Mood implies a way of being and being, a pentagram that deals with the emotion with which the day-to-day experience is faced. Most often it fluctuates from the situations lived and the way they are interpreted, all within limits that the person feels as tolerable.
Sometimes, however, some mental disorder may arise that alters the internal balance to which we refer. In these cases, the affect acquires an overflowing entity, which comes to undermine the quality of life and hinders adaptation to the different contexts in which the person participates.
This type of mental health problem has the particularity of triggering a disparity of challenges (academic, occupational, social or other), as well as alterations in the structure of the central nervous system, which generate an extraordinary risk of other pathologies arising during its evolution.
In this case, we are talking about the comorbidities of bipolar disorder , a special situation in which a double reflection on the treatment to be followed is necessary. In this article we will address this issue in depth, focusing on its clinical expressions.
What is Bipolar Disorder
Bipolar disorder is a nosological entity included in the category of mood disorders , as is depression. However, its chronic and disabling course tends to differentiate it from the rest of the psychopathologies of such family, requiring an intensive therapeutic approach and a rather gloomy prognosis.
It is characterized by the presence of manic episodes in which the individual is expansive and irritable and which may alternate with depressive symptoms (in the case of type I); or by hypomanic episodes of lower intensity than the previous ones, but which are interspersed with periods of sadness of enormous clinical relevance (in subtype II).
One of the main difficulties associated with living with this disorder, in whatever form it may take, is the possibility of suffering other mental health conditions over time . The evidence concerning this question is clear, as it is highlighted that those who refer to this problem show a higher risk of satisfying the diagnostic and clinical criteria reserved for many other conditions; or what is the same, of suffering comorbidities of different natures and consequences.
In this article we will address precisely such an issue, investigating the most common comorbidities of bipolar disorder as we know them today.
Comorbidities of Bipolar Disorder
Comorbidity is such a common phenomenon in bipolar disorder that it is often considered the rule rather than the exception. Between 50% and 70% of those who suffer from it will manifest it at some point in their lives, shaping the way it is expressed and even treated. Bipolar disorder is defined as the confluence of two or more clinical problems within the area of mental health.
More specifically, this assumption refers to the co-occurrence (at a single moment) of bipolar disorder and of another condition different from it, between which a very deep interaction would become evident (they would become something different from what they would be separately).
There is evidence that individuals with bipolar disorder and comorbidities report that their mood problem had an early onset and that it evolves less favorably. At the same time, the pharmacological treatment does not generate the same beneficial effect as that which would be observed in people without comorbidities, which results in an evolution “splashed” by all kinds of “obstacles” that both the patient and his or her family will have to overcome. One of the most pressing is, without a doubt, the increase in suicidal ideation and behavior.
It is also known that comorbidity increases residual symptoms (subclinical mania/depression) between episodes, so that some degree of affectation is persistently maintained (absence of euthymia states), and sometimes it is even observed that the same problem is reproduced in other members of the “nuclear family”. The fact is that mental disorders among people who are close to each other are the most relevant risk factor of all those considered in the literature on the basis of bipolar disorder.
In the following, we will go deeper into which are the disorders that most commonly coexist with bipolar disorder, as well as the clinical expression associated with this phenomenon.
1. Anxiety disorders
Anxiety disorders are very common in the context of bipolarity, especially in depressive episodes. When the individual is going through a period of acute sadness, it is likely that this coexists with a mixed symptomatology that includes nervousness and agitation, and even that all the criteria for the diagnosis of an entity such as social phobia or panic attacks are met. Thus, it has been estimated that 30% of these patients suffer at least one clinical picture of anxiety, and that 20% refer two or more.
The most common of these is undoubtedly social phobia (39%). In such cases the person manifests a great physical hyperactivity when exposed to situations where others “could evaluate” it. When it is more intense, it may arise at other simpler times, such as eating and drinking in public, or during informal interactions. A high percentage of these patients also anticipate the possibility that they may have to face a feared social event one day, which becomes a source of constant concern.
Panic attacks are also common (31%), and are characterized by the sudden irruption of a strong physiological activation (tremors and dizziness, sweating, tachycardia, respiratory acceleration, paresthesias, etc.) that triggers a catastrophic interpretation (“I am dying” or “I am going crazy”) and finally sharpens the original sensation, in an upward cycle that is extremely aversive to those who enter it. In fact, a high percentage will try to avoid anything that could provoke, according to their own ideas, new episodes of this type (thus giving rise to agoraphobia).
The presence of these pathologies in a bipolar subject merits independent treatment, and should be thoroughly explored in the evaluation sessions.
2. Personality disorders
Personality disorders in cases of bipolarity have been studied by looking at two possible prisms: either as a “base” foundation from which the latter emerges, or as a direct consequence of its effects.
Regardless of the order of appearance, there is evidence that this comorbidity (up to 36% of cases) is a very relevant complication. Today we know that this group of patients admits to having a worse quality of life.
Those most frequently living with bipolar disorder are those included in cluster B (borderline/narcissistic) and cluster C (obsessive-compulsive). Among all of them, perhaps the one that has reached the most consensus in the literature is Borderline Personality Disorder, with approximately 45% of those who suffer from it also suffering from bipolar disorder. In this case it is considered that bipolar disorder and TLP share some emotional reactivity (excessive affective responses in light of the events that trigger them), although with different origins: organic for bipolar disorder and traumatic for borderline.
The joint presence of antisocial disorder and bipolar disorder is linked to a worse course of the latter, mainly mediated by increased substance consumption and by the increase in suicidal ideation (very high in itself in these cases). This comorbidity favours an accent on manic episodes, being a confluence that emphasizes basal impulsivity and the risk of criminal consequences for the acts themselves. Similarly, drug dependence contributes to symptoms such as paranoia, which is closely linked to all cluster A personality disorders.
Finally, personality disorders increase the number of acute episodes that people go through throughout the life cycle, which clouds the overall state (even at the cognitive level).
3. Substance use
A very high percentage, ranging from 30%-50% of the subjects with bipolar disorder, abuse at least one drug . A detailed analysis indicates that the most commonly used substance is alcohol (33%), followed by marijuana (16%), cocaine/amphetamine (9%), sedatives (8%), heroin/opioids (7%) and other hallucinogens (6%). Such comorbidities have severe effects and can be reproduced in both type I and type II, although it is particularly common in fast cyclers of the former.
There are suggestive hypotheses that the pattern of consumption may correspond to an attempt at self-medication, that is, the regulation of internal states (depression, mania, etc.) through the psychotropic effects of the particular drug introduced into the body. The problem, however, is that this use can lead to shifts in mood and act as a springboard for manic or depressive episodes . Furthermore, there is evidence that stressful events (especially those with social roots), as well as expansiveness, are important risk factors.
Precisely with regard to the latter issue, on possible risk factors for drug use in bipolar disorder, a constellation of personality traits has been described as “potential candidates” (sensation-seeking, frustration intolerance and impulsivity). Anxiety disorders and ADHD also increase the odds, as does being male. The prognosis is also known to be worse when addiction precedes the bipolar disorder itself, as opposed to the opposite situation.
In any case, drug use involves a more severe course, a high prevalence of suicidal ideas or behaviour, the emergence of more common and mixed expression episodes (depression/mania), very poor adherence to treatment, a higher number of hospital admissions and a pronounced tendency to commit crimes (along with any legal consequences that might be anticipated).
4. Obsessive-compulsive disorder (OCD)
Obsessive-compulsive disorder (which involves the irruption of obsessive ideas and generating psychological discomfort, followed by some behaviour or thought aimed at alleviating it) is very common in bipolarity, especially during type II depressive episodes (in 75% of patients). Both are chronic disorders, although their presentation fluctuates according to the way in which they interact with each other. In most subjects, obsession-compulsion is the first to appear, although other times they arise concurrently.
People suffering from this comorbidity refer to longer and more intense affective episodes, with a diminished response to the use of drugs (for both conditions) and a low adherence to them and/or to psychotherapy . There is evidence that these patients use drugs much more frequently (to which the risk described above would be associated), as well as that they live with a notable prevalence of suicidal ideas that require the greatest possible attention (especially during depressive symptomatology).
The most common obsessions and compulsions in this case are those of checking (making sure everything is as it should be), repeating (washing hands, clapping, etc.) and counting (randomly adding or combining numbers). A high percentage of these patients tend to be constantly “re-assured” (asking others to alleviate a persistent concern).
5. Eating disorders
Approximately 6% of people living with bipolar disorder will experience symptoms of an eating disorder at some point in their lives. The most common are, without doubt, bulimia nervosa and/or binge eating disorder ; bipolarity occurs first in 55.7% of cases. It is usually more common in subtype II, with an equal emphasis on hypomanic and depressive episodes. The relationship between bipolarity and anorexia nervosa seems somewhat less clear.
Studies on this subject indicate that the concurrent presence of both conditions is associated with a higher severity of bipolar disorder, and apparently more frequent depressive episodes and early onset (or debut) of symptoms. An important additional aspect is that increases the risk of suicidal behavior, which is usually noticeable in the two psychopathologies separately (although feeding off each other on this occasion). The above is even more remarkable in the case of women; a greater number of binges may occur during menstruation.
Finally, there is consensus that both pathologies precipitate a danger of the subject abusing drugs or referring to suffer any of the disorders included in the nosological category of anxiety. Personality disorders, and particularly those in cluster C, may also arise in patients with this complex comorbidity.
6. Attention Deficit Hyperactivity Disorder (ADHD)
A significant percentage of children with bipolar disorder also suffer from ADHD, which causes hyperactivity and problems in maintaining attention for long periods of time. In cases where ADHD is isolated, approximately half of them reach adulthood and meet their diagnostic criteria, a percentage that extends beyond those who suffer from the comorbidity in question. In this sense, it is estimated that up to 14.7% of men and 5.8% of women with a bipolar disorder (adults) present it .
These comorbidity cases involve earlier onset for bipolar disorder (up to five years earlier than average), shorter symptom-free periods, depressive emphasis, and risk of anxiety (especially panic attacks and social phobia). Alcohol and other drug use may also be present, severely impairing quality of life and the ability to contribute to society with a job. The presence of ADHD in a child with bipolar disorder requires extreme caution with the use of methylphenidate as a therapeutic tool, as stimulants can alter emotional tone.
Finally, some authors have objected to the connection between this situation and antisocial behaviour , which would be expressed in the commission of illicit acts together with potential civil or criminal sanctions. The risk of ADHD is four times higher in children with bipolar disorder than in their counterparts with depression, especially in subtype I.
Some studies suggest that autism and bipolarity may be two disorders for which high comorbidity is seen in both adulthood and childhood. In fact, it is estimated that up to one-quarter of all people with this neurodevelopmental disorder would also have this mood problem. However, this data has been constantly questioned, due to the difficulties of this population to suggest in words their subjective experiences (when there is no propositional language).
Some symptoms, moreover, may overlap in these two pathologies, which could end up causing confusion in the clinician. Issues such as irritability, excessive and endless speech, a tendency to distraction or even rocking can occur in both cases, so special care must be taken when interpreting them. Insomnia is also often confused with the typical activation or tiredness of manic episodes.
Thus, it is possible that the symptoms of bipolarity in autistic people are different from those usually identified in other populations . The most recognized are the pressure of speech or taquilalia (accelerated rhythm), swinging much more pronounced than usual, unexplained decrease in sleep time (becoming an abrupt change without evident cause) and an impulsivity that often leads to aggression.
- Brieger, P.. (2011). Comorbidity in bipolar disorders. Nervenheilkunde. 30. 309-312.
- Parker, G., Bayes, A., McClure, G., Moral, Y. And Stevenson, J.. (2016). Clinical status of comorbid bipolar disorder and borderline personality disorder. The British Journal of Psychiatry. 209(3), 109-132.