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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.
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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).

Distinguishing between bipolar, depression and schizophrenia in patients with chronic pain.

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:

  • Being overly confident
  • Having racing thoughts
  • Being easily distractible
  • Being excessively involved in pleasurable activities resulting in negative consequences
  • Excessive talkativeness
  • Decreased need for sleep
  • Increase in goal-directed activity

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.

Last updated on: June 15, 2017
Continue Reading:
Treating Multiple Pain Syndromes: A Case Series Using a Functional Medicine Model
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