Chronic Pain and Bipolar Disorders: A Bridge Between Depression and Schizophrenia Spectrum

The author discusses the association between bipolar disorders and chronic pain, which often can go undiagnosed and untreated.

By David Cosio, PhD, ABPP

Bipolar and related disorders are distinct from depression, which was covered in the first installment of the A to Z Mental Health Series,1 and are commonly found in patients who suffer from migraines and chronic pain. The 12-month prevalence of bipolar-I disorder across 11 countries ranged anywhere from 0.0% to 0.6%, with the United States having the highest prevalence (Table 1).2

Individuals diagnosed with bipolar-I disorder have high rates of serious and often untreated comorbid medical conditions.3-5 According to a recent meta-analysis of people with bipolar disorder, the prevalence of clinical pain is approximately 29%; migraine is about 14%; and chronic pain is 24% (Table 2).6 In fact, individuals diagnosed with bipolar disorder report around 4 pain complaints at any given time.7 Musculoskeletal conditions, such as lower back pain, arthritis, and hip problems, have been found to be more prevalent among individuals with bipolar disorder than the general Department of Veteran Affairs patient population.3 As noted, migraine is among the most common comorbid medical conditions diagnosed in individuals with bipolar disorder compared to the general population.8,9

Migraines affect about 1 in 7 (14%) persons diagnosed with bipolar disorder, who are 3 times more likely to experience migraines compared to the general population.6 The risk of developing migraines is not the same among all types of bipolar disorders. A study by Low et al found that in the subgroup of patients with bipolar-II disorder, the lifetime prevalence of migraine was 65%.10 In the same study, the overall lifetime prevalence of migraine among all patients with bipolar disorder was 39.8% (43.8% among women and 31.4% among men).

Bipolar disorder and migraines are multifactorial in etiology—there appear to be vascular, cellular, molecular, neurochemical (serotonergic and noradrenergic), and genetic (KIAA0564) components in common between bipolar disorder and migraine conditions.11

Individuals who suffer from pain and are diagnosed with a mental disorder, such as bipolar disorder, have been found to experience a worsening of psychiatric symptoms.12 In addition, health care professionals may at times fail to give complaints about physical health problems serious consideration among patients with serious mental illness.13 These patients are also less likely to recognize or monitor their comorbid medical conditions compared to the general population.14 In addition, they have an increased likelihood of experiencing conditions that cause pain, and a lower probability of receiving adequate care.15 For example, people diagnosed with bipolar disorder have an increased prevalence of depression, which has been linked to greater pain sensitivity.16 Chronic pain in persons diagnosed with bipolar disorder is associated with impaired recovery,17 greater functional incapacitation,11 lower quality of life,7 and increased risk for suicide18 compared to individuals without pain.

How Is Bipolar Disorder Defined?

In the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the bipolar and related disorders are broken into the following categories: bipolar-I disorder, bipolar-II disorder, cyclothymic disorder, substance/medication-induced, due to another medical condition, and “other specified category.”19 The defining feature of bipolar-I disorder is the presence of at least 1 manic episode. Mania is defined by the DSM-5 as a distinct period of abnormally and persistently euphoric or irritable mood that lasts at least 1 week.19 Mood changes are accompanied by at least 3 of the following symptoms:

The manic episode must result in marked impairment in social or occupational functioning, or require hospitalization to prevent harm to self or others (such as financial losses, illegal activities, loss of employment, and self-injurious behavior). It is necessary to meet criteria for a manic episode to make a diagnosis of bipolar-I disorder, but it is not required to have hypomanic (a mild form of mania marked by elation and hyperactivity) or major depressive episodes.

The other diagnoses under the bipolar and related disorders umbrella differ from the bipolar-I diagnosis. Bipolar-II disorder requires the presence of at least 1 episode of major depression and at least 1 hypomanic episode. Cyclothymic disorder is diagnosed when an individual experiences at least 2 years of both hypomanic and depressive periods without ever fulfilling the criteria for an episode of mania, hypomania, or major depression. The diagnosis of substance/medication-induced bipolar disorder is attributable to mania from the physiological effects of drug abuse (eg, cocaine or amphetamine intoxication), or the side effects of medications or treatments (eg, steroids, antidepressants, or stimulants). However, a manic episode that arises during treatment (eg, medications, electroconvulsive therapy, or light therapy) or drug use and persists beyond the physiological effect of the inducing agent is sufficient evidence for a manic episode, the defining feature of bipolar-I disorder diagnosis.

The other specified bipolar and related disorder category recognizes individuals, particularly children, who experience bipolar-like phenomena that do not meet the criteria for bipolar-I, bipolar-II, or cyclothymic disorders. However, if children exhibit recurrent silliness and “goofiness” beyond what is expected for their developmental level, have significant mood changes, attempt feats that are clearly dangerous and different from their normal behavior, and experience obvious and persistent increases in activity or energy levels, then a diagnosis of bipolar-I should be considered.

How Is the Diagnosis Different Now in the DSM-5?

In the DSM-5, the chapter on bipolar and related disorders was placed between the schizophrenia spectrum and depressive disorders to serve as a “bridge.” This bridge outlines how the new DSM-5 has moved away from a categorical to a dimensional approach. This decision was made due to its connection with psychosis and depression in terms of symptomatology, family history, and genetics.2 A few other details have been changed, including new mania criteria with an emphasis on changes in activity and energy, as well as mood. In addition, a new specifier—“with mixed features”—has been added that can be applied to episodes of mania or hypomania when depressive features are present, and to episodes of depression in the context of major depressive disorder or bipolar disorder when features of mania/hypomania are present. The DSM-5 also allows the specification of particular conditions for “other specified bipolar and related disorders.”

How Do You Assess for Bipolar Disorder?

Due to informal or poor screening, the average time between onset of symptoms and formal diagnosis of bipolar disorder is greater than 7 years.20 Several semi-structured interviews have been developed to assess bipolar disorder in adults. The 2 most commonly used measures are the Structured Clinical Interview for DSM-4 (SCID) and the Schedule for Affective Disorders and Schizophrenia (SADS). The SCID and SADS both provide interview probes, symptom thresholds, and information about exclusion criteria (eg, medical or pharmacological conditions). The most reliable and valid way to obtain a diagnosis of bipolar disorder is through a structured interview with a trained mental health provider. However, several self-report measures have been developed to help identify persons most likely to meet criteria for bipolar disorders, such as the General Behavior Inventory and the Mood Disorder Questionnaire.21

What Does the Treatment of Bipolar Disorder Entail?

Individuals diagnosed with bipolar disorder who are treatment adherent report statistically lower levels of pain than their non-treatment-adherent counterparts.22 Given these symptom patterns, there is a need for treatments that can provide mood stabilization in addition to the treatment of pain. Medications are recommended as the first line of treatment for bipolar disorder by a psychiatric provider.23

When treating more severe manic or mixed episodes, the initiation of either lithium plus an antipsychotic or valproate plus an antipsychotic is recommended. For less ill patients, monotherapy with lithium, valproate, or an antipsychotic may be sufficient. Monotherapy using an antidepressant is not recommended.

A better understanding of the association of bipolar disorder and chronic pain can help limit adverse pharmacological side effects. For example, a tricyclic antidepressant (TCA) is often prescribed to treat chronic pain, but such medication (in the absence of a mood stabilizer) may trigger a manic episode in someone diagnosed with bipolar disorder.24 There is also evidence that suggests that nonsteroidal anti-inflammatory drugs (NSAIDs) may increase serum lithium levels, possibly eliciting lithium toxicity.25 In addition, analgesics, such as opioids, may alter mood, increasing the risk of eliciting a manic episode.26

Psychological treatment research has focused mostly on outcomes for mania and depression separately. There is strong research support for psychoeducation and systematic care, and modest support for cognitive therapy (CT) for the treatment of mania, but psychoeducation and CT only have modest support for depression (Table 3).27 Psychoeducation may be provided using the “Life Goals Program” manual28 to teach patients about their symptoms and the need for medications, and to provide support in achieving occupational and social goals. Participants also create personal self-management plans detailing coping strategies for early warning signs of symptoms.

Systematic care consists of a system-level intervention and a group therapy component, perhaps CT. At the system level, care for bipolar patients is provided by an outpatient specialty team composed of a nurse care coordinator and a psychiatrist, with staff-patient ratios at a level that provides clients with regular appointments and easily available telephone consultations. According to the American Psychiatric Association, CT includes “a psychoeducational component regarding the biological basis of the illness, the need for medications, and the early warning signs of symptoms.” They also include “a focus on identifying maladaptive, negative thoughts about the self, and teaching patients skills to challenge these overly negative thoughts.” Many manuals also include ideas about how to target the overly positive thoughts that might be present during mania.29

There is strong research support for family-focused therapy (FFT) and modest research support for interpersonal and social rhythm therapy (IPSRT) for bipolar disorder, but FFT and IPSRT do not have research support for mania.27 FFT is a behavior-based intervention that includes psychoeducation, communication skills training, and problem-solving skills training. Families are taught to respond early to emergent symptoms, and they are provided with training about the best coping responses.30 IPSRT builds upon the traditional focus of interpersonal psychotherapy by incorporating a behavioral self-monitoring program.31 The intention is to help patients diagnosed with bipolar disorder to initiate and maintain a lifestyle characterized by more regular sleep-wake cycles, mealtimes, and other cues given by the environment. The ultimate goal is to help regulate circadian disturbances that may provoke or exaggerate episodes of mood disorder.

When the functional impairments of bipolar disorder are severe and persistent, other services may also be necessary, such as case management, assertive community treatment, psychosocial rehabilitation, and supported employment. These approaches, which have traditionally been studied in patients with schizophrenia, also show effectiveness for certain individuals diagnosed with bipolar disorder. Of course, we recommend physicians defer to a mental health professional for an accurate diagnosis and determination of appropriate treatment options.

In the next installment in the A to Z Mental Health Series, the author will discuss anxiety disorders and pain.

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