-IV Bipolar Spectrum: 16\%$(mean$71.70$, SD =$19.97$).</p></li></ul></li><li><p><strong>Correlations with MCMI-IV Bipolar Spectrum Scale</strong>:</p><ul><li><p>Significantly and positively correlated with all CAARS-S:L scales except Problems with Self-Concept.</p></li><li><p><strong>Strong Correlations ($r \ge .50$)</strong>: CAARS-S:L Impulsivity, DSM-IV Hyperactive-Impulsive Symptoms, DSM-IV ADHD Symptoms Total, ADHD Index; BASC-3 Hyperactivity Scale.</p></li><li><p><strong>Moderate Correlations ($.30 \le r \le .49$)</strong>: CAARS-S:L Inattention/Memory Problems, Hyperactivity/Restlessness, and DSM-IV Inattentive Symptoms.</p></li><li><p>Trending toward significance with BASC-3 Mania and Attention Problems Scales (potentially due to low N for these comparisons,$n=18$).</p></li></ul></li><li><p><strong>Correlations with BASC-3 Mania Scale</strong>:</p><ul><li><p>Significantly and positively correlated with all CAARS-S:L scales.</p></li><li><p><strong>Strong Correlations ($r \ge .50$)</strong>: All CAARS-S:L scales except Problems with Self-Concept (moderate correlation).</p></li><li><p>Strongly correlated with ADHD-related BASC-3 scales: Attention Problems and Hyperactivity.</p></li><li><p><strong>Substantially High Correlations ($r \ge .70$)</strong>: CAARS-S:L Hyperactivity/Restlessness ($r = .70$), DSM-IV Inattentive ($r = .70$), DSM-IV Hyperactivity ($r = .71$), DSM-IV ADHD Symptoms Total ($r = .74$); BASC-3 Hyperactivity Scale ($r = .72$).</p><ul><li><p>Such high correlations ($r \ge .70$) are generally interpreted as indexing the same underlying construct (Dormann et al.,$2013$).</p></li></ul></li></ul></li><li><p><strong>Final Diagnoses (Multimodal Assessment)</strong>:</p><ul><li><p>$21.8\%$met criteria for ADHD.</p></li><li><p>$5.0\%$met criteria for bipolar spectrum disorder.</p></li><li><p>$0.8\%$had comorbid ADHD and bipolar disorder.</p></li><li><p>$55.5\%$met criteria for other diagnoses (mood, anxiety, trauma, learning disorders).</p></li><li><p>$17.6\%$did not meet criteria for any diagnosis.</p></li><li><p>$3.4\%$met criteria for a substance use disorder.</p></li></ul></li></ul></li><li><p><strong>Stepwise Multiple Regression Analyses (Final Models)</strong>:</p><ul><li><p><strong>Outcome: CAARS-S:L DSM-IV ADHD Symptoms Total ($n=65$)</strong>:</p><ul><li><p>BASC-3 Mania, Attention Problems, and Hyperactivity Scales were uniquely related.</p></li><li><p>Final model accounted for$69.6\%$of variance (Mania:$54.1\%$, Attention Problems:$12.6\%$, Hyperactivity:$2.9\%$).

  • Outcome: CAARS-S:L ADHD Index ($n=65$):

    • BASC-3 Attention Problems and Mania Scales were uniquely related.

    • Final model accounted for $56.9\%$ of variance (Attention Problems: $48.7\%$, Mania: 8.2\%$).

  • Outcome: MCMI-IV Bipolar Spectrum Scale (n=71$)</strong>:</p><ul><li><p>CAARS-S:L DSM-IV Hyperactive-Impulsive Symptoms and Impulsivity/Emotional Lability Scales were uniquely related.</p></li><li><p>Final model accounted for$39.1\%$of variance (DSM-IV Hyperactive-Impulsive Symptoms:$33.4\%$, Impulsivity/Emotional Lability:$5.7\%$).

• Outcome: BASC-3 Mania Scale ($n=65$):

  • CAARS-S:L DSM-IV ADHD Symptoms Total, Hyperactivity/Restlessness, and Inattention/Memory Problems Scales were uniquely related.

    • Note: DSM-IV Inattentive Symptoms Scale was removed due to problematic VIFs (>4.0).

    • DSM-IV ADHD Symptoms Total was no longer significantly related once Inattention/Memory Problems was added.

  • Final model accounted for $63.2\%$ of variance (DSM-IV ADHD Symptoms Total: $54.1\%$, Hyperactivity/Restlessness: $4.7\%$, Inattention/Memory Problems: 4.3\%$).

Strengths and Future Directions

• Strengths:

  • Novel Sample: Used an ADHD assessment-seeking sample from real-world clinical practice, bolstering ecological validity.

  • Comprehensive Assessment: Highlights the importance of comprehensive assessment and follow-up beyond brief screenings.

  • Rigorous Data-Driven Analytic Strategy: Employed bivariate correlations, stepwise multiple regressions, and cross-validated with hierarchical regressions to strengthen interpretation and address limitations.

  • Reinforces the necessity of multimodal psychological assessment.

• Limitations:

  • Archival Data: Participants did not all complete the same full assessment battery, leading to varying sample sizes for different scale comparisons.

  • Small Sample Size: While adequate per guidelines for multiple regression, a larger sample would provide more statistical power for subtler effects.

  • Demographic Homogeneity: Predominantly White sample, and low prevalence of significantly elevated bipolar symptoms (though commensurate with population base rates). Future studies need larger, more ethnically diverse samples.

  • Sex vs. Gender Identity: Collected biological sex, limiting the ability to test gender differences in symptom presentations.

  • Reliance on Self-Report: Self-report measures depend on individual insight and perception, which can be impacted by conditions like bipolar disorder (decreased insight) and implicit bias. Multimethod assessment (e.g., including observer reports) is recommended.

Conclusion

• Self-report inventories commonly used in psychological/psychiatric assessments can index or conflate converging symptoms of ADHD and mania/bipolar disorder.

• Efficient and effective discernment of ADHD from bipolar spectrum disorders is critical, especially with increasing demands for rapid diagnosis after brief evaluations, and due to the potential for negative side effects from bipolar medications if misdiagnosed.

• Assessors must be aware of the possible conflation due to the current diagnostic models (discrete clinical syndrome categories vs. transdiagnostic models like RDoC or HiTOP).

• Multimodal assessment (combining subjective and objective measures, with appropriate follow-up clinical interviews) is essential for distinguishing these disorders, particularly given their substantial symptom overlap.