
- Vol 38, Issue 11
Sorting Out Comorbidities
BIPOLAR UPDATE
The last column discussed how to improve precision in the diagnosis of mania and hypomania and how to identify likely prebipolar depressions that may evolve into a diagnosis of
Taking Time for Diagnosis
When there is a comorbidity, one should first delineate the various DSM-5 diagnoses that are present (
After establish the diagnoses, determine (with the patient) those that may be contributing the most to the patient’s distress or dysfunction, and treat those first with what the evidence best supports. For example, active and severe substance use disorders may deserve priority management.
Treating Common Comorbidities
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. This is a much better approach than the shortcut of treating the insomnia symptom by proceeding through a list of hypnotics that might include antihistamines,
Patients with BD are also prone to anxiety symptoms. It may be reasonable to use antianxiety agents like buspirone, benzodiazepines, or possibly gabapentin. However, there may be another disorder that is the primary cause of the anxiety. PTSD comes up again because the anxiety can be related to events, fears, triggers, and inability to avoid reminders of their trauma. Buspirone and benzodiazepines have not shown efficacy for that kind of anxiety, and antidepressants are probably best avoided in patients with BD.
Concluding Thoughts
Comorbidities in patients with BD are the rule rather than the exception. Good clinical practice requires us to spend the time to complete a comprehensive evaluation to tease out the various comorbidities and then to treat each one appropriately.
Dr Osser is an associate professor of psychiatry at Harvard Medical School and codirector of the US Department of Veterans Affairs’ National Bipolar Disorder Telehealth Program in Brockton, Massachusetts. The author reports no conflicts of interest concerning the subject matter of this article.
References
1. Baldessarini RJ. Chemotherapy in Psychiatry: Pharmacologic Basis of Treatments for Major Mental Illness. 3rd ed. Springer; 2013.
2. Osser DN.
3. Mammen G, Rueda S, Roerecke M, et al.
4. Davis LL, Davidson JRT, Ward LC, et al.
5. Hamner MB, Faldowski RA, Robert S, et al.
6. Faraone SV, Banaschewski T, Coghill D, et al.
7. Viktorin A, Rydén E, Thase ME, et al.
8. Osser DN.
Articles in this issue
almost 4 years ago
PTSD in Late Life: An Update on Clinical Issuesalmost 4 years ago
Recognizing and Addressing Psychiatric Implications of Sleep Disordersalmost 4 years ago
COVID-19, Cognition, and Dementias: What Role Has the Pandemic Played?almost 4 years ago
Caring for Older Adults With Mental Health Disorders During the Pandemicalmost 4 years ago
Heal Thyself, Then Heal Others? The Power of Lived Experiencesalmost 4 years ago
Mirrors and Jeweled Netsalmost 4 years ago
Psychiatric Views on the Daily Newsalmost 4 years ago
Majority of Americans Favor President’s Vaccine Mandate: Pollalmost 4 years ago
Listening to Terry Grossalmost 4 years ago
Bipolar Disorder: The Difficult DiagnosisNewsletter
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