Bipolar Disorder & Addiction

Bipolar disorder is a serious mood disorder that’s characterized by alternating episodes of extremely high and very low moods. According to the Depression and Bipolar Support Alliance, bipolar disorder affects around 5.7 million adult Americans each year, and it’s the sixth leading cause of disability in the world.1

Bipolar disorder is the sixth leading cause of disability in the world.

Bipolar disorder commonly co-occurs with substance use disorders. Results of the U.S. National Comorbidity Survey found that 71 percent of people with bipolar disorder reported at least one lifetime substance use disorder.2 Alcohol dependence was reported by 61 percent of respondents, and 40.7 percent reported drug dependence.

How Substance Abuse Affects Bipolar Disorder

According to an article published in the journal Science & Practice Perspectives, people with bipolar disorder who abuse alcohol had an earlier onset of symptoms, more frequent hospitalizations and more mental illnesses.3

Those who suffer from bipolar disorder and a co-occurring substance use disorder are also the highest risk group for suicide. This is largely due to the combination of risk-taking behaviors and major depressive episodes that characterize bipolar disorder and the loss of inhibition and a deepening of despair that often characterize intoxication.

If you or someone you love suffers from co-occurring bipolar disorder and a substance use disorder, then the sooner treatment begins, the better the outcome is likely to be. Each disorder worsens the other, and left unchecked, co-occurring disorders can lead to devastating disability.

That said, even severe cases of co-occurring bipolar disorder and addiction can be successfully treated, as long as an individual remains committed to treatment and fully engaged in the treatment plan.

Even severe cases of co-occurring bipolar disorder and addiction can be successfully treated as long as an individual remains committed to treatment and fully engaged in the treatment plan.

Signs and Symptoms of Bipolar Disorder

Bipolar disorder is characterized by four types of mood episodes. These are mania, hypomania, depression and mixed episodes. Each type of episode can last for weeks or months, especially when left untreated, and each has its own set of signs and symptoms. Signs of bipolar episodes are those that others may notice, while symptoms are those that an individual with bipolar will feel.

Mania

Signs and symptoms of a manic episode include:

  • Feelings of grandiosity and self-importance
  • Talking rapidly
  • Alternating moments of incredible elation and intense pessimism
  • A reduction in hours of sleep per night
  • Engaging in risk-taking behaviors
  • Impaired judgment
  • Irrational thoughts and behaviors
  • Hallucinations

Hypomania

Psychotic symptoms are absent during periods of hypomania, which has symptoms that are similar to but far less intense than those of the manic phase. During hypomania, a person will likely:

  • Be capable of managing day-to-day activities
  • Feel happier, more energetic or more irritable than usual
  • Need less sleep
  • Feel capable of taking on more responsibility at work or school
  • Be more likely than usual to engage in high-risk behaviors, including substance abuse
  • Feel like the bipolar disorder is under control

Depression

The depressive phase of bipolar disorder is marked by severe lows and includes signs and symptoms such as:

  • Feelings of hopelessness, helplessness and sadness
  • A loss of interest in activities you once enjoyed
  • Fatigue and sleepiness
  • Appetite changes or changes in weight
  • Feelings of guilt and self-hatred
  • Thoughts of death or suicide

Mixed Episodes

Bipolar symptoms aren’t always cut and dry. A mixed episode is a combination of symptoms for mania and depression.

Five types of bipolar disorder are commonly diagnosed:

  • Bipolar I Disorder is the most severe form of the disorder and is characterized by one or more mixed or manic episodes and one or more major depressive episodes.
  • Bipolar II Disorder is characterized by lower highs than bipolar I disorder. Bipolar II is diagnosed after one or more major depressive episodes and at least one hypomania episode.
  • Bipolar Not Otherwise Specified doesn’t follow a pattern. For example, you may have very rapid swings between manic and depressive episodes, or you may experience recurring hypomanic episodes without any depressive episodes.
  • Cyclothymia is a mild form of bipolar disorder that’s characterized by alternating hypomanic episodes and milder episodes of depression. These alternating episodes must last for at least two years to be diagnosed as cyclothymia.
  • Bipolar with Rapid Cycling is characterized by having four or more depressive, manic or hypomanic episodes in a 12-month period. Rapid cycling can occur with any of the types of bipolar.

Substance Use Disorders: Addiction and Dependence

Addiction is characterized by continuing to use a psychoactive substance even though it’s causing problems in your life. Addiction affects the structures and functions of the brain and is widely considered to be a diagnosable, treatable and preventable brain disease. If you’re addicted to drugs or alcohol, a number of psychological and physiological mechanisms are likely at work, including learned, reinforced behaviors and changes in the way the chemicals in your brain function.

Signs and symptoms of addiction include:4

  • Using drugs or alcohol despite negative consequences to your health, relationships, finances or legal status
  • A loss of control over the frequency of using drugs or alcohol, the duration of use and the amount consumed
  • A loss of interest in hobbies and activities you once enjoyed
  • Increasingly neglecting your responsibilities at home, work or school
  • Taking serious risks as a result of drug-seeking or drug-taking behaviors
  • Hiding the extent of your drug use from family and friends
  • Problems in your relationships with family, friends or coworkers
  • Neglecting personal hygiene

Dependence is characterized by changes in brain function that reach a tipping point at which the brain now needs a psychoactive substance in order to function “properly.” When the substance is withheld from the body, withdrawal symptoms set in as your brain’s way of telling you it can’t operate normally without the substance of abuse present. Withdrawal symptoms are the main indication that physical dependence has occurred.

Why Bipolar Disorder Commonly Co-Occurs with a Substance Use Disorder

A number of theories attempt to explain the high prevalence of bipolar disorder co-occurring with a substance use disorder.3

Self-Medication

One theory proposes that having a mood disorder increases the risk of developing a substance use disorder, and vice versa. The effects of a mood disorder often lead to self-medication with drugs or alcohol. Substance use may seem to reduce symptoms initially, but almost always worsens a mental disorder.

Someone with bipolar disorder may try to suppress feelings of rage or anger with an opiate like oxycodone; someone else may try to lift a depressed mood with cocaine or another stimulant. In many cases, chronic substance abuse causes mild symptoms of mental illness to worsen to a clinically significant level, due to changes in already-abnormal neurotransmitter activity. As such, it can be difficult to determine which occurred first: the substance abuse or the bipolar disorder.

It can be difficult to determine which occurred first: the substance abuse or the bipolar disorder.

Kindling

Kindling occurs when repeated disruptions sensitize brain cells and lead to symptoms that become more frequent and severe over time. Some substances, like alcohol and cocaine, sensitize neurons, and this makes them more easily disrupted. This may help explain the progression of a substance use disorder from chronic abuse to addiction, and it may explain why mood disorders often progress as well, with symptoms worsening over time and increasingly shorter periods of remission occurring between episodes.

Genetics

Both substance use disorders and mood disorders have genetic risk factors, and some genetic influences may increase the risk of developing both bipolar disorder and an addiction. This may occur in three ways:

  • The genetic variable makes an individual vulnerable to a mood disorder, which that person may then self-medicate, leading to addiction.
  • The genetic variable causes the brain to respond to drug exposure in a way that leads to chronic abuse, which then causes changes that lead to or uncover the mood disorder.
  • The genetic variable causes the brain to develop in a way that makes it vulnerable to both addiction and bipolar through mechanisms like sensitized neurons and kindling.

Diagnosing Co-Occurring Bipolar and Addiction: Integrated Screening and Assessment

The Substance Abuse and Mental Health Services Administration has developed a best-practices protocol for the integrated screening and assessment of co-occurring disorders.5 Individuals who seek treatment for a mental health issue will be screened for a substance use disorder as a matter of course, and those who seek treatment for a substance use disorder will be screened for mental illness. The screening process serves to answer the question of whether a co-occurring disorder may be present.

If the screening is positive, a detailed and thorough assessment will take place, and if the presence of a co-occurring disorder is established, this assessment will serve as the basis for an individualized treatment plan.

According to the Substance Abuse and Mental Health Services Administration’s 10 Guiding Principles of Recovery, there is no single way to treat addiction, because nobody responds to the same treatments in the same way. Every individual has a unique combination of issues, needs and preferences when it comes to treatment, and these must be addressed through a unique, personalized treatment plan.6

Every individual has a unique combination of issues, needs and preferences when it comes to treatment, and these must be addressed through a unique, personalized treatment plan.

Why Integrated Treatment is Essential for Co-Occurring Disorders

If you suffer from co-occurring bipolar and substance use disorders, choosing a dual diagnosis treatment program is crucial for improving your chances of long-term recovery from each disorder.

Treating only the bipolar disorder won’t address the issues underlying the substance use disorder, which will typically continue to worsen the bipolar symptoms. Conversely, treating only the substance use disorder won’t help curb the self-medicating and risk-taking behaviors that are associated with bipolar disorder, which will likely contribute to relapse very quickly.

Integrated treatment for co-occurring disorders is a meaningful collaboration among the treatment teams for both disorders, each of which is treated in the context of the other. An enormous body of research shows that specialized, dual diagnosis treatment for co-occurring disorders has a far better outcome than stand-alone treatments for a substance use disorder and other mental illness.

Integrated treatment for co-occurring disorders is a meaningful collaboration among the treatment teams for both disorders.

It is important to find an evidence-based integrated treatment program if you have a co-occurring disorder.7 This type of treatment involves treatment specialists who are trained to treat both substance use disorders and serious mental illnesses. These specialists:

  • Strive to meet all of the various unique needs of people with co-occurring disorders
  • Use treatment interventions that are appropriate for an individual’s particular stage of recovery
  • Administer treatment therapies in group, individual and family settings
  • Involve the individual in the development of a treatment plan
  • Integrate medication services with other treatment protocol

Using a combination of behavioral therapies and medication is the most effective way to treat a co-occurring disorder. A holistic approach to treatment is essential and should include both traditional and complementary treatment therapies that address issues of the body, mind and spirit.

Medications Used for Treating Bipolar Disorder

Bipolar disorder can be successfully managed with a variety of medications, depending on the symptoms.8

  • Mood stabilizers help control manic and hypomanic episodes and include drugs like lithium and lamotrigine.
  • Antipsychotics like risperidone and aripiprazole help control symptoms that other medications have been unable to affect.
  • Antidepressants effectively treat depression, but since these medications can trigger a manic episode, they’re usually taken with a mood stabilizer or antipsychotic. Common antidepressants include fluoxetine and citalopram.
  • Combination medications are those which contain both an antidepressant and a mood stabilizer.
  • Anti-anxiety medications in the benzodiazepine family may be prescribed for short-term use to reduce anxiety and improve sleep.

Treatment Therapies for Co-Occurring Bipolar Disorder and Addiction

Psychotherapy, or talk therapy, helps individuals learn to change their way of thinking and behaving. Research shows that psychotherapy is highly effective for treating both bipolar disorder and substance use disorders.

Group Therapy

Peer groups are valuable sources for developing coping skills and strategies. Sharing similar experiences provides a strong sense of belonging to people who may otherwise feel disenfranchised. Group members hold each other accountable and help one another evaluate their thoughts and behaviors. The opportunity to help others itself can also help bring about meaningful change.

Family Therapy

Family therapy is essential for restoring function to the household and improving communication among family members. Both bipolar and addiction take a major toll on the functioning of the family system, and fostering a healthy home environment goes a long way toward preventing relapse.

Family therapy is essential for restoring function to the household and improving communication among family members.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy helps you learn to identify and evaluate self-destructive thoughts, beliefs and attitudes and replace them with healthier ways of thinking and behaving. It also helps you cope with symptoms and recognize the signs that point to a mood shift. Research shows that cognitive-behavioral therapy is highly effective for treating those with bipolar disorder.9

Dialectical Behavior Therapy

A 2013 study found dialectical behavior therapy to be a promising treatment for bipolar disorder, according to an article published in Psychiatric Times.10 Originally developed to treat people with suicidal thoughts and actions, dialectical behavior therapy involves teaching participants four sets of essential behavior skills:

Mindfulness – the practice of being aware and present in the moment

Distress tolerance – how to tolerate, rather than eliminate, painful situations

Interpersonal effectiveness – how to say no to people and ask for what you want in a way that promotes healthy relationships and a high level of self-respect

Emotional regulation – how to control your emotions and change those you want to change

Interpersonal Therapy

Bipolar disorder and addiction both have a strong influence on your interactions with others. Interpersonal therapy addresses your various relationships and explores how your interactions with others affect your disorders and vice versa.

Social Rhythm Therapy

Keeping a routine and getting adequate sleep are both crucial for recovering from co-occurring disorders. The body’s circadian rhythms are deeply affected by bipolar disorder. Resetting and stabilizing your biological clock for better sleep, daily functioning and overall mental health can make a big difference in your recovery.

Challenges in Recovery from Bipolar Disorder and Addiction

Recovery from a substance use disorder can be particularly challenging if you have bipolar disorder. The nature of manic and depressive episodes, such as the prevalence of risk-taking behaviors during a manic episode and the feelings of hopelessness that characterize a depressive episode, can lead to disengagement with your treatment plan. This can quickly lead to a relapse.

Although research shows that people with bipolar disorder recover more slowly when alcohol abuse or addiction co-occurs, with the right dual diagnosis program and a high level of engagement in treatment, many people can and do recover from bipolar disorder and addiction.

With the right dual diagnosis program and a high level of engagement in treatment, many people can and do recover from bipolar disorder and addiction.

Choosing a Recovery Program

If you have bipolar and a substance use disorder and you’re ready to get the help you need to recover from both disorders, choosing a residential dual diagnosis treatment program is essential for the best possible outcome. Residential treatment programs enable you to focus solely on recovery, and they offer an enormous amount of support during treatment. Components in choosing a treatment program include:

  • State accreditation. Make sure the facility is accredited by the state it’s in.
  • Licensing. Ensure the mental health professionals and addiction specialists are fully licensed and well trained.
  • Research-based treatment protocol. Find out whether the program uses a research-based, best-practices treatment protocol and adheres to the National Institute on Drug Abuse’s Principles of Effective Treatment.11
  • Statistics. Ask about the program’s outcome statistics. Treatment programs should have readily available statistics concerning their success rates, and they should be forthcoming with that information.
  • Personal preferences. Make sure the program and the facility are a good match for your personal preferences. For example, if you’re vegetarian, are meatless options available for meals?
  • Are the residential facilities clean and comfortable? Does the facility feel like a hospital or a home?
  • A holistic approach. High-quality treatment programs will offer a number of holistic, research-based complementary therapies like yoga, art therapy, acupuncture or nature therapy.
  • Insurance. Does the facility accept your insurance? Keep in mind that under the Mental Health Parity and Addiction Equity Act of 2008, insurance companies must offer the same level of benefits for mental health and addiction recovery services that they do for standard medical treatments.12

Recovering from a co-occurring disorder isn’t easy, but the hard work pays off in a dramatically higher quality of life and sense of self-efficacy and well-being. Hope is the foundation of recovery, which is a process of change that occurs from the inside out and leads to better health and wellness and a self-directed life.13 As long as you have hope for a better future in which you’re able to strive to reach your full potential, there’s always a high potential for long-term recovery.

Sources:

  1. Bipolar Disorder Statistics. (n.d.). Retrieved from http://www.dbsalliance.org/site/PageServer?pagename=education_statistics_bipolar_disorder
  2. Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005, June). Prevalence, Severity, and Comorbidity of Twelve-Month DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 617-627. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2847357/
  3. Quello, S. B., Brady, K. T., & Sonne, S. C. (2005, December). Mood Disorders and Substance Use Disorder: A Complex Comorbidity. Science & Practice Perspectives, (3)1, 13-21. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851027/
  4. About Addiction: Signs and Symptoms. (2015, July 25). Retrieved from https://ncadd.org/about-addiction/signs-and-symptoms/signs-and-symptoms
  5. Substance Abuse Treatment for Persons with Co-Occurring Disorders. (2005). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK64196/
  6. SAMHSA’s Working Definition of Recovery: 10 Guiding Principles of Recovery. (2012). Retrieved from https://store.samhsa.gov/shin/content/PEP12-RECDEF/PEP12-RECDEF.pdf
  7. Integrated Treatment for Co-Occurring Disorders. (2009). Retrieved from http://store.samhsa.gov/shin/content//SMA08-4367/Brochure-ITC.pdf
  8. Bipolar Disorder: Treatment & Drugs. (2015, February 10). Retrieved from http://www.mayoclinic.org/diseases-conditions/bipolar-disorder/basics/treatment/con-20027544
  9. Psychotherapies. (n.d.). Retrieved from http://www.nimh.nih.gov/health/topics/psychotherapies/index.shtml
  10. Duerr, H. A. (March, 2013). DBT Holds Promise for Patients With Bipolar Disorder. Retrieved from http://www.psychiatrictimes.com/bipolar-disorder/dbt-holds-promise-patients-bipolar-disorder
  11. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). (2012, December). Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/principles-effective-treatment
  12. Implementation of the Mental Health Parity and Addiction Equity Act. (2016, March 18). Retrieved from http://www.samhsa.gov/health-financing/implementation-mental-health-parity-addiction-equity-act
  13. Recovery and Recovery Support. (2015, October 5) Retrieved from http://www.samhsa.gov/recovery