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The Relationship of Stress to the Expression and Treatment of Bipolar Disorder – Part II

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The Relationship of Stress to the Expression and Treatment of Bipolar Disorder  (Part II)

by Julie Myers, PsyD, MSCP

Licensed Clinical Psychologist in San Diego;


The Comorbidity of Bipolar Disorder and Stress disorders

 Comorbidity is common in BD, further complicating the diagnosis.  In one study, a comorbid disorder was found in all of the samples, and in 59% the condition preceded the onset of BD symptoms (Kessler, Rubinow, Holmes, Abelson, & Ahao, 1997).  Common among the comorbid disorders are anxiety, substance abuse, ADHD, Oppositional-Defiant Disorder, Bulimia, Social Phobia, Panic Disorder, and Obsessive Compulsive Disorder  (Correll, et al., 2007) and (Perugi, Ghaemi, & Akiskal, 2006), many of which are stress related.  Personality disorders also occur at a higher rate than the general public, which may actually be an expression of phenotypic expression of a bipolar diathesis (Correll, et al., 2007).  BD has the highest prevalence of any psychiatric disorder for alcohol and other substance use disorders, with a lifetime comorbidity estimated from 17 – 61% (Vizzarri, et al., 2007).  In one large study of 500 bipolar patients, a lifetime substance use disorders was found in the entire sample (Simon, et al., 2004).     In many cases, it is unclear whether these co-occurring disorders are truly biologically distinct, or simply risk markers, prodromal states, overlapping  characteristics, or subtypes (Correll, et al., 2007).

 Comorbidity of BD with anxiety disorders is particularly high.  In one large study of 500 BD patients, the lifetime comorbidity with anxiety disorder occurred in over half the sample (Simon, et al., 2004); approximately 11-63% had panic disorder, 8-47% social anxiety disorder, 3-35% obsessive compulsive disorder, 7-39% posttraumatic stress disorder and 7-32% generalized anxiety disorder.   Overall anxiety comorbidity was higher in Bipolar I disorder than Bipolar II disorder. The presence of anxiety predicted a lower age of onset (about 16 as opposed 20 years old) and a shorter time in the euthymic state.  Presence of anxiety disorder also was associated with impaired function, poorer quality of life, decreased likelihood of recovery, greater prevalence of substance abuse, and greater likelihood of suicide attempt.    In my experience, those in hypomanic states have a high reactivity to stress, often engaging in activities to relieve stress, such as compulsive shopping, sexual activity, or risk-taking.  Substances are often used to “self-medicate.”

When chronic stress in family, romantic, and peer relationships is present, there is less improvement in mood symptoms in adolescents.  “The association between chronic stress in peer relationships and mania symptoms is likely a recursive one in which the most impaired youths generate the highest levels of peer-related stress, which further exacerbates their mood symptomatology”  (Kim, Miklowitz, Biuckians, & Mullen, 2007, p. 37).  Possibly, this may create a pattern of dysfunctional reactivity to stress.

In one case example, Bob is an 18 year old male, who expressed BD at the age of 5 after a family stress.  Although he did not receive a diagnosis of BD until the age of 12, his symptoms where characteristic of juvenile BD.   He had symptoms of obsessive compulsive disorder, social anxiety disorder, separation anxiety, and generalized anxiety disorder.  His mind was often occupied with ruminative “bad” thoughts.  He developed many compensatory behaviors to relieve his stress including a shut-down depressive state, psychomotor agitation and tics.  Bob manifested psychotic symptoms and suicidal ideation during times of heightened stress.  School, for example, was a continual source of stress from teachers and peers, resulting in poor performance and exacerbation of bipolar switching.  This further resulted in a deterioration of peer relationships, recursively leading to a greater number of bipolar episodes.

Copyright (2011):  Julie Myers, PsyD:   All rights reserved.

Written by Julie Myers, PsyD, MSCP

June 25, 2011 at 6:48 pm

The Diagnosis of Bipolar II Disorder

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The Diagnosis of Bipolar II Disorder

By Julie Myers, PsyD, MSCP

Licensed Clinical Psychologist in San Diego

Bipolar II Disorder  is a mood disorder, characterized by shifting states between hypomania and depression. Diagnosing Bipolar II Disorder is particularly difficult, because those with this disorder often do not recognize their hypomanic episodes as being abnormal and so do not report their presence. They may also loathe to give-up these hypomanic states. Patients usually present for help during the depressive stage (Perugi, Ghaemi, & Akiskal, 2006), and when in a depressive state, patients may have difficulty remembering their hypomanic states, feeling that they have always felt low; insight is state-dependent. “Diagnosis may only be possible retrospectively utilizing histories from patients who have distorted recollections” (Stahl, 2005, p. 14.)  Because of these distorted recollections, it is important to have collaborating information from family members or close friends.  The hypomania, which the client so often enjoys, is often more problematic to those close to the patient than to the patient themselves and may lead to dysfunctional family interactions and stress.

It may be the patient’s unwillingness to disclose these hypomanic states and the stressful events that trigger them that often leads to misdiagnosis. As a case example, Mr. Smith symptoms of depression had become so severe that he was no longer able to function. From the age of 30, he was treated intermittently for depression, acquiring a long medication history from many different psychiatrists, even one of the leading authority in psychopharmacology in the world, but he continued to cycle in and out of depression. It was not until he was persuaded, at the age of 57, to bring a close friend in with him to treatment that he was finally given a diagnosis of Bipolar Disorder II and received adequate treatment. It was Mr. Smiths’ unwillingness to share his hypomanic states, which were generally triggered by stressful events, which kept him from receiving a diagnosis of Bipolar II Disorder.

When assessing anyone with repeated periods of depression, it is extremely important to carefully consider the possibility of Bipolar II Disorder.  By creating an open and safe environment for the client to recount his/her history, periods of mood instability and hypomania are more likely to be revealed to the therapist. Mood-charts, which detail lifetime events and mood events, are particularly beneficial for use with those who either do not recognize their own hypomanic states or who may be unwilling to address them. Once properly diagnosed, someone with Bipolar II Disorder can be helped to manage their hypomanic and depressive states with various therapeutic methods.

Julie Myers, PsyD, MSCP

Licensed Psychologist, MS Clinical Psychopharmacology, Master Addiction Counselor, Board Certified Biofeedbac  


Perugi, G., Ghaemi, N., & Akiskal, H. (2006). Diagnosis and clinical management approaches to bipolar depression, bipolar II and their comorbidities. In S. Hagop, & A. Tohen, Bipolar Psychopharmacotherapy: Caring for the Patient. John Wiley & Sons, Ltd.

Stahl, S. (2005). Diagnosis and treatment of bipolar spectrum disorders. NEI Psychopharmacology Academy 2-Day Series (pp. 37-54). United States: Neuroscience Education Institute.