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Bipolar Disorder and
Comorbid Disorders
Kurt Weber, PhD
Mental Health America – Brown County
Bemis International Center
St Norbert College
May 13, 2008
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Many disorders have been shown to be
comorbid with bipolar disorder
Some conditions are treated by treating BPD
first
Others more clearly show the BD when the
comorbid problem is cleared up…
AODA
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many factors may contribute to these
substance abuse problems, including
Self-medication of mood-related symptoms
 mood symptoms either brought on or
perpetuated by substance abuse, and risk
factors that may influence the occurrence of
both bipolar disorder and substance use
disorders.
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Treatment of one does not resolve the
other, but controlled bipolar disease usually
leads to the diminishing of AODA symptoms.
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23.6% of bipolar clients have an alcohol use
disorder
12.9% have a drug abuse disorder
37% have nicotine dependence (NESARC)
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Bipolar clients are unreliable reporters of
AODA use
They also underreport psychiatric
symptoms.
Nonetheless, substance abuse complicates
bipolar disorder, of course…
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Stimulants may precipitate a manic episode.
Chronic use of CNS stimulants like
amphetamine and cocaine cause
euphoria
 decreased appetite
 increased energy
 grandiosity
 sometimes paranoia that mimics mania
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The incidence of “revolving door” clients is
higher with concurrent substance abuse
Substance abuse is associated with a
relatively poor response to lithium.
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Hallucinations are more refractory (resistant
to treatment or cure) in clients with
substance abuse
Substance abuse is related to higher
mortality by suicide (15-19%) and other
causes.
from about.com
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"I made a serious commitment to quit all drug use
(street & rx) when I was pregnant (7 years ago)
which actually led to my diagnosis of BP, as I could
no longer hide my illness without the drug use.“
"I stopped alcohol 5 years ago and street drugs
four. Of course, this is when my depression
(possibly BP with no formal dx) and OCD really
began to peek out from beneath the foggy cover
of my substance abuse camouflage.“
hard to identify comorbidity at first
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One study found that of those with a
substance problem among severely mentally
ill patients seen in a university hospital
emergency room -- only 2 percent were
detected.
The state hospital did only slightly better,
detecting 15 percent
why?
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Emergency rooms are just not often able to do
structured interviews about drug and alcohol use
Patients tend to underestimate the problems
caused by the drugs, and they rarely disclose that
they have a problem with substance abuse
Practitioners should also keep in mind that illicit
drugs and alcohol can cause the development, the
reemergence, or even worsen the severity of
mental disorders
These drugs can also present symptoms that
parallel those of mental disorders or even cover
them up.
Polcin
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Issues in the Treatment of Dual Diagnosis
Clients Who Have Chronic Mental Illness
poor treatment response
 high rates of rehospitalization
 aggravated psychotic thoughts
 changes in neurophysiology
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Polcin, continued
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notes that those dually diagnosed are often less
responsive to medications than those who do not
abuse substances, specifically stating that cocaine
users have problems with lithium
systems have not been well designed with this
population in mind
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community may have treatment services for people with
mental illness in one agency and treatment for
substance abuse in another
clients are referred back and forth between them in
what some have called 'ping -pong' therapy" (NAMI).
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Often the very treatment approach of one service
may cause problems for the other side of the
condition.
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substance abuse workers traditionally consider the use
of medications to be a crutch for those struggling with
addiction
psychiatrists rely on prescriptions to treat the
mental illness
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while psychiatrists rarely give much credence to spiritual
or self-help approaches, those working with addictions
place a great deal of emphasis here
poor communication
between practitioners
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Those struggling to reach stability with their
mental illness and to achieve sobriety are,
more often than not, shuffled between
different practitioners.
Even when these counselors and doctors
work within the same facility, there is
seldom good, if any, communication
between offices
HHS plan
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first area relates to decision-making with
regard to treatment plans.
Second is the use of psychotropic
medications.
Accurate diagnostic tools is another area
greatly needing research
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currently no good instrument for detecting or
classifying substance use disorders in the
mentally ill, in that those available were
developed for use in the general population
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outlook for those with dual diagnosis seems grim
What is the long-term prognosis? Is there any hope
for stability and sobriety?
lifetime prevalence of substance use disorders is as
much as seven times greater for those with bipolar
disorder than those in the general population
however, there are successes…
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"My life is quite manageable today with the proper
medication, therapy, a wonderful support program and
recovery program. And no booze ... not a drop. Works
the best I have ever had it."
Anxiety
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the first 500 patients with bipolar I or bipolar II disorder
enrolled in the Systematic Treatment Enhancement
Program for Bipolar Disorder
Lifetime comorbid anxiety disorders were common,
occurring in over one-half of the sample
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were associated with
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younger age at onset
decreased likelihood of recovery
poorer role functioning and quality of life
less time euthymic
greater likelihood of suicide attempts.
comorbid anxiety appeared to exert an independent,
deleterious effect on functioning, including history of
suicide attempts
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highlighting the need for greater clinical attention
to anxiety in this population, particularly for
enhanced clinical monitoring of suicidality.
In addition, it is important to determine whether
effective treatment of anxiety symptoms can
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lessen bipolar disorder severity
improve response to treatment of manic or depressive
symptoms
reduce suicidality
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The interaction between anxiety disorders and
substance use goes both ways: patients with
bipolar disorder have a higher rate of substance
use and anxiety disorder, and vice versa.
Bipolar disorder is also associated with borderline
personality disorder and ADHD, and to a lesser
extent with weight gain.
As more than 40% of bipolar patients have anxiety
disorder, it is indicated that while diagnosing
bipolar patients, systematic enquiry about different
anxiety disorders is called for
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therapeutic challenge, since agents that effectively
treat anxiety disorders are associated with the risk
of induced mania.
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the treating psychiatrist needs to carefully evaluate the
potential benefit of treating the anxiety against the
potential cost of inducing a manic episode
possible solution would be to use, when possible, a nonpharmacological intervention, such as a
cognitivebehavioural approach
clinician may attempt to ensure that the patient receives
adequate treatment with mood stabilizers before slowly
and carefully attempting the addition of anti-anxiety
compounds with a relatively lower risk of mania
induction
social phobia
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Strong associations exist between lifetime social phobia
and major depressive disorder (odds ratio 2.9), dysthymia
(2.7) and bipolar disorder (5.9).
Odds ratios increase in magnitude with number of social
fears.
Reported age of onset is earlier for social phobia than
mood disorders in the vast majority of co-morbid cases.
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Social phobia is a commonly occurring, chronic and
seriously impairing disorder that is seldom treated
unless it occurs in conjunction with another comorbid condition
adverse consequences of social phobia include
increased risk of onset, severity and course of
subsequent mood disorders.
Early outreach and treatment of primary social
phobia might not only reduce the prevalence of
this disorder itself, but also the subsequent onset
of mood disorders.
Axis II personality disorders
– study A
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association of mood disorders with personality disorders
(PDs) is relevant from a clinical, therapeutic and prognostic
point of view
avoidant PD, borderline PD and obsessive-compulsive PD
were the most prevalent axis II diagnoses among patients
with depressive disorder
in bipolar disorder group, patients showed more frequently
obsessive-compulsive PD, followed by borderline PD and
avoidant PD
different pattern of PDs emerges between depressive and
bipolar patients.
Axis II personality disorders
– study B
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Axis II disorders can be rated reliably among
bipolar patients who are in remission. Co-diagnosis
of personality disorder occurred in 28.8% of
patients.
Cluster B (dramatic, emotionally erratic) and
cluster C (fearful, avoidant) personality disorders
were more common than cluster A (odd, eccentric)
disorders.
Bipolar patients with personality disorders differed
from bipolar patients without personality disorders
in the severity of their residual mood symptoms,
even during remission.
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When structured assessment of personality
disorder is performed during a clinical
remission, less than one in three bipolar
patients meets full syndromal criteria for an
axis II disorder.
Examining rates of comorbid personality
disorder in broad-based community samples
of bipolar spectrum patients would further
clarify the linkage between these sets of
disorders.
Axis II personality disorders
– study C
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Thirty-eight percent of the bipolar patients met
criteria for an axis II diagnosis.
Two (4%) met criteria for (only) a Cluster A
disorder, four (8%) for (only) a Cluster B, and six
(12%) for (only) a Cluster C disorder.
One (2%) bipolar patient met criteria a disorder in
both Clusters A and B, and one (2%) for a disorder
in Clusters B and C.
Five (10%) met criteria for at least one disorder in
Clusters A and C, and one met criteria for disorders
in Clusters A, B, and C.
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The presence of a personality disorder was
significantly associated with a lower rate of current
employment, a higher number of currently
prescribed psychiatric medications, and a higher
incidence of a history of both alcohol and
substance use disorders compared with the bipolar
patients without axis II pathology.
results extend previous findings of an association
between comorbid personality disorder in bipolar I
patients and factors that suggest a more difficult
course of bipolar illness.
Axis I
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authors assessed comorbid lifetime and current axis I
disorders in 288 patients with bipolar disorder and the
relationships of these comorbid disorders to selected
demographic and historical illness variables
65% of the patients with bipolar disorder also met DSM-IV
criteria for at least one comorbid lifetime axis I disorder
no differences in comorbidity between patients with
bipolar I and bipolar II disorder
patients with bipolar disorder often have comorbid anxiety,
substance use, and, to a lesser extent, eating disorders
axis I comorbidity, especially current comorbidity, may be
associated with an earlier age at onset and worsening
course of bipolar illness
diabetes mellitus
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Several papers have reported higher
prevalence of diabetes mellitus (DM) type 2
in patients suffering from bipolar disorder
(BD)
possible links between these disorders
include treatment, lifestyle, alterations in
signal transduction, and possibly, a genetic
link
prevalence of DM in sample -- 11.7% (n = 26)
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Diabetic patients
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were significantly older than nondiabetic patients
had higher rates of rapid cycling
chronic course of BD
scored lower on the Global Assessment of Functioning Scale
were more often on disability for BD
had higher body mass index
increased frequency of hypertension
Lifetime history of treatment with antipsychotics was not
significantly associated with an elevated risk of diabetes (P
= 0.16); however, the data showed a trend toward more
frequent use of antipsychotic medication among diabetic
subjects
diagnosis of DM in BD patients is relevant for their
prognosis and outcome
obesity
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Obesity is more prevalent in patients than in
the general population.
Obesity prevalence is clearly related to the
administration of antipsychotic drugs…
migraine headaches
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association between migraine and affective
disorders, but the information is sparse
concerning the prevalence of migraine in
subgroups of the affective disorders
present study was undertaken to investigate
the prevalence of migraine in unipolar
depressive, bipolar I and bipolar II disorders
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striking difference between the two diagnostic
subgroups
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prevalence of 77% in the bipolar II group
14% in the bipolar I group
“These results support the contention that bipolar
I and II are biologically separate disorders and
point to the possibility of using the association of
bipolar II disorder with migraine to study both the
pathophysiology and the genetics of this affective
disorder."
age of onset
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320 subjects with a diagnosis of BP I or BP II
significantly earlier AAO in subjects
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with anxiety disorders
rapid cycling course
more frequent suicidal ideation/attempts
Axis I comorbidity
substance use disorders
“Overall, these results suggest a role of early AAO
as a significant predictor of poor outcome in BP
and, if replicated, they may have important clinical
implications."
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“Assessment of bipolar disorder must include
careful attention to comorbid disorders and
predictors of compliance.
“Randomized trials are needed to further evaluate
the efficacy of medication, psychosocial
interventions, and other health service
interventions, particularly as they relate to the
management of acute bipolar depression, bipolar
disorder co-occurring with other disorders, and
maintenance prophylactic treatment."