BIPOLAR DISORDER AND ADDICTION
Introduction
Bipolar disorder and addiction often occur together, making addressing either condition a challenge. The presence of one can exacerbate the other, leading to a volatile combination. When a person has both bipolar disorder and addiction, the risk for adverse effects of either increases. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), addictions are more common in people who have a mental illness, like bipolar disorder. In SAMHSA's 2018 National Survey on Drug Use and Health, about 9.2 million U.S. adults have a mental illness along with an addiction, which is called a "co-occurring disorder" or a "dual-diagnosis." 1, 2 Although having bipolar disorder and an addiction presents more challenges than experiencing just one, recovery is possible with support and treatment.
What is Bipolar Disorder?
The former clinical term for bipolar disorder is \"manic-depressive illness\" or manic-depression.3 The condition is characterized by unusual -- sometimes drastic -- fluctuations in moods, energy, and attention levels. According to the National Institutes of Health (NIH), about 2.8% of U.S. adults experienced bipolar disorder in the past year. There are more than three types of bipolar disorder, and in their lifetime, 4.4% of adults will have had some kind of bipolar disorder.4
Bipolar 1 Disorder
Bipolar 1 disorder is defined by periods of manic thoughts and behaviors which last around seven days. These manic episodes can become so disruptive and dangerous that immediate interventions may be needed to subdue the mania. Also, depressive symptoms can occur alongside manic symptoms, making treatment and diagnosis challenging.
Bipolar 2 Disorder
When comparing bipolar 1 versus 2, the manic and depressive episodes in Bipolar 2 disorder are less evident than bipolar 1. Periods of hypomania occur, in which a heightened sense of energy, without the impairment of mania, exists. People diagnosed with bipolar 2 typically have at least one manic episode in their life, but most of their struggles occur with depressive episodes.
Cyclothymic Disorder (Cyclothymia)
In cyclothymic disorder, also called cyclothymia, hypomania and depressive symptoms last for at least two years. Although the symptoms span a longer length of time than bipolar 1, they aren't the full-blown manic or depressive episodes found in the other two types of bipolar disorder.
Rapid Cycling Bipolar Disorder and Other Types
Not all types of bipolar disorder fit into the above three categories. For example, people who have rapid cycling bipolar disorder transition between manic episodes, hypomania, and depressive episodes unusually quickly, typically four or more episodes within 12 months. These significant swings in episodes can alternate within days.
Signs of Bipolar Disorder
It's difficult for people who have bipolar disorder to recognize that their emotions are unusually intense or that their behaviors are harmful. Individuals going through mania often see the world unrealistically and make irrational decisions.
They may act in ways that aren't typical for someone who doesn't have an emotional disorder. Actions or emotions don't always need to be extreme to show the presence of bipolar disorder, like hypomania.
Frequently, the symptoms can be more muted, as in bipolar II disorder. However, in others, mania or depression can become so severe that they may require hospitalization to remain safe. Just like bipolar 1 versus 2, the symptoms occur in varying degrees.
The following are common signs of bipolar disorder.
Signs of Manic Episodes
- Racing thoughts
- Pressured rapid speech
- Reduced need to sleep
- Feeling grandiose or exceptionally talented or important
- Feeling that they can do many activities at once
- Loss of appetite
- Making poor decisions like spending too much money or having unsafe sex
- Feeling irritable and agitated
Signs of Depressive Episodes
- Feeling hopeless, sad, and empty
- Changes in sleep behavior, like sleeping too much or trouble falling asleep
- Trouble concentrating or focusing
- Talking slowly
- Feeling unable to perform simple activities of daily living (showering, laundry, etc.)
- Reduced interest in activities previously enjoyed
- Inability to experience pleasure or joy
- Desire to commit suicide
Diagnosis
Correct diagnosis of bipolar disorder and addiction involves meeting with a doctor or other licensed healthcare provider. A complete physical assessment can rule out other medical conditions that can mimic bipolar disorder and addiction symptoms. A thorough health history and mental health assessment is what enables a doctor to diagnose bipolar disorder.
How are Bipolar Disorder and Addiction Connected?
According to the National Alliance on Mental Illness (NAMI), over 40 percent of adults with bipolar disorder in the U.S. have an alcohol dependency.5 More than half of people with bipolar disorder have a history of drug abuse. There may be significant hurdles to overcome for people with bipolar disorder and addiction to achieve recovery and maintain sobriety. For example, hypomania can feel euphoric, and there may be a desire to preserve the feeling through drug use.
The high-risk behaviors associated with bipolar disorder can lead people to misuse drugs, increasing the likelihood of addiction.6 Some people mistakenly use substances as a way of self-medicating or helping adjust their mood. Like alcoholism and other use disorders, bipolar disorder can also have a genetic component, especially when it comes to first degree relatives.7 The manic episodes and disordered thinking associated with bipolar disorder can lower inhibitions and produce a false sense of security, leading to a higher risk of relapse.
Bipolar Disorder Co-Occurring with Common Addictions
Symptoms of bipolar disorder can be affected by drugs or alcohol. A brain with bipolar disorder is more sensitive to the changes that drugs and alcohol create. While addiction can negatively impact life, it can quite literally change the mental and emotional state of people with bipolar disorder. The combination of bipolar disorder and addiction can present a unique set of challenges.
Alcohol
Alcohol acts as a depressant on the central nervous system (CNS), often causing lethargy and slowing response times in people who use it.8 In people with bipolar disorder and addiction, it can make both manic and depressive symptoms worse. Alcohol can be hazardous for people who have the rapid cycling type of bipolar disorder because it can swiftly exaggerate their symptoms.
During hypomania, the increased social interactions can expose someone to alcohol. Because alcohol is widely available, people with bipolar disorder may use alcohol to self-medicate, hoping to stabilize their moods. Unfortunately, this usually starts an addiction or a worsening of symptoms instead.
Cocaine and Amphetamines
Stimulants like cocaine and amphetamines can amplify mania, making it more likely that someone with bipolar disorder may harm themselves or place themselves in a dangerous situation. The stimulants can affect the neurotransmitter dopamine within the brain. The brain depends on dopamine to function, and irregular amounts of dopamine can lead to problems with the brain's reward system, making addiction more likely. Cocaine can also amplify mania and cloud judgment, leading to dangerous and reckless behavior.
Opioids
Research into opioids indicates that people with bipolar disorder have high pain rates and are more likely to receive prescriptions for opioids. More prescription opioid use can contribute to opioid addiction. Long-term opioid use may also impact both the manic and depressive episodes of someone who is bipolar.
Sedatives
During the manic stage, sedatives like benzodiazepines may be prescribed to help people with bipolar disorder regain control of their emotions.9 Despite their benefits, however, sedatives can have negative consequences due to their potential for misuse and dependence. Long-term sedative use can also interfere with sleep, intensify depressive symptoms, and impact motor response.
Treating a Dual Diagnosis of Bipolar Disorder and Addiction
Cognitive Behavioral Therapy
According to the American Psychological Association APA) the core principles of Cognitive Behavioral Therapy (CBT) are that:10
- Psychological problems occur, part, because of faulty or harmful ways of thinking.
- Learned patterns of unhelpful behavior can, in part, contribute to psychological problems.
- People who have mental health problems can improve their ways of thinking, leading to the relief of symptoms and improving their quality of life.
Because CBT involves efforts to change thought and behavior patterns, it's also effective at addressing the thinking patterns that lead to addiction. CBT identifies distorted thinking and leads people to a better understanding of themselves and others.
Interpersonal and Social Rhythm Therapy
Studies into Interpersonal Rhythm Therapy (IPSRT) indicate its effectiveness in managing bipolar symptoms.11, 12 Its focus is on stabilizing daily rhythms, like the sleep-wake cycle and regular meals. The "interpersonal" part of IPSRT is the connection between how a person's mood affects their life and how they relate to the world around them. By developing an awareness of how routines, structure, and moods affect a person's environment, individuals with bipolar disorder can adjust their lives to manage their symptoms.
Bipolar Medications
Establishing the correct balance of medications may take some trial and error. Doctors work with clients to find the right mix of bipolar medications to help both bipolar disorder and addiction. Common medications to treat bipolar disorder are mood stabilizers, antipsychotics, antidepressants, anti-anxiety medications, and antipsychotics.
Resources
- https://store.samhsa.gov/product/key-substance-use-and-mental-health-indicators-in-the-united-states-results-from-the-2018-national-survey-on-Drug-Use-and-Health/PEP19-5068
- https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/co-occurring-disorders
- https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
- https://www.nimh.nih.gov/health/statistics/bipolar-disorder.shtml
- https://www.nami.org/Blogs/NAMI-Blog/March-2018/Understanding-the-Spectrum-of-Bipolar-Disorder
- https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/expert-answers/bipolar-disorder/faq-20057890
- https://medlineplus.gov/images/PX0002I7_PRESENTATION.jpeg
- https://www.nichd.nih.gov/health/topics/neuro/conditioninfo/parts
- https://www.pulsus.com/scholarly-articles/the-use-of-benzodiazepines-in-bipolar-disorders.pdf
- https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral
- https://link.springer.com/article/10.1007/s11482-019-09740-1
- https://annals-general-psychiatry.biomedcentral.com/articles/10.1186/s12991-020-00266-7
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