Bipolar Disorder: Sorting Out Comorbidities
Because patients with bipolar disorder often have underlying comorbidities, a thorough diagnosis is imperative.
It is important to identify comorbid disorders that add to the symptoms of bipolar disorder, so that these symptoms can be targeted appropriately. Some prescribers tend to target symptoms (eg, anxiety, insomnia, and irritability) with medications while leaving the underlying disorder(s) unrecognized and/or untreated.
The evaluation may require several meetings to reach the initial diagnostic impression, and it can take 90 minutes to evaluate a complex new patient, including reviewing the previous record and writing the assessment.
Experienced clinicians may convince themselves that they can do an adequate assessment in less time and choose the correct medications for the correct diagnoses. However, a competent and comprehensive psychiatric evaluation requires time. Brief evaluations, followed by quick prescribing, are often experienced by patients as rushed and unsatisfying. Confidence in and respect for our profession can be undermined by these practices.
Determine whether the irritable mood occurs in discrete episodes of mania that last at least several days and are accompanied by the other manic symptoms in the mania criteria (noting that 4 other symptoms are needed if the mood is only irritable). If not, and the irritable mood is invariably occurring when triggered by events that produce reexperiencing and the fight-or-flight adrenalized immediate reactions to those triggers, then it is likely due to PTSD. For these patients, the treatment would likely be more effective with an antiadrenaline agent in the PTSD armamentarium such as prazosin or clonidine.
It is important to make this diagnosis, using the DSM-5 criteria, and consider which symptoms could be attributed to ADHD and which occur mostly or to a greater extent during discreet manic episodes.
Sleep impairment is seen in comorbid diagnoses. In mania, there is decreased need for sleep, and the treatment of choice would be an antimanic agent rather than a hypnotic. However, often sleep impairment has other causes. There are medical causes, such as sleep apnea, restless leg syndrome (RLS), caffeinism, nocturia from prostate hypertrophy or diabetes, and pain syndromes, etc. Among psychiatric comorbidities, PTSD, which is associated with sleep disturbance, including difficulty initiating sleep and difficulty maintaining it due to nightmares, disturbed awakenings, and night terrors. A thorough evaluation of insomnia is indicated to identify the leading cause(s), including asking about all examples of PTSD-related sleep disturbance.
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