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.

Not withstanding this ambiguity and the lack of large epidemiological studies, there is general agreement regarding the co-occurrence of BPD and ADHD.⁴⁷ In a recent review, Singh and colleagues⁴⁸ found a bidirectional relationship between the 2: ADHD occurred in up to 85% of children with BPD, and BPD occurred in up to 22% of children with ADHD. The authors further explored 4 hypotheses:

• BPD symptoms lead to overdiagnosis of ADHD in youth.

• ADHD is a prodromal or early manifestation of childhood BPD.

• ADHD is treated with psychostimulants that trigger the onset of childhood BPD.

• ADHD and BPD share an underlying biological mechanism (ie, common familial, genetic, or neurophysiological).

Despite limitations, current literature best supports the second hypothesis—that ADHD may be a marker of the development of early-onset BPD. Ultimately, longitudinal controlled studies are needed to help us diagnose this disorder more precisely and to manage it rationally. Pharmacological studies may offer insights into the efficacy of mood stabilizers and/or the failure of psychostimulants; conversely, the induction of bipolar symptoms with psychostimulants or antidepressants may also be instructive.

Personality disorders

As with the comorbid conditions discussed earlier, the presence of a comorbid personality disorder complicates diagnostic interpretation and treatment decisions.⁴⁹ Marked personality disorder–related symptoms may also negatively influence the outcome of the bipolar illness.⁵⁰ The severity of residual mood symptoms in bipolar patients with personality disorders differs from that in bipolar patients without personality disorders—even during periods of remission.⁴⁹

Features of a personality disorder may overlap with a bipolar mood episode.⁵¹ It may therefore be too challenging to diagnose a personality disorder until the mood episode has been successfully treated. A careful personal and collateral history may be most instructive in establishing the presence of personality traits that predate the onset of a discreet mood disturbance. Conversely, personality features that endure after the resolution of a mood episode may reveal the comorbid condition. A positive family history of a mood disorder and antidepressant-induced mood elevation also serve as important clues.

A recent study found that cluster B (borderline, narcissistic, antisocial, histrionic) personality disorder features were evident in about one-third of bipolar patients, with possible associations to childhood emotional and/or physical abuse.⁵² An independent, elevated lifetime risk of suicide was attributed to cluster B comorbidity. Recent literature advocates a more careful approach to diagnosing borderline personality disorder in the face of the mood-cycling pattern seen in bipolar II disorder; a cyclothymic temperament has been proposed as the underlying feature of this atypical mood, anxiety, impulsivity continuum.^53,54

Clearly, treatment of this comorbid subtype requires a greater degree of finesse in the integration of psychotherapeutic and psychopharmacological modalities—especially in restoring functionality and ensuring compliance. Again, mood stabilization with lithium(Drug information on lithium) appears less effective than anticonvulsants, such as valproate(Drug information on valproate) or lamotrigine(Drug information on lamotrigine), in this comorbid population.^55-57 Second generation antipsychotics (olanzapine, risperidone(Drug information on risperidone)) have also played a role in improving symptoms and regulating affective lability.^58-61

Medical comorbidities

Cardiovascular disease, type 2 diabetes mellitus, and other endocrine disorders tend to occur more often in patients with BPD than in the general population.^62,63 According to population-based studies, cardiovascular mortality is almost twice as high in patients with BPD, which may be related to higher rates of obesity.^5,64 Mechanisms hypothesized to explain this finding include smoking, diet, sedentary lifestyle, and unrecognized risk factors (insulin resistance, inflammation, hypercortisolemia).^65,66

Comorbid neurological disorders, including migraine headache, have also been reported at higher rates in patients with BPD, especially bipolar II disorder. The latter may represent a subtype of the disease.⁶⁷

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