A 28-year-old man presented to the outpatient clinic with a complaint of lack of concentration and an inability to focus for approximately the past 8 months. He reported that his performance at his job had been severely compromised and that his supervisor was unsatisfied with his performance in the past 8 months because he has been unable to complete numerous projects assigned to him. During the evaluation, the patient was quite active and was answering most questions in haste. He denied any current symptoms of depression, anxiety, or psychosis and mainly had concerns about his inability to concentrate. Upon mental status examination, his thought process was somewhat circumstantial and jumped from one topic to another, and his speech was rather loud. The clinician diagnosed him with adult attention-deficit/hyperactivity disorder (ADHD). He was prescribed amphetamine/dextroamphetamine at a starting dose of 10 mg in the morning, which was then increased by 10 mg every week up to a dose of 30 mg daily. Three weeks later, the patient returned for a follow-up visit and reported some improvement in his ability to focus and concentrate.
Two months after the initial visit, the patient returned with his girlfriend who was concerned about his worsening behavior. She mentioned that the patient was extraordinarily energetic and has been more interested in activities in the past few months. Every weekend he wanted to go scuba diving or bungee jumping, and in addition he was also spending a lot of money on unnecessary shopping even though it had put him in a serious financial debt. She mentioned that he had been an introvert for as long as she could recall and that she was very concerned with his changing attitude. She further added that he had an episode of depression at age 24 years for which he was treated that lasted 8 months. The patient seemed satisfied with his progress and suggested that the stimulant medication had helped, and he felt more successful at work and in his personal interactions.
However, considering his hyperactivity, impulsivity, and recent spending spree, it was decided to perform another detailed history and include his girlfriend of 8 years in the process. To the surprise of his clinician, the girlfriend mentioned that the patient had exhibited similar behavior 7 years ago for which he did not seek any medical help, and although it subsided after a week or so, it led to more than $10,000 in debt and cost him his job. Although the patient did not report any problems in his sleeping pattern, his girlfriend reported that in the past 6 to 8 months his sleep had decreased, and during the past few weeks he was only sleeping 2 to 3 hours every 24 hours. She also reported that the patient was hyperenergetic and spending a lot of money again, accumulating a debt of over $20,000 in the past few months. He had also changed jobs 4 times in the past 8 months, all due to his poor performance. She also reported that he usually talks fast, stays up late at night to clean his house, and is always “on the go.”
Bipolar II Disorder
Based on this added history, his diagnosis was changed to bipolar II disorder according to criteria in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),1 as it seems that he had a hypomanic episode 7 years ago at the age of 21 years and was now again having hypomanic symptoms. The ADHD diagnosis was not confirmed and was removed from his chart based on the new information.
His stimulant was immediately discontinued and quetiapine was prescribed at a dose of 100 mg at bedtime, which was increased to 100 mg every other night until a dose of 400 mg at bedtime was achieved. When the patient was seen for follow-up in 1 week his symptoms had drastically improved, which was also confirmed by his girlfriend. His second follow-up appointment was 1 month later, when he informed the clinician that his performance at work had also improved and his supervisor was happy and satisfied with his performance. The patient continues to take 400 mg/day of quetiapine and is currently stable on this dose.
Lack of concentration and the inability to focus is a common presenting symptom, especially in adults, and can be a symptom of numerous diseases. Major depressive disorder,2 generalized anxiety disorder,3 bipolar disorder,4 ADHD,5 and many others disorders are conditions that may present with a lack of concentration and inability to focus.
According to one estimate, adult ADHD affects 3.4% of people in developing countries and 4.2% to 4.4% of people in developed countries such as the United States.6,7 One study shows that 2.6% of the US population suffers from bipolar disorder.8
At times, bipolar disorder and ADHD can be difficult to distinguish on patient history because of overlapping symptoms. Although both ADHD and bipolar disorder can be misdiagnosed, they also sometimes co-present; therefore, patients who are positively identified as bipolar should be screened for ADHD and vice versa.9 The comorbidity of ADHD and bipolar disorder remains undiagnosed in many patients, as the ADHD symptoms are incorrectly diagnosed as a part of bipolar disorder and treated first.10 It is the opinion of most physicians that ADHD is a continuous disorder, whereas bipolar disorder is more cyclical or episodic. Patients with both disorders have trouble with sleep, although ADHD patients have trouble going to sleep but have a desire to go to sleep, whereas bipolar patients have no desire to go to sleep due to excessive energy. In the case discussed here, family/caregiver history was significant and made it easy to correctly diagnose the patient. This case illustrates the importance of obtaining a history from a significant other, caregiver, or family member in most psychiatric disorders.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
- Rock PL, Roiser JP, Riedel WJ, Blackwell AD. Cognitive impairment in depression: a systematic review and meta-analysis. Psychol Med. 2014;44(10):2029–2040. doi:10.1017/S0033291713002535 [CrossRef].
- Yang Y, Zhang X, Zhu Y, Dai Y, Liu T, Wang Y. Cognitive impairment in generalized anxiety disorder revealed by event-related potential N270. Neuropsychiatr Dis Treat. 2015;11:1405–1411. doi:10.2147/NDT.S84666 [CrossRef].
- Torrent C, Martínez-Arán A, Daban C, et al. Cognitive impairment in bipolar II disorder. Br J Psychiatry. 2006;189(3):254–259. doi:10.1192/bjp.bp.105.017269 [CrossRef].
- Adler LA, Faraone SV, Spencer TJ, Berglund P, Alperin S, Kessler RC. The structure of adult ADHD. Int J Methods Psychiatr Res. 2017; Feb17. doi:10.1002/mpr.1555 [CrossRef].
- Fayyad J, De Graaf R, Kessler R, et al. Cross-national prevalence and correlates of adult attention-deficit hyperactivity disorder. Br J Psychiatry. 2007;190:402–409. doi:10.1192/bjp.bp.106.034389 [CrossRef].
- Kessler RC, Adler L, Barkley R, et al. The prevalence and correlates of adult ADHD in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(4):716–723. doi:10.1176/ajp.2006.163.4.716 [CrossRef].
- Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry. 2005;62(6):617–627. doi:10.1001/archpsyc.62.6.617 [CrossRef].
- Halmøy A, Halleland H, Dramsdahl M, Bergsholm P, Fasmer OB, Haavik J. Bipolar symptoms in adult attention-deficit/hyperactivity disorder: a cross-sectional study of 510 clinically diagnosed patients and 417 population-based controls. J Clin Psychiatry. 2010;71(1):48–57. doi:10.4088/JCP.08m04722ora [CrossRef].
- Klassen LJ, Katzman MA, Chokka P. Adult ADHD and its comorbidities, with a focus on bipolar disorder. J Affect Disord. 2010;12(1–2):1–8. doi:10.1016/j.jad.2009.06.036 [CrossRef].