Bipolar disorder with OCD symptoms

1. Bipolar Disorder
with
Obsessive Compulsive
Symptoms
Two entities or one!
Yousef Semnani. M.D.
Psychiatrist, Associate professor of psychiatry

2. Agenda
 Introduction
 History
 Epidemiology
 Disorder definition
 Management

3. OCD- bipolar publications

4. History
 French psychiatrist Benedict Augustin Morel
first described (1860) patients with BD-OCD
arising questions around the nosological and
clinical meaning of this condition.
 In a standard 1969 psychiatry textbook,
Mayer-Gross and colleagues, mostly
considering course of illness, included patients
with BD-OCD in the manic-depressive
disorders

5. Epidemiology
 Epidemiological Catchment Area study,
– where 23% of those with BPD also met criteria for OCD
 Lifetime comorbidity prevalence was 11–21% in BD
patients and 6–10% in OCD patients (Amerio et al.,
2014).
 This is much higher than the prevalence of OCD, 2–
3% in the general population (Sadock et al., 2014) and
exceeds the estimated rate of 12–13% in
schizophrenia patients (Schwartz, 1986; Schirmbeck
and Zink, 2013)

6. Epidemiology
 According to a recent systematic review
(Amerio et al., 2015), the comorbidity rate of
OCD in BDs seems to be higher in children
and adolescents than in adults, and in bipolar I
disorder (BD-I) than in the other subtypes of
BD
 The majority of comorbid OCD cases appear to
be secondary to mood episodes, while a
substantial minority of comorbid OCD cases
are not episodic and may represent “true” OCD
independent of BD.

7. Diagnostic validators
 Phenomenology
 Course
 Genetics
 Treatment response
 Biological factors

8. Phenomenology
 Symptoms characteristics?
 Panic disorder and other anxiety disorders are
common comorbid conditions in OCD patients
(Pigott et al., 1994; Torres et al., 2006; Torresan
et al., 2013).
 Shashidhara et al. (2015) reported higher rates
of social anxiety disorder and anxious avoidant
personality disorder in OCD-BD patients than in
non-OC BD patients.

9. Course
 OC symptoms in comorbid patients appear more often
during depressive episodes, and comorbid BD and OCD
cycle together, with OC symptoms often remitting during
manic/hypomanic episodes (Amerio et al., 2014a).
 From a neurobiological perspective, BD mostly showed
hypoactivity in orbitofrontal cortex (OFC) (i.e. decision
making, impulse control) and in dorsolateral prefrontal
cortex (DLPFC) (i.e. planning, attentional set shifting) with
grey matter volume reduction associated to manic
episodes, while OCD mainly presented hyperactivity of
OFC with deficit in emotional processing
 The overlap of similar cortical–subcortical circuits may
partially explain clinical features of comorbid patients with
BD-OCD during the course of illness

10. Family history (Genetics)
 BD is significantly more common in the relatives of OCD
probands than in those of matched control subjects.
This finding suggests a shared genetic etiology between
OCD and BD(Cederlof et al., 2015)
 BD–OCD patients presented higher prevalence of family
history for mood disorders and lower prevalence of
family history for OCD versus non-BD–OCD patients
(Amerio et al., 2015).
 Comorbidity rates are higher in youths compared to
adults, with the majority of patients that experienced the
onset of OCD prior to the onset of BD (Tonna et
al.,2016)

11. OC characteristics predicting
bipolarity
 Hoarding ⁄ saving obsessions and compulsions
 More frequency of major depressive episodes,
 Obsessive compulsive symptoms preceding mood symptoms
 History of suicide attempts,
 Resistant to treatment
 more frequent hospitalizations
 poorer global functioning,
 More multiple anxiety disorders
 Earlier onset
 Episodic course
 Acute onset
 Being female
 Tendency to show fewer compulsive
 Family history of mood disorder

12. Osler’s view
medicine should be treatment
of diseases, not of symptoms

13. Treatment response
 Mood stabilizers are common treatment
 Which mood stabilizer is the choice?
 SGAs as major augmentation in OC symptoms
 No difference in SGA priorities
 second-generation antipsychotics (SGA) as mood
stabilizers in BD patients triggering or exacerbation of
obsessive-compulsive symptoms by these drugs are also
expected in BD patients, as has been clearly identified in
schizophrenia patients (Lim et al., 2007; Hong, 2015)

14. Treatment response
 Lithium carbonate-SGAs was the commonest combination followed by
valproate-SGAs (Saraf et al., 2017; Shashidhara et al., 2015).
 Topiramate and Memantine augmentation in BD–OCD treatment
showed both were more effective than placebo in decreasing
obsessive-compulsive symptoms in BD patients, manic phase
 Six studies examined the efficacy of aripiprazole augmentation in
treating BD–OCD patients (Amerio, 2018; Amerio and Odone, 2018;
Amerio et al., 2017; Lai et al., 2017; Patra, 2016; Sahraian et al.,
2018).
 Five case reports suggested benefit with aripiprazole augmentation,
even at low dose (10 mg/day), to lithium carbonate or valproate as
maintenance therapy in comorbid patients with complete remission of
bipolar and obsessive-compulsive symptoms (Amerio, 2018; Amerio
and Odone, 2018; Amerio et al., 2017; Lai et al., 2017; Patra, 2016)

15. Treatment response
 ECT treatment was administered after eight weeks of in-
patient care and psychotropic drug trials (Rask et al.,
2017).
 Only one case report showed the efficacy of citalopram
augmentation to valproate as maintenance therapy of a
young BD patient with persistent OCD with mood
stabilization and well control of obsessive- compulsive
symptoms for twelve months (Amerio et al., 2016b).
 On the contrary, manic/hypomanic switches induced by
antidepressants were reported by several studies
(Amerio, 2018; Amerio et al., 2017; Jeon et al., 2018;
Patra, 2016)

16.  First generation Antipsychotics
 Gabapentin?

17. Case 1
 The patient is a 56 year-old Caucasian unmarried woman with positive family history for major
depressive disorder.
 From the age of 20, she had presented fear of contamination, leading to elaborate washing and
cleaning rituals that had partially impaired her functional capacity and were untreated for 34 years.
 No history of manic or depressive episodes was reported.
 At the age of 54, a few months after leaving her parents’ home, the obsessions and compulsions
increased and she presented with depressed mood and feelings of worthlessness.
 She was admitted to the inpatient service and treated with sertraline 200 mg/day; obsessive-
compulsive and affective symptoms were well controlled and satisfactory quality of life was
regained.
 After eight months on sertraline 250 mg/day, she developed a manic episode. Her therapy was
modified to valproate 1000 mg/day and olanzapine 10 mg/day.
 Olanzapine was gradually decreased and valproate was continued for the next five months with
remission of obsessive-compulsive symptoms and mood stabilization.
 After her father’s death, compulsive rituals increased prominently. Sertraline 75 mg/day was added
to valproate and again complete remission of bipolar and obsessive-compulsive symptoms for the
following months was reported.

18. Case 2
 The patient is a 32 year-old Caucasian man with positive family history for recurrent
depression.
 From the age of 21, he had presented recurrent, intrusive, ego-dystonic thoughts
having sexual and aggressive content that led him to compulsive mental acts
(specifically, praying). No history of manic or depressive episodes was reported.
 He was admitted to the inpatient service and treated with citalopram 60 mg/day with
satisfactory control of obsessive-compulsive symptoms.
 After three months on citalopram 60 mg/day, he developed a manic episode. His
therapy was modified to valproate 800 mg/day and olanzapine 20 mg/day.
 Olanzapine was gradually decreased and valproate was continued with remission of
obsessive-compulsive symptoms and mood stabilization.
 After eight months he decided to stop valproate and compulsive rituals increased
prominently. Citalopram 20mg/day was added to valproate with improvement of OC
symptoms and mood stabilization.

19. Case 3
 The patient is a 24 year-old Caucasian woman with positive family history for recurrent depression.
 At 19 years of age, two weeks after delivery, she presented a major depressive episode that
improved in the next few weeks with fluvoxamine 100 mg/day.
 From the age of 22, she had gradually presented fear of contamination with hand washing more
than ten times per day, pathological doubts about daily events, and compulsive checking of light
switches.
 No history of manic episodes was reported.
 She was admitted to the inpatient service and initially treated with fluvoxamine 200 mg/day without
satisfactory control of obsessive-compulsive symptoms. Her therapy was modified to clomipramine
150 mg/day.
 After four weeks she developed a manic episode. Her therapy was modified to lithium 900 mg/day
and aripiprazole 30 mg/day. Aripiprazole was gradually decreased and lithium was continued with
mood stabilization and remission of obsessive-compulsive symptoms.
 After three months washing and checking rituals increased prominently. Aripiprazole 10 mg/day was
added to lithium and affective and obsessive-compulsive symptoms were well controlled for the
following twelve months.