Proposal for a bipolar-stimulant spectrum: temperament, diagnostic validation and therapeutic outcomes with mood stabilizers.

BACKGROUND: Stimulant abuse and dependence in confusing admixtures with features of bipolar disorder has been variously conceptualized. DSM-IV-TR rules tend to be liberal in permitting the diagnosis of substance-induced disorder, and rather strict for a bipolar diagnosis in such cases. Accordingly, if bipolarity is ever considered in this interface, it usually pertains to syndromal bipolar I disorder.

METHOD: We therefore focused on the more prevalent but relatively neglected admixture of stimulant abuse with bipolar II and lesser degrees of bipolarity. We examined in our dual diagnosis program the longitudinal progression of the dual pathology in 10 patients who had proven refractory to past efforts to treat the stimulant component. In doing so, we wished to better delineate the nature of the clinical interface of the stimulant bipolar spectrum and its response to anticonvulsant mood stabilizers.

RESULTS: In nearly all cases cyclothymic and hyperthymic traits preceded the use of stimulants by years, which seemed to serve the purpose of controlling or maintaining the subthreshold rewarding mood condition. Eventually clinically more ominous and socially destructive pathology evolved, with contributions from both the bipolar diathesis and the addictive process. Seven of 10 cases had bipolar familial indicators. Nearly all evidenced hypomanic and/or irritable depressive states with mixed features during protracted sobriety from the stimulant. Except for two of the 10 patients, substantial (30-45 point) gains were made on DSM-IV-TR axis V general assessment of functioning (GAF) scores with the use of largely "mood-stabilizing" anticonvulsants. This was paralleled with the reduction of craving. These data highlight the human dimensions of the bipolar-stimulant abuse interface, and document functional outcomes (rather than mere changes in rating scales which may not necessarily reflect clinically relevant improvement).

LIMITATION: Open case series of 10 patients.

CONCLUSION: We propose a bipolar-stimulant spectrum-what the senior author has elsewhere labeled bipolar III-1/2-where subthreshold bipolar traits are complicated by stimulant abuse, eventually leading to pathology characteristic of both disorders. The contribution of bipolarity to this spectrum is supported by: (1) premorbid cyclothymic and hyperthymic traits; (2) familial bipolarity; (3) presence of subthreshold bipolar signs and symptoms during protracted sobriety. We further submit that anticonvulsants in this spectrum not only treat the acute escalation of activated and mixed depressive states, withdrawal phenomena, and craving for the stimulant, but also the craving for activation and mood enhancement of the underlying temperament. We submit that the latter might be crucial for the successful attenuation of the underlying diathesis for stimulant seeking behavior, abuse and dependence.