الفهرس 
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Abstract
Bipolar disorder (BD) is a considerable public health concern, with lifetime prevalence around 1% for bipolar I disorder and up to 5% when including all bipolar spectrum disorders (Wingo and Ghaemi, 2007).
This disorder is recognized to have a considerable negative impact on patient functioning and quality of life (Sentissi et al., 2008).
ADHD, originally described in a pediatric population, it is now also recognized as a condition found in adults. Depending on the study, childhood prevalence of ADHD varies between 3 and 12% (Tamam et al., 2008), while adult prevalence is quite similar across studies, usually 4–5% (Wingo and Ghaemi, 2007).
Thus, it can be estimated that up to 50% of children affected by ADHD retain the condition during their adult years (Tamam et al., 2008).
Although the condition is now well characterized in adults, it is generally accepted that the onset of ADHD occurs during childhood (Biederman, 2005).
Furthermore, adults with ADHD tend to present less with externalizing and hyperactive symptoms, compared to ADHD when initially diagnosed in childhood, which further complicates referral and diagnosis (Karam et al., 2008). In addition, adult ADHD is often associated with a number of psychiatric co-morbidities such as major depressive disorder (MDD), Generalized Anxiety Disorder (GAD), alcohol and /or substance abuse, bipolar disorder (BD), and a variety of conduct or behavioral disorders.
Therefore, many symptoms that are directly attributable to ADHD are often mistakenly associated with other psychiatric conditions and consequently not fully treated (Fischer et al., 2007).
Accurate diagnosis of adult ADHD remains a clinical challenge. It is a “hidden disorder” representing extremes of normal behaviors, with no clear consensus regarding the clinical boundaries, particularly for adults (Levy et al., 1997).
In recent years, the distinction between bipolar disorder (BD) and attention deficit hyperactivity disorder (ADHD) became a topic of growing interest (Galanter and Leibenluft, 2008).
A possible association between ADHD and the manic phase of bipolar disorder has attracted significant interest because the symptoms of both disorders are so similar across all age groups: talkativeness, distractibility, and increased motor activity (Sachs et al., 2000).
Bipolar patients with comorbid ADHD are reported to have higher affective dysregulation, earlier onset of the disease, more depressive and mixed periods, shorter inter-episode euthymic periods, and more frequent accompanying disorders, like alcohol and substance abuse, than patients without comorbid ADHD (Tamam et al., 2006).
Moreover, in State et al. (2004), reported that adult bipolar patients with a history of childhood ADHD demonstrated an attenuated response to pharmacotherapy with mood stabilizers, indicating the possible unfavorable effect of ADHD on the course of bipolar disorder.
Some authors have suggested that ADHD and mania may be independent disorders, and that the comorbid condition may represent a distinct clinical phenotype of bipolar disorder featuring earlier age of onset, poorer response to treatment, and poorer prognosis (Wilens et al., 2002).
In particular, the age of onset was proposed to be the critical developmental variable identifying a subtype of bipolar disorder highly comorbid with ADHD (Masi et al., 2006).
Noting the predominantly chronic course and the irritable mood common to bipolar disorder and childhood ADHD, Masi et al. (2006) suggested that this specific phenotype might be indicative of a symptomatological continuity between ADHD and early onset bipolar disorder.
Understanding the relationship between ADHD and bipolar disorder has been made difficult by the use of different diagnostic criteria, such as the Utah and DSM criteria, the lack of a standardized semistructured interview procedure, and problems in obtaining third-party corroboration for childhood ADHD (Tamam et al., 2008).
This study is a cross-sectional, case control, observational study, and was designed aiming at covering the following area in the theoretical part: (1) Review of BD historical background, causes, associated features, onset, course, number of episodes, psychiatric comorbidity, and its presentation in different age groups. (2) Review of ADHD developmental model across lifespan, psychiatric comorbidity, and how to diagnose adult ADHD. (3) Review of comorbidity between BD and ADHD in children and adults, and its impact on patients.
The practical part aimed at:
1- To demonstrate the differences between the case and control group as regards socio-demographic data, frequency of ADHD symptoms, WAIS, and WCST.
2- To demonstrate the prevalence of ADHD symptoms among a sample of bipolar adult patients in remission in comparison to control sample.
3- To demonstrate the effect of the presence of ADHD symptoms on the bipolar subjects as regards the socio-demographic data, clinical characteristics, treatment received, general intellectual functioning and executive functions.
We hypothesized that there are overlapping symptoms and high co-morbidity between BD and ADHD in adults.
The present investigation evaluated collectively 30 subjects who were organized into three major groups, two patient groups (12 bipolar, 8 bipolar/ADHD) and one control group (10 controls). The study was carried out at the outpatient clinics of the Institute of Psychiatry, Ain Shams University.
We obtained an informed consent and inclusion criteria were insured before the study which included age between 18-35 years, male and female subjects, were in euthymic phase of bipolar disorder.
The tools were carefully selected to serve for the purpose of the study, Young Mania Rating Scale (YMRS), Kiddie- Schedule for Affective Disorders and Schizophrenia for School Aged Children- Lifetime Version (K-SADS-PL), Conners Adult ADHD Rating Scale Self report Long version form (CAARS-S: L), Wechsler Adult Intelligence Scale (WAIS), Wisconsin Card Sorting Test (WCST),
The study proper was preceded by translation of (CAARS-S: L) into Arabic. Then, Arabic version was back translated into English. Then both translations were compared and they were almost similar.
All data gathered were recorded, tabulated and transferred on Statistical Package for Social Sciences (SPSS) Version 19, using personal computer and the suitable statistical parameters were used. Results were displayed to answer questions raised in the hypothesis of this study.
Results were in favor that BD negatively affects the patients as regards the occupation (p=0.04), and general intellectual functions (TIQ p=0.001) as well as executive functions (p=0.037) in comparison with control group. It also revealed that most of the patients have positive family history of psychiatric illness in comparison with control group (p=0).
We found that ADHD symptoms were more frequent with BD patients (30%) in comparison with control group as indicated by the differences in impulsivity/ emotional lability (p=0.014), problem with self- concept (p=0.025) and ADHD index (p=0.004) domains of (CAARS-S: L). In addition, the statistical difference between the 2 groups as regards (Hyperactivity/ restlessness, DSM-IV inattentive symptoms, DSM-IV ADHD symptoms total) items tended to be significant with (p=0.088, p=0.076, p=0.056) respectively. Moreover, there was a pervasive differences in all domains of (CAARS-S: L) with higher values in those with comorbid ADHD symptoms comparing with control group.
In addition, ADHD symptoms comorbidity with BD has an impact on gender prevalence of BD that favors males than females, as well as the occupation in comparison with control group (p=0.04), and with earlier age of onset (19.5±3.585) than BD patients (21.58±4.252).
Our research recommendations included replication of the study on a larger sample of patients, with documented medical reports to ascertain the significance of some results, conduct similar comparisons in bipolar disorder in the setting of a longitudinal study to investigate causal relationships between various factors and outcomes, and comparison of cognitive deficits in bipolar patients with comorbid ADHD with additional tests that may identify deficits specific to ADHD disorder.
Our clinical recommendations included better screening for ADHD disorder in the general population, especially in those with prolonged or treatment resistant disorders, help develop strategies for cognitive enhancement and cognitive rehabilitation in bipolar patients with ADHD symptoms suffering from cognitive deficits.