Mania and ADHD: Suggested Comparisons

The following essay was conceived several years ago and is currently under review for publication. JB.
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Abstract
Hyperactivity is common to both mania and attention deficit-hyperactivity disorder; treatment, however, is often not the same and procedures for one of them are assumed to be detrimental to the other. Impairment in executive functions and the sociobiological concept of hierarchic competition provide descriptions for ADHD and for mania, respectively, that are somewhat independent of hyperactivity. Failure to emphasize factors other than hyperactivity for diagnosis leads to confusion between these two disorders. Activity level and vitality have plausible evolutionary advantages; grandiosity and impaired executive functions appear to be liabilities in most social conditions whether now or in our evolutionary past.

Mania, ADHD, psychostimulants, differential diagnosis, executive functions, evolution

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Bipolar Disorder (BPD) is thought to be a function of pathological mood changes and is a frequent and significant difficulty for children, rather than affecting only adolescents and adults (Faedda et al., 1995). Attention Deficit/Hyperactivity Disorder (ADHD) consists of impairments involving sustained attention (task persistence), impulsiveness, and hyperactivity and also affects children and adults (American Psychiatric Assn., 1994).

Recent conceptions of mania and BPD grew from research with adults; the disorders were considered to appear first in adolescence, perhaps in association with depression, itself once hypothesized to be absent in children (Faedda, et al., 1995). Treatment for BPD commonly involves mood stabilizers, benzodiazepines, and neuroleptics along with psychotherapy. ADHD was defined first by observations of children and thought to vanish in adolescence. Treatment consists of parent training and teacher training, behavior modification, and stimulant medication sometimes in conjunction with alpha-adrenergic blocking agents (DuPaul & Barkley, 1990).

Despite the different recent histories, treatment, labels, and even professional journals devoted to these two disorders, there can be substantial difficulty cleanly separating them in individual clients (e.g. Murphy, 1998). Both mania and ADHD include excessive movement, talkativeness, and racing thoughts as part of the diagnosis; both are considered to depend heavily upon genetic factors. Potential areas of confusion include appropriate diagnosis and individual treatment as well as the identification of clients for genetic studies and for long term outcomes research.

Both groups exhibit hyperactive traits (excessive movement and talking) thought inherent to either diagnosis and both syndromes appear to include distractibility during repetitive chores and lessons (Wozniak & Biederman, 1994). Clients with either disorder may be intolerant of delays and can be socially disruptive at home, in classrooms, or at work.

Both disorders are associated with a lifelong pattern of difficulties in personal relationships, in school, and in vocational settings. Both are associated with a lifestyle that neglects or even defies health management and temperate habits; thus, affected individuals die relatively younger than people without the disorders (Barkley, 1996). There is also a heightened risk for legal difficulties, drug abuse, and continuing aggression against peers or adults with either conduct disorder (a frequent comorbidity with ADHD) or BPD (Barkley, 1996; Faedda et al., 1995).

Wozniak et al. found that 91% of BPD children meet criteria for ADHD while 19% of ADHD diagnosed children meet criteria for clinical BPD (Wozniak, et al., 1995). Applying a concept of "subclinical intensity" for BPD makes it likely that such traits exist in an even higher percentage of ADHD individuals. Given the substantial awareness that now exists about ADHD, it is likely that a child with mania will be labeled as ADHD or the manic contributions to the ADHD child's difficulties will be considered as just another aspect of ADHD.

Eliminating Hyperactivity to Make Distinctions: ADHD.

ADHD and mania must be identified on some basis other than their shared trait of hyperactivity. Barkley (1997) (1997) 16, 8 and Gardner (1982) respectively, have made promising starts. There is a tendency for ADHD to be associated with a 3 - 7% reduction in I.Q. and with socioeconomic under achievement in comparison with siblings. (Weiss & Hechtman, 1993; Murphy & Barkley, 1996; Wilson & Marcotte, 1996) Barkley (1997) postulates that impulsiveness, a failure of response inhibition, is an essential aspect of ADHD, a failure that results in impairments in neuropsychological executive functions (EF). The model is an elaboration of one sketched by Bronowski (1977) in which the capacity to inhibit prepotent responses creates a delay between stimulus and response. This delay allows the successive development and use of working memory, a comparison of current events with past ones, and a change in future response probabilities that reflects the combined influence of working and longer term memory. The same delay allows the development of planning within and between individuals; it eventually allows modulation (either inhibition or kindling) of affective responses, situation analysis, and the creation of novel solutions to problems. It is suggested that deficiencies in these domains account for the relative social immaturity, under achievement, and academic and vocational difficulties characteristic of individuals with ADHD. Barkley's model is consistent with several recent studies that are not primarily interested in hyperactivity (Mariani & Barkley, 1997; MacLeod & Prior, 1996; Hall et al., 1997; Dooling-Litfin, 1997; Mealer et al., 1996).

Mania.
When groups of children or adults are considered, mania has several features that separate it from both ADHD and from hyperactivity. First, mania (and BPD) are associated with a higher than average I.Q., opposite the association found with ADHD. Second, mania can be linked to outstanding personal achievement, again a pattern opposite to that of ADHD. For example, Sulloway (1996) documents multiple histories of manic personalities who achieved well in science and politics. Jamison (1993) presents similar findings for the fine arts. Symptoms of mania in adults include an increase in goal-directed activity, inflated self-esteem, a decreased need for sleep, and an excessive involvement in pleasurable activities (A.P.A., 1994). Manics often attempt to dominate other people, are spiteful when opposed, and often resist psychiatric treatment (Gardner, 1982).

Manic characteristics are similar to those ascribed to "alpha" status in groups of creatures having a dominance hierarchy (Gardner, 1982; Wilson, 1980). Alpha status is defined by the physical and social dominance towards individuals lower in the hierarchy and is associated with greater access to food and sexual partners. Primate alphas often build alliances to attain and to keep their standing; there is sometimes a shift in the dominance hierarchy with changes in group membership and with social tasks. While alpha males can be altruistic towards infants or physically impaired members of the troop, they can also be less altruistic and more selfish and retaliatory towards rivals (DeWaal, 1994).

Grandiosity becomes a promising way to separate mania from hyperactivity just as the EFs are for ADHD. The alpha pattern is symptomatic when there is a mismatch between an individual's actions and his or other attributes, when individual perceptions and conduct suggest an unrealistically high view of one's own social standing. Human behaviors of bragging, ignoring rules, calling higher-ups by familiar names, and exaggerated pretensions of alliances with other alphas are signs of grandiosity as possibly are the manic features of excessive spending, sexual activity, and expansive career plans. There is an assumed immunity from social punishments for bragging, manipulation, spending, and multiple sexual partners. The same assumption sometimes appears in regard to physical harm for driving too fast or extreme sports. Likewise for drug and alcohol abuse or sexual diseases.

The alpha concept implies that we might look for grandiosity and for unusual degrees of persistence in regard to material possessions, access to family resources, management of friends, and attainment of higher social standing. Hierarchy problems should be relatively common and are already cited in the literature under the headings of aggression, oppositionality, or conduct disorder (Satterfield et al., 1994; Claude & Firestone, 1995; Lynskey & Fergusson, 1995; Stormont-Spurgin & Zentall, 1995).

Overlapping Data:
There are several areas in which findings about ADHD suggest the operation of a second variable such as mania. These domains include continuous performance tests (CPT), sleep disturbances, erratic responses to stimulants, differential reproductive success, and contrasts in family histories.

Continuous Performance Tests. The CPT is supposed to be a measure of ADHD that is independent of rater bias; however, estimates are that one-third to one-half of children, rated as ADHD by teachers and parents, perform well on a CPT (Matier-Sharma et al., 1995). However, children passing a CPT have been reported to be more socially disruptive than those who do not (Fischer et al., 1995), a finding consistent with mania. Some active children respond on a CPT with very rapid but highly accurate responses that vary little during the 14 minutes of the test. Some make up strategies such as "say the letter first" and stick to it for the entire test, a performance that is inconsistent with ADHD. Other children are erratic on the CPT despite attempting to "say the letter first." They don't stick to their plan, abandoning it after a couple of errors; these latter are perhaps more representative of ADHD. However, the CPT is presently downplayed for diagnosis while teacher and parent ratings (which should also be viewed critically) are accepted as the primary definition of ADHD. This practice might be reconsidered in order to include the possibility of mania.

Sleep Disturbances. A related phenomenon is that of delayed sleep onset being commonly but not always linked to using a psychostimulant in the afternoon. The medication should be out of the client's system by bedtime, yet sleep is delayed. Mania, even without stimulants, is often associated with lessened sleep. Thus, mania can account not only for the behavior being treated with a stimulant but also for the lack of sleep when the medication has left the client's system. Research is needed to determine if children with great persistence or those with family histories of mood disorders and domineering behavior are be more likely to show sleep disruptions during stimulant trials.

Response to Medications. Use of stimulants represents an intriguing phenomenon in which a single procedure is either recommended or strongly discouraged for closely similar symptoms and almost exclusively as a function of the label given those symptoms. The stimulants are estimated to be highly effective for ADHD (DuPaul & Barkley, 1990) yet there are recurrent difficulties for some children, teens, and adults who have been so diagnosed and given stimulants. Some children and teens are maintained on 50 mg of methylphenidate, three times a day, primarily to treat oppositional behavior and aggression. Removing hyperactivity as a cardinal feature allows such behavior to be classified as mania rather than as impulsiveness. Aggressive behavior can occur rapidly but be triggered by highly specific issues involving relative dominance and compliance with parental directions.

In contrast with practice for ADHD, the use of stimulants to treat mania is considered unusual or inappropriate; a positive response to stimulants is sometimes taken to mean that ADHD was the correct diagnosis rather than BPD (e.g., Murphy 1998). There are, however, phenomena inconsistent with prevailing belief.

First, given the close similarity of mania and ADHD, a similarity largely due to hyperactive features, it is overwhelmingly likely that manic children and adults, diagnosed with ADHD, are currently being treated successfully with stimulants. We might examine clinical records and correlate behavior ratings with stimulant dose as well as with later diagnoses of mania or BPD.

Second, manics often seek and abuse a wide variety of stimulants, whether legal or not, but the existing research appears to be correlational and anecdotal in regard to the effect of stimulants on specific symptoms such as cognitive restlessness and motor activity. Stimulants may aggravate mania in some people but this effect may occur less often than is commonly believed. Given the calming effect of stimulants on hyperactivity in ADHD, there is no empirical reason to expect a different response with mania. There is also no reason to expect that the variability of individual responses to the prescribed stimulants will be any different from that shown for nicotine, caffeine, or other psychoactives.

Third, the suggestion that mania and ADHD can be comorbid raises the issue of appropriate pharmacological treatment. Mood stabilizers might be given first to ameliorate mood changes, followed by stimulants for impulse problems. It may also be true that mood stabilizers and stimulants, given separately or in combination, will have similar outcomes in either ADHD or manic clients. We might expect some people diagnosed with manic features to respond well to only a stimulant and some with an ADHD label to react well to only a mood stabilizer.

Fourth, approximately 20% of BPD adults were originally diagnosed as having ADHD (Faedda et al., 1995); many of them were likely managed with stimulants when younger. (Including the notion of subclinical mania increases the numbers and percentages of people having manic features and given stimulant treatment.) We can incorporate these findings into our existing schema only by assuming that ADHD is truly a disorder of childhood when it is to be treated with stimulants and mania is truly a disorder of late adolescence and adulthood when it is to be treated with mood stabilizers. Neither assumption is workable.

It should be remembered that the original observations of stimulant use with children were not to treat hyperactivity but were attempts to control their weight (Bradley, 1937) There was an ensuing 20 year interval in which the calming effect of stimulants on children was felt to be "paradoxical." Our beliefs about stimulants in children has shifted but remain unchanged with respect to adults. The contradictions in our attitudes toward stimulants for ADHD or mania might be resolved were hyperactivity to be considered apart from either diagnosis and careful research defined dose response phenomena as has been done with other medications and for other syndromes.

Reproductive Success. Given possible ties between dominance and mating, parents might be cautioned to expect more or earlier sexual activity in a manic child in puberty than in other children. ADHD males, on the other hand, are found to be more socially isolated and less successful than average males when finding sexual partners. This is consistent with suggestions that lack of persistence is a significant negative factor in mate preferences shown by females (Buss, 1994). Manic males can be highly determined to pursue a specific female, experience positive affective shifts in her presence, appearing more emotionally stable (another significant factor in female mate preference), and be successful in obtaining partnerships for whatever duration. Thus, mania rather than ADHD might be considered when the hyperactive male has steadily had a girlfriend, even if rarely the same one, since 2nd or 3rd grade.

Family history. Both BPD and ADHD are thought to have genetic foundations; a similar pattern exists for BPD and likely exists for milder forms of mania. In the event the child is highly persistent, especially about accumulating and using social power, a family history may reveal a prevalence of determined, easily angered, high energy, highly competitive people as well as higher incidences of diagnosed BPD. Temper problems, high activity level, heightened sexuality, lying, and social manipulation ought to be more frequent in first degree relatives. More extreme beliefs, long-standing feuds, excessive spending patterns, alcohol abuse, or legal difficulties in relatives of BPD children might also be expected. Both disorders, ADHD and BPD, are commonly marked by family history; ADHD children ought to have more first degree relatives with ADHD whereas BPD children should have a higher incidence of first degree relatives with BPD.

More General Issues: Evolution and Adaptations
The Barkley ADHD model de-emphasizes but does not abandon traditional ADHD markers such as calling out in class, fidgeting, impatience with delays, difficulty remaining seated, and other correlates of hyperactivity. These traits are felt to be another expression of impulsiveness, the same feature theorized to underlie deficiencies in EFs. Barkley attempts to incorporate them as a foundation for the EF model. However, a complete separation of hyperactivity from ADHD can be accomplished by distinguishing elicited from emitted behaviors, assigning "impulsiveness" to describe elicited actions associated with ADHD and "hyperactivity" to the emitted ones seen with mania. This distinction allows us to consider impulsiveness and hyperactivity as separate factors in various speculations about evolutionary advantages.

Relative deficits in the EFs that arise from impulsiveness should reflect a genuine impairment in any culture and in any era. Impulsive behavior and poorly regulated affect are signs of "immaturity" for any species, not just humans. These trends are consistent with a disability regardless of setting. Although some writers have suggested that ADHD is an evolved trait and a disability only within our current society, (Hartmann, 1993; Jensen et al., 1997; Austin, 1998) it is difficult to imagine any environment in which ADHD -- within Barkley's definition -- provides a fitness (survival or reproductive) advantage.
On the other hand, hyperactivity itself is a likely vitality marker, a competitive advantage for attracting female interest (Miller, 1998; Hess, 1962) as well as in establishing territory and defending it. Liveliness has been found to be negatively correlated with depression and illness. To the extent that high activity level is a sign of health, we might expect it to correlate positively with symmetry, physical strength and speed, and hierarchic position. Thus, liveliness, but only to the extent that EFs are also intact, should be an advantage for recruiting mates and for building alliances, themselves an attraction for prospective mates.

Hyperactivity is common to BPD and ADHD. Separating hyperactivity from mania and ADHD allows us to avoid the need to create separate genes for "bipolar hyperactivity" and for "ADHD hyperactivity." This conceptual maneuver should allow us to appreciate high cognitive and motor activity or to develop procedures that change it without impeding EFs or hierarchic position. Protecting hierarchic standing seems especially important when treating mania; complaints and discontinuing medication are associated with no longer being the funniest, the smartest, or feeling the most attractive.

We might also expect grandiosity but without hyperactivity to occur but not appear in clinic offices; clinical problems seem more likely from the combination of hyperactivity and grandiosity. Likewise, there are likely people who have difficulty with task persistence but who are not hyperactive.

There remains the problem of why behavior routines associated with dominance, getting money, gathering the best property, and building things can be intact in some ADHD children but lacking in others. Pennington (1991) has suggested that more recently evolved CNS functions are more sensitive to disruption; older systems have greater stability or resilience because they are simpler and there may be greater physiological redundancy. The executive functions of planning, memory retrieval, problem analysis and solving seem phylogenetically new and most elaborate in humans. The mechanisms for dominating others, amassing property and wealth, tool use, and mating may be phylogenetically older in contrast to newer EFs that finely adjust personal behavior in response to other people's emotional cues and stated wishes. Thus, many complex behaviors for acquiring resources and maintaining status could be intact while the more subtle behavior routines for social achievement are impaired in ADHD.

A similar theme was addressed by Rapoport (1995) who noted that LD children without ADHD can compensate for their LD problems. Children having both disorders at once depend on tutors less for teaching information and more for discovering effective learning strategies. Applying this analysis to children with both mania and ADHD suggests that impairments in EFs cause the child to prolong his mistakes more than the same child would without ADHD. Thus, ADHD children with extremely domineering behaviors will not be very successful with them.

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