Main comorbidities of bipolar disorder

The mood implies a way of being and of being, a pentagram on which the emotion with which the day-to-day experience is confronted is concerned. The most common is that it fluctuates from the situations experienced and the way they are interpreted, all within limits that the person feels tolerable.

Sometimes, however, some mental disorder may arise that alters the internal balance to which we refer. In these cases, the affection 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 peculiarity of triggering a disparity of challenges (academic, labor, 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 talk about the comorbidities of bipolar disorder , a special situation in which you have to reflect twice on the treatment to follow. In this article, this issue will be addressed in depth, especially in its clinical expressions.

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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 psychopathologies of such a family, requiring an intensive therapeutic approach and plotting a rather bleak prognosis.

It is characterized by the presence of manic episodes in which the individual is expansive and irritable and can alternate with depressive symptomatology (in the case of type I); or by hypomanic episodes of lower intensity than the previous ones, but that 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 any of the ways it can take, is the possibility of suffering from other mental health conditions over time . The evidence concerning the issue is clear, noting that those who refer to this problem show a higher risk of satisfying the diagnostic and clinical criteria reserved for many other cadres; or what is the same, of suffering comorbidities of nature and diverse consequences.

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

Comorbidities of bipolar disorder

Comorbidity is such a frequent phenomenon in bipolar disorder that it is usually considered the norm, rather than the exception. Between 50% and 70% of those who suffer will manifest it at some point in their lives, shaping the way it is expressed and even treated. “Comorbidity” means 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 another condition different from this, among which a very deep interaction would become evident (they would be transformed into 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 their evolution is less favorable. At the same time, the pharmacological treatment does not generate the same beneficial effect as that which would be observed in people without comorbidity, which results in an evolution “splashed” by all kinds of “obstacles” that both the patient and his family will have to overcome. One of the most pressing is undoubtedly the increase in suicidal ideation and behavior.

It is also known that comorbidity increases residual symptoms (subclinical manic / depressive) between episodes, so that some degree of affectation (absence of eutymia states) is persistently maintained, and sometimes it is even observed that the same problem It reproduces in other members of the “nuclear family.” And it is that mental disorders among close friends are the most relevant risk factor of all those considered in the literature on the fundamentals of bipolar disorder.

Hereinafter we will deepen in 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 he is living 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 seizures are met. panic. 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 hyperactivation when exposed to situations in which others “could evaluate”. 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 eventuality that any day must face a feared fact of social order, which becomes a source of incessant concern.

Panic attacks are also common (31%), and are characterized by the sudden emergence of a strong physiological activation (tremor and dizziness, sweating, tachycardia, respiratory acceleration, paraesthesia, etc.) that triggers a catastrophic interpretation (“I am dying “or” I’m going crazy “) and in the end it sharpens the original sensation, in an ascending cycle that is extremely aversive for those who enter it. In fact, a high percentage will try to avoid everything that could cause, according to their own ideas, new episodes of this type (thus creating agoraphobia).

he presence of these pathologies in a bipolar subject merits independent treatment, and should be thoroughly explored in the evaluation sessions.

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2. Personality disorders

Personality disorders in cases of bipolarity have been studied in response to two possible prisms: pray as “base” foundations from which the latter comes to rise, pray 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 recognizes having a worse quality of life.

Those most frequently living with bipolar disorder are those included in cluster B (boundary / 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 a bipolar disorder. In this case, it is considered that bipolar disorder and BPD share a certain emotional reactivity (excessive emotional responses according to the events that trigger them), although with different origins: organic for bipolar disorder and traumatic for the limit.

The joint presence of antisocial disorder and bipolar disorder is linked to a worse course of the latter, especially mediated by increased substance use and by the increase in suicidal ideation (very high in itself in these cases). This comorbidity favors an accent in 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, closely linked to all personality disorders of cluster A.

Personality disorders increase, finally, the number of acute episodes that people go through the life cycle, which blurs the general state (even cognitively).

3. Substance use

A very high percentage, which ranges around 30% -50% of subjects with bipolar disorder, abusively consume 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 / 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 fast cyclists of the first of them.

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 that is introduced into the organism. The problem, however, is that this use can cause mood swings and become a spring for manic or depressive episodes . In addition, there is evidence that stressful events (especially those of social roots), as well as expansiveness, are important risk factors.

Precisely regarding this last issue, about possible risk factors for drug use in bipolar disorder, a constellation of personality traits has been described as “potential candidates” (the search for sensations, intolerance to frustration). and impulsivity). Anxiety disorders and ADHD also increase the chances, as does belonging to the male sex. 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, the use of drugs implies a more severe course, a high prevalence of suicidal ideas or behaviors, the emergence of more common episodes and mixed expression (depression / mania), a very poor adherence to treatment, a higher number of hospital admissions and a marked trend towards the commission of crimes (together with the legal consequences that could be expected).

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4. Obsessive compulsive disorder (OCD)

Obsessive compulsive disorder (which involves the emergence of obsessive ideas and generating psychological distress, followed by some behavior or thought aimed at relieving it) is very common in bipolarity, especially during depressive episodes of type II (in 75% of patients ). These are chronic disorders in both cases, although their presentation fluctuates from the way in which they interact with each other. In most subjects, the obsession-compulsion is the first to appear, although other times arise concurrently.

People suffering from this comorbidity report more prolonged and 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 (to which the risk described above would be associated), as well as that they coexist with a notable prevalence of suicidal ideas that require as much attention as possible (especially during depressive symptomatology ).

The most common obsessions and compulsions in this case are those of verification (watch that everything is in the planned way) those of repetition (hand washing, clapping, etc.) and counting (add randomly or combine numbers). A high percentage of these patients tend to have a constant “reinsurance” (ask others to alleviate a persistent concern).

5. Eating disorders

Approximately 6% of people living with a bipolar disorder will experience, at some point in their lives, symptoms of a food pathology. The most common are undoubtedly bulimia nervosa and / or binge eating disorder ; Bipolarity presented first in 55.7% of cases. It is usually more common in subtype II, with equal intensity affecting hypomanic and depressive episodes. The relationship between bipolarity and anorexia nervosa seems somewhat less clear.

Studies on this issue are indicative of the fact that the concurrent presence of both conditions is associated with a higher severity of bipolar disorder, and apparently with more frequent depressive episodes and with an early onset (or debut) of symptoms. An additional important aspect is that it raises the risk of suicidal behavior, which is usually notable in the two psychopathologies separately (although nourishing each other on this occasion). The review is more notable, if possible, in the case of women; being able to arise a greater number of bingeing during menstruation.

Finally, there is consensus regarding the fact that both pathologies precipitate a danger that the subject abuses drugs or reports 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.

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6. Attention deficit hyperactivity disorder (ADHD)

A relevant percentage of boys and girls with a bipolar disorder also suffer from ADHD, which is accompanied by hyperactivity and problems maintaining attention for long periods of time. In cases where ADHD is in isolation, approximately half reach adulthood meeting their diagnostic criteria, a percentage that extends beyond those who suffer from the comorbidity that concerns us. 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 cases of comorbidity involve an earlier onset for bipolar disorder (up to five years before average), shorter periods free of symptoms, depressive emphasis and risk of anxiety (especially panic attacks and social phobia). The consumption of alcohol and other drugs may also be present, which seriously impairs 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 emotional tone.

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 high comorbidity is observed, 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. However, this data has been constantly questioned, due to the difficulties of this population to suggest with words their subjective experiences (when there is no proactive language).

Some symptoms, in addition, can overlap in these two pathologies, which could end up causing confusion in the clinician. Issues such as irritability, excessive speech and without a clear end, the tendency to distraction or even the swinging happen in both cases; therefore, special caution must be taken when interpreting them. Insomnia is also often confused with the typical activation or tirelessness 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), rocking much more pronounced than usual, descent without explanation in sleep time (becoming an abrupt change and without obvious cause) and an impulsiveness that often leads to aggression.


by Abdullah Sam
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