I could hyperfocus on this, should I?
.........OK.
The full NICE Guideline 72 is really the bible. The full version is over 700 pages long!
guidance.nice.org.uk/CG72/Guidance/pdf/EnglishExtracts that are usefull for Bipolar misdiagnosis
P131
5.16.2 Mood disorders
Depression
A volatile and irritable mood is frequently seen in adult ADHD and is not usually
the consequence of coexisting depression or bipolar disorder. The overlap of mood
symptoms does mean that care must be taken to exclude the possibility of a major
affective disorder and that mood lability does not occur solely within the context
of such disorders. Attending to the time-course of the symptoms and psychopathology
can help to distinguish the two. Early onset, chronic trait-like course, frequent
mood swings throughout the day, no recent deterioration or severe exacerbation
frequently accompany ADHD, whereas extreme low or high moods, sustained
mood change for long periods of time and recent onset are more indicative of a
primary affective disorder. Some individuals previously diagnosed with atypical
depression, cyclothymia or unstable emotional personality disorder will have a
primary diagnosis of ADHD.
Bipolar disorder
Traditionally, the distinction between ADHD and bipolar disorder has been fairly
easy to make. Bipolar disorder has been associated with euphoria, grandiosity and a
cycling course, with each episode lasting for several days at least. ADHD, by contrast,
has been regarded as a persisting disability in which euphoria is not particularly a
feature. The goal-directed over-activity of mania is usually seen to be in contrast
with the disorganised and off-task activity of ADHD. Individuals with ADHD often
have difficulty sleeping but unlike mania or hypomania they complain about their
lack of sleep and often feel exhausted during the day. In general individuals with
ADHD report that they cannot function effectively and this is often associated
with chronic low self-esteem, very different from the feelings of heightened
efficiency seen in mania. In ADHD thoughts are often described as ‘on the go’ all the
Diagnosis
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time, but unlike mania or hypomania, these are experienced as unfocused, muddled
and inefficient and there is no subjective sense of improved efficiency of thought
processes.
There has, however, been a broadening of the concept of bipolar disorder, to
include cases where the mood change is not euphoria but irritability or chronic mixed
affective states, and where the cyclical nature consists of many changes within a
single day (indistinguishable from a volatile, labile mood). This leads to a very
considerable similarity in formal definitions between this so-called ultradian
version of bipolar disorder and ADHD. An unstable and over-reactive mood is very
commonly seen in ADHD, even though it is not part of the diagnostic definitions,
and the development of an oppositional disorder, in which frequent tantrums
are common, can be described as an ‘irritable’ state and therefore contributes to a
bipolar diagnosis.
One of the main questions relates to the validity of a diagnostic concept broadlydefined
as bipolar disorder, or whether mood instability/irritability in the presence of
ADHD may be more adequately described by a new dimension, such as mood dysregulation.
Until the relevant empirical data become available, the classic definition of
mania should be maintained: a diagnosis of bipolar disorder requires euphoria,
grandiosity and episodicity, and the differential between ADHD and bipolar disorder
remains explicit.