Bipolar disorder comorbidity with dissociative and conversion disorders

The prevalence of bipolar disorder (BD) was determined to be 0.4-1.1%. However, the lifetime prevalence estimates of bipolar spectrum disorder are now placed at least 5% of the general population. Psychiatric comorbidities are common in the patients with BD. Some authors report the incidence rates of lifetime comorbidity in BD as high as 70%. Bipolar patients with a history of childhood trauma have an earlier age of onset, have more affective and rapid cycling episodes, have more psychotic symptoms and suicide attempts. Latalova et al found that bipolar patients had higher DES scores compared to healthy volunteers. Although comorbidities are common in DD, cases in which BD is comorbid with DD is generally overlooked because dissociative symptoms obscure and impair the individual’s self-perception and self-report. In a study by Jans et al, affective disorder co-morbidity is found 71% among adult patients with dissociative disorders. Foote et al found that a dissociative disorder diagnosis was more strongly associated with suicidality or self-harm than any other diagnosis. Studies show that 1 to 2.1% of patients with DID had completed suicide, with an incidence of 61 to 72%, who have attempted suicide. Studies conducted in patients with the most complex dissociative disorder, dissociative identity disorder (DID), have found between 34%and 86%have histories of self-mutilation. Patients with DD have been reported to have used more methods of self-injury and started to injure themselves at an earlier age than patients who have not dissociated. Conşict with others and difficulty with boundaries as well as frequent re-victimization in subsequent relationships are all too common. Emotional dysregulation occurs frequently in this subset and may be the precipitant of psychiatric treatment. There is evidence that patients with DD may drop out of cognitive behavioral treatments, indicating that programs that do not specifically address dissociation may not be well tolerated. Atypical antipsychotic drugs that block both D2 and 5-HT2A receptors may be of use in treating complex trauma cases with “psychotic features” although auditory hallucinations and voice hearing in subjects with trauma disorders could be conceptualized as dissociative rather than psychotic in some cases. Most medications (e.g., antidepressants, anxiolytics) are prescribed for comorbid anxiety and mood symptoms, but these medications do not specifically treat the dissociation. Presently, no pharmacological treatment has been found to reduce dissociation. Although antidepressant and anxiolytic medications are useful in the reduction of depression and anxiety and in the stabilization of mood, the psychiatrist must be cautious in using benzodiazepines to reduce anxiety as they can also exacerbate dissociation. In treating patients with DID, there are reports of some success with selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, monoamine oxidase inhibitors, beta blockers, clonidine, anticonvulsants, and benzodiazepines in reducing intrusive symptoms, hyperarousal, anxiety, and mood instability. Other possible suggestions for pharmacological interventions for DID include the use of prazosin in reducing nightmares, carbamazepine to reduce aggression, and naltrexone for amelioration of recurrent self-injurious behaviors.