Bipolar Plus OCD: Which to Treat First?

Psychiatric TimesVol 33 No 12
Volume 33
Issue 12

Be cautious: not all obsessive thinking is OCD.

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A 30-year-old woman with subtle paranoia and a history of mood cycling and obsessive preoccupations is brought by her family for treatment. Only after she is given an antidepressant for her presumed obsessive-compulsive disorder (OCD) does she begin to have delusional thoughts.


Is there some sort of overlap between OCD and bipolar disorder? If so, how can one treat the OCD without worsening the bipolar? On the issue of overlap, a search of PubMed yields many articles describing a clear connection between the two, from genetics to prevalence to clinical occurrence. Are these just unlucky people with 2 problems? Or do these folks have bipolar disorder, with an OCD-like presentation?

Combination bipolar disorder–OCD patients are more likely to have a family history of mood disorders and less likely to have a family history of OCD, “supporting the view that the majority of cases of comorbid BD-OCD are, in fact, BD cases.”1 This is not just an academic issue: if in these overlap cases the OCD symptoms are somehow part of bipolar disorder, treatment can focus on bipolar and the “OCD” may resolve without adding an antidepressant that could worsen bipolar cycling, induce mixed states, or even cause psychosis.

Bipolar disorder–OCD overlap is common: between 15% and 20% of patients with bipolar disorders also meet criteria for OCD.2 When found together, the conditions interact: OCD symptoms worsen during depression and improve during mania (most but not all of the time).3 Importantly then, in the overlapping presentation, OCD symptoms often cycle. In one study, they worsened then remitted in 75% of the OCD-bipolar patients versus only 3% of pure OCD patients.3

Therefore, in a patient whose OCD symptoms clearly come and go and who also has episodes of depression, one should consider the possibility of a bipolar disorder before treating with antidepressants. (Oh, all right, yes, you should consider bipolar disorder in nearly every patient; very few conditions in the DSM do not warrant bipolar disorder in the differential.)

Can treating the bipolar make the “OCD” go away? The answer is clearly yes, though not in all such cases.4 Even a case of hoarding remitted when serotonin reuptake inhibitors were discontinued in favor of lamotrigine.5 Thus, when one sees bipolar disorder and OCD together, treat the bipolar first. The OCD symptoms might remit.

And if they don’t? Then first turn to the non-medication approach to OCD: the variation of cognitive- behavioral therapy (CBT) known as exposure and response prevention (ERP). Indeed, ERP is a good place to start for all OCD patients. ERP yields slightly more improvement than does antidepressant medication6; and it is obviously preferable as a long-term treatment, since its benefits last when treatment is stopped.7

But ERP is hard to access: very few CBT specialists also regard themselves as ERP specialists. This is ironic because “inexperienced master’s students with no postgraduate training can be as capable as experienced and certified behavior therapists in treating OCD patients, as long as therapists adhere to a standardized treatment manual and adequate training and supervision is provided.”8 So presumably an ex­perienced CBT therapist could follow the manual and do well the first time.

The American Psychological Association has a remarkable collection of resources on one webpage, with links to 2 manuals, handouts, references, and trainings.9One free online manual written for patients could be used as the guide while the therapist coaches, though this approach has not been studied in a randomized trial.10

There may be clues that OCD is not an independent comorbid condition but is instead a manifestation of bipolar disorder.

There may be clues that OCD is not an independent comorbid condition but is instead a manifestation of bipolar disorder. First, bipolar OCD cycles, as described above.3,11 Second, although I did not encounter this in a brief review, in my experience most patients with bipolar-related OCD tend not to have “classic” features (though the literature makes clear that even typical OCD is among these combined presentations). The typical OCD obsessions are12:

• Contamination (germs, dirt, feces, chemicals)

• Losing control (acting on an impulse, uncontrolled images in one’s mind, blurting out, stealing)

• Harm (being responsible for something terrible happening, not being careful enough)

• Perfection (evenness; exactness; fear of forgetting, losing things; lucky numbers; superstition)

• Unwanted sexual thoughts (forbidden, perverse thoughts/impulses/images)

• Religion (concern with offending God or concern about blasphemy)

By comparison, I often see patients who’ve received a diagnosis of OCD based on their obsessive thinking, ruminating about extreme ideas that are not on this list. Their “OCD” often completely disappears when their bipolar disorder is well controlled. Even plain hypomania can look like OCD: eg, “cataloging, organizing, copying lyrics and downloading all the Beatles’ songs from the band’s first performance through its last.”13

So be cautious: not all obsessive thinking is OCD; it’s a common feature in bipolar disorder as well. When it appears both are present, treat the bipolarity first.

This article was originally posted on 10/10/2016 and has since been updated.


Dr Phelps is Director of the Mood Disorders Program at Samaritan Mental Health in Corvallis, Ore. He is the Bipolar Disorder Section Editor for Psychiatric Times. Dr Phelps stopped accepting honoraria from pharmaceutical companies in 2008 but receives honoraria from McGraw-Hill and W.W. Norton & Co. for his books on bipolar disorders.


1. Amerio A, Odone A, Liapis CC, Ghaemi SN. Diagnostic validity of comorbid bipolar disorder and obsessive-compulsive disorder: a systematic review. Acta Psychiatr Scand. 2014;129:343-358.
2. Amerio A, Stubbs B, Odone A, et al. The prevalence and predictors of comorbid bipolar disorder and obsessive-compulsive disorder: a systematic review and meta-analysis. J Affect Disord. 2015;186:99-109.
3. Amerio A, Tonna M, Odone A, et al. Course of illness in comorbid bipolar disorder and obsessive-compulsive disorder patients. Asian J Psychiatr. 2016;20:12-14.
4. Amerio A, Odone A, Marchesi C, Ghaemi SN. Treatment of comorbid bipolar disorder and obsessive-compulsive disorder: a systematic review. J Affect Disord. 2014;166:258-263.
5. Laurito LD, Fontenelle LF, Kahn DA. Hoarding symptoms respond to treatment for rapid cycling bipolar II disorder. J Psychiatr Pract. 2016;22:50-55.
6. Foa EB, Liebowitz MR, Kozak MJ, et al. Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. Am J Psychiatry. 2005;162:151-161.
7. Marks I. Behaviour therapy for obsessive-compulsive disorder: a decade of progress. Can J Psychiatry. 1997;42:1021-1027.
8. van Oppen P, van Balkom AJ, Smit JH, et al. Does the therapy manual or the therapist matter most in treatment of obsessive-compulsive disorder? A randomized controlled trial of exposure with response or ritual prevention in 118 patients. J Clin Psychiatry. 2010;71:1158-1167.
9. Ozdemiroglu F, Sevincok L, Sen G, et al. Comorbid obsessive-compulsive disorder with bipolar disorder: a distinct form?Psychiatry Res. 2015;230:800-805.
10. Clark DA, Radomsky AS. Introduction: a global perspective on unwanted intrusive thoughts. J Obsessive Compuls Relat Disord. 2014;3:265-268. [As excerpted by the International OCD Foundation;]
11. Federman R. Is there such a thing as bipolar OCD disorder? Psychology Today. October 26, 2011. Accessed October 7, 2016.


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