Jesse Viner, MD Jennifer L. Tanner, PhD, Photo Not Available
Jesse Viner         Umee Davaé

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High-strung and strung-out:

Clinically relevant questions regarding adult ADHD and comorbid bipolar and substance abuse disorder

Jesse Viner, MD, Founder and Executive Medical Director and Umee Davaé, DO

The clinical dilemma of using medications in substance-abusing adolescents and adults with attention-deficit/hyperactivity disorder remains. What does the literature tell us? Reports indicate that the initial interventions for treating comorbid ADHD/substance abuse disorder must first focus efforts on detoxification; the remission of the substance abuse is targeted next. Following these steps, psychiatric disorder should be addressed; and subsequently, the addition of stimulants for treating ADHD. Planning for an enduring outcome, it is also essential to include psychotherapy and support to facilitate the development of delayed or impaired executive skill functioning.

In conclusion, this paper reviewed current issues relevant to the diagnosis and treatment of ADHD in emerging adulthood. We attempted to emphasize the significance of diagnosing ADHD during these critical years because it has the potential to persist from youth into adulthood without notice. Lack of recognition of this disorder in emerging adulthood will permit functional impairments to persist and reduce quality of life in emerging and later adulthood. ADHD may be difficult to differentially diagnose from bipolar disorder; and it may be over-shadowed when substance abuse is also present. But, treatment of ADHD can reduce the risk of substance abuse and other psychiatric comorbidities. In terms of treatment, it appears unwarranted to withhold stimulants for the treatment of ADHD. And therapeutic support to reduce associated impairments is also recommended to achieve long-term positive outcomes.

Figure 1.

Overlapping and non-overlapping symptoms in ADHD and bipolar disorder. Adapted with permission from Kent & Craddock (2003) and Wingo & Ghaemi (2007).

ADHD Bipolar disorder
Overlapping symptoms
1. Talks excessively 1. More talkative than usual
2. Easily distracted/jumps from one activity to the next 2. Distractibility or constant changes in activity or plans.
3. Difficulty sustaining attention  
4. Fails to give close attention to details/makes careless mistakes.  
5. Fidgets 3. Increased activity or physical restlessness
6. Difficulty remaining seated  
7. Runs or climbs about inappropriately  
8. Difficulty engaging in leisure activities quietly  
9. On the go as if driven by a motor  
10. Interrupts or butts in uninvited 4. Loss of normal social inhibitions
11. Blurts out answers before questions have been completed  
12. Difficulty awaiting turns  
Non-overlapping symptoms
13. Forgetful in daily activities 5. Inflated self-esteem/grandiosity
14. Difficulty organizing tasks and activities 6. Increase in goal-directed activity
15. Loses things 7. Flight of ideas
16. Avoids sustained mental effort 8. Decreased need for sleep
17. Does not seem to listen when spoken to directly 9. Excessive involvement in pleasurable activities with disregard for potential adverse consequences.
18. Difficulty following through on instructions/fails to finish work