Main comorbidities of bipolar disorder

The state of mind implies a way of being and being, a pentagram about the emotion with which the day-to-day experience is faced. The most common is that it fluctuates from the situations experienced and the way in which they are interpreted, all within limits that the person feels as tolerable.

Sometimes, however, a mental disorder may arise that alters internal balance to which we refer. In these cases, the affect acquires an overflowing entity, which comes to undermine the quality of life and hinder the adaptation to the different contexts in which the person participates.

This type of mental health problems has the particularity of triggering a disparity of challenges (academic, work, social or of another nature), 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 comorbidities of bipolar disorder, a special situation in which it is necessary to reflect twice on the treatment to follow. This article will address this issue in depth, focusing especially on its clinical expressions.

• Related article: "Differences between bipolar disorder type I and II"

What is bipolar disorder

Bipolar disorder is a nosological entity included in the category of mood disturbances, like depression. However, its chronic and disabling course tends to differentiate it from the rest of such psychopathologies. family, requiring an intensive therapeutic approach and drawing a much bleaker prognosis.

It is characterized by the presence of manic episodes in which the individual is expansive and irritable and which can 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 from other mental health conditions over time. The evidence concerning the issue is clear, highlighting that those who refer to this problem manifest a higher risk of satisfying the diagnostic and clinical criteria reserved for many others paintings; or what is the same, to suffer comorbidities of a different nature and consequences.

In this article we will address precisely this question, investigating the most common comorbidities of bipolar disorder according to what we know today.

Comorbidities of bipolar disorder

Comorbidity is such a common phenomenon in bipolar disorder that it is often considered the norm rather than the exception. Between 50% and 70% of those who suffer it will manifest it at some point in their lives, shaping the way it is expressed and even treated. "Comorbidity" is understood as the confluence of two or more clinical problems within the area of ​​mental health.

More specifically, this assumption refers to the co-occurrence (in a single moment) of bipolar disorder and a different condition to this, between which a very deep interaction would become evident (they would transform into something different from what they would be for separated).

There is evidence that individuals with bipolar disorder and comorbidities report that their mood problem had an early onset and that its evolution is less favorable. At the same time, drug treatment does not generate the same beneficial effect than the one that would be observed in people without comorbidity, which results in an evolution "dotted" by all kinds of "obstacles" that both the patient and her family will have to overcome. One of the most pressing is, without a doubt, the increase in suicidal ideation and behavior.

Comorbidity is also known to increase residual symptoms (subclinical manic / depressive) between episodes, so that some persistent degree of affectation (absence of states of euthymia), and sometimes it is even observed that the same problem is reproduced in other members of the "family nuclear". And it is that mental disorders among close people are the most relevant risk factor of all those considered in the literature on the foundations of bipolar disorder.

Hereinafter we will delve into 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 mixed symptoms 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 satisfied. Thus, it has been estimated that 30% of these patients suffer at least one clinical picture of anxiety, and that 20% report two or more.

The most common of all is, without any doubt, social phobia (39%). In such cases the person manifests a great physical hyperarousal when exposed to situations in which others "could evaluate it." When it is more intense, it may arise in other simpler moments, such as eating and drinking in public, or during informal interactions. A high percentage of these patients also anticipate the eventuality that any day they will have to face a feared event of a social order, which becomes a source of incessant concern.

Panic attacks are also common (31%), and are characterized by the sudden outbreak of a strong physiological activation (tremors and dizziness, sweating, tachycardia, respiratory acceleration, paresthesia, etc.) that detonates a catastrophic interpretation ("I am dying" or "I am going crazy") and in the end it sharpens the original sensation, in an ascending cycle that is extremely aversive for those who enter in the. In fact, a high percentage will try to avoid everything 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 warrants independent treatment, and should be thoroughly explored in the evaluation sessions.

• You may be interested: "Types of Anxiety Disorders and their characteristics"

2. Personality disorders

Personality disorders in bipolar cases have been studied according to two possible prisms: now as "base" foundations from which the latter comes to emerge, now as a direct consequence of their 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 admit to having a worse quality of life.

Those who most frequently live with bipolar disorder are those included in cluster B (borderline / narcissistic) and in cluster C (obsessive compulsive). Among all of them, perhaps the one that has reached the most consensus in the literature is the Borderline personality disorder, finding that approximately 45% of those who suffer from it also suffer from bipolar disorder. In this case it is considered that bipolar disorder and BPD share some emotional reactivity (excessive affective responses based on 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 use and increased suicidal ideation (very high by itself in these cases). This comorbidity encourages an accent on manic episodes, being a confluence that emphasizes baseline impulsivity and the risk of criminal consequences for the acts themselves. Similarly, drug dependence contributes to symptoms such as paranoia, closely linked to all cluster A personality disorders.

Ultimately, personality disorders increase the number of acute episodes that people experience. traverse throughout the life cycle, which clouds the general state (even at the level cognitive).

3. Substance use

A very high percentage, ranging around 30% -50% of subjects with bipolar disorder, abuse at least one drug. A detailed analysis indicates that the most used substance is alcohol (33%), followed by marijuana (16%), cocaine / amphetamine (9%), sedatives (8%), heroin / opiates (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 rapid cyclers of the former.

There are suggestive hypotheses that the consumption pattern may correspond to an attempt at self-medication, that is, to the regulation of internal states (depression, mania, etc.) through the psychotropic effects of the particular drug that is introduced into the organism. The problem, however, is that this use can lead to mood swings and act as a spring for manic or depressive episodes. In addition, there is evidence that stressful events (especially those of social origin), as well as expansiveness, are important risk factors.

Precisely with regard to this last issue, about possible risk factors for drug use in bipolar disorder, it has been described a constellation of personality traits as "potential candidates" (sensation seeking, intolerance of frustration, and impulsiveness). Anxiety disorders and ADHD also increase the odds, as does being male. It is also known that the prognosis is worse when the addiction precedes the bipolar disorder itself, in contrast to the opposite situation.

In any case, drug use implies a more severe course, a high prevalence of suicidal ideas or behaviors, the emergence of more common episodes and mixed expression (depression / mania), very poor adherence to treatment, a higher number of hospital admissions and a marked tendency to commit crimes (together with the legal consequences that could foresee).

• You may be interested: "The 14 most important types of addictions"

4. Obsessive compulsive disorder (OCD)

Obsessive compulsive disorder (which involves the emergence of obsessive ideas that generate psychological discomfort, followed by some behavior or thought aimed at alleviating it) is very common in bipolarity, especially during type II depressive episodes (in 75% of patients). They are disorders of chronic course in both cases, despite the fact that their presentation fluctuates based on the way in which one and the other interact reciprocally. In most subjects, the obsession-compulsion is the first to appear, although other times they appear concurrently.

People with this comorbidity report longer and more intense affective episodes, with an attenuated response to the use of drugs (for both conditions) and poor adherence to them and / or to psychotherapy. There is evidence that these patients use drugs much more frequently (which would be associated with the risk described above), as well as that they live with a notable prevalence of suicidal ideas that require the greatest possible attention (especially during depressive symptoms).

The most common obsessions and compulsions in this case are those of verification (watch that everything is in the expected way) repetition (washing hands, clapping, etc.) and counting (adding randomly or combining numbers). A high percentage of these patients tend towards constant "reassurance" (asking others to alleviate a persistent concern).

5. Eating disorder

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 a doubt, bulimia nervosa and / or binge eating disorder; bipolarity presenting first in 55.7% of cases. It is usually more common in subtype II, affecting hypomanic and depressive episodes with equal intensity. The relationship between bipolarity and anorexia nervosa seems somewhat less clear.

The studies carried out on this matter are indicative that the concurrent presence of both conditions is associated with a seriousness of bipolar disorder, and apparently more frequently of depressive episodes and with an early onset (or debut) of symptomatology. An additional important aspect is that increases the risk of suicidal behavior, which is usually noticeable in the two psychopathologies separately (although feeding on each other this time). What is reviewed is more remarkable, if possible, in the case of women; being able to arise a greater number of binges during the menstruation.

Finally, there is consensus regarding the fact that both pathologies precipitate a danger that the subject abuse drugs or report suffering from any of the disorders included in the nosological category of anxiety. Personality disorders, and especially those of cluster C, could also arise in patients with this complex comorbidity.

• You may be interested: "The 10 most common eating disorders"

6. Attention deficit hyperactivity disorder (ADHD)

A relevant percentage of boys and girls with bipolar disorder also suffer from ADHD, which causes hyperactivity and problems with maintaining attention for long periods of time. In cases where ADHD occurs in isolation, approximately half reach adulthood by completing its diagnostic criteria, a percentage that extends further to those who suffer from the comorbidity at hand. In this sense, It is estimated that up to 14.7% of men and 5.8% of women with bipolar disorder (adults) have it.

These cases of comorbidity imply an earlier onset for bipolar disorder (up to five years earlier than average), shorter periods free of symptoms, depressive emphasis and risk of anxiety (especially panic attacks and phobia Social). The use of alcohol and other drugs can also be present, seriously impairing the quality of life and the ability to contribute to society with employment. 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 the tone emotional.

Finally, some authors have objectified the connection between this situation and antisocial behavior, which would be expressed in the commission of illegal acts together with potential civil or criminal penalties. The risk of ADHD is four times higher in boys and girls with bipolar disorder than in their counterparts with depression, especially in subtype I.

7. Autism

Some studies suggest that autism and bipolarity could be two disorders for which there is a high comorbidity, both in adulthood and in childhood. In fact, it is considered that up to a quarter of all people with this neurodevelopmental disorder would also have this mood problem. Nevertheless, This data has been constantly questioned, due to the difficulties of this population to suggest with words their subjective experiences (when there is no purposeful language).

In addition, some symptoms may overlap in these two pathologies, which could end up causing confusion in the clinician. Issues such as irritability, excessive speech without a clear end, the tendency to be distracted or even swaying come to pass in both cases; therefore, special caution must be exercised when interpreting them. Insomnia is also often confused with the typical activation or indefatigability of manic episodes.

A) Yes, bipolar symptoms in autistic people may be different from those commonly seen in other populations. The most recognized are the pressure of speech or taquilalia (accelerated rhythm), rocking much more pronounced than usual, descent without explanation in the time of sleep (becoming an abrupt change and without obvious cause) and an impulsiveness that frequently leads to aggression.

Bibliographic references:

• 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.