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Bipolar Disorder and Comorbid Disorders

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Title: Bipolar Disorder and Comorbid Disorders


1
Bipolar Disorder and Comorbid Disorders
  • Kurt Weber, PhD
  • Mental Health America Brown CountyBemis
    International Center
  • St Norbert College
  • May 13, 2008

2
  • 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

3
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.

4
  • 23.6 of bipolar clients have an alcohol use
    disorder
  • 12.9 have a drug abuse disorder
  • 37 have nicotine dependence (NESARC)

5
  • Bipolar clients are unreliable reporters of AODA
    use
  • They also underreport psychiatric symptoms.
  • Nonetheless, substance abuse complicates bipolar
    disorder, of course

6
  • 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

7
  • The incidence of revolving door clients is
    higher with concurrent substance abuse
  • Substance abuse is associated with a relatively
    poor response to lithium.

8
  • 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.

9
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.

10
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

11
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.

12
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

13
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).

14
  • 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

15
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

16
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

17
  • 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."

18
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

19
  • 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

20
  • 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

21
  • 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

22
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.

23
  • 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.

24
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.

25
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.

26
  • 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.

27
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.

28
  • 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.

29
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

30
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)

31
  • 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

32
obesity
  • Obesity is more prevalent in patients than in the
    general population.
  • Obesity prevalence is clearly related to the
    administration of antipsychotic drugs

33
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

34
  • 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."

35
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."

36
  • 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."
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