What are treatment options for a patient with bipolar disorder who also exhibits compulsive behaviors, such as skin picking or hair pulling?

Treatment Options for Bipolar Disorder with Comorbid Compulsive Behaviors

For patients with bipolar disorder who also exhibit compulsive behaviors such as skin picking or hair pulling, a combined approach using mood stabilizers with specific behavioral therapies and potentially adjunctive medications targeting the compulsive behaviors is recommended. 1

Understanding the Comorbidity

• Bipolar disorder requires stabilization as the primary concern, while addressing the compulsive behaviors (trichotillomania/hair pulling or excoriation/skin picking) as a separate but related condition 1, 2
• These compulsive behaviors are distinct from obsessive-compulsive disorder (OCD), as they often lack the obsessional thoughts that drive OCD behaviors 1
• The presence of both conditions can complicate treatment and requires careful medication selection to avoid worsening either condition 1

First-Line Treatment Approach

Mood Stabilization (Primary)

• Begin with mood stabilizers to address the bipolar disorder component:
  • Lithium remains the most effective overall treatment for bipolar disorder and should be considered first-line for most patients 3
  • Valproate is an alternative first-line option, particularly when rapid stabilization is needed 1
  • Lamotrigine may be particularly helpful for patients with predominant depressive episodes 3, 4

Atypical Antipsychotics

• Atypical antipsychotics can be effective for both bipolar disorder and may help with compulsive behaviors:
  • Olanzapine has shown efficacy for both bipolar disorder and trichotillomania/skin picking 5, 2
  • Other options include quetiapine, aripiprazole, and cariprazine, which are FDA-approved for bipolar disorder 3
  • Monitor carefully for metabolic side effects, including weight gain, diabetes risk, and lipid abnormalities 1

Behavioral Interventions (Essential Component)

• Habit Reversal Training (HRT) combined with stimulus control is the first-line behavioral treatment for compulsive behaviors 6, 2

  • Involves awareness training, competing response development, and stimulus control techniques
  • Particularly effective when picking/pulling occurs with lowered awareness

• Dialectical Behavior Therapy (DBT) is recommended when emotional dysregulation triggers the compulsive behaviors 6

  • Helps patients develop skills to manage emotions that may trigger both bipolar symptoms and compulsive behaviors
  • Particularly useful for patients whose picking/pulling is triggered by negative emotions

• Cognitive Behavioral Therapy (CBT) adapted for both conditions 1

  • Addresses cognitive distortions related to both bipolar disorder and body-focused repetitive behaviors
  • Includes psychoeducation about both conditions and their interaction

Adjunctive Pharmacological Options for Compulsive Behaviors

• N-acetylcysteine (NAC) has shown efficacy for trichotillomania and skin picking with minimal side effects and no known negative interactions with bipolar medications 6, 4

  • Typically dosed at 1200-2400 mg/day
  • Can be safely combined with mood stabilizers

• Selective Serotonin Reuptake Inhibitors (SSRIs) may be considered with caution 4

  • May help with compulsive behaviors but carry risk of triggering mania/hypomania
  • Should only be used in combination with mood stabilizers, never as monotherapy 3
  • Careful monitoring for mood switches is essential

Psychoeducation and Lifestyle Components

• Psychoeducational therapy for both patient and family regarding:

  • Symptoms and course of both disorders 1
  • Treatment options and medication adherence strategies 1
  • Recognition of early warning signs of relapse 1

• Stress reduction and sleep hygiene are particularly important 1

  • Stable sleep patterns help prevent bipolar episodes and may reduce compulsive behaviors
  • Stress management techniques can reduce triggers for both conditions

Treatment Algorithm

1. Stabilize bipolar disorder first with appropriate mood stabilizers (lithium, valproate, or lamotrigine) 1, 3
2. Add behavioral therapy targeting the compulsive behaviors (HRT, DBT, or CBT) 6, 2
3. Consider adding N-acetylcysteine as a first adjunctive agent for compulsive behaviors 6, 4
4. If inadequate response, consider carefully adding olanzapine (which may help both conditions) 5, 2
5. For persistent compulsive behaviors despite above measures, consider adding an SSRI with careful monitoring for mood switches 4

Special Considerations

• Regular monitoring for side effects of medications is essential, particularly:

  • Metabolic parameters for atypical antipsychotics (weight, glucose, lipids) 1
  • Thyroid and renal function for lithium 1
  • Liver function for valproate 1

• Avoid antidepressant monotherapy as it may trigger manic episodes 3

• Treatment adherence is critical, as more than 50% of bipolar patients struggle with medication adherence 3