Main comorbidities of bipolar disorder

Mood implies a way of being and being, a scope on which the emotion with which we live everyday life revolves. The most common is that it varies depending on the situations experienced and the way they are interpreted, all within limits that the person feels tolerable.

Sometimes, however, a mental disorder may occur that alters internal balance what we mean. In these cases, the affect acquires an overflowing entity, which manages to alter the quality of life and to hamper adaptation to the different contexts in which the person participates.

This type of mental health problem has the particularity of exploding a disparity of challenges (academic, professional, social or other), as well as alterations in the structure of the central nervous system, which generate an extraordinary risk of other pathologies occurring. during their evolution.

In this case we are talking about comorbidities of bipolar disorder, A particular situation in which it is necessary to think twice about the treatment to follow. This article will address this question in depth, focusing primarily on its clinical expressions.

    What is bipolar disorder

    Bipolar disorder is a nosological entity included in the category of mood disorders, As well as depression. However, its chronic and debilitating evolution tends to differentiate it from other psychopathologies of such a family, requiring an intensive therapeutic approach and tracing a somewhat darker prognosis.

    It is characterized by the presence of manic episodes in which the individual is expansive and irritable and may alternate with depressive symptoms (in the case of type I); or by hypomanic episodes of lower intensity than the preceding ones, but which are interspersed with periods of sadness of enormous clinical importance (in subtype II).

    One of the main challenges associated with living with this disorder, regardless of its form, is the possibility of suffering from other mental health problems over time. The evidence on the issue is clear, noting that those who report this problem are at a higher risk of meeting diagnostic and clinical criteria reserved for many other cases; or what is the same, suffer from comorbidities of various nature and consequences.

    In this article, we will address precisely this question, studying the most common comorbidities of bipolar disorder as we know it today.

    Comorbidities of bipolar disorder

    Comorbidity is such a common occurrence in bipolar disorder that it is generally considered the norm rather than the exception. Between 50% and 70% of those who suffer from it will manifest it at some point in their life, shaping the way it is expressed and even processed. “Comorbidity” means the confluence of two or more clinical problems in the field of mental health.

    Specifically, this hypothesis refers to the co-occurrence (in a single instant) of bipolar disorder and another condition other than this, between which a very deep interaction would be evident (they would be transformed into something different from who would be separated).

    There is evidence that people with bipolar disorder and co-morbidities report that their mood problem started early and progressed less favorably. At the same time pharmacological treatment does not generate the same beneficial effect than what would be observed in people without co-morbidities, which translates into an evolution “sprinkled” with all kinds of “obstacles” that the patient and his family will have to overcome. One of the most urgent is undoubtedly the increase in suicidal ideation and behavior.

    It is also known that comorbidity increases the residual symptoms (subclinical manic depression) between episodes, so that a certain degree of affectation is persistently maintained (absence of euthymic states), and sometimes even to observe that the same problem recurs in other members of the “nuclear family.” And it is that mental disorders in relatives are the most relevant risk factor of all those considered in the literature on the bases of bipolar disorder.

    In what follows, we will explore the disorders that most often coexist with bipolar disorder, as well as the clinical expression associated with this phenomenon.

    1. Anxiety disorders

    Anxiety disorders are very common against the background of bipolarity, especially in depressive episodes. When the individual is going through a period of acute sadness, it is likely that it coexists with mixed symptoms. which includes nervousness and restlessness, and even that all of the diagnostic criteria for an entity such as social phobia or panic attacks are met. Thus, it has been estimated that 30% of these patients suffer from at least one clinical picture of anxiety and that 20% report two or more.

    The most common of all is, without a doubt, social phobia (39%). In these cases, the person exhibits a great deal of physical hyperactivation when exposed to situations in which others “might assess”. When it is more intense, it can occur 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 one day they will have to face a dreaded social event, which becomes a source of unrelenting concern.

    Panic attacks are also common (31%), and are characterized by the sudden appearance of a strong physiological activation (tremors and dizziness, sweating, tachycardia, respiratory acceleration, paresthesias, etc.) which explodes a catastrophic interpretation (“I die” or “I am going mad ”) and in the end it sharpens the original sensation, in an ascending cycle which is extremely aversive for whoever enters it. In fact, a high percentage will try to avoid anything that could cause, according to their own ideas, new episodes of this type (thus arising agoraphobia).

    The presence of these pathologies in a bipolar subject deserves independent treatment and must be studied in depth during the evaluation sessions.

      2. Personality disorders

      Personality disorders in cases of bipolarity have been studied in terms of two possible prisms: now as the “basic” foundations from which the latter originates, now as a direct consequence of their effects.

      Whatever the order of occurrence, it is proven that this comorbidity (up to 36% of cases) is a very important complication. Today, we know that this group of patients recognizes having a poorer quality of life.

      Those who coexist most frequently with bipolar disorder are those included in group B (borderline / narcissistic) and group C (obsessive-compulsive disorder). Of all of them, perhaps the one that has gained the most consensus in the literature is borderline personality disorder, finding that around 45% of those who have it also have bipolar disorder. In this case, we consider that bipolar disorder and borderline disorder share some emotional reactivity (Excessive emotional responses depending on the events that cause them to explode), although of different origins: organic for bipolar disorder and traumatic for the limit.

      The combined presence of antisocial disorder and bipolar disorder is linked to a worse course of the latter, particularly mediated by increased substance use and increased suicidal ideation (Very high inherently in these cases). This comorbidity emphasizes manic episodes, being a confluence that emphasizes basal impulsivity and the risk of criminal consequences for the acts themselves. Likewise, drug addiction contributes to symptoms such as paranoia, which is closely related to all personality disorders in group A.

      Personality disorders ultimately increase the number of acute episodes people go through throughout the life cycle, which blurs the overall condition (even at the cognitive level).

      3. Substance use

      A very percentage high, ranging from about 30% to 50% of people 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%). These comorbidities have serious effects and can be reproduced in both type I and type II, although they are particularly common in fast cyclists of the former.

      There are hypotheses suggesting that the pattern of consumption may correspond to an attempt at self-medication, i.e. the regulation of internal states (depression, mania, etc.) by the psychotropic effects of the particular drug introduced into the patient. the body. The problem, however, is that this use can cause mood swings and serve as a springboard for manic or depressive episodes.. In addition, there is evidence that stressful events (especially those of social origin), as well as expansion, are important risk factors.

      Specifically with regard to this last question, on possible risk factors for drug use in bipolar disorder, a constellation of personality traits has been described as “potential candidates” (sensation seeking, intolerance to frustration and impulsiveness). Anxiety disorders and ADHD also increase the odds, as does male membership. It is also known that the prognosis is worse when the addiction precedes the bipolar disorder itself, unlike the reverse situation.

      In all cases, drug use implies a more severe course, a high prevalence of suicidal ideation or behavior, the appearance of more frequent episodes and mixed expression (depression / mania), very poor compliance treatment, a higher number of hospitalizations and a marked tendency to commit crimes (with foreseeable legal consequences).

        4. Obsessive Compulsive Disorder (OCD)

        Obsessive-compulsive disorder (which involves the emergence of obsessive ideas that generate psychological distress, followed by behavior or thought aimed at relieving) it is very common in bipolarity, especially during type II depressive episodes (In 75% of patients). They are chronic developmental disorders in both cases, although their presentation varies depending on how they interact with each other. In most subjects, the obsession-compulsion is the first to appear, although other times they occur simultaneously.

        People with this comorbidity report longer and more intense emotional episodes, with an attenuated response to drug use (for both conditions) and poor adherence to them and / or psychotherapy. There is evidence that these patients consume drugs much more frequently (which would be associated with the risk described above), as well as coexist with a remarkable prevalence of suicidal ideation which requires the greatest possible care (especially during depressive symptoms). ).

        The most common obsessions and compulsions in this case are those of checking (making sure everything goes as planned), repetition (washing hands, clapping, etc.), and counting (randomly adding or combine numbers). A high percentage of these patients tend toward constant “reassurance” (asking others to alleviate a lingering concern).

        5. Eating disorders

        About 6% of people 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.; exhibiting bipolarity first in 55.7% of cases. It is generally more common in subtype II, affecting hypomanic and depressive episodes with the same intensity. The relationship between bipolarity and anorexia nervosa seems a little less clear.

        Studies on this subject indicate that the concomitant presence of the two conditions is associated with a higher severity of bipolar disorder, and more frequent onset of depressive episodes and an early onset (or onset) of symptoms. Another important aspect is that increases the risk of suicidal behavior, which is usually noticeable in the two psychopathologies separately (Although feeding on each other on this occasion). The examination is most notable, if possible, in the case of women; more binge eating attacks may occur during menstruation.

        Finally, there is a consensus on the fact that the two pathologies precipitate the danger that the subject abuses drugs or declares to suffer from one of the disorders included in the nosological category of anxiety. Personality disorders, and in particular those in group C, could also occur 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 results in hyperactivity and problems maintaining attention for long periods of time. In cases where ADHD works in isolation, about half reach adulthood meeting their diagnostic criteria, a percentage that goes beyond those with the comorbidity of concern to us. In this way, It is estimated that up to 14.7% of men and 5.8% of women with bipolar disorder (adults) have it..

          These comorbid cases involve an earlier onset of bipolar disorder (up to five years earlier than average), shorter periods without symptoms, depressive stress, and risk of anxiety (particularly panic attacks and depression). social phobia). The use of alcohol and other drugs can also be present, which seriously affects the 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 objectified the link between this situation and anti-social behavior, This would be expressed by the commission of illegal acts alongside possible civil or criminal sanctions. The risk of ADHD is four times higher in boys and girls with bipolar disorder than in their depressed counterparts, especially in subtype I.

          7. Autism

          Some studies suggest that autism and bipolar disorder may be two disorders in which high comorbidity is observed, both in adulthood and in childhood. In fact, it’s estimated that up to a quarter of all people with this neurodevelopmental disorder would also have this mood problem. however, this fact has been constantly questioned, because of the difficulties of this population to suggest in words its subjective experiences. (When there is no targeted language).

          Some symptoms, moreover, may overlap in these two conditions, which could end up confusing the clinician. Problems such as irritability, excessive language and without a clear purpose, tendency to distraction or even swaying occur in both cases; special care must therefore be exercised when interpreting them. Insomnia is also often confused with the typical or indefatigable activation of manic episodes.

          like that, Symptoms of bipolarity in people with autism may be different from those commonly identified in other populations.. The most recognized are the pressure of speech or tachycardia (accelerated rhythm), swaying much more pronounced than usual, an unexplained decrease in sleep time (becoming a sudden change and without an obvious cause) and an impulsivity which often leads to aggression.

          Bibliographical references:

          • Brieger, P. (2011). Comorbidity in bipolar disorder. Nervenheilkunde. 30. 309-312.
          • Parker, G., Bayes, A., McClure, G., Moral, Y. Y Stevenson, J .. (2016). Clinical status of comorbid bipolar disorder and borderline personality disorder. The British Journal of Psychiatry. 209 (3), 109-132.

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