Dual Diagnosis with AUD and Bipolar Disorder

Are you worried that you or someone you love may be suffering from alcohol use disorder (AUD). Not everyone who drinks is, or will become, an addict. In fact, alcohol consumed responsibly and in moderation is not cause for alarm at all. It’s when drinking becomes a compulsive behavior that negatively impacts the individual and those in his or her life that action may be required.

Those with AUD constantly crave alcohol and consume it in quantities that regularly exceed acceptable daily ranges. Their lack of ability to control intake frequently leads to both physical and mental health complications, including certain cancers, heart disease, and depression, to name just a few. Additionally, many AUD patients experience difficulty interacting socially with others as the act of drinking becomes more and more a priority. Consistent and continued consumption also leads to addiction, which can cause a number of emotional, mental, and physical withdrawal symptoms to develop when alcohol isn’t available.

It’s important to realize that AUD is not a choice; it’s a chronic, relapsing brain disease that can be extremely dangerous and debilitating. Anyone can develop this condition, regardless of age, gender, ethnicity, body type, and religious beliefs.

While AUD is problematic enough on its own, it’s fairly common for patients to suffer from mood disorders as well. A very common dual diagnosis is AUD and bipolar disorder. In fact, the National Institute of Mental Health’s Epidemiologic Catchment Area (ECA) found that over 46 percent of individuals with bipolar I had AUD in 1990. The same study revealed that over 39 percent of people diagnosed with bipolar II also had AUD.

What is Dual Diagnosis?

Dual diagnosis occurs when an individual is diagnosed with a mental disorder as well as a substance abuse problem. The abused substance can be alcohol or drugs but, for the purpose of this article, alcohol will be the primary focus. Dual diagnosis is often referred to as co-occurring disorders and there are a number of mental conditions that may be simultaneously diagnosed. Some other common mental disorders associated with AUD are:

Depression
Anxiety Disorders
Schizophrenia
Personality Disorders

In 2014, the Substance Abuse and Mental Health Services Administration (SAMHSA) conducted the 2014 National Survey on Drug Use and Health. This survey found that approximately 43.6 million Americans over the age of 18 had been diagnosed with a mental illness and that roughly 20.2 million were diagnosed with a substance abuse disorder. Dual diagnosis is significantly more common than perceived, as SAMHSA also found that 7.9 million adults in the United States alone suffered from co-occurring disorders.

What is Bipolar Disorder?

Bipolar disorder is a very serious mental disorder that causes those diagnosed to experience unusual changes in mood and energy level. Sometimes referred to as manic-depression, this condition also creates shifts in activeness, as well as an inability to complete daily tasks. Patients frequently go through “up swings” of extreme happiness (mania) that are inexplicably, and often quickly, followed by “down swings” of sadness (depression). These intense periods of emotion are often called “mood episodes,” which are identified by the following:

Manic Episode

During manic episodes, people with bipolar disorder often feel “high” and energized. While symptoms can be difficult to discern, they frequently include:

Inflated self-esteem and self-worth
Increase in energy level
Difficulty sleeping or needing less sleep than usual
Being more talkative than usual
Racing thoughts
Quickly jumping from one topic to another
Feeling jumpy or wired
Being agitated or irritable
Distractibility
Belief that multiple tasks can be completed at once
Intolerance
Increase focus on certain activities
Involvement in dangerous or risky activities

Depressive Episode

During depressive episodes, people with bipolar disorder often feel very sad, irritable, or numb. These periods will likely last longer than manic episodes. While symptoms are often confused with depression, they frequently include:

Depression or hopelessness
Emptiness
Loss of interest
Changes in weight and appetite
Difficulty sleeping or sleeping too much
Restlessness and lethargy
Being irritable and worried
Fatigue
Feeling worthless or guilty
Inability to concentrate
Difficulty remembering things
Reoccurring thoughts about death

It is possible for people to experience both sides of the disorder at the same time. This is referred to as an episode with mixed features. Rapid cycling is also possible, which occurs when someone has four or more episodes in one year. Additionally, some individuals may experience hypomania, which is a less severe version of a manic episode. The symptoms will be similar, but are unlikely to greatly impact the person’s daily activities.

Symptoms of bipolar disorder usually begin to become apparent when an individual becomes a teen or young adult. It is, however, possible for young children and older adults to develop the disorder as well. While treatment can help to manage the symptoms of the condition, bipolar disorder generally lasts a lifetime.

While every individual is different, common warning signs of bipolar disorder include:

Extreme irritation and hostility
Moodiness
Suddenly impulsive behavior
Lack of attention and/or confusion
Anxiousness
Needing little to no sleep
Sleeping too much
Melancholy
Overconfidence

The causes and risk factors of bipolar disorder are still being studied, but it’s believed that there’s no single cause. Like with AUD, however, research indicates that several factors influence the development of the condition. It does tend to run in families, as studies have found children of bipolar disorder patients are 10 times more likely to have it than children of parents without the disorder. Genetics are not solely responsible, however, as twins do not always develop the condition. Brain structure and the way the brain functions are also important. In some cases, a head injury or brain disease may be responsible. Traumatic experiences may also play a role.

Bipolar disorder must be diagnosed by a licensed healthcare provider. The diagnosis will generally be made after a complete physical exam and the determination that symptoms are not being caused by another illness. Professionals often classify the disorder as follows:

Bipolar I

Patients diagnosed with bipolar I disorder experience both manic and depressive episodes. Manic episodes will usually last for at least seven days, while depressive episodes usually last for at least two weeks. Mixed feature episodes are also possible. It’s not uncommon for the manic symptoms to be so severe that hospitalization is required.

Bipolar II

Patients diagnosed with bipolar II disorder primarily experience depressive episodes and hypomanic episodes. While hypomanic symptoms are similar to manic symptoms, manic episodes are usually not present.

Cyclothymia

Patients diagnosed with cyclothymia disorder, experience several periods during which hypomanic-like symptoms are present. These symptoms are noticeable and last for at least one to two years (depending on age), but do not meet minimum diagnostic requirements to be considered a full hypomanic or depressive episode.

Other Specified and Unspecified Bipolar and Related Disorders

Patients with this diagnosis exhibit bipolar disorder symptoms, but not in a way that fits into any of the three classifications above.

Drinking’s Effect on Bipolar Disorder

A dual diagnosis of bipolar disorder and AUD occurs more frequently than does a dual diagnosis of AUD and basic depression. In fact, the ECA study previously mentioned found that the only other condition more commonly associated with alcoholism than bipolar I disorder is antisocial personality disorder. Bipolar I disorder and AUD are six times more likely to occur together than would be expected by chance.

While not always the case, research suggests that alcoholism is more commonly a secondary condition for individuals with bipolar disorder. This means that AUD is more often a complication, rather than a risk factor.

Unfortunately, bipolar disorder and AUD generate a number of negative effects when diagnosed together. Alcohol can have an extremely poor impact on the progression and treatment of bipolar disorder. Patients with dual diagnosis, for example, are more likely to need frequent hospitalization. Additionally, those who experience symptoms like rapid cycling and episodes with mixed features are more likely to develop an alcohol addiction. Similarly, those with AUD going through withdrawal are more likely to experience worsening mood symptoms. When paired together, it’s not uncommon for a very unhealthy cycle of alcohol use and mood instability to develop.

Unique Issues Faced by Bipolar Patients with AUD

One of the biggest issues bipolar disorder patients with AUD will face is difficulty properly diagnosing both conditions. It’s not uncommon for an individual to be diagnosed and treated for one disorder, while the other is largely ignored. There are several reasons that this oversight may occur, including:

Inability of healthcare providers to correctly diagnose bipolar disorder
Presence of numerous other mental health illnesses that present similar symptoms to bipolar disorder
Use of alcohol can drastically impact mood and behavior or be mistaken for depression
Alcohol withdrawal symptoms closely resemble the symptoms of almost every psychiatric disorder
Intoxication often produces mental instability that is hard to distinguish from manic episodes and hypomania

It is particularly difficult for healthcare professionals to diagnose bipolar II disorder and cyclothymia in the presence of AUD because the symptoms are often much subtler to begin with. Due to these difficulties with the diagnosis process, patients with bipolar disorder and AUD may experience significant frustration or a delay in receiving the necessary treatment. Other issues that individuals with dual diagnosis may face include:

Many, if not all, of the common symptoms associated with bipolar disorder, including extreme mood swings, emotional episodes, and irregular sleep patterns
Many, if not all, of the common symptoms associated with AUD, including impulsive drinking, incapacity to stop drinking, and mental/physical withdrawals when alcohol isn’t available
Higher risk of many medical conditions, including:
- Migraine headaches
- Certain cancers
- Diabetes
- Thyroid disease
- Heart disease
- Liver disease
- High blood pressure
- Obesity
- Stroke
- Alcohol poisoning
- Digestive problems
- Memory loss
Higher risk of psychotic symptoms, such as hallucinations and/or delusions

Another important element that must be considered is gender. While males and females are equally likely to develop bipolar I disorder, bipolar II disorder impacts more females. Females are also more likely to develop AUD. This means that females with bipolar disorder should be especially careful about their alcohol consumption.

Treatment

The order of onset plays a very significant role in treating dual diagnosis bipolar disorder and AUD patients. While treatment is often most successful when both conditions are addressed simultaneously, research shows that effectively treating the primary disorder positively impacts the secondary one. For example, an individual who is first diagnosed with bipolar disorder and later develops AUD is more likely to stop drinking when his or her bipolar disorder symptoms are being properly treated. This works similarly for patients who are first diagnosed with AUD and later develop bipolar disorder.

While identifying the primary disorder is important, attempting to treat just one of the conditions at a time will not work. This is because, as previously mentioned, bipolar disorder and AUD tend to create a vicious cycle of alcohol use and mood instability. Drinking and withdrawal symptoms can create significant emotional imbalances, while both manic and depressive episodes tend to increase the desire to consume alcohol.

Integrated treatment plans that work to address both mental health and substance abuse symptoms at the same time, however, have proven quite effective. This approach is often less expensive, and frequently results in a decrease in substance abuse, better psychiatric functioning, less need for hospitalization, more stability, fewer arrests, and a higher quality of life. While every plan is different and will be tailored to the individual patient, most will consist of a combination of therapy and medicine.

Therapy

Therapy can be very beneficial when used to treat both bipolar disorder and AUD. In fact, many of the same principles are applied when treating the conditions separately. Regular sessions also serve as an optimal opportunity to educate patients about the relationship between their two disorders. This is particularly important considering that bipolar disorder and AUD can play so negatively off of one another.

Medicine

Medicine is often used to treat both bipolar disorder and AUD. Bipolar disorder patients frequently notice a decrease in symptoms when taking mood stabilizers like lithium and valproate. Some healthcare providers also prescribe medication to address AUD symptoms, reduce the desire to drink, or cause a negative physical response to alcohol. Disulfiram, naltrexone, and acamprosate are historically prescribed to AUD patients, but naltrexone is more commonly utilized when both conditions are present.

Medication compliance can be a problem in some cases. While lithium is the standard prescription for bipolar disorder, research indicates that dual diagnosis patients may be less likely to take it. This is because the bottle usually warns specifically against drinking alcohol while on it.

Do you think you or a loved one has dual diagnosis bipolar disorder and AUD? If so, it’s important to speak with a professional healthcare provider as soon as possible. The first step to recovery is working with a doctor to determine an accurate diagnosis. After a comprehensive mental evaluation and physical exam, you can begin creating an individualized treatment plan that meets your goals and utilizes strategies you’re comfortable with.

Living with bipolar disorder and AUD isn’t easy, but the help you or your loved one needs is available. Don’t struggle in silence; find a healthcare professional or addiction hotline today.

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