Recognizing the Signs of Co-Occurring Bipolar Disorder and Addiction

Bipolar disorder (BPD), with its rollercoaster of emotions, from the highest highs to the lowest lows, complicates the path to sobriety for someone battling with substance misuse issues.

Bipolar disorder and drug addiction exhibit overlapping mechanisms, such as impulsivity, challenges in modulating motivation, reactions to rewarding stimuli, and a propensity for behavioral sensitization. So, it makes sense that they frequently co-occur. Without appropriate treatment for mental health conditions, individuals may attempt to manage their fluctuating moods through the use of illicit drugs, leading to negative outcomes.

The complexity of these two conditions presents those struggling and their circle of support with challenges that demand careful attention. However, a dual diagnosis is not a rare occurrence – it’s thought that 4 out of 10 people with bipolar disorder also struggle with substance use disorder (SUD).

Research conducted by the National Institutes of Health (NIH) reveals that among all Axis I disorders, bipolar disorder has the highest probability of coinciding with alcohol or substance use.[2] Additionally, there’s growing evidence to suggest that individuals with bipolar disorder who use substances may encounter more frequent irritable and dysphoric mood states. Such people also face increased resistance to treatment and a heightened necessity for hospital admissions.

Resources:
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3486639/
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021702/

Breaking Down Bipolar Disorder

Bipolar disorder is a mental health condition characterized by extreme emotional volatility that includes emotional highs (mania or hypomania) and lows (depression). These mood swings can affect energy levels, behavior, and ability to think clearly, often leading to significant challenges. There are several types of BPD, each with distinct characteristics:

Bipolar I involves periods of severe mood episodes from mania to depression.
Bipolar II is defined by a pattern of depressive episodes and hypomanic episodes but not the full-blown manic episodes seen in Bipolar I.
Cyclothymic disorder (or cyclothymia) includes periods of hypomanic symptoms and depressive symptoms lasting for at least two years; however, the symptoms do not meet the full diagnostic criteria for hypomania or depression.
Rapid Cycling Bipolar Disorder: In rapid cycling bipolar disorder, individuals experience more frequent and rapid shifts between manic or hypomanic and depressive episodes. While these episodes typically last for weeks or months, in rapid cycling, they may occur within a few days. This extreme mood instability can significantly impair functioning. Depressive episodes during rapid cycling are often more severe, leading to self-destructive behaviors, suicidal thoughts, and suicide attempts. Rapid cycling is defined by four or more mood fluctuations within a 12-month period.
Bipolar Disorder with Mixed Episodes: In some cases, manic and depressive episodes overlap, making it challenging to differentiate between the two. Individuals with mixed bipolar.

This condition’s cyclical nature means that individuals will experience varying degrees of mood swings, impacting their overall quality of life. Each type of bipolar disorder affects individuals differently, making personalized treatment and understanding essential.

Understanding Mania and Depression

The manifestations of bipolar disorder can vary from person to person, as with any illness. However, the hallmark of bipolar disorder is emotional instability, characterized by frequent and extreme shifts between manic/hypomanic highs and depressive lows. Understanding that both depression and mania/hypomania can present in unexpected ways is crucial in recognizing these mood fluctuations.

Indications of a depressive episode may include:

Difficulty concentrating and sluggish thinking
Loss of interest in previously enjoyable activities
Withdrawal from social interactions and self-isolation
Changes in sleeping patterns – either excessive sleep or insomnia
Altered eating habits – either increased or decreased appetite
Feelings of hopelessness, helplessness, or worthlessness
Self-harming behaviors and suicidal thoughts
Irritability and emotional volatility
Neglect of personal hygiene
Persistent fatigue or low energy levels

Signs of a manic/hypomanic episode may include:

Heightened energy levels and decreased need for sleep
Excessive talking and rapid speech patterns
Racing thoughts and jumping from one topic to another (flight of ideas)
Experience of delusions, including grandiose beliefs or paranoid thoughts
Intense euphoria and elevated mood
Outbursts of rage and hostility
Engaging in risky behaviors and impulsive decision-making
Presence of psychosis, marked by strong false beliefs indicating a detachment from reality

Where Bipolar Disorder Meets Addiction

When bipolar disorder co-occurs with addiction, the challenges of each condition can amplify the other. This intersection is not coincidental but rather an interplay of genetic, psychological, and environmental factors predisposing individuals to both conditions.

The Slope of Self-Medication

The journey into self-medication begins with the intent to alleviate the distressing mood swings associated with bipolar disorder. People may turn to substances such as alcohol, illicit drugs, or even prescription medications, seeking temporary relief. However, this route can quickly evolve into a dependency, as these substances offer only fleeting solace and can intensify the reliance on them for emotional stability.

Prescription medications present a particularly nuanced challenge. While they can be effective under medical supervision, misuse or reliance on black market options to manage bipolar symptoms can be dangerous. This situation mirrors the dilemmas in pain management, where therapeutic use can inadvertently slide into misuse, highlighting a cycle of dependency that can be difficult to break.

Genetic Predisposition

Research suggests a genetic link between bipolar disorder and addiction, with individuals having a family history of either condition being at a higher risk for developing both. BPD is thought to have a heritability of 60-80% and addiction between 50-70% depending on the substance.[3] If we’re born with both genetic markers, it can increase our risk of having these co-occurring illnesses.

It’s important to remember that our understanding of genetic markers is still relatively new, and testing is not a reliable prediction that you will develop a certain condition. It’s possible to carry genetic markers and never develop any symptoms at all.

Environmental Triggers

Stressful life events, trauma, and environmental stressors can trigger BPD, subsequent episodes, and substance use disorder.[4][5] People with bipolar disorder may turn to drugs or alcohol as a form of self-medication, attempting to alleviate the distressing symptoms of their mood swings. Unfortunately, substance use can exacerbate the symptoms of bipolar disorder, creating a vicious cycle that complicates both diagnosis and treatment.

The self-medication hypothesis posits that individuals with bipolar disorder may use substances to manage their symptoms, such as using stimulants during depressive episodes or alcohol to calm manic symptoms.[6] While this may provide temporary relief, it ultimately leads to a pattern of addiction, as the person becomes reliant on substances to cope with their mood swings. This is especially problematic as it leads to tolerance and increased emotional volatility during withdrawal.

Resources:
[3] https://www.rutgers.edu/news/rutgers-researchers-delve-deep-genetics-addiction
[4] https://www.tandfonline.com/doi/full/10.1080/1533256X.2015.996501
[5] https://link.springer.com/article/10.1186/s40345-015-0042-0
[6] https://pubmed.ncbi.nlm.nih.gov/24677651/

Overlapping Signs of Addiction and Bipolar

Dual Withdrawal

Individuals may experience withdrawal symptoms from both their mood disorder (e.g., depressive episodes when not using a substance that elevates mood) and the substance itself. This relationship can make diagnosis complicated, as substance withdrawal might be overlooked as a bipolar symptom and vice versa.[7]

Concealed Usage

When struggling with bipolar disorder and addiction, individuals may hide their substance use or underplay the severity of their mood swings. This concealment stems from various factors, including stigma, denial, or fear of repercussions. Concealed substance use complicates the clinical picture, as healthcare providers may not have all the necessary information to make an accurate diagnosis. Similarly, minimizing the impact of mood swings can prevent people from receiving the help needed for bipolar disorder, further enabling the cycle of untreated mental illness.

Impact on Daily Functioning

The erratic nature of mood swings combined with the compulsive behaviors associated with substance misuse can damage personal relationships, diminish job performance, and lead to withdrawal from social activities. The result is often a cycle of isolation that exacerbates both conditions, and people may find themselves increasingly distanced from supportive networks.

Resources:
[7] https://www.frontiersin.org/journals/psychiatry/articles/10.3389/fpsyt.2021.660432/full

Understanding Impulsivity in Addiction and Bipolar

Impulsivity is a key concern within the dynamics of co-occurring bipolar disorder and addiction, as it can result in dangerous decision-making. This trait, characterized by acting on a whim without considering the consequences, plays a significant role in both conditions and can link them together.

Bipolar Disorder and Impulsivity

During manic or hypomanic episodes inherent to bipolar disorder, people often exhibit increased impulsivity.[8] This heightened state can manifest in risky behaviors, such as extravagant spending, promiscuous activities, or making sudden large-scale life decisions. In bipolar disorder, impulsivity stems from a combination of heightened energy, reduced need for sleep, and an inflated sense of confidence or grandiosity, which skews judgment and risk assessment.

Impulsivity Within Addiction

Addiction itself is closely tied to impulsivity, with substance use often being an impulsive act aimed at immediate gratification or relief from discomfort.[9] The cycle of craving and using substances reinforces impulsive behavior patterns, making it challenging to resist urges or consider the long-term implications of substance use. For those with a dual diagnosis, impulsive tendencies can be particularly pronounced, driving the cycle of addiction even in periods of mood stability.

The interplay between impulsivity, bipolar disorder, and addiction creates a complex feedback loop that not only contributes to the onset and escalation of substance use but can also exacerbate the symptoms of bipolar disorder, leading to more severe manic or hypomanic episodes. Conversely, the mood disturbances associated with bipolar disorder can increase impulsiveness, further complicating the struggle with addiction.

Resources:
[8] https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1399-5618.2010.00806.x
[9] https://nyaspubs.onlinelibrary.wiley.com/doi/abs/10.1111/nyas.12388

Treating Bipolar Disorder and Addiction

Addressing co-occurring bipolar disorder and substance use disorders (SUD) requires a comprehensive and nuanced treatment strategy that considers the intricacies of both conditions. Integrated treatment plans are essential, combining psychiatric care for bipolar disorder with specialized addiction counseling and support, tailored to each individual’s unique circumstances.

Effective treatment begins with an integrated approach that addresses both bipolar disorder and addiction simultaneously. This means providing dual diagnosis treatment that combines psychiatric care for bipolar disorder with addiction counseling and support. Treatment plans are personalized, considering the individual’s unique experiences, symptoms, and needs.

Some other forms of treatment can include:

A key component of treating co-occurring bipolar disorder and addiction is careful medication management. Psychiatrists may prescribe medication to manage the symptoms of bipolar disorder. Concurrently, addressing substance misuse may involve the use of medication-assisted treatments (MAT) to reduce cravings and withdrawal symptoms. Importantly, medication plans are closely monitored to prevent the potential for misuse or negative interactions. Some specific medication classes used might include:

Mood stabilizers such as Lithium, proven to effectively reduce the frequency and severity of manic episodes.
Anticonvulsants, which can alleviate the severity of depressive episodes.
Antipsychotics, capable of mitigating delusional thinking and erratic behaviors associated with mania.
Central nervous system (CNS) and hormonal therapies to address physical symptoms by regulating CNS activity and correcting hormonal imbalances.

Psychotherapy

Psychotherapy is another cornerstone of treatment, with cognitive-behavioral therapy (CBT) being particularly effective. CBT helps individuals identify and change maladaptive thought patterns and behaviors related to both bipolar disorder and substance use. Other therapeutic approaches, like dialectical behavior therapy (DBT) and family therapy, can also play significant roles in treatment, offering strategies for emotion regulation, improving interpersonal relationships, and enhancing communication skills. Other effective therapies include:

Motivational interviewing (MI): This fosters goal-setting and bolsters motivation for recovery.
Solution-focused therapy (SFT): This empowers patients to actively engage in their healing journey, utilizing patient-directed problem-solving and goal-setting.
Trauma therapies: Given the potential exacerbation of addiction and bipolar disorder by unresolved trauma, evidence-based approaches like eye movement desensitization and reprocessing (EMDR) can be highly effective.

Supportive Therapies

The inclusion of supportive therapies—such as group therapy, peer support groups, and 12-step programs—provides a community of understanding and encouragement. These settings allow individuals to share their experiences, learn from others facing similar challenges, and build a network of support that extends beyond the treatment environment.

Addressing Prescription Medication and Self-Medication

A specific focus on the misuse of prescription medication and tendencies towards self-medication is key. Treatment plans emphasize the importance of using prescription drugs as directed and exploring healthier coping mechanisms for managing mood swings. Education about the dangers of self-medication and the pathway to illicit drug use or dependency on black market medications is a critical component of recovery education.

By addressing bipolar disorder and addiction with a holistic and integrated treatment approach, individuals can embark on a path to recovery that encompasses their entire well-being. This comprehensive strategy ensures that both the mental health condition and the substance use disorder are treated in tandem, offering the best chance for long-term recovery and a return to a fulfilling life.

Empowerment Through Recovery: Pathways to Wellness

Recovery from co-occurring bipolar disorder and addiction is not just about managing symptoms; it’s about empowering people to build a pathway to wellness that meets their unique needs. Some strategies that could be incorporated into a program of recovery for both conditions could include:

Self-Awareness: Understanding one’s mood fluctuations and substance use patterns is important. Self-awareness helps us recognize early signs of relapse, making it possible to take proactive steps to stay sober.
Lifestyle Modifications: Healthy lifestyle choices, such as regular exercise, a balanced diet, and adequate sleep, can significantly impact mental health and aid recovery. Good lifestyle habits provide a stable foundation for individuals to address their dual diagnosis more effectively.
Goal Setting: Setting realistic, achievable goals helps us feel a sense of accomplishment when we complete them. Regardless of the topic, goals can provide direction and motivation during the recovery process.
Embracing Community Support: 12-step recovery groups, family, and friends provide a supportive community that offers a network of understanding and encouragement. Additionally, shared experiences can reduce feelings of isolation and provide valuable insights and coping strategies.

Recovery is a continuous journey that benefits from ongoing support and professional guidance. Regular check-ins with mental health professionals and participation in support groups can offer stability as individuals grow and change.

Get Help for Bipolar and Addiction Today

Recognizing the signs and symptoms of BPD and SUD is the first step toward a life defined not by struggle but by stability and wellness. At Crossroads Antigua, we understand the complexities of dual diagnosis and are here to offer the compassionate support and specialized care needed to navigate this path.

We warmly invite anyone struggling with a dual diagnosis of bipolar disorder and addiction to reach out. Our dedicated team is committed to providing a holistic approach and tailored recovery support, ensuring that each person’s journey is met with empathy and understanding.