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Co-Occurring Diagnosis: Bipolar Disorder and Alcohol Use Disorder

man looking out his window struggling from co-occurring diagnosisAccording to the National Comorbidity Survey Replication, an estimated 4.4% of people will experience Bipolar Disorder at some point in their lives. Approximately 60% of people suffering from BPD have a history of substance abuse. Living with both a mental illness and a substance use disorder is referred to as a dual diagnosis, or a co-occuring disorder. According to the National Institute on Alcohol Abuse and Alcoholism, Bipolar Disorder and alcoholism co-occur more often than even alcoholism and unipolar depression.

What is BPD?

Bipolar Disorder (or manic depressive illness) is characterized by severe mood swings or “episodes” of intense highs and lows, affecting concentration and energy. These shifts are more severe than the normal ups and downs that people without Bipolar Disorder experience. Due to the intensity of these mood swings, people with Bipolar Disorder often struggle with financial trouble, difficulties in relationships, addiction, and thoughts of suicide.


The intense mood swings characteristic of Bipolar Disorder are called episodes and are classified in four categories. On average, episodes occur at least twice a year, with duration varying from person to person, ranging from hourly, daily, weekly, or monthly shifts. The four types of episodes are Mania, Hypomania, Major Depressive, and Mixed.


Mania is defined by euphoria or hostility lasting at least one week or more, with severe symptoms causing difficulty and impairment to daily life. This type of episode can last from a few days to several months. People experiencing manic episodes show symptoms like:

  • Hyperactivity and increased energy
  • Inflated sense of self-confidence
  • Decreased need for sleep
  • Fast, loud, and excessive speech
  • Easily agitated or irritable
  • Racing thoughts
  • Short attention span
  • Overly occupied with specific tasks
  • Risky behavior (overspending, reckless sex, substance use, etc)


The symptoms of a hypomanic episode are similar to those of a manic episode but much shorter and less severe. This means that they do not drastically affect daily social tasks or work.

  • Inflated self-esteem or grandiosity
  • Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
  • More talkative than usual or pressure to keep talking
  • Flight of ideas or subjective experience that thoughts are racing
  • Poor attention and easily distracted (e.g., attention too easily drawn to unimportant or irrelevant external stimuli)
  • Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
  • Excessive involvement in pleasurable activities that have a high potential for painful consequences (unrestrained buying sprees, wreckless sexual practices, impulsive financial decisions)


A major depressive episode leaves a person detached, uninterested in their typically enjoyable activities or depressed for at least 2 weeks. These episodes occur after a manic episode and can happen every few weeks or months for some. Symptoms present themselves as:

  • Extreme sadness, worry, and guilt
  • Feelings of emptiness, hopelessness, or worthlessness
  • Decrease in energy and activity levels
  • Trouble with sleeping (they may sleep too little or too much)
  • Feeling tired or “slowed down”
  • Restlessness, fatigue, or insomnia
  • Feeling they cannot enjoy anything
  • Lack of interest or motivation
  • Trouble concentrating
  • Forgetful and poor memory formation
  • Poor eating (too much or too little)
  • Weight fluctuation
  • Thoughts of death or suicide

Mixed Episodes

These episodes are mostly what the name reflects. The person displays a presence of high and low symptoms at the same time or within an episode of mania or depression. Moods alternate between elevated and depressed over time in most forms. A person with mixed features goes through symptoms of both mood “poles” in rapid sequence or at the same time.

Types of Bipolar Disorder

The two most common types of Bipolar are Bipolar 1 and Bipolar 2. The main differences lie in severity:

  • A person with BPD 1 will experience a severe manic episode that can often lead to hospitalization, and may or may not experience a severe depressive episode.
  • A person with BPD 2 will experience less severe hypomanic episodes and will experience a major depressive episode.

Dr. Patrick McKeon explains that Bipolar Disorder inhibits the ability to clearly recollect the past or see towards the future. This can explain why people with Bipolar Disorder are less prone to learning from mistakes, making it difficult to perceive the repercussions of future actions. These two symptoms of BPD make a person extremely prone to impulsive and dangerous risk-taking. In short, despite having a bad experience with alcohol and substance abuse, they may fail to weigh the consequences. When living in the “right here, right now”— highs are experienced in extremes, as are lows.

What causes BPD?

Bipolar Disorder is the result of hormonal and chemical imbalances in the brain. However, there is no clear cause for Bipolar Disorder. Genetic predisposition has some correlation. Family members of those with BPD have a 5-10% risk of also having it. However, simply being at a higher risk does not mean it will be developed. Most scientists believe certain environmental factors like stress, trauma, and substance abuse are necessary to trigger symptoms in people with Bipolar Disease. Understanding these triggers—and avoiding them—can minimize symptoms and limit the number of cycles a person will go through. Types of triggers include:

  • Poor health
  • i.e poor sleep habits, lack of exercise, hormonal changes like pregnancy/menstruation)
  • Toxic relationships and altercations with loved ones
  • Alcohol and drug misuse
  • OTC medications (i.e. antidepressants/stimulants)
  • Drastic life changes
  • Grief, loss, a new responsibility, falling in love, vacations, seasonal change, loud music