Treating Bipolar & Related Disorders
The prevalence of substance abuse in people with bipolar disorders is relatively high. If someone is diagnosed with any of the major forms of bipolar disorder, they should be automatically screened for a potential substance use disorder.
Treating bipolar disorder and co-occurring substance abuse requires an integrated treatment program that utilizes a team of treatment professionals. This ensures both disorders are effectively addressed and gives the person the best chances of a full and sustained recovery on all fronts.
What Is Bipolar Disorder?
Bipolar disorder is a severe psychiatric disorder that can take several different forms.
The person will typically need to display either mania or hypomania in order to receive a bipolar disorder diagnosis. The person may or may not have mania or hypomania that alternates with periods of depression, but they will demonstrate periods of elated or irritable moods with periods of less elation or irritability.
In addition to two types of bipolar disorder, there are several related disorders. These include the following:
- Cyclothymic disorder
- Bipolar disorder that is induced by drugs
- Bipolar disorder that is due to another medical condition
Several other disorders have bipolar features, but they do not meet the diagnostic criteria for the disorder.
The presentation of bipolar disorder can be quite varied. There are numerous specifiers that can be added to the diagnosis, such as bipolar disorder with anxious distress, bipolar disorder with mixed features (both mania and depression together), and bipolar disorder with rapid cycling (numerous and relatively quick periods of mania and/or depression).
People with bipolar disorder can also appear psychotic and may be mistakenly diagnosed with schizophrenia or some other psychotic disorder.
Manic-depressive disorder and bipolar disorder are the same disorder.
Manic-depressive disorder is the older name for what would now be termed bipolar I disorder. Manic-depressive disorder is one of the first formally described psychiatric disorders.
The manic-depressive label is not commonly used by clinicians these days, although it still turns up in some venues, leading to confusion regarding how it differs from bipolar disorder. It does not.
The Current Classification of Bipolar Disorder & Related Disorders
In the previous psychiatric classification systems, such as the system used by the American Psychiatric Association (APA), mood disorders were a group of disorders that included depressive disorders, bipolar disorder, and other related disorders. Mood disorders were believed to be disorders of mood or emotional functioning.
As of 2013, in the publication of the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM–5), all the disorders related to depression were placed in one category of mental illnesses. The bipolar disorders were placed in a separate category: bipolar and related disorders. This reflects the research regarding these disorders and how they are now conceptualized.
Mania & Hypomania
Being diagnosed with any form of bipolar disorder is a very serious diagnosis.
According to APA’s current diagnostic formulation, in order to be diagnosed with either one of the two primary forms of bipolar disorder, you must display an episode of mania or hypomania. These expressions represent the other side of the extreme in emotional experience from a depressed mood.
The diagnosis of mania includes displaying an extremely elevated, expanded, or irritable mood state that has persisted for at least one week. Sometimes, the person may receive treatment before the week has been completed, and mania or hypomania can still be diagnosed in these cases.
In addition to elevated mood, there are numerous other signs that must appear. If the person is displaying expansive or elevated mood, they must also have three of the symptoms below. If they are primarily displaying extreme irritability, they must have four of the following symptoms:
- Significant talkativeness
- Inflated self-esteem or grandiosity
- Racing thoughts that are usually diagnosed through rapid speech patterns or pressured speech
- An unusual decrease in the need for sleep
- Significant distractibility
- An increase in goal-directed behaviors (like going on a housecleaning binge without needing rest) or behaviors that are not goal-directed (like performing extended aimless pacing)
- A significant increase in potentially dangerous or damaging behaviors, such as shopping binges, gambling sprees, engaging in multiple sexual activities, and so forth
The difference between the diagnosis of mania and hypomania depends on the severity and duration of the above behaviors.
Hypomania is typically characterized by irritability and will have a shorter duration. Manic episodes are characterized by expansive mood (like extreme grandiosity) and a duration of at least seven days.
Hypomania will often not significantly interfere with the ability to function, whereas mania always interferes with this ability. People in manic episodes are far more likely to be hospitalized or arrested than those in hypomanic episodes.
Primary Types of Bipolar Disorders
Although there are numerous specifiers that describe the different manifestations of bipolar disorder, there are two basic bipolar disorder types, according to APA.
- Bipolar I disorder is diagnosed when there is at least one full documented episode of mania. The person may or may not have had other manifestations like depression and hypomania, but if they have ever been diagnosed with a manic episode, they should be diagnosed with bipolar I. The prevalence of this form of the disorder is about 0.6 percent.
- Bipolar II disorder occurs when the person has only been diagnosed with one or more hypomanic episodes. They may or may not have had depressive episodes, but they cannot have ever been diagnosed with a manic episode. The prevalence for this form of the disorder is about 0.3 percent.
How Does Depression Fit In?
Someone can be diagnosed with either of the two types of bipolar disorder even if they have never been diagnosed with any form of clinical depression. However, most people who have a diagnosis of bipolar disorder will also experience episodes of depression.
The depression will most often occur in between the manic or hypomanic episodes, although in some cases, it can occur during the episodes (mixed features). The depression should satisfy the diagnostic criteria from APA for major depressive disorder (MDD).
There are nine potential symptoms that can occur in individuals with MDD. In order for a formal diagnosis, the person would have to demonstrate at least five of these within the same two-week period. One of the symptoms must include a significantly decreased mood (sadness) or a significant loss of interests or the inability to experience pleasure.
Symptoms of major depressive disorder include:
- Extreme periods of sadness that occur most of the day nearly every day.
- A loss of interest in things that are normally enjoyed or the inability to experience pleasure from things that used to give pleasure.
- Sleep issues, either insomnia or hypersomnia (sleeping too much).
- Cognitive issues, such as problems with memory or attention.
- Significantly decreased self-esteem.
- Extremely low levels of energy or high levels of irritability.
- A change in appetite (too little or too much).
- Feelings of being worthless or feelings of wanting to die or cause self-harm.
The manic or hypomanic episodes in bipolar disorder are typically shorter than the periods of depression, which may last for several weeks or more.
Other Related Disorders Within the Category
There are other major disorders within the category of bipolar and related disorders.
- Cyclothymic disorder: This is a chronic disorder (requires a minimum of two years in adults and one year in adolescents and children) where there are periods of hypomanic-like episodes that do not fully meet the diagnostic criteria for hypomania. These can be interspaced with possible depressive episodes that do not quite meet the diagnostic criteria for major depressive disorder. The prevalence rate of cyclothymic disorder is estimated to be between 0.3 percent and 1 percent.
- Substance-induced bipolar or related disorder: This occurs as a result of the use of drugs or alcohol. It appears like mania or hypomania, but it is due to the use of these substances. Generally, once the substance consumption stops, the disorder lifts.
- Bipolar disorder due to another medical condition: This occurs when an individual presents with mania or hypomania as a result of a medical condition like a metabolic imbalance, a head injury, or another medical issue.
There are several other vaguely described disorders that include manic-like or hypomanic-like symptoms. These are rarely diagnosed.
Bipolar disorder has many different variations in its presentation, and the disorder can be quite different from person to person. As a result, the diagnosis of bipolar disorder may include different specifiers that describe these specialized presentations of the disorder.
The most common are issues with psychosis, anxiety, and rapid cycling. Very often, individuals who have these special presentations are initially diagnosed with a different disorder (like schizophrenia or an anxiety disorder) before it is recognized that they are suffering from mania or hypomania. Once recognized, the diagnosis is adjusted accordingly.
Substance Abuse & Bipolar Disorder
Many of the different mental health disorders are known to be associated with an increased risk for substance abuse. However, if a person is diagnosed with bipolar disorder, they are at an elevated risk for substance abuse compared to many of the other types of mental health disorders listed in the DSM-5.
APA reports that well over half of people who are diagnosed with bipolar I disorder have some type of co-occurring substance use disorder. Nearly 40 percent of people diagnosed with bipolar II disorder have some type of co-occurring substance use disorder. Cyclothymic disorder is also associated with an increased risk to develop a substance use disorder.
The most common substances of abuse in people who are diagnosed with a bipolar disorder include:
- This is by far the most common of abuse.
- Prescription medications. Opioids and benzodiazepines are often drugs of abuse for people with a bipolar disorder.
- Cannabis use disorders occur in increased rates in people with bipolar disorder.
What Causes Bipolar Disorder?
Except in cases where it can be determined that manic or hypomanic behaviors are caused by a medical condition or drugs, there is no identified cause of any of the bipolar disorders.
It is generally considered that bipolar disorder has a strong genetic component to it. Other factors, such as pre-existing drug use and the experience of early trauma, may interact with genetics to trigger the disorder.
Treatment for Co-Occurring Bipolar Disorder & Addiction
APA and the American Society of Addiction Medicine (ASAM) acknowledge that when a person has co-occurring conditions, such as bipolar disorder and a substance use disorder, the symptoms of either disorder are typically more severe and more resistant to treatment. The person is more apt to relapse and more likely to be noncompliant with their treatment instructions. This makes the treatment of people with dual diagnoses (where the person has a psychological disorder like bipolar disorder and a co-occurring substance use disorder) complicated.
Typically, the person is treated via a team approach. Team members consist of specialists from different fields who work together to treat the entire client. Both the bipolar disorder and the substance use disorder must be addressed at the same time. The treatment will not work if only one disorder is treated and the other is left alone.
The front-line approach to treating bipolar disorder is to use medications, particularly mood-stabilizing drugs like lithium or medications that are commonly used to treat epilepsy. Antidepressant medications may also be used to address depression or anxiety.
In severe cases, antipsychotic medications that are normally used to treat schizophrenia can be used. The use of therapy alone is not recommended, but it can be used to assist with treatment compliance and to address issues with everyday functioning.
The protocol for addressing the substance use disorder will vary depending on the substance in question. It will typically include a medical detox program, substance use disorder therapy, support group participation like getting involved in 12-step groups, and taking other medications to address cravings for drugs or alcohol.
Unlike bipolar disorder, substance use disorders are primarily addressed through the use of behavioral interventions like therapy and group participation. Medications are secondary treatments except in the case of medical detox when they are used to control withdrawal symptoms.
Both bipolar disorders and substance use disorders are considered long-term disorders that require lifetime interventions in most cases.
People will most likely remain on their medication for bipolar disorder for the rest of their lives. They will also need to be involved in ongoing continuing care for their substance abuse.
The intensity of the care for substance abuse will lessen as people have more time in recovery. While they may begin in a structured treatment program, they will ultimately transition to weekly therapy sessions or simply attending regular 12-step meetings over time.
The ultimate goal is to structure a life that is supportive of recovery. This means building habits and structures that are healthy, such as meditation, exercise, a strong support network, and coping mechanisms for stress. This setup ensures people have a solid foundation to turn to when they are tempted to return to substance abuse.
Since going off bipolar medication can be a trigger for substance abuse, it’s important that those dealing with these co-occurring disorders maintain regular checkups with their supervising physician to ensure ongoing treatment compliance.