Axis II Comorbidity in Patients with Bipolar Disorder
By Arline Kaplan © 2000 (All Rights Reserved)
The rate of personality disorders (Axis II) in patients with bipolar disorder
has been reported to be significantly higher than that of the general population,
but that rate is often influenced by the patient’s mood, the assessment
instrument used and other comorbid conditions, said Lori Altshuler, M.D., professor
of psychiatry and biobehavioral sciences at the University of California, Los
Angeles.
Altshuler discussed some recent studies on comorbid personality disorders and
bipolar disorder at the 153rd Annual Meeting of the American Psychiatric Association.
"In studies [Kay et al., 1999] that have looked at Axis II pathology [in
the general population] using semi-structured or structured interviews, the
rates have varied from 6% to 18%," with an average being about 10%, she
said.
In contrast, studies looking at Axis II pathology in patients with bipolar disorder
have reported rates of 9% to 89% (Dunayevich et al., 2000; O’Connell et
al., 1991; Peselow et al., 1995; Pica et al., 1990).
The variability, Altshuler said, relates to methodological differences between
studies, such as retrospective design versus prospective evaluation and differences
in instruments used (e.g., the self-report Personality Diagnostic Questionnaire-Revised
[PDQ-R] versus the Structured Clinical Interview for DSM-III-R Personality Disorders
[SCID-II]). She added that a person’s mood state can dramatically affect
their Axis II pathology, and most of the studies do not control for other Axis
I comorbidities.
When the studies are limited to euthymic bipolar outpatients assessed for personality
disorders using a structured clinical interview, the rate of Axis II disorders
generally ranges between 35% and 45%, according to Altshuler, who is director
of UCLA’s Mood Disorders Research Program.
If the general population rate for Axis II disorders is 10% or at the extreme,
18%, "than even in euthymic outpatients with bipolar illness, these rates
appear to be severalfold higher," Altshuler said.
Axis II pathology can significantly affect the patient’s prognosis, according
to Altshuler. Dunayevich and colleagues (2000), for example, studied the 12-month
course of illness after hospitalization for patients with a DSM-III-R diagnosis
of bipolar disorder, manic or mixed episode, to identify the impact of co-occurring
personality disorders on outcome.
"They looked at 59 bipolar inpatients, so these were not patients who had
the diagnosis made while they were euthymic," Altshuler said. Thirty patients
were hospitalized first time. The patients were assessed using the Structured
Clinical Interview for the DSM-III-R patient (SCID-P) and SCID-II. Patients
were assessed with the SCID-II near the time of discharge, when they had achieved
sufficient symptomatic recovery from the affective episode to participate in
the interview. Twenty-seven patients (48%) were diagnosed with a coexistent
personality disorder, and eight (30%) of those were diagnosed with more than
one personality disorder.
Outcome assessments were scheduled at two, six and 12 months after discharge.
The researchers divided recovery into three categories: syndromic recovery,
where the patients no longer met criteria for a manic episode; symptomatic recovery,
where the patients experienced minimal symptoms for at least eight weeks; and
functional recovery, where the patients returned to their comorbid level of
functioning for at least eight contiguous weeks.
"They found that having an Axis II disorder is not benign," Altshuler
said.
In all three categories of recovery, there was a significant decrement in the
number of patients who recovered if they had comorbid Axis II pathology, according
to Altshuler.
"Sixty-nine percent of bipolar patients without Axis II [18 of 26] achieved
symptomatic recovery and only 35% with Axis II disorder [nine of 26] achieved
symptomatic recovery," she said.
Ten patients (38%) without personality disorder achieved symptomatic recovery,
compared with only three (12%) with personality disorder. Additionally, eight
patients (31%) without personality disorder and only three (10%) with personality
disorder achieved functional recovery.
Altshuler also discussed a major project looking at Axis II comorbidity and
bipolar disorder being conducted by the Stanley Foundation Bipolar Network at
several centers in the United States and abroad.
"We have analyzed 371 patients who had Axis I disorder of bipolar illness,
Altshuler said. "In this study, patients did not undergo a structured clinical
interview for the data I’m presenting here, but they did fill out a self-assessment,
a PDQ-R."
Looking at the rate of Axis II disorder across mood states, the investigators
have found that among bipolar patients who are euthymic, 58% had self-diagnosed
Axis II disorder, but the rate went up if they were depressed, manic or mixed,
significantly so.
"So the state of the person when you are making an Axis II diagnosis is
very important and should only be made when they are euthymic," she said.
Altshuler also discussed whether the comorbidity of alcoholism among patients
with bipolar disorder could lead to an increased risk for SCID-II pathology.
She described a study she conducted with colleagues. They studied 61 outpatients
with bipolar I disorder who were euthymic, 53% had a comorbid alcohol use disorder
and 47% did not.
Those with the alcohol use disorder had to be sober for at least six months
to enter the study. Both groups of patients (alcohol use disorder and no alcohol
use disorder) were assessed with the SCID-II and/or the PDQ-R.
"Part of what we wanted to do is take a look at whether these self-report
inventories overdiagnose Axis II pathology…The bottom line is yes, self-reports
do overdiagnose Axis II pathology. They are very good in terms of their sensitivity,
but very poor in terms of their specificity. You get a high rate of false positives,"
she said.
Reporting on just the SCID results, Altshuler said that 38% of the bipolar patients
met criteria for an Axis II diagnosis based on the SCID-II, but those with a
history of comorbid alcohol use disorder were significantly more likely to have
a SCID-II diagnosis.
"We found that…52% of patients with the comorbidity had Axis II pathology,
whereas only 24% without the comorbidity had Axis II pathology," she said.
They then evaluated the results according to Cluster A, B and C diagnoses.
Cluster C pathology (avoidant, anxious personality disorders) were most common
in bipolar patients in their presentation of Axis II pathology, as opposed to
the Cluster B pathology (antisocial, borderline, histrionic, narcissistic personality
disorders), Altshuler said.
She explained that "there is a lot of folklore in the literature"
about a high Cluster B pathology in patients with bipolar disorder. That perception
may relate to patients being interviewed during a manic rather than euthymic
state. If you look at the Cluster B checklist and you look at the criteria for
mania and hypomania, she said, a lot of the symptoms overlap.
A
very striking finding in their study, Altshuler said, was the difference in
cluster pathology between bipolar patients with a history of alcohol use disorder
and those without such a history.
"If we look at what separates Axis II bipolar patients with alcoholism
versus those without, nine (33%) of sample who were comorbid for alcoholism
had Cluster A pathology [paranoid, schizoid and schizotypal], whereas none of
the 25 patients without alcohol comorbidity had cluster A pathology," she
said. "The odds of having an Axis II cluster A disorder if you have comorbidity
of alcoholism with bipolar illness are 10fold, than if you do not."
In the question-answer portion of the presentation, Altshuler was asked about
treatment for patients with "triple comorbidity"—bipolar disorder,
a history of alcohol use disorder and an Axis II disorder.
"The reason we undertook the study in the first place was there were a
lot of patients who seemed refractory to treatment. They were getting treated
with multiple medications, and often it was their Axis II disorder that the
clinicians didn’t have time to treat or deal with; [the patients] may have
been getting medications which we know are not the most effective treatment
for that," she said. "Since we have done that study, we have been
trying to take a look at different treatment intervention strategies, I don’t
have answer yet for you. But certainly the fact that Axis II disorders [have
an] impact on the course of illness, on the likelihood of recovery and on the
use of medications warrants taking a look at different intervention strategies
than just our usual ones."
References
Altshuler LL, Kay JH, Ventura J, Mintz J (2000), Alcohol and axis II comorbidity
in bipolar patients, Symposium 3—bipolar illness and alcohol abuse: course
and treatment. Presented at the 153rd Annual Meeting of the American Psychiatric
Association. May 15, Chicago.
Dunayevich E, Sax KW, Keck PE et al. (2000), Twelve-month outcome in bipolar
patients with and without personality disorders. J Clin Psychiatry 61(2):134-139.
Kay JH, Altshuler LL, Ventura J, Mintz J (1999), Prevalence of Axis II comorbidity
in bipolar patients with and without alcohol use disorders. Ann Clin Psychiatry
11(4):187-195.
O’Connell RA, Mayo JA, Sciutto MS (1991), PDQ-R personality disorders in
bipolar patients. J Affect Disord 23(4):217-221.
Peselow
ED, Sanfilipo MP, Fieve RR (1995), Relationship between hypomania and personality
disorders before and after successful treatment. Am J Psychiatry 152(2):232-238.
Pica S, Edwards J, Jackson HJ et al. (1990), Personality disorders in recent-onset
bipolar disorder. Compr Psychiatry 31(6):499-510.
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