The Bipolar-Addiction Connection
Undetected bipolar disorder often frustrates addiction recovery.
Posted September 10, 2018
It was once believed by many that alcohol and drug addiction recovery should be addressed apart from mental illnesses. While others did see that co-occurring substance use and mood disorders have negative crossover effects that complicate addiction recovery, the relationship between these disorders was not well understood. More and more, this concept is changing, and people affected by addictive substance use are more thoroughly assessed for mood disorders while in treatment. But too often, an underlying bipolar disorder can go unnoticed through the addiction recovery process.
As I have written before, bipolar disorder is often unidentified and mistreated. Most people with bipolar disorder endure many years of misdiagnoses; or in the case of substance use, their addiction issues may be addressed, but an underlying bipolar disorder may not be recognized. People in recovery who actually have an undiagnosed or untreated bipolar disorder can suffer through years of needless complications to maintaining long-term sobriety, including substance use relapses and a high potential for suicide.
The first principle in the bipolar-addiction connection is this: Bipolar disorder frequently co-occurs with substance use and substance dependence. Reiger, et al (1990) found 60.7% of people with bipolar I disorder (considered the more severe form of the disorder) had some kind of co-occurring substance abuse or dependence, while 48.1% of those with bipolar II disorder (generally considered less severe) had some kind of co-occurring substance abuse or dependence. These numbers are significantly higher than in any other mood disorder, including non-bipolar major depression.
The relationship between substance use disorders and bipolar disorder is important to understand for anyone striving to recover from the effects of severe mood swings because they present real complications in stabilizing the disorder. For example, Rakofsky and Dunlop (2013) found that alcohol use disorders destabilize the course of bipolar disorder, resulting in more mood episodes of mania and depression, with greater rapid cycling between those mood states. And this destabilization effect frequently results in aggression against self or others. One study showed an increase in violence among male bipolar patients who were using substances (Alniak, Erkiran, & Mutlu, 2016), while a meta-analysis by Carra, et al. (2014) showed a significant increase in suicide attempts when substance use disorders accompanied bipolar disorder.
Since many people in addiction recovery may not know they have bipolar disorder, untreated mood swings could be a reason why they’re struggling to stay sober. It’s not uncommon for people with bipolar to have unknowingly been self-medicating bipolar depression or the high level of irritability that often accompanies mania. An addictive pattern of substance use may have covered bipolar symptoms, and when that veil is lifted through addiction treatment, bipolar symptoms can become clearer to see. Depression itself is a common part of the withdrawal from substances. But severe depressive cycles or evidence of manic symptoms, such as euphoric mood, high agitation or irritability (known as dysphoria), pressured speech, rapid thoughts, decreased need for sleep, or increased impulsivity or suicidal thoughts, could be a sign that bipolar has emerged past the self-medication barrier.
People in a manic state often use substances to extend the euphoric and hypercreative feelings of the manic episode. It is one of the important reasons to understand the bipolar-addiction connection. Removing drugs or alcohol won’t simply take away the impulsivity and other manic-type behaviors that were believed to be the sole result of substance use. But it can provide the evidence needed towards assessing and treating a bipolar disorder that’s been with that person all along.
It’s also good to know that unidentified bipolar disorder may account for many aspects of an individual’s typical behavior away from substances. For years, we have often talked about the “alcoholic personality” or the “dry drunk” who has refrained from using substances but still displays characteristics that can further interpersonal dysfunction. Some of these individuals may have had an underlying personality disorder, but if there are drastic shifts in mood, they may instead have been suffering from bipolar disorder.
Once bipolar disorder is diagnosed along with a substance use disorder, a real opportunity opens for understanding how mood swings have driven the drug or alcohol problems. In turn, individuals can focus on proper solutions with their treatment teams. Treatment decisions become centered on achieving mood stabilization in all aspects of the patient’s life, but particularly for sobriety maintenance. For example, certain bipolar mood-stabilizing medications may be better than others when a substance use disorder is present (Sonne & Brady, 2002). And an overall therapy approach that integrates addiction recovery into a mood stabilization plan can offer real and lasting results since both disorders require lifelong care.
Whether the bipolar symptoms occurred before substance use was a problem, or substance use became a catalyst for bipolar symptoms, the bipolar-addiction connection is common among people suffering from substance abuse disorders. Unidentified and untreated bipolar disorder may be lurking beneath the surface of addictive behavior, making both conditions worse. If you or your loved one is facing a substance use disorder crisis, be sure to discuss the possibility of a co-occurring mood disorder, especially bipolar disorder.
Alniak, I., Erkian, M., Mutlu, E. (2016). Substance use is a risk factor for violent behavior in male patients with bipolar disorder. Journal of Affective Disorders, (193)89-93.
Carra, G, Bartoli, F, Cristina, C, Brady, KT, Clerici, M (2014). Attempted suicide in people with co-occurring bipolar and substance use disorders: Systematic review and meta-analysis. Journal of Affective Disorders, (167)125-135.
Rakofsky, JJ, Dunlop, BW (2013), Do alcohol use disorders destabilize the course of bipolar disorder? Journal of Affective Disorders, (145)1-10.
Reiger, DA, Farmer ME., Rae, DS, et al, (1990). Comorbidity of mental disorders with alcohol and other drug abuse: Results from the Epidemiologic Catchment Area (ECA) study. Journal of the American Medical Association, (264)2511-2518.
Sonne, S.C., Brady, K.T. (2002). Bipolar disorder and alcoholism. Alcohol Research and Health. Retrieved September 24, 2016 from http://pubs.niaaa.nih.gov/publications/arh26-2/103-108.htm