Varun Bisessar

Michael Grove

ENGL21003

11/10/2018

Is there a treatment? The Relationship Between Obsessive Compulsive Disorder and Bipolar Disorder

Studies have indicated that Obsessive Compulsive Disorder (OCD) and Bipolar Disorder (BD) share symptoms. However, confusion has surrounded whether OCD is a type of BD or if there is a comorbidity between OCD and BD, referred to as “bipolar-OCD”. Psychiatrists face a major dilemma when attempting to treat patients suffering from bipolar-OCD because the Selective Serotonin Reuptake Inhibitors (SSRIs) used for a patient singularly affected by OCD may exacerbate the symptoms of BD in a patient suffering from bipolar-OCD. This review will analyze relevant research findings and assessments, define OCD and BD and their symptoms, the revelation that BD and OCD can cooccur, why this comorbid disorder has posed a diagnostic dilemma for psychiatrists, and how the treatments of these disorders differ. Of the current research available, many studies display limitations that must be addressed in order for further research to be conducted.

“OCD is an anxiety disorder in which people have reoccurring, unwanted thoughts, ideas or sensations (obsessions) that make them feel driven to do something repetitive (compulsions)” (American Psychiatric Association, 2013). “Bipolar I disorder is diagnosed when a person has a manic episode. Bipolar II disorder involves a person having at least one major depressive episode and at least one hypomanic episode” (American Psychiatric Association, 2013). When disorders as such are comorbid psychiatrists have to separate the symptoms of the main disorder and the comorbid disorder. Treating the symptoms of both OCD and BD as separate disorders require years of therapy along with medication. The (SSRIs) that are institutionally accepted for treating OCD become less effective when given to a comorbid patient because (SSRIs) exacerbate manic episodes.

With regard to the discovery of OCD, French physicians are credited. Consequently, a study conducted in Germany in 1995 revealed that patients with a primary diagnosis of bipolar disorder had experienced other mental disorders, prevalent were symptoms of OCD (Shi, 2015). The comorbidity of bipolar-OCD is no secret to psychiatrists. However, the discovery of bipolar-OCD has recently revealed flaws in the methodology used for diagnosis. Manic episodes are a primary symptom of bipolar I disorder, and it has been proven that symptoms of OCD occur frequently during manic episodes. Research currently available on bipolar-OCD has not specified whether or not publications are based off of groups experiencing manic or hypomanic episodes.

Analyzing this background, since most publications available on bipolar-OCD were published after studying a group of patients who were experiencing a manic or hypomanic episode, then the publications are not plausible for diagnosis. “A systematic review by Amerio and colleagues found that among patients with comorbid bipolar disorder and OCD, OCD symptoms were more likely to occur during depressive episodes than manic episodes” (Shi, 2015). In addition, Shi suggests that “the occurrence of obsessive-compulsive symptoms during the depressive (or manic) episodes of a bipolar disorder should not be sufficient to merit a diagnosis of comorbid bipolar disorder and OCD.” In particular, this limitation in current publications has led to precautionary action by psychiatrists responsible for diagnosing patients suspectible to bipolar-OCD. Consideration of data from future studies must specify whether or not the study was conducted while patients were experiencing manic episodes.

Recent research has focused on proving the prevalence of obsessive-compulsive symptoms during manic episodes, as a relative agreement around the field of bipolar-OCD has emerged. “Obsessive-compulsive symptoms occurred only during manic episodes with complete remission during periods between manic episodes” (Chandran, 2017).  In the same vein, current publications discuss the occurrence of obsessive-compulsive symptoms only during manic episodes. Based upon the background that BD and OCD can cooccur (bipolar-OCD), the major challenge in this scientific discussion has shifted to diagnosis. The objective is to separate the primary disorder from the cooccurring disorder to establish where a psychiatrist should begin treatment.

The uncertainty aroused by where psychiatrists should begin treatment exposed the variation in responses from individuals dedicated to the field. For example, “One very unusual finding in our patient might support the possibility of obsessive-compulsive symptoms being a part of BPAD and not a separate diagnosis” (Chandran, 2017). Chandran’s diagnostic was based upon the initial studies that did not acknowledge the connection between obsessive-compulsive symptoms and manic episodes. This instance exposes errors that psychiatrists did not intend to make because they used the research available to them. As a result, the approach for diagnosing bipolar-OCD now relies solely on the standardized testing criteria established in the DSM validated assessment scales. The DSM criteria is the only relatively accepted framework because the scales are institutionally accepted for the separated disorders, in this case they are a merged assessment.

The diagnostic scales fall into two categories, patients with a primary diagnosis of BD whose comorbid OCD appears related to manic episodes (Amerio, 2016). This conceptualization reveals the limitations referred to earlier in this review. The patients who are primarily diagnosed with BD only experienced obsessive-compulsive symptoms during manic episodes, making it less likely that (SSRIs) would exacerbate obsessive-compulsive symptoms. However, the second category of patients are diagnosed with primary OCD and a secondary diagnosis of BD with obsessive-compulsive symptoms (Amerio, 2016). The second category of patients suffer from both OCD and BD, however when they experience a manic episode their obsessive-compulsive symptoms are exacerbated. Studies conducted by Amerio have illustrated the details to pay attention to when studying bipolar-OCD. Diagnosing bipolar-OCD is not easy for psychiatrists, however having these two categories assist because treatment begins with the primary diagnosis and is modified to reduce the chances of exacerbating the comorbid disorder.

In an attempt to test the effectiveness of the DSM criteria scale, a study assessing bipolar-OCD patients and BD patients with obsessive-compulsive symptoms used the structured clinical interview criteria laid out in DSM-IV alongside the Yale-Brown Obsessive-compulsive scale (Y-BOCS). “A total score ≥16 on the Y-BOCS was required for a diagnosis of clinically significant OCD; patients showing a total score <16 on the Y-BOCS and not fulfilling DSM-IV criteria for OCD were labelled as having obsessive-compulsive symptoms (OCS)” (Kazhungil, 2017). Scales such as the Y-BOCS can be used in conjunction with the DSM criteria because they give psychiatrists two sets of data to analyze before diagnosis. The Y-BOCS scale conveniently clarifies if the patient is experiencing bipolar-OCD or a primary BD with obsessive compulsive symptoms, thus verifying the effectiveness of the institutionally accepted DSM scale.

If a patient is properly diagnosed, then the treatment process becomes manageable for the psychiatrist. Unlike diseases, disorders cannot be cured and often last a lifetime therefore treatment is necessary to gradually manage symptoms. Normally (SSRIs) are prescribed to patient’s suffering from OCD, Fluoxetine is the most commonly used anti-obsessional drug. However, a side effect of (SSRIs) include hypomania which is a symptom of bipolar II disorder. “Serotonin reuptake inhibitors (SSRIs) for OCD can cause mania and/or more mood episodes in BD” (Amerio, 2015). A reason as to why this could happen is both OCD and BD can be managed by taking (SSRIs), however the (SSRIs) used to treat isolated OCD and BD differ and therefore using Fluoxetine to treat bipolar-OCD would exacerbate the symptoms of BD. Currently there is no medication that can relieve the symptoms a bipolar-OCD patient experiences which forces psychiatrist to experiment with Fluoxetine to the best of their ability.

Working with Fluoxetine requires low dosages ranging from 20 mg to 60mg capsules, in general OCD treatment the initial dosage is one 20mg capsule for the day. Capsules are fast acting and enter the blood stream relatively quickly which relieves the obsessive-compulsive symptoms. The approach for bipolar-OCD is cautiously taken among psychiatrists, understanding the patient’s mood should be the first step. “Mood stabilization should be the first objective in treating apparent BD-OCD patients, not immediate treatment with selective serotonin reuptake inhibitors (SSRIs)” (Amerio, 2015). The treatment methodology that Dr. Amerio describes is ultimately suited for bipolar-OCD patients because there is a possibility that Fluoxetine can relieve the symptoms of bipolar-OCD.

Considering Dr. Amerio’s diagnosis, before prescribing medication the psychiatrists should attempt to understand the patient’s mood changes. “In a minority of BD patients with refractory OCD, addition of low doses of antidepressants might also be considered while strictly monitoring emerging symptoms of mania and hypomania.” (Amerio, 2015). As of now there is not an institutionally accepted treatment for bipolar-OCD, full dosage of (SSRIs) cannot be used because they will exacerbate hypomania. Overall, the commonalities in available research has deemed the DSM validated assessment scales suitable to accurately diagnose bipolar-OCD. Psychiatrists such as Dr. Amerio suggest scheduling therapy sessions with patients to stabilize their mood and if the psychiatrist deems it necessary to prescribe (SSRIs), they should do so with low dosage and strict monitoring of the symptoms.

The contribution that this article makes to the literature at present is acknowledging the scope of bipolar-OCD and display the limitations that must be addressed in order for further research to be conducted. The limitations of bipolar-OCD research have partly decreased because of the recent publications. Previously vast publications had not specified whether the groups they studied were experiencing manic episodes during the study time frame. Manic episodes increase the occurrence of obsessive-compulsive symptoms which could have resulted in wrongful diagnosis of patients. Also, as attention towards these patients has grown, the research produced must also grow. Many of these studies are conducted in India and China, the scale size of the research groups has limited the number of patients that can be studied. The studies currently available have not declared a funding source which may reason the limitations of research.

In the United States alone hundreds of thousands of OCD cases are reported and millions of BD cases. Accordingly, Shi recommends “Well-designed prospective studies with relatively large samples that are specifically focused on this important subgroup of bipolar disorder patients are needed.” With larger studies, physiatrists could reveal if the DSM validated assessment scales have any underlying faults. The best suited psychiatrists for further research include those specialized in BD and OCD treatment as individual disorders. “The clinicians who regularly treat bipolar patients need more high-quality, evidence-based information to improve their identification and management of this relatively severe and refractory subgroup of bipolar patients.” (Shi, 2015). In the future, medicine manufactures could partner with psychiatrists to conduct imaging that could corroborate the possibility of developing a specific medication for bipolar-OCD patients. The complexity of comorbid bipolar-OCD requires further prospection, although it will never be treated its conditions could become easily targeted and suppressed with the advancements called for in this review.

References:

Amerio, A., Stubbs, B., Odone, A., Tonna, M., Marchesi, C., & Nassir Ghaemi, S. (2016). Bipolar I and II Disorders; A Systematic Review and Meta-Analysis on Differences in Comorbid Obsessive-Compulsive Disorder. Iranian journal of psychiatry and behavioral sciences, 10(3).

Amerio, A., Tonna, M., Odone, A., Stubbs, B., & Ghaemi, S. N. (2015). Heredity in comorbid bipolar disorder and obsessive-compulsive disorder patients. Shanghai archives of psychiatry, 27(5), 307-310.

Chandran, N., Parmar, A., & Deb, K. S. (2017). A Rare Presentation of a Case of Obsessive-compulsive Disorder Comorbid with Bipolar Affective Disorder. Indian journal of psychological medicine, 39(6), 794-796.

Kazhungil, F., Cholakottil, A., Kattukulathil, S., Kottelassal, A., & Vazhakalayil, R. (2017). Clinical and familial profile of bipolar disorder with and without obsessive-compulsive disorder: an Indian study. Trends in Psychiatry and Psychotherapy, 39(4), 270-275.

Shi S. (2015). Obsessive compulsive symptoms in bipolar disorder patients: a comorbid disorder or a subtype of bipolar disorder. Shanghai archives of psychiatry, 27(4), 249-51.