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.

What Is Bipolar Disorder?

Before discussing the link between bipolar disorder and OCD, it may be 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.

• Dramatic decrease in the need for sleep
• Engaging in pleasurable activities with a high potential for painful consequences, such as impulsive spending and risky sex
• Extreme distraction and unable to focus
• Goal-directed activity (often of a social, professional or sexual nature)
• Inflated self-esteem or grandiosity
• More talkative than usual or pressure to keep talking
• Racing thoughts

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: The most severe form, usually requires hospitalization
• Bipolar II: Similar symptoms, but the mania is not as severe; however, people often experience severe depression
• Cyclothymia: Rapid fluctuation between hypomania and depressive symptoms that are not severe enough to meet the criteria for a Major Depressive Episode
• Bipolar Disorder Not Otherwise Specified: Disorders with bipolar features that do not meet the criteria for the specific bipolar disorders

OCD and Bipolar Disorder

Research has established a strong link between bipolar disorder and OCD.

Interestingly, one analysis found that OCD occurs with bipolar disorder at a much higher rate than the 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 a decrease in specific types of verbal memory.

Implications for Treatment

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 fewer 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. Mood stabilization should be the priority of treatment. SRI medications may be unnecessary with CBT preferred for OCD symptoms.

Also, when OCD and bipolar disorder co-occur, it has been suggested that the treatment of bipolar disorder symptoms takes priority owing to their potentially destructive and harmful nature.