On the last track, we discussed techniques to predict manic and
depressive states and to aid clients through the cycles of Listing Symptoms
to Category; Preventative Maintenance Plan; and Three-Part Breathing
On this track, we will examine conditions that may co-occur with bipolar
disorder: autoimmune disorders, borderline personality disorder, and cyclothymic disorder. We will also present ways to diagnose these comorbid conditions along with ways to treat clients with comorbid conditions.
3 Comorbid Conditions
1. Autoimmune Disorders
The first type of conditions that can co-occur with or may be mistaken for
bipolar disorder is autoimmune disorders. Many of these
include AIDS and lupus, affect the nervous system and produce severe and
rapid behavioral changes. Those clients that have been infected with
HIV virus exhibit moodiness, irritability, memory loss, and confusion.
As you know, those clients suffering from the early stages of lupus may display
ranging from mild anxiety to severe psychosis.
Generally, an inquiry
the client’s medical history will reveal a potential for any co-morbid
autoimmune disorders. If a client is experiencing symptoms
ranging outside of a bipolar diagnosis and the cause is suspected to be an autoimmune
disorder, I schedule an interview session with the client.
4 Questions for Autoimmune Disorders
Some of the questions I ask the client include the following:
1. Have you ever experienced swelling or pain of the joints?
2. Has this swelling or pain ever caused you to walk with a cane or other assistance?
3. Have you ever noticed a red or purplish rash on your face or lesions on
any part of your body?
4. Have you ever experienced a mild to severe seizure?
Kelly was 42 years old and a bipolar client of mine. Kelly reported to
that during an outing with her friends, she noticed that her ankle swelled up without explanation. Later, her knee on the other leg also swelled,
again without any noticeable injury. The swelling caused Kelly to walk
around with the assistance of a cane. Kelly stated that these attacks
happened before in the past. I referred her to a rheumatologist who diagnosed her with lupus. Although Kelly did indeed have bipolar disorder,
the mood swings that occur in early lupus were masked by her manic-depressive cycles and therefore, the lupus remained undiagnosed.
2. Borderline Personality Disorder
A second type of condition that can be comorbid with bipolar disorder is
borderline personality disorder. Diagnosing this disorder when a client
might also be suffering from bipolar disorder is extremely difficult because
the two conditions share much in common, particularly the rapid cycling periods. However, a client suffering from borderline personality disorder
has shorter periods of depressive states and do not experience the manic
state of a strictly bipolar client.
To effectively discern BPD from
bipolar, I find it is helpful to look at a client’s relationships. Often,
client with BPD will idealize the person they become close to and then
quickly devalue them. A BPD client will also go to great lengths to avoid
being "abandoned" by their partner. Also, BPD clients’ mood
swings are impulsive and unpredictable, whereas bipolar cycles are somewhat easier to
predict with the right symptom chart.
Laura, age 27, called her boyfriend
up to 10 times a day. When she
did, she often raged at him for "not being there for her" and,
if she couldn’t
reach him, accused him of being with another woman. When alone, she would
feel like disappearing and feel intolerable cravings to eat, smoke, drink alcohol, or cut herself with glass. These problems had continued for several years, despite the fact that she was in psychotherapy and had tried
various forms of antidepressant medication.
I suspected that Laura was
suffering from BPD along with bipolar disorder and put this questionnaire
1. Do you have difficulty defining for yourself who you are or who you want
2. Do you have a history of very intense and unstable relationships?
3. Do you have a history of making great efforts to keep people from
abandoning or leaving you?
4. Do you have difficulty controlling angry outbursts?
5. Do you have a history of impulsive or reckless behavior in sex, spending
money, or eating?
6. Do you have a history of self-destructive acts?
Because Laura responded yes to all of these questions, I diagnosed her with
BPD comorbid with bipolar disorder. Because BPD clients are treatment
refractory, I recommend cognitive-behavioral psychotherapy. You may learn
more about treating clients with BPD in the Healthcare Training Institute’s
course "Diagnosis and Treatment: Borderline Personality Impulse
with Schema Therapy".
3. Cyclothymic Disorder
In addition to autoimmune disorders and borderline personality disorder, as you
may know a
third condition that may be comorbid with bipolar disorder is cyclothymic disorder. Cyclothymic disorder is characterized by short periods of feeling active, irritable and excited; short periods of feeling mildly depressed;
and a tendency to alternate back and forth between the two.
cyclothymic disorder may be a precursor to bipolar disorder and even shares
many characteristics with bipolar II disorder. As a result of this, many
psychiatrists, including myself, treat cyclothymic disorder with the same
medications as bipolar II. However, cyclothymic disorder clients can often function without the medication as their symptoms are shorter and less
Stephen was a 30-year-old client of mine who, since
adolescence, had experienced a pattern of alternating between three day
periods in which he cried considerably and lost interest in things. This
was followed by another three day period in which he would feel irritable, energetic,
and talkative. Stephen
had never been hospitalized for either his depressive or hypomanic symptoms, nor
had he been suicidal, unable to concentrate, or lost significant amounts of
weight. His girlfriend sometimes complained about his moodiness and
ragefulness. Although it was more difficult to work when he was depressed,
Stephen had never lost a job because of it. As a result of this behavior,
diagnosed Stephen with cyclothymic disorder.
On this track, we discussed conditions that may co-occur with bipolar
disorder: autoimmune disorders, borderline personality disorder, and
cyclothymic disorder. We also presented ways to diagnose these comorbid
conditions along with ways to treat clients with comorbid conditions.
On the next track, we will examine the traits of the sleep-wake cycle and
how it affects bipolar clients: social Zeistorers; social Zeitgebers; and
regulated sleep pattern.
Peer-Reviewed Journal Article References:
Iverson, G. L. (1995). The need for psychological services for persons with systemic lupus erythematosus. Rehabilitation Psychology, 40(1), 39–49.
Lee, J. Y., & Harvey, A. G. (2015). Memory for therapy in bipolar disorder and comorbid insomnia. Journal of Consulting and Clinical Psychology, 83(1), 92–102.
Menninger, K. A. (1919). Cyclothymic Fugues: Fugues associated with manic-depressive psychosis: A case report. The Journal of Abnormal Psychology, 14(1-2), 54–63.
Sauer-Zavala, S., Cassiello-Robbins, C., Woods, B. K., Curreri, A., Wilner Tirpak, J., & Rassaby, M. (2020). Countering emotional behaviors in the treatment of borderline personality disorder. Personality Disorders: Theory, Research, and Treatment. Advance online publication.
Smith, L. A. (1995). "Acute psychiatric illness: Effects on HIV-risk behavior": Comment. Psychosocial Rehabilitation Journal, 18(3), 5–6.
Online Continuing Education
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