In a 37‑year‑old woman with bipolar disorder, recurrent aggressive outbursts (punching walls) and nicotine dependence, what is the most likely diagnosis and recommended management?

Diagnosis and Management of a 37-Year-Old Woman with Bipolar Disorder, Aggressive Outbursts, and Nicotine Dependence

This patient has bipolar disorder with comorbid tobacco use disorder (nicotine dependence), and the aggressive outbursts (punching walls) represent mood dysregulation requiring mood stabilization before addressing smoking cessation. 1

Primary Diagnoses

• Bipolar disorder with inadequate mood control, manifesting as anger episodes and aggressive behavior (punching walls) 2
• Tobacco use disorder (nicotine dependence) per DSM-5 criteria, which now aligns nicotine dependence with other substance use disorders 2

The aggressive outbursts are consistent with mood lability and irritability seen in bipolar disorder, particularly when mood is not adequately stabilized 2. These episodes do not constitute a separate diagnosis but rather reflect poor mood control requiring optimization of bipolar treatment.

Management Algorithm

Step 1: Prioritize Mood Stabilization (4-6 Weeks Minimum)

Never attempt intensive smoking cessation during active mood instability—this is a critical pitfall that can worsen outcomes. 1

• Initiate or optimize mood stabilizer therapy with lithium, valproate, or atypical antipsychotics 1
• Ensure therapeutic medication levels are achieved and maintained 1
• Schedule weekly to biweekly visits during the first month to monitor mood stability, assess for manic or depressive symptoms, and evaluate suicidal ideation 1
• Continue mood stabilizer adjustments until anger episodes, irritability, and aggressive behaviors are controlled for at least 4-6 weeks 1

Step 2: Address Nicotine Dependence After Mood Stabilization

Only after achieving adequate mood control with therapeutic medication levels for 4-6 weeks should you add cessation pharmacotherapy. 1

Pharmacotherapy Options:

• First-line medications: Varenicline, bupropion SR, or nicotine replacement therapy (NRT patch, gum, lozenge, inhaler, nasal spray) 2
• Combination therapy is more effective than monotherapy, particularly for moderate to severe dependence 2
• Varenicline (1 mg twice daily after titration from 0.5 mg once daily) is the newest first-line option and may be tried if other medications have failed 2
• Continue maintenance mood stabilizer therapy throughout the cessation process to prevent mood destabilization 1

Counseling Approach:

• Use the 5 As strategy: Ask about tobacco use, Advise to quit, Assess willingness, Assist with counseling and pharmacotherapy, Arrange follow-up 2
• Brief 3-minute counseling focusing on: "Are you willing to make a quit attempt now?" and "What worked or didn't work when you tried to quit before?" 2
• Acceptance and Commitment Therapy (ACT) combined with nicotine patches shows preliminary evidence of efficacy in bipolar patients, with 40% abstinence rates in pilot studies 3
• Cognitive Behavioral Therapy (CBT) or ACT-based psychotherapies are suitable for this population 4

Step 3: Intensive Monitoring During Cessation

• Schedule weekly to biweekly visits during the first month of cessation attempts 1
• Monitor for mood destabilization, emergence of manic or depressive symptoms, and suicidal ideation at each visit 1
• Continue monthly monitoring for at least 6 months after achieving abstinence, as relapse risk remains elevated 1
• Verify therapeutic drug levels before and during cessation attempts 1

Step 4: Long-Term Maintenance

• Maintain mood stabilizer therapy for at least 12-24 months after mood stabilization 1
• Address the high likelihood of relapse to smoking (adults with bipolar disorder are 50% less likely to quit than the general population) 3
• Consider that nicotine withdrawal symptoms (depression, anxiety, anger/irritability, sleep disturbance) may confound psychiatric assessment and require extra attention 5

Critical Considerations and Pitfalls

Common Mistakes to Avoid:

• Never initiate smoking cessation during acute mania, mixed episodes, or severe depression 1
• Do not assume the aggressive outbursts represent a separate impulse control disorder—they are manifestations of inadequate mood control 2
• Avoid stopping mood stabilizers during cessation attempts, as this increases risk of mood destabilization 1

Special Population Factors:

• Women with bipolar disorder experience more severe nicotine withdrawal symptoms than men 5
• Smoking prevalence in bipolar disorder is 45-70%, which is 2-3 times higher than the general population 4, 6
• Polysubstance use (if present) predicts more severe nicotine withdrawal and requires concurrent treatment 5
• Chronic mood dysregulation, high prevalence of alcohol/drug use, more severe nicotine dependence, and limited social support make quitting more difficult in this population 6

Monitoring Parameters:

• Assess for mood destabilization at every visit during cessation attempts 1
• Monitor adherence to both mood stabilizers and cessation pharmacotherapy 1
• Screen for suicidal ideation, as bipolar symptoms may include thoughts of suicide or self-harm 7
• Evaluate for other substance use disorders that require concurrent treatment 1

Addressing Nicotine Withdrawal in Context

Most smokers with mental illness (65%) experience moderate to severe nicotine withdrawal even with NRT 5. Nicotine withdrawal severity is associated with greater cigarette dependence, more severe overall psychopathology, female sex, and polysubstance abuse 5. This underscores the importance of adequate mood stabilization before cessation and the need for combination pharmacotherapy rather than monotherapy 2.