Bipolar disorder rarely exists on its own. Ninety-five percent of patients have at least one other diagnosable psychiatric disorder. Anxiety disorders are the most common. These include generalized anxiety disorder, panic disorder, social phobia, specific phobias, post-traumatic stress disorder and obsessive compulsive disorder (OCD). Up to 20% of people with bipolar disorder also have obsessive compulsive disorder. When bipolar disorder and OCD combine, the course of each illness can change and different treatments must be considered.
Anxiety is a part of bipolar disorder, but not all anxious behavior can be considered obsessive or compulsive. If obsessive or compulsive behavior does exist, it has to be evaluated to determine the amount of interference it causes in the patient’s life. At that point, a separate obsessive compulsive disorder can be diagnosed. Conversely, when anxious behavior presents in bipolar disorder, it may not be recognized by the patient as a separate problem. So, it’s important to know what to look for.
The Diagnostic and Statistical Manual of Mental Disorders version IV (DSM-5) defines obsessions as “[R]ecurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted[.]” Compulsions are “repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.”
Wanting wall hangings to be straight or the dishwasher to be loaded a certain way does not mean a person has OCD. Obsessive compulsive disorder is one of the many mental illnesses that are trivialized by common usage and slang.
With OCD, patients either attempt to ignore the persistent, negative urges or to neutralize them in some way. This often leads to compulsive behavior. The action is made to reduce the anxiety associated with the obsession, but is either not connected to the obsession in an obvious way or is clearly excessive. Examples include repeating an action until it “feels right” or showering multiple times a day due to fear of germs or contamination.
The DSM-5 includes subcategories of OCD:
- Body dysmorphic disorder
- Hoarding disorder
- Trichotillomania (hair pulling disorder)
- Excoriation (skin-picking) disorder
- Substance/medication-induced obsessive-compulsive and related disorder
- Obsessive-compulsive and related disorder due to another medical condition
- Other specified obsessive-compulsive and related disorder and unspecified obsessive-compulsive and related disorder (e.g., body-focused repetitive behavior disorder, obsessional jealousy).
Bipolar disorder with OCD has been found to have distinctive traits. The onset of bipolar disorder tends to be earlier. It is more common in bipolar II, rapid-cycling bipolar disorder and in those who are sensitive to seasonality. These patients also tend to have more episodic obsessive compulsive behavior and more depressive episodes. Hospitalization and suicidal behavior are also more common in bipolar disorder patients with comorbid OCD.
The problem with diagnosing OCD as a comorbid disorder is that most bipolar disorder patients only experience obsessive compulsive behavior during mood cycles. In these cases, OC behavior coincides almost exclusively with depressive episodes. Since the OC symptoms don’t persist after episodes, it is difficult to classify the behavior as a separate disorder and not just a distinctive type of bipolar disorder.
Treatment for bipolar disorder with OCD can be complicated as it is often treatment resistant. In the cases where the OC behavior may not qualify as a fully comorbid disorder, mood stabilizers regularly used to treat bipolar disorder are typically enough to treat the OC behavior as well.
If OCD persists outside of mood episodes, additional treatment may be needed. Here is where complications in treatment arise. OCD is generally and successfully treated with antidepressants (SSRI’s). However, SSRI’s can trigger hypomanic or manic episodes in people with bipolar disorder. For these patients, it’s important to treat bipolar disorder as the primary illness. Moods should be stabilized before attempting to introduce SSRI’s and the patient should be continuously monitored for medication-induced mania. In some cases, atypical antipsychotics have been found beneficial as a substitute for SSRI’s.
If a patient is showing signs of obsessive compulsive behavior, it’s important that they contact their doctor. Bipolar disorder with comorbid OCD can have poorer outcomes, so assessments and/or medication changes may need to be made.
Image credit: Arlington County