Bipolar Disorder and Comorbid Disorders

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Bipolar Disorder and Comorbid Disorders

• Kurt Weber, PhD
• Mental Health America Brown CountyBemis
  International Center
• St Norbert College
• May 13, 2008

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• Many disorders have been shown to be comorbid
  with bipolar disorder
• Some conditions are treated by treating BPD first
• Others more clearly show the BD when the comorbid
  problem is cleared up

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AODA

• many factors may contribute to these substance
  abuse problems, including
• Self-medication of mood-related symptoms
• mood symptoms either brought on or perpetuated by
  substance abuse, and risk factors that may
  influence the occurrence of both bipolar disorder
  and substance use disorders.
• Treatment of one does not resolve the other, but
  controlled bipolar disease usually leads to the
  diminishing of AODA symptoms.

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• 23.6 of bipolar clients have an alcohol use
  disorder
• 12.9 have a drug abuse disorder
• 37 have nicotine dependence (NESARC)

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• Bipolar clients are unreliable reporters of AODA
  use
• They also underreport psychiatric symptoms.
• Nonetheless, substance abuse complicates bipolar
  disorder, of course

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• Stimulants may precipitate a manic episode.
• Chronic use of CNS stimulants like amphetamine
  and cocaine cause
• euphoria
• decreased appetite
• increased energy
• grandiosity
• sometimes paranoia that mimics mania

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• The incidence of revolving door clients is
  higher with concurrent substance abuse
• Substance abuse is associated with a relatively
  poor response to lithium.

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• Hallucinations are more refractory (resistant to
  treatment or cure) in clients with substance
  abuse
• Substance abuse is related to higher mortality by
  suicide (15-19) and other causes.

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from about.com

• "I made a serious commitment to quit all drug use
  (street rx) when I was pregnant (7 years ago)
  which actually led to my diagnosis of BP, as I
  could no longer hide my illness without the drug
  use.
• "I stopped alcohol 5 years ago and street drugs
  four. Of course, this is when my depression
  (possibly BP with no formal dx) and OCD really
  began to peek out from beneath the foggy cover of
  my substance abuse camouflage.

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hard to identify comorbidity at first

• One study found that of those with a substance
  problem among severely mentally ill patients seen
  in a university hospital emergency room -- only
  2 percent were detected.
• The state hospital did only slightly better,
  detecting 15 percent

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why?

• Emergency rooms are just not often able to do
  structured interviews about drug and alcohol use
• Patients tend to underestimate the problems
  caused by the drugs, and they rarely disclose
  that they have a problem with substance abuse
• Practitioners should also keep in mind that
  illicit drugs and alcohol can cause the
  development, the reemergence, or even worsen the
  severity of mental disorders
• These drugs can also present symptoms that
  parallel those of mental disorders or even cover
  them up.

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Polcin

• Issues in the Treatment of Dual Diagnosis Clients
  Who Have Chronic Mental Illness
• poor treatment response
• high rates of rehospitalization
• aggravated psychotic thoughts
• changes in neurophysiology

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Polcin, continued

• notes that those dually diagnosed are often less
  responsive to medications than those who do not
  abuse substances, specifically stating that
  cocaine users have problems with lithium
• systems have not been well designed with this
  population in mind
• community may have treatment services for people
  with mental illness in one agency and treatment
  for substance abuse in another
• clients are referred back and forth between them
  in what some have called 'ping -pong' therapy"
  (NAMI).

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• Often the very treatment approach of one service
  may cause problems for the other side of the
  condition.
• substance abuse workers traditionally consider
  the use of medications to be a crutch for those
  struggling with addiction
• psychiatrists rely on prescriptions to treat the
  mental illness
• while psychiatrists rarely give much credence to
  spiritual or self-help approaches, those working
  with addictions place a great deal of emphasis
  here

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poor communication between practitioners

• Those struggling to reach stability with their
  mental illness and to achieve sobriety are, more
  often than not, shuffled between different
  practitioners.
• Even when these counselors and doctors work
  within the same facility, there is seldom good,
  if any, communication between offices

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HHS plan

• first area relates to decision-making with regard
  to treatment plans.
• Second is the use of psychotropic medications.
• Accurate diagnostic tools is another area greatly
  needing research
• currently no good instrument for detecting or
  classifying substance use disorders in the
  mentally ill, in that those available were
  developed for use in the general population

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• outlook for those with dual diagnosis seems grim
• What is the long-term prognosis? Is there any
  hope for stability and sobriety?
• lifetime prevalence of substance use disorders is
  as much as seven times greater for those with
  bipolar disorder than those in the general
  population
• however, there are successes
• "My life is quite manageable today with the
  proper medication, therapy, a wonderful support
  program and recovery program. And no booze ...
  not a drop. Works the best I have ever had it."

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Anxiety

• the first 500 patients with bipolar I or bipolar
  II disorder enrolled in the Systematic Treatment
  Enhancement Program for Bipolar Disorder
• Lifetime comorbid anxiety disorders were common,
  occurring in over one-half of the sample
• were associated with
• younger age at onset
• decreased likelihood of recovery
• poorer role functioning and quality of life
• less time euthymic
• greater likelihood of suicide attempts.
• comorbid anxiety appeared to exert an
  independent, deleterious effect on functioning,
  including history of suicide attempts

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• highlighting the need for greater clinical
  attention to anxiety in this population,
  particularly for enhanced clinical monitoring of
  suicidality.
• In addition, it is important to determine whether
  effective treatment of anxiety symptoms can
• lessen bipolar disorder severity
• improve response to treatment of manic or
  depressive symptoms
• reduce suicidality

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• The interaction between anxiety disorders and
  substance use goes both ways patients with
  bipolar disorder have a higher rate of substance
  use and anxiety disorder, and vice versa.
• Bipolar disorder is also associated with
  borderline personality disorder and ADHD, and to
  a lesser extent with weight gain.
• As more than 40 of bipolar patients have anxiety
  disorder, it is indicated that while diagnosing
  bipolar patients, systematic enquiry about
  different anxiety disorders is called for

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• therapeutic challenge, since agents that
  effectively treat anxiety disorders are
  associated with the risk of induced mania.
• the treating psychiatrist needs to carefully
  evaluate the potential benefit of treating the
  anxiety against the potential cost of inducing a
  manic episode
• possible solution would be to use, when possible,
  a non-pharmacological intervention, such as a
  cognitivebehavioural approach
• clinician may attempt to ensure that the patient
  receives adequate treatment with mood stabilizers
  before slowly and carefully attempting the
  addition of anti-anxiety compounds with a
  relatively lower risk of mania induction

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social phobia

• Strong associations exist between lifetime social
  phobia and major depressive disorder (odds ratio
  2.9), dysthymia (2.7) and bipolar disorder (5.9).
  
• Odds ratios increase in magnitude with number of
  social fears.
• Reported age of onset is earlier for social
  phobia than mood disorders in the vast majority
  of co-morbid cases.

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• Social phobia is a commonly occurring, chronic
  and seriously impairing disorder that is seldom
  treated unless it occurs in conjunction with
  another co-morbid condition
• adverse consequences of social phobia include
  increased risk of onset, severity and course of
  subsequent mood disorders.
• Early outreach and treatment of primary social
  phobia might not only reduce the prevalence of
  this disorder itself, but also the subsequent
  onset of mood disorders.

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Axis II personality disorders study A

• association of mood disorders with personality
  disorders (PDs) is relevant from a clinical,
  therapeutic and prognostic point of view
• avoidant PD, borderline PD and obsessive-compulsiv
  e PD were the most prevalent axis II diagnoses
  among patients with depressive disorder
• in bipolar disorder group, patients showed more
  frequently obsessive-compulsive PD, followed by
  borderline PD and avoidant PD
• different pattern of PDs emerges between
  depressive and bipolar patients.

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Axis II personality disorders study B

• Axis II disorders can be rated reliably among
  bipolar patients who are in remission.
  Co-diagnosis of personality disorder occurred in
  28.8 of patients.
• Cluster B (dramatic, emotionally erratic) and
  cluster C (fearful, avoidant) personality
  disorders were more common than cluster A (odd,
  eccentric) disorders.
• Bipolar patients with personality disorders
  differed from bipolar patients without
  personality disorders in the severity of their
  residual mood symptoms, even during remission.

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• When structured assessment of personality
  disorder is performed during a clinical
  remission, less than one in three bipolar
  patients meets full syndromal criteria for an
  axis II disorder.
• Examining rates of comorbid personality disorder
  in broad-based community samples of bipolar
  spectrum patients would further clarify the
  linkage between these sets of disorders.

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Axis II personality disorders study C

• Thirty-eight percent of the bipolar patients met
  criteria for an axis II diagnosis.
• Two (4) met criteria for (only) a Cluster A
  disorder, four (8) for (only) a Cluster B, and
  six (12) for (only) a Cluster C disorder.
• One (2) bipolar patient met criteria a disorder
  in both Clusters A and B, and one (2) for a
  disorder in Clusters B and C.
• Five (10) met criteria for at least one disorder
  in Clusters A and C, and one met criteria for
  disorders in Clusters A, B, and C.

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• The presence of a personality disorder was
  significantly associated with a lower rate of
  current employment, a higher number of currently
  prescribed psychiatric medications, and a higher
  incidence of a history of both alcohol and
  substance use disorders compared with the bipolar
  patients without axis II pathology.
• results extend previous findings of an
  association between comorbid personality disorder
  in bipolar I patients and factors that suggest a
  more difficult course of bipolar illness.

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Axis I

• authors assessed comorbid lifetime and current
  axis I disorders in 288 patients with bipolar
  disorder and the relationships of these comorbid
  disorders to selected demographic and historical
  illness variables
• 65 of the patients with bipolar disorder also
  met DSM-IV criteria for at least one comorbid
  lifetime axis I disorder
• no differences in comorbidity between patients
  with bipolar I and bipolar II disorder
• patients with bipolar disorder often have
  comorbid anxiety, substance use, and, to a lesser
  extent, eating disorders
• axis I comorbidity, especially current
  comorbidity, may be associated with an earlier
  age at onset and worsening course of bipolar
  illness

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diabetes mellitus

• Several papers have reported higher prevalence of
  diabetes mellitus (DM) type 2 in patients
  suffering from bipolar disorder (BD)
• possible links between these disorders include
  treatment, lifestyle, alterations in signal
  transduction, and possibly, a genetic link
• prevalence of DM in sample -- 11.7 (n 26)

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• Diabetic patients
• were significantly older than nondiabetic
  patients
• had higher rates of rapid cycling
• chronic course of BD
• scored lower on the Global Assessment of
  Functioning Scale
• were more often on disability for BD
• had higher body mass index
• increased frequency of hypertension
• Lifetime history of treatment with
  antipsychotics was not significantly associated
  with an elevated risk of diabetes (P 0.16)
  however, the data showed a trend toward more
  frequent use of antipsychotic medication among
  diabetic subjects
• diagnosis of DM in BD patients is relevant for
  their prognosis and outcome

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obesity

• Obesity is more prevalent in patients than in the
  general population.
• Obesity prevalence is clearly related to the
  administration of antipsychotic drugs

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migraine headaches

• association between migraine and affective
  disorders, but the information is sparse
  concerning the prevalence of migraine in
  subgroups of the affective disorders
• present study was undertaken to investigate the
  prevalence of migraine in unipolar depressive,
  bipolar I and bipolar II disorders

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• striking difference between the two diagnostic
  subgroups
• prevalence of 77 in the bipolar II group
• 14 in the bipolar I group
• These results support the contention that
  bipolar I and II are biologically separate
  disorders and point to the possibility of using
  the association of bipolar II disorder with
  migraine to study both the pathophysiology and
  the genetics of this affective disorder."

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age of onset

• 320 subjects with a diagnosis of BP I or BP II
• significantly earlier AAO in subjects
• with anxiety disorders
• rapid cycling course
• more frequent suicidal ideation/attempts
• Axis I comorbidity
• substance use disorders
• Overall, these results suggest a role of early
  AAO as a significant predictor of poor outcome in
  BP and, if replicated, they may have important
  clinical implications."

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• Assessment of bipolar disorder must include
  careful attention to comorbid disorders and
  predictors of compliance.
• Randomized trials are needed to further evaluate
  the efficacy of medication, psychosocial
  interventions, and other health service
  interventions, particularly as they relate to the
  management of acute bipolar depression, bipolar
  disorder co-occurring with other disorders, and
  maintenance prophylactic treatment."