Comorbidity in BiPolar Disorder
What is comorbid with bipolar disorder?
Clinical comorbidity is defined as the occurrence of two or more syndromes in the same patient. The syndromes do not negate one another and are able to potentially influence the other’s course, outcome, and treatment response.1 The complexity of bipolar disorder (BPD) increases as more often than not there is usually the presence of comorbid conditions.1 In fact, the National Comorbidity Survey reports that 95 percent of respondents with BPD met criteria for three or more lifetime psychiatric disorders. Associate Vice President of Clinical Research at Eli Lilly Canada, Inc. and Staff Psychiatrist at Toronto East General Hospital Doron Sagman, M.D. and Distinguished Lilly Scholar for Neurosciences at Lilly Research Laboratories in Indianapolis, Mauricio Tohen, M.D. state that the presence of comorbidities in BPD patients leads to negative prognoses regarding psychological and medical well-being.1 Sagman and Tohen review the common comorbid conditions found in BPD patients in their article “Comorbidity in Bipolar Disorder: The Complexity of Diagnosis and Treatment.”1
Bipolar Disorder and Anxiety
The relationship between anxiety and bipolar disorder can create a more difficult course of treatment if comorbid. In fact, studies suggest that the rates of anxiety in persons with bipolar disorder are greater than those of the general population. The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) reports the lifetime prevalence of a comorbid anxiety disorder to be 51.2 percent, usually more common in patients with bipolar I disorder compared with bipolar II. According to Sagman and Tohen, patients with bipolar disorder are more likely to have one of the following anxiety subtypes: generalized anxiety disorder, simple phobia, social phobia, obsessive-compulsive disorder, posttraumatic stress disorder, and/or panic disorder.1 They state that panic disorder seems to be the most common comorbidity, manifesting in bipolar mixed states.1 Unfortunately, comorbid anxiety disorders tend to adversely affect the symptoms, course of illness, and treatment of persons with bipolar disorder.1
Sagman and Tohen state that few studies review treatment strategies for patients with bipolar disorder and a comorbid anxiety disorder. In fact, when anxiety co-occurs, traditional bipolar medicines, such as lithium, tend to be less effective than if anxiety was absent. Antidepressants, the usual treatment for anxiety disorders, are controversial for use in patients with bipolar as they may be associated with rapid switching of moods; however, they are commonly used to treat anxiety in bipolar patients. Also, second-generation antipsychotic agents, such as olanzapine, risperidone, and quetiapine, have been shown to benefit patients in the treatment of anxiety, and as they are also mood stabilizers, are useful in helping to avoid rapid mood switching.
Bipolar and Substance Abuse
Sagman and Tohen state that patients with bipolar disorder and a comorbid substance use disorder substantially complicates the course of illness and treatment course.1 Substance use disorders are found in 61 percent of patients with bipolar disorder, with the most common being alcohol abuse and dependence. Usually, patients experience higher rates of mixed episodes, rapid cycling, mood lability, suicidality, and other medical conditions that complicate BPD. Unfortunately, according to Sagman and Tohen, few studies have been completed on pharmacotherapeutic management of comorbid substance use disorders and BPD.1 However, anticonvulsants have shown promise in decreasing the use of alcohol and cocaine in patients with BPD. Also, second-generation antipsychotics, such as quetiapine and aripiprazole, have shown to reduce drug use and cravings. Sagman and Tohen state that the treatment of comorbid BPD and substance use disorders should use an integrated approach which focuses on psychotherapy and pharmacotherapy for each disorder simultaneously.1
Bipolar and ADHD
In 2001, a NIMH consensus conference reported that there is the potential for diagnosis of BPD in children, as the mixed-state symptoms of BPD seems to overlap with symptoms of attention-deficit/hyperactivity disorder (ADHD), including irritability, impulsivity, distractibility, overactivity, rapid speech, and emotional lability. Singh and colleagues recently reported that there is a relationship between the two disorders, as ADHD occurs in up to 85 percent of children with BPD and BPD occurs in up to 22 percent of children with ADHD. Therefore, Sagman and Tohen state that ADHD may be a marker of the development of early onset BPD; however, more studies are needed to fully understand how to accurately diagnose the disorders in children.1
Bipolar and Personality Disorders
Another common comorbid condition found in patients with BPD is personality disorders.1 Features of certain personality disorders may overlap with features of a bipolar mood episode; therefore, until the mood episode has been treated, it is difficult to correctly diagnose the personality disorder. A detailed personal history may help to establish which personality traits are present before the onset of a mood episode, and therefore, personality features that continue after the episode has resolved may reveal the personality disorder.1 Recently, a study reported that cluster B personality disorders—borderline, narcissistic, antisocial, and histrionic—are the most common in BPD patients.1 Treatment includes both psychotherapeutic and psychopharmacological modalities.1
Bipolar and Medical Conditions
There are also several medical comorbidities that occur in patients with BPD, according to Sagman and Tohen.1 Cardiovascular disease, type II diabetes, and other endocrine disorders are commonly diagnosed among persons with BPD compared to the general population. Also, migraine headaches are reported at higher rates in patients with bipolar II disorder.1
While bipolar disorder is in itself a difficult disorder to treat, it is common that patients have more than one comorbid disorder as well, further complicating the situation.1 However, there are limited recommendations regarding how to treat the comorbidities; therefore, further research needs to be completed in order to refine the resources clinicians need to effectively treat persons with BPD and their comorbid conditions.1
 Sagman, D. and Tohen, M. (2009, March 23). Comorbidity in Bipolar Disorder: The Complexity of Diagnosis and Treatment. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/1391541
 Kessler R. Comorbidity of unipolar and bipolar depression with other psychiatric disorders in a general population survey. In: Tohen M, ed. Comorbidity in Affective Disorders. New York: Marcel Dekker Inc; 1999:1-25.
 McIntyre RS, Soczynska JK, Bottas A, et al. Anxiety disorders and bipolar disorder: a review. Bipolar Disord. 2006;8:665-676.
 Keller MB. Prevalence and impact of comorbid anxiety and bipolar disorder. J Clin Psychiatry. 2006;67 (suppl 1):5-7.
 Simon NM, Otto MW, Wisniewski SR, et al. Anxiety disorder comorbidity in bipolar disorder patients: data from the first 500 participants in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Am J Psychiatry. 2004;161:2222-2229.
 Keck PE Jr, Strawn JR, McElroy SL. Pharmacologic treatment considerations in co-occurring bipolar and anxiety disorders. J Clin Psychiatry. 2006;67(suppl 1):8-15.
 Boylan KR, Bieling PJ, Marriott M, et al. Impact of comorbid anxiety disorders on outcome in a cohort of patients with bipolar disorder. J Clin Psychiatry. 2004; 65:1106-1113.
 Holma KM, Melartin TK, Holma IA, Isometsä ET. Predictors for switch from unipolar major depressive disorder to bipolar disorder type I or II: a 5-year prospective study. J Clin Psychiatry. 2008;69:1267-1275.
 Singh JB, Zarate CA Jr. Pharmacological treatment of psychiatric comorbidity in bipolar disorder: a review of controlled trials. Bipolar Disord. 2006;8: 696-709.
 Tohen M, Greenfield SF, Weiss RD, et al. The effect of comorbid substance use disorders on the course of bipolar disorder: a review. Harv Rev Psychiatry. 1998; 6:133-141.
 Goldberg JF, Garno JL, Leon AC, et al. A history of substance abuse complicates remission from acute mania in bipolar disorder. J Clin Psychiatry. 1999;60: 733-740.
 Salloum IM, Cornelius JR, Daley DC, et al. Efficacy of valproate maintenance in patients with bipolar disorder and alcoholism: a double-blind placebo-controlled study. Arch Gen Psychiatry. 2005;62:37-45.
 Brown ES, Nejtek VA, Perantie DC, Bobadilla L. Quetiapine in bipolar disorder and cocaine dependence. Bipolar Disord. 2002;4:406-411.
 National Institute of Mental Health research roundtable on prepubertal bipolar disorder. J Am Acad Child Adolesc Psychiatry. 2001;40:871-878.
 Singh MK, DelBello MP, Kowatch RA, Strakowski SM. Co-occurrence of bipolar and attention-deficit hyperactivity disorders in children. Bipolar Disord. 2006;8:710-720.
 Stormberg D, Ronningstam E, Gunderson J, Tohen M. Brief communication: pathological narcissism in bipolar disorder patients. J Personal Disord. 1998;12: 179-185.
 Krishnan KR. Psychiatric and medical comorbidities of bipolar disorder. Psychosom Med. 2005;67:1-8. bipolar.