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.

Conclusion

Given the substantial overlap between symptoms of BPD and other psychiatric conditions, an accurate cross-sectional assessment is inherently difficult to achieve. A careful longitudinal assessment that establishes a chronology of onset of different conditions, a symptom and functional profile between mood episodes, the course of illness, and response to treatment are essential for a more robust diagnosis.⁴⁴ Furthermore, the inherent challenge in obtaining an accurate history from a bipolar patient—especially one with comorbidities—requires corroboration from family members.

Although clinical guidelines for BPD acknowledge the complexity of treating the illness, most have limited recommendations specific to the patient with comorbidities. This may reflect the limited nature of the clinical evidence in this field.^68,69 The cost of diagnostic and therapeutic uncertainty, however, is calculated through the high cost of chronicity, with elevated rates of suicide, legal and interpersonal difficulties, and repeated hospitalizations.

As the field of neurobiology of bipolar and affective disorders advances, we hope to begin to refine our view of the comorbid interface. Forging the pathophysiological links between specific medical illnesses and BPD, including the use of clinical biomarkers to help refine the understanding of bipolar subtypes, may help clarify the pathophysiology of BPD itself. This will ultimately suggest new measures for secondary prevention and long-term treatments.^4,70

Pages: 1 2 3 4 5

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

Also in this Special Report

Comorbidity: Schizophrenia With Obsessive-Compulsive Disorder

Comorbidity: Psychiatric Comorbidity in Persons With Dementia

Cormorbidity: Diagnosing Comorbid Psychiatric Conditions

Development of a Dual Disorders Program

Comorbidity in Bipolar Disorder

Related Articles

Novel Treatment Avenues for Bipolar Depression

Comorbidity in Bipolar Disorder

Treatment-Resistant Depression: Strategies for Management

Hyperparathyroidism Resulting From Lithium Treatment Remains Underrecognized

Drugs Mentioned in This Article

Aripiprazole (Abilify)
Carbamazepine (Carbatrol, Tegretol, others)
Gabapentin (Neurontin)
Lamotrigine (Lamictal)
Lithium (Eskalith, Lithane, Lithobid)
Olanzapine (Zyprexa)
Pregabalin (Lyrica)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Topiramate (Topamax)
Valproate/valproic acid (Depakote, others)

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Evidence-Based References
Kessler R. Comorbidity of unipolar and bipolar depression with other psychiatric disorders in a general population survey. In: Tohen M, ed. Comorbidity in Affective Disorders. New York: Marcel Dekker Inc; 1999: 1-25.
Perlis RH, Miyahara S, Marangell LB, et al. Long-term implications of early onset in bipolar disorder: data from the first 1000 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD). Biol Psychiatry. 2004;55:875-881.

Comorbidity in Bipolar Disorder

The Complexity of Diagnosis and Treatment

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