Mood and Obsessive-Compulsive Disorder

Science Finds a Link between OCD and Bipolar Disorder

Comorbid OCD and Mania or Depression

Comorbidity, when one is diagnosed with two or more psychiatric disorders, is very common. Depression has long been known to be comorbid with obsessive-compulsive disorder (OCD), but it was not until recently that bipolar disorder was also shown to be linked to OCD. Perhaps this is not surprising, as major depressive episodes are crucial elements of bipolar disorder.

Bipolar Disorder

Bipolar disorder was once called "manic depression." Bipolar disorder is characterized by alternating extreme "poles" of emotion, with periods of mania and periods of depression. According to the DSM-IV-TR (the diagnostic manual for professionals created by the American Psychiatric Association), a manic episode is a "distinct period during which there is an abnormal and persistently elevated, expansive, or irritable mood." People in manic episodes often feel euphoric, full of energy, and have inflated self-esteem, all of which lead to impairment in social and occupational functioning.

Manic episodes appear in stark contrast to major depressive episodes, which are an equal and opposite component of bipolar disorder. The DSM-IV-TR describes major depressive episodes as "period(s) of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities." People in depressive episodes often feel tired, hopeless, and unable to concentrate, and they typically experience changes in their weight and sleep cycle.

People experiencing at least one manic and one major depressive episode may be diagnosed with Bipolar I disorder. There is also a diagnosis for Bipolar II disorder in which one suffers from major depressive episodes and hypomanic, rather than manic episodes. Hypomanic episodes have the same set of symptoms as manic episodes, but they do not result in significant social and occupational impairment. Hypomania can be thought of a less severe form of mania.

The OCD Connection

In a study by Angst et al (2004), of those with OCD, 53% had hypomanic symptoms and 30% were given a Bipolar II diagnosis. Other studies have supported the increased prevalence of OCD with Bipolar II over Bipolar I (Masi et al, 2004). That study also reported that for those with comorbid bipolar and OCD, the age of onset for OCD is earlier. A study analyzing data from a large nation-wide sample found that for those with either Bipolar I or II (although most had Bipolar II), 21% had comorbid OCD (Raja, 2005).

In terms of the presentation of the disorders, Masi et al (2004) found that the types of compulsions differ between those with comorbid bipolar and OCD and those with just OCD. Those with pure OCD have more checking compulsions while those with comorbidity exhibit more obsessions that are classified as "other," which they described as "existential, philosophical, and/or superstitious." In general they found that although the amount of obsessions were equal whether comorbid or not, those who also had bipolar disorder actually had fewer compulsions.

Those with comorbid bipolar disorder and obsessive-compulsive disorder typically experience heightened feelings of distress over those with only one of the disorders. This is not unique to comorbid OCD and bipolar disorder; comorbidity in general is typically reflected by increased levels of distress and increased treatment (Angst et al, 2005). For those with comorbid OCD and bipolar disorder, there is also an increased risk for alcohol and substance abuse (Perugi & Toni, 2004).

Treatment

For those with comorbid bipolar disorder and OCD, a combination pharmacological treatment of mood stabilizers and antidepressants is recommended (Angst et al, 2005). Although cognitive-behavior therapy is extremely effective in treating the symptoms of OCD, bipolar symptoms are best treated with medication. Perugi & Toni (2004) name Valproate as a good mood stabilizer. Interestingly, however, they note that antidepressants commonly used for OCD, such as SSRIs, may worsen bipolar disorder (particularly if given prior to mood stabilizers), and atypical antipsychotics, commonly used for bipolar patients, may worsen OCD. Clearly one must proceed with caution when attempting to treat the common occurrence of comorbid OCD and Bipolar disorder. Competent psychiatric care is essential as medications may need to be adjusted frequently to address shifts in mood.

References: American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, DSM-IV-TR. Washington, DC: American Psychiatric Association. Angst, J., Gamma, A., Endrass, J., Hantouche, E., Goodwin, R., Ajdacic, V., et al. (2005). Obsessive-compulsive syndromes and disorders: Significance of comorbidity with bipolar and anxiety syndromes. European Archives of Psychiatry and Clinical Neuroscience, 255, 65-71. Angst, J., Gamma, A., Endrass, J., Goodwin, R., Ajdacic, V., Eich, D., et al. (2004). Obsessive-compulsive severity spectrum in the community: Prevalence, comorbidity, and course. European Archives of Psychiatry and Clinical Neuroscience, 254, 156-164. Freeman, M. P., Freeman, S. A., & McElrow, S. L. (2000). The comorbidity of bipolar and anxiety disorders: Prevalence, psychobiology, and treatment issues. Journal of Affective Disorders, 68, 1-23. Masi, G., Perugi, G., Toni, C., Millepiedi, S., Mucci, M, Bertini, N., et al. (2004). Obsessive-compulsive bipolar comorbidity: focus on children and adolescents. Journal of Affective Disorders, 78, 175-183. Perugi, G., & Toni, C. (2004). Bipolarity presenting as anxiety disorders. Primary Psychiatry, 11(10), 31-35. Raja, M. (2005). Comorbidity and management of obsessive-compulsive disorder and bipolar disorder. Directions in Psychiatry, 25(3), 183-196.

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Disclaimer: This information should not be considered medical advice and should not substitute the judgment of a competent psychiatrist.

Credits: Article written by E. Mcgee, edited and reviewed by M. Williams, Ph.D.