Comorbidity in Bipolar Disorder

The Complexity of Diagnosis and Treatment

By Doron Sagman, MD and Mauricio Tohen, MD | March 23, 2009

Dr Sagman is staff psychiatrist, Toronto East General Hospital, Toronto, and associate vice-president, clinical research, Eli Lilly Canada Inc, and Dr Tohen is Distinguished Lilly Scholar for Neurosciences, Lilly Research Laboratories, Indianapolis. The authors report that they have no other conflicts of interest concerning the subject matter of this article.

The phenomenological and treatment course of bipolar illness is significantly affected by comorbid SUD.³¹ As with other comorbidities, substance use may start before presentation of actual bipolar symptoms, and may obscure the mood diagnosis.³² The temporal onset of substance abuse and bipolar disorder may also reflect different clinical courses.³³

In general, higher rates of mood lability, rapid cycling, mixed episodes, suicidality, and other medical conditions complicate BPD and affect recovery times as well as rates of remission during hospitalization.^34,35 There is also the risk of violent behavior with comorbid substance abuse.¹⁹ Impulsivity is an overlapping and overarching feature of bipolar and substance use disorders, and it further complicates the course of the illness.³⁶ Comorbid substance abuse is also a significant contributor to treatment nonadherence in patients with bipolar disorder. Its presence confounds attempts at symptomatic and functional recovery.³¹

Treatment approaches. Unfortunately, there are few controlled data on the pharmacotherapeutic management of comorbid SUD and BPD. Response to lithium(Drug information on lithium) is generally poor in patients with BPD comorbid with alcohol(Drug information on alcohol) abuse, although it is not clear whether this relates to nonadherence or the association with mixed states.^29,34

Anticonvulsants (eg, valproate(Drug information on valproate), topiramate(Drug information on topiramate), carbamazepine(Drug information on carbamazepine), and lamotrigine(Drug information on lamotrigine)) have shown a favorable effect in decreasing use of alcohol and cocaine.^37-40 In another study, treatment with valproate or carbamazepine was more likely to induce remission in hospitalized bipolar patients with histories of substance abuse other than lithium.³⁴ A major concern with these agents, however, is balancing the treatment effects with the potential for hepatic, hematological, and other adverse effects, especially in this susceptible patient population.

Second-generation antipsychotic agents, including quetiapine and aripiprazole(Drug information on aripiprazole), reduced drug use and craving in small open-label studies.^41,42

Treatment of comorbid BPD and SUD invariably requires an integrated approach that focuses on both disorders simultaneously, and incorporates both psychotherapy and pharmacotherapy. This dual-disorder approach incorporates case management, vocational rehabilitation, individual and family counselling, housing, and medications.^43-44

Attention-deficit/hyperactivity disorder

Kraepelin’s insight into the onset and atypical phenomenology of BPD in childhood/adolescence was not fully acknowledged until recently.¹⁵ Despite the lack of a formal nosology in this age group, a 2001 NIMH consensus conference affirmed the existence and potential diagnosis of BPD in prepubertal children.⁴⁵ This atypical mixed-state phenotype seems to overlap with symptoms of attention-deficit/hyperactivity disorder (ADHD), which include irritability, impulsivity, distractibility, overactivity, rapid speech, and emotional lability. The overlap generates the need for diagnostic precision or the determination of a separate comorbid condition. The lack of diagnostic tools and the overlap of these disorders with conduct disorder and oppositional defiant disorder adds to the diagnostic confusion. Irritability, for example, cuts across all diagnostic categories and is a poor differentiator.⁴⁶

Pages: 1 2 3 4 5

Previous Next

by john gergen | September 12, 2011 3:26 PM EDT

There are those of us who feel that the biological linage of bipolar disorders, particularly bipolar II and bipolar NOs with ADHD is very strong when an early onset (by age 21) is present. In support of this is the recognition that many of the positive or unusual features of the genetic basis of ADHD also occur in many bipolar patients. To begin with ADHD is a highly genetic disorder whose biological traits are equally present in both sexes and which from a trait point of view is essentially dominant in a traditional sense. About half of individuals with trait evidences actually become clinically cases of ADHD but confirmation of trait presence emerges in their offspring. Among common trait issues are an all-or-none memory, a strong push towards leadership or or its alternative (essentially social withdrawal.. a so-called leader or loner position, think Bill Clinton for instance), a hyperfocus in areas of interest with a push towards goal completion, an ability to think outside the box with creativity (think Steve Jobs for instance). Energy like other areas is usually bimodal, either high of low. The presence of bipolarity seems to push traited individuals into difficult to treat situations. Personality disorders such as borderline syndromes are not uncommon along with a propensity to develop anxiety difficulties and post-traumatic stress problems (presumably a function of altered fragments of overly embedded memories). One further argument around ADHD traits are whether on the whole they have a positive social value in cultures such as our which emphasizes the individual over the group and values creativity.
John Gergen, MD

by Bennie Bennie | July 08, 2010 12:39 PM EDT

When this writer read the following two papers it seemed that in principle the mystery of bipolar disorder was solved. It still seems that way:

The primacy of mania: A reconsideration of mood disorders

Athanasios Koukopoulos a,*, S. Nassir Ghaemi b

a Centro Lucio Bini, 42, Via Crescenzio, 00193 Rome, Italy

b Mood Disorders Program, Department of Psychiatry, Tufts Medical Center, Boston, MA, USA

Received 6 March 2008; received in revised form 7 July 2008; accepted 13 July 2008

Available online 11 September 2008

Biological Sensitivity to Context

Bruce J. Ellis1 and W. Thomas Boyce2

1John and Doris Norton School of Family and Consumer Science, University of Arizona, and 2College for

Interdisciplinary Studies and Faculty of Medicine, University of British Columbia