The Link Between OCD and Bipolar Disorder

Clinical research suggests that OCD and bipolar disorder co-occur with each other at a higher rate than would be expected by chance. Importantly, the presence of bipolar disorder can affect OCD symptoms and treatment. Let’s explore the link between OCD and bipolar disorder.

Before discussing the link between bipolar disorder and OCD, it may helpful to first describe the symptoms of bipolar disorder. Bipolar disorder is a mental illness where the affected person experiences one or more "manic" or "mixed" episodes; however, most people with bipolar disorder have also had one or more ​episodes of depression.

Mania is a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week. A manic episode is usually accompanied by three or more of the following symptoms.

• inflated self-esteem or grandiosity.
• a dramatic decrease in the need for sleep.
• feeling more talkative than usual or a pressure to keep talking.
• racing thoughts.
• feeling extremely distracted and unable to focus.
• increase in goal-directed activity (often of a social, professional or sexual nature).
• excessive involvement in pleasurable activities that have a high potential for painful consequences, such as spending sprees, sexual indiscretions, or impulsive investments.

To be diagnosed as a manic episode, these symptoms have to be severe enough to cause major disruption at work or at home. In addition, a manic episode often requires that the person goes to the hospital for treatment. It is not uncommon for people with mania to show features of psychosis, such as delusions.

Currently, there are four subtypes of bipolar disorder: Bipolar I, Bipolar II, Cyclothymia, and Bipolar Disorder Not Otherwise Specified.

• Bipolar I is the most severe form and usually requires hospitalization.
• Bipolar II has similar symptoms, but the mania is not as severe; however, people affected by bipolar II often experience severe depression.
• Cyclothymia is an illness in which the person fluctuates rapidly between periods of hypomania and depressive symptoms that are not severe enough to meet criteria for a Major Depressive Episode.
• The Bipolar Disorder Not Otherwise Specified category includes disorders with bipolar features that do not meet criteria for the specific bipolar disorders.

Research has established a strong link between bipolar disorder and OCD. It has been estimated that between 10 to 35% of people with bipolar disorder also have OCD, with most reporting that their OCD symptoms started first. Indeed, OCD is thought to be the most frequently occurring anxiety disorder among people with bipolar disorder.

Interestingly, one analysis found that OCD occurs with bipolar disorder at much higher rate than major depressive disorder. This study found that people with bipolar disorder are between two and five times more likely to have OCD than people with major depressive disorder.

In general, people who are affected by both bipolar disorder and OCD seem to have very high rates of other forms of mental illness; in particular, panic disorder as well as impulse control disorders.

Although there is not one particular gene that links OCD and bipolar disorder, there is increasing evidence that these two disorders may share some genes. Behaviorally, both people with bipolar disorder and people with OCD show decreases in specific types of verbal memory.

When bipolar disorder and OCD occur together, the symptoms of bipolar disorder tend to be much worse and more difficult to treat than bipolar conditions that occur without OCD. People with both OCD and bipolar disorder also tend to show more frequent use and abuse of substances such as drugs and alcohol. Substance use often complicates treatment and usually predicts worse outcomes. There is also some evidence that when OCD occurs with bipolar disorder, there are less checking compulsions but more obsessions related to religious and sexual themes.

It is important to note that OCD in the presence of bipolar disorder may require the use of different treatment strategies, as many of the antidepressants that are commonly used to treat OCD can sometimes exacerbate or even cause symptoms of mania or hypomania. Also, when OCD and bipolar disorder co-occur, it has been suggested that treatment of the bipolar disorder symptoms take priority owing to their potentially destructive and harmful nature.