ANXIOUS–BIPOLAR COMORBIDITY: Diagnostic and Treatment Challenges
Section snippets
EXTENT OF ANXIETY–BIPOLAR SPECTRUM COMORBIDITY
The occurrence of bipolar features in patients with anxiety disorders is counterintuitive, but evidence for such a relationship has come from both epidemiologic and clinical studies. In the National Comorbidity Survey, the reported risk of comorbid PD and SP is higher in bipolar disorder (odds ratios of 11.0 versus 4.6) compared to unipolar disorder (odds ratios of 7.0 versus 3.6). Chen and Dilsaver,23 analyzing the epidemiologic catchment area (ECA) database, reported lifetime rates of OCD
IMPACT OF ANXIOUS–BIPOLAR COMORBIDITY ON COURSE
It follows that the bipolar-unipolar distinction in affective comorbidity has relevant clinical implications as far as other concomitant disorders, clinical features, and course of anxiety disorders are concerned. In the aforementioned study on 342 OCD patients,61 the authors observed that when OCD was associated with bipolar disorder, there proved also to be an increased lifetime and intraepisode comorbidity with PD-agoraphobia. Moreover, bipolar OCD patients evidenced more frequently than
BIPOLAR II AND EPISODIC OBSESSIVE-COMPULSIVE DISORDER
The authors published a study of 135 OCD patients with an illness duration of at least 10 years divided on the basis of course: episodic (27.4%) versus continuous (72.6%). Multivariate stepwise discriminant analysis on clinical and familial characteristics revealed a positive correlation between episodic course, family history for mood disorders, lifetime comorbidity for panic and bipolar II disorders, late age at onset, and negative correlation with generalized anxiety disorder. These data are
FAMILIAL-GENETIC IMPLICATIONS OF BIPOLAR II–PANIC COMORBIDITY
In a more practical vein, multiple comorbidity and consequent symptomatologic instability appear as the most relevant clinical implications of anxious–bipolar presentations. Many patients receive diagnoses of borderline, narcissistic, or histrionic personality disorders, which may rob them of the opportunity to receive adequate pharmacologic treatment. Increased risk of mixed states,73 suicidal behavior, and alcohol and drug abuse60 are other important prognostic possibilities. Further
TEMPORAL RELATIONSHIPS BETWEEN ANXIETY DISORDERS AND HYPOMANIA
Available data on temporal relationships between anxiety and mood disorders are currently limited almost exclusively to major depression, and there does not seem to be a consistent pattern. In some studies, depression was found to be more likely to precede anxiety disorders,19, 25, 70 whereas other investigators reported the opposite tendency.76 The latter is in accordance with the hypothesis that depression, at least in some cases, may be secondary to anxiety disorders. The complexity of the
ATYPICAL DEPRESSION, INTERPERSONAL SENSITIVITY, CYCLOTHYMIA, AND BORDERLINE PERSONALITY
In exploring the putative temperamental foundations of comorbidity between anxiety and mood disorders, atypical depression represents an intriguing challenge. The rubric atypical depression defines a large subset of depressive states, in which mood and anxiety disorders are commonly coexisting, characterized by reactive mood; a pattern of stable interpersonal sensitivity (exaggerated vulnerability to feeling hurt by criticism or rejection); and reverse vegetative symptoms, such as increased
TREATMENT CONSIDERATIONS
Although comorbidity between bipolar and anxiety disorders reported in this article is partly due to the fact that centers specializing in these illnesses are referred the most difficult patients in this realm, there remains the challenge of how best to treat them in the long-term. Anxiety disorders are usually treated with antidepressants, which, not infrequently, trigger hypomanic or mixed states in patients with bipolar diathesis.36, 48, 66, 80, 82 Some antimanic agents, such as classic
CONCLUSIONS
Although the relationship between anxiety and mood disorders has been conventionally limited to unipolar depression, clinical observations have revealed complex associations between anxiety and bipolar disorders. The frequent coexistence of anxiety and bipolar disorders (mainly bipolar II) has also been reported in epidemiologic samples12 and primary care settings,52 indicating that clinical referral bias is unlikely to be the main explanation for this phenomenon.
Symptomatologic instability,
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2022, Journal of Psychiatric ResearchCitation Excerpt :Huntingdon's disease (Johnson et al., 2017) and Parkinson's disease (Antonelli et al., 2011; Martini et al., 2018). At the same time, they are also common in both Mood and Anxiety Disorders (DSM-5; American Psychiatric Association & American Psychiatric Association, 2013) characterized by abnormal functioning of the serotoninergic system, as exemplified in disorders such as bipolar disorder II (Perugi et al., 1999; C. T. Taylor et al., 2008) major depressive disorder (Fields et al., 2021; Moustafa et al., 2017), cyclothymic disorder (Perugi et al., 2011), separation anxiety disorder (Kahya and Taşkale, 2019) panic disorder such as agoraphobia (Beşirli, 2018), and generalized anxiety disorder (Ferreira-Garcia et al., 2019; Gecaite-Stonciene et al., 2021; Moustafa et al., 2017). Recent neuroscientific evidence has further established that both dopamine (DA) and serotonin (5-HT) play a crucial role in the regulation of impulsive behaviour (Dalley and Roiser, 2012) and negative affect manifestations such as depression, anxiety, and apathy (de la Mora et al., 2010; Dunlop and Nemeroff, 2007; Peciña et al., 2017).
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2015, Journal of Affective DisordersCitation Excerpt :They also showed: a higher number and severity both of depressive and hypomanic symptoms, earlier age at the first initiation of psychopharmacological therapy, a lower response to conventional anti-OCD treatments, higher rates of hypomanic antidepressant-induced switches and “paradoxical” worsening under drug therapy. Some authors (Hantouche et al., 2003b; Perugi et al., 1999b) have hypothesized that cyclothymic OCD might be a distinct clinical form of OCD. The relationship between cyclothymia and attention deficit/hyperactivity disorder (ADHD) is controversial.
Phenomenological subtypes of severe bipolar mixed states: A factor analytic study
2014, Comprehensive PsychiatryIs comorbid borderline personality disorder in patients with major depressive episode and bipolarity a developmental subtype? Findings from the international BRIDGE study
2013, Journal of Affective DisordersCitation Excerpt :This perspective is essentially based on the misconception that unstable, depressive, irritable, anxious and labile mood, with superimposed paroxysms of rage, described by BPD criteria, must be relegated into the personality realm and that only classical episodic depressive-euphoric–euthymic affective disorder is a “true” bipolar disorder. However, it is not clear whether the mood reactivity and instability described by BPD patients are distinct in quality from the subjective mood experienced in an anxious, irritable or dysphoric manic/hypomanic/mixed states (Young et al., 1993; Perugi et al., 1999; Dilsaver et al., 2005; Sato et al., 2003). Unless such evidence were established, the results we report provide evidence that current BPD criteria can describe a BD sub-population from a different perspective.
Impulsivity in anxiety disorder patients: Is it related to comorbid cyclothymia?
2011, Journal of Affective DisordersA population-based analysis of distinguishers of bipolar disorder from major depressive disorder
2010, Journal of Affective Disorders
Address reprint requests to Giulio Perugi, MD, Institute of Psychiatry, Via Roma 67, 56100, Pisa, Italy, e-mail: [email protected]