Conditions such as anxiety disorders, substance abuse, and obesity often occur alongside bipolar disorder, making management of the illness more difficult. Understanding why can help.If you have bipolar disorder, you are more likely to have another, accompanying condition, known as a comorbid condition, or a comorbidity. Some bipolar comorbidities are psychiatric; others are medical — but all affect the management and treatment of bipolar disorder.
Comorbid Conditions of Bipolar Disorder
Some of the more common comorbidities of bipolar disease include:
- Attention deficit hyperactivity disorder (ADHD). Between 10 and 20 percent of adults living with bipolar disorder have ADHD as well. Symptoms of ADHD — including concentration difficulties, restlessness, and talkativeness — overlap those of the manic phase of bipolar disorder, so early symptoms of bipolar disorder can be mistaken for ADHD. Also, stimulants given to treat ADHD sometimes reveal bipolar disorder symptoms, says Jeffrey Rakofsky, MD, a psychiatrist at the Emory University Bipolar Disorders Clinic in Atlanta.
- Anxiety disorders. People with bipolar disorder may also experience an anxiety disorder. Anxiety disorders include panic disorder, post-traumatic stress disorder (PTSD), social anxiety disorder, generalized anxiety disorder, specific phobias, and obsessive-compulsive disorder. “Studies have shown that about 50 percent of patients have a lifetime anxiety disorder along with bipolar disorder,” says Dr. Rakofsky. Specifically, he adds, panic disorder tends to be associated with bipolar disorder, so it’s thought the two may be genetically related.
- Substance disorders. About 60 percent of people with bipolar disorder also have a problem with either alcoholism or drug use. Factors such as the development of bipolar disorder at a young age, mixed episodes (depression and mania at the same time), or a family history of substance abuse may increase the likelihood that a person living with bipolar disorder will have substance abuse problems.
- Obesity. Medications used to treat bipolar disorder can cause weight gain, and during the depressive phase of the illness, people often do not feel like being active, which further increases the risk of obesity. In addition, people with psychiatric conditions tend to have high levels of the stress hormone cortisol in their systems, which affects metabolism. Given these factors, it’s not surprising that an estimated 75 percent of people with bipolar disorder are either obese or overweight.
- Metabolic syndrome. Between 22 and 30 percent of people living with bipolar disorder also have metabolic syndrome — a combination of obesity, elevated blood triglyceride levels, low levels of “good” (HDL) cholesterol, high blood pressure, and insulin resistance — which is a risk factor for cardiovascular disease. One reason for this is that medications known as atypical antipsychotics, which are used to treat the manic phase of bipolar disorder, increase the risk of metabolic syndrome.
The Impact of Comorbidities
Many of these comorbidities, especially ADHD and anxiety disorders, are “associated with longer bipolar episodes, episodes that might be less responsive to lithium (a standard treatment for bipolar disorder), more episodes, more severe episodes, and more risk of suicide,” explains Rakofsky.
The treatment of bipolar disorder can also be more difficult when comorbidities are involved.
- People may miss doses of their medications. People with anxiety disorders may be overly concerned about the side effects of their medications and therefore less likely to take them. Those with substance problems may forget to take their bipolar medications while intoxicated or under the influence of drugs.
- Medications for one condition may adversely affect the other. ADHD is typically treated with stimulants, anxiety disorders with antidepressants. “But stimulants and antidepressants have the potential to destabilize bipolar disorder and make people manic,” Rakofsky says.
- Bipolar disorder treatment may have caused the comorbid condition.This is sometimes the case with obesity and metabolic syndrome.
Managing Bipolar Treatment With Comorbidities
The key to treating bipolar disorder with comorbidities is to try different approaches or medications until you find the combination that works for you.
- ADHD. Behavioral treatments for ADHD are useful alternatives to drug treatments, because someone with bipolar disorder should avoid using stimulants whenever possible. “Usually, the rule of thumb is to control the bipolarity first and then address the ADHD,” Rakofsky says. That approach also helps determine whether the symptoms are a combination of ADHD and bipolar disorder or are just part of the manic phase of bipolar disorder.
- Anxiety disorders. Alternatives to antidepressants can include psychotherapy and medications such as benzodiazepines or novel anticonvulsants that have been shown to be effective in treating anxiety.
- Substance disorders. There are dual-diagnosis recovery programs that treat both bipolar disorder and substance disorders, and Rakofsky stresses that it is vital to address both conditions at the same time.
- Obesity and metabolic syndrome. Doctors routinely monitor weight gain and cholesterol changes in patients with bipolar disorder and make “appropriate medication changes when it makes sense,” says Rakofsky. He also informs his patients that medications may cause weight gain, and reviews the importance of healthy eating habits and exercise.
Comorbidities are a factor of bipolar disorder for a lot of people, and they can make the condition more difficult to treat. But with vigilance and persistence on the part of doctors and patients alike, bipolar disorder and its comorbid conditions can be effectively managed.