Comorbid PTSD, Bipolar I, and Substance Use Disorder

Convoy in Somalia, by Peter Varisano, courtesy of the Army Art Collection, US Army Center of Military History.

On its own, posttraumatic stress disorder (PTSD) is a devastating disorder. However, it is not always seen as the sole diagnosis: the most challenging PTSD patients are often the ones whose symptoms do not fit neatly into one diagnosis, but instead present with symptoms that span multiple diagnostic categories. In particular, the constellation of PTSD, bipolar I disorder, and substance use disorder creates a daunting challenge, as each diagnosis brings with it a set of symptoms that interfere with treatment of the others, and the synergies between co-occurring disorders yield a result far more complex than just a sum of the component disorders’ symptoms.

For example, PTSD is typified by avoidance, which reinforces the desire to use substances for escape. The same avoidance can lead to the patient’s noncompliance with their treatment plan for bipolar I disorder. Also, bipolar I disorder can take the paranoia and reexperiencing seen in PTSD and bring it to the level of true psychosis , making these symptoms more real and terrifying to the person reexperiencing his trauma. In addition, substance use in PTSD can blunt the ability to participate in psychotherapies requiring higher-level cognition, such as exposure therapy, and may even reinforce the disordered brain chemistry that medications prescribed for bipolar I disorder attempt to correct [1]. Finally, all three can interfere with sleep, which is often one of the most important symptoms to manage in the pursuit of recovery.

The following two examples will explore these issues in case format, and were created with compiled details from multiple active duty patients treated by the author. It will discuss the risks of polypharmacy, additional areas of caution for medication management, and the consideration of somatic and complementary treatments. It will also discuss the goals of an appropriate treatment plan and the prognostic indicators for the patient suffering from all three disorders.

17.1 Case 1

17.1.1 Case Presentation/History

17.1.1.1 Identifying Information

SPC Jones is a 43-year-old married Caucasian male diagnosed with PTSD, bipolar I disorder, and alcohol use disorder, severe. He is an activated US Army National Guard reservist, and completed a 9-month deployment to Operation Iraqi Freedom 6 months ago. As will be described below, he had significant exposure to death and combat during this deployment. He is a combat support specialist (31B) with 4 years’ time in service. When not activated, he works as a commercial building inspector for his home state.

He was referred to the clinic for medical management after having been stabilized in the inpatient unit for a manic episode with psychosis. He has gone back and forth between hospitalizations and the partial hospitalization program over the past 6 months, with sometimes less than 24 h between admissions.

A chart review reveals that he also showed hypomanic and depressive symptoms during his deployment, though the deployed behavioral health assets were able to help him remain in theater and avoid early return. Psychiatric testing done by the partial hospitalization team confirmed these diagnoses.

17.1.1.2 History of Present Illness

SPC Jones arrived on time for his initial appointment, but took 20 min longer than average to fill out the clinic paperwork. When he finally finished, it was incomplete and confusingly written, with arrows and extrapolations filling the blank sides of the form for some questions, while others were left blank. He appeared hypomanic with pressured, barely interruptible speech, flights of ideas, psychomotor agitation, and frequent tangents.

He had some insight into his current state however, saying, “This is nothing Doc, usually I’m at a 10/10, but today I’m just a 7!” When asked to explain what that means he reported that he always feels “keyed up” and cannot relax. He was entertaining in his long-winded and tangential stories, but very difficult to interview. He also interrupted to mention that his main agenda today is to convince the provider to increase his lithium in the hopes that this might help him “chill out.” After reviewing his recent lithium blood level of 1.1 and providing education on therapeutic range and toxicity risks, he agreed to not take more than prescribed. He denied recent depressive symptoms, though he has gone through severe depressive episodes in the past.

When asked, he reported that he sleeps “okay.” However, when pressed for more detail he admitted that his roommates in the barracks have complained that he screams, yells, cries, and kicks the walls at night. He does not remember these episodes now that he is taking risperidone and quetiapine fumarate every evening, but he sometimes wakes up feeling sore.

He first began drinking at age 15, and told the provider that he does not remember most of his 20s or 30s due to his heavy drug and alcohol use. While he admitted to using multiple drugs, alcohol was always his drug of choice. Despite that history, his last drink was 7.5 years ago due to extensive involvement in Alcoholics Anonymous (AA).

During the periods of heavy alcohol and drug use he had numerous encounters with law enforcement. The reasons for arrest were always related to his substance use, to include several Driving Under the Influence(DUIs). When asked how he was able to enlist with that background, he reported that it was during the height of the Iraq and Afghanistan conflicts when recruiters were unable to meet their minimum quotas, especially in the National Guard. His recruiter had minimal difficulty helping him obtain waivers, especially since none of his convictions were felony charges.

In regard to his PTSD diagnosis, he reports that during his deployment , “We were in a complete industrial wasteland… People just hobbling down the street… kids begging for water and food….” He had to dispose of body parts regularly; the worst was when he was ordered to transport a killed civilian Iraqi’s head in a bag and then pry open an eye in order for the receiving personnel to perform biometric iris scanning. He was also regularly exposed to mortar attacks and the occasional chaotic combat mission where his unit took active fire and casualties.

He described intrusive, vivid memories/flashbacks/hallucinations of these incidents, and used to experience nightmares prior to his current med regimen. At his worst he “sees severed heads everywhere,” and this combined with his increasing mania led to his most recent hospital admission. He avoids everything that might remind him of these events, and this has begun to include all public transportation and crowded locations. He has not left the base that houses the hospital and his barracks since arriving, and has refused to go on therapeutic outings sponsored by the hospital or warrior transition unit.

He has started to generalize this fear to the base as well, and sometimes believes he is seeing snipers hidden in various places when he walks from building to building. He showed the provider the knife that he wears on his belt to protect himself when he has to leave his barracks room, and does not respond well to the request that he should not bring weapons to the clinic, though he put the knife away without making any threats.

He has no interest in any of his old pre-deployment activities outside of AA, and while he is still married he feels very disconnected from his wife, friends, and family. His wife has chosen to stay in their home state instead of joining him while he goes through the medical board process. He speculates that she must be having an affair and probably intends to leave him, but feels too removed to care.

17.1.2 Diagnosis/Assessment

This is a patient who meets the criteria for PTSD, bipolar I disorder, and alcohol use disorder , severe. The diagnoses for this patient are clear, and have been verified by multiple providers across various medical settings as well as with psychological testing. The challenge here is not diagnosis, but coming up with a treatment regimen able to control his symptoms and get him well enough to return to post-deployment life.

Contributing to his current presentation are his history of substance use, military deployment with repeated traumatic exposure, and long-standing mood symptoms. These symptoms have led to decades of dysfunction starting in his teen years, though he was able to hold a steady job and maintain his marriage for a few years prior to the deployment. While he has a wife and extended family, his support system is tenuous at best. His long history of sobriety might be considered a positive prognostic indicator, though the severity of his previous substance use history puts him at high risk for relapse during this time of significant stress.

17.1.3 Treatment/Management

There are two important considerations to keep in mind for medication management in such cases. The first is the risks versus benefits of polypharmacy. The medications tried for this patient include aripiprazole, olanzapine, lithium, gabapentin, fluoxetine, trazodone, propranolol, buspirone, quetiapine fumarate, hydroxyzine, clonazepam, and ziprasidone, at various times over 1 year of treatment. Though he never suffered from extrapyramidal side effects, neuroleptic malignant syndrome, or serotonin syndrome, he was at high risk for all three, as well as p450 interactions. This is of course in addition to the myriad other side effects that each medication could cause on its own.

In addition to interactions and side effects, polypharmacy for a patient like this can lead to poor medication compliance and accidental overdose. An unintentional overdose did occur when this patient accidentally took his evening medication twice, leading to mental status changes, QT prolongation, temporary renal injury, and a brief hospitalization, but luckily no long-term complications.

The second consideration is that medication used as first-line treatment for one diagnosis might be contraindicated for another. For example, clonazepam (for acute mania only) and second-generation antipsychotics are recommended treatments for bipolar I disorder, yet both carry D-level recommendations (harms outweigh benefits) in Veterans Affairs/Department of Defense (VA/DOD) guidelines for the treatment of PTSD [2]. As stated in these guidelines:

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