Obsessive-compulsive disorder with and without bipolar disorder

Clinical features in co-occuring obsessive-compulsive disorder and bipolar disorder: A systematic review and meta-analysis

Obsessive-compulsive disorder (OCD) frequently co-occurs with various psychiatric conditions and may impact as many as one-fifth of individuals diagnosed with bipolar disorder (BD). Despite the expanding body of literature on the coexistence of OCD and BD, there is a notable lack of comprehensive data pertaining to the distinct features of obsessive-compulsive symptoms that define this comorbidity. To bridge this knowledge gap, we conducted a systematic search of PubMed/MEDLINE, Scopus, EMBASE, and PsycINFO until August 7th, 2023. We performed random-effects meta-analyses to compare individuals with both OCD and BD to those with OCD in terms of OCD symptomatology as well as the specific categories of obsessions and compulsions. Out of the 10,393 records initially screened, 17 studies were ultimately incorporated into the qualitative assessment, with 15 of them being included in the quantitative analysis. Individuals with OCD and BD experienced fewer lifetime contamination obsessions (OR=0.71; 95 %CI=0.53, 0.95; p = 0.021) and more sexual obsessions (OR=1.77; 95 %CI=1.03, 3.04; p = 0.04) compared to individuals with OCD without BD. No significant difference was observed for other types of obsessions or compulsions or for the severity of OCD symptoms, although BD type may play a role according to meta-regression analyses. The detection of the presence of sexual or contamination obsessions through a detailed interview may be the focus of clinical attention when assessing OCD in the context of comorbid BD. Sub-phenotyping complex clinical presentation of comorbid psychiatric disorders can aid in making more informed decisions when choosing an appropriate treatment approach.

Obsessive-Compulsive Disorder as an Epiphenomenon of Comorbid Bipolar Disorder? An Updated Systematic Review

BACKGROUND

Bipolar disorder (BD) and obsessive-compulsive disorder (OCD) comorbidity is an emerging condition in psychiatry, with relevant nosological, clinical, and therapeutic implications.

METHODS

We updated our previous systematic review on epidemiology and standard diagnostic validators (including phenomenology, course of illness, heredity, biological markers, and treatment response) of BD-OCD. Relevant papers published until (and including) 15 October 2023 were identified by searching the electronic databases MEDLINE, Embase, PsychINFO, and Cochrane Library, according to the PRISMA statement (PROSPERO registration number, CRD42021267685).

RESULTS

We identified 38 new articles, which added to the previous 64 and raised the total to 102. The lifetime comorbidity prevalence ranged from 0.26 to 27.8% for BD and from 0.3 to 53.3% for OCD. The onset of the two disorders appears to be often overlapping, although the appearance of the primary disorder may influence the outcome. Compared to a single diagnosis, BD-OCD exhibited a distinct pattern of OC symptoms typically following an episodic course, occurring in up to 75% of cases (vs. 3%). Notably, these OC symptoms tended to worsen during depressive episodes (78%) and improve during manic or hypomanic episodes (64%). Similarly, a BD course appears to be chronic in individuals with BD-OCD in comparison to patients without. Additionally, individuals with BD-OCD comorbidity experienced more depressive episodes (mean of 8.9 ± 4.2) compared to those without comorbidity (mean of 4.1 ± 2.7).

CONCLUSIONS

We found a greater likelihood of antidepressant-induced manic/hypomanic episodes (60% vs. 4.1%), and mood stabilizers with antipsychotic add-ons emerging as a preferred treatment. In line with our previous work, BD-OCD comorbidity encompasses a condition of greater nosological and clinical complexity than individual disorders.

Episodic obsessive-compulsive disorder and bipolar spectrum disorder: new evidence from a large Italian OCD sample

OBJECTIVES

Obsessive-Compulsive Disorder (OCD) has been considered to be a chronic illness; however, some authors described a subtype of OCD characterised by symptom-free periods of time: Episodic-OCD (E-OCD). Only few studies focussed on this subtype of the disorder. The objectives of this research were to study the association between the episodic course of the disorder and lifetime psychiatric comorbidities and to investigate socio-demographic and other clinical features correlated to the episodic course.

METHODS

The sample is composed of adult OCD patients. The course was defined episodic when at least one circumscribed symptom-free interval of at least 6 months was present. The sample was divided into two subgroups: Episodic-OCD and Chronic-OCD. Differences between groups were analysed with Student's t-test, χ2 tests, Fisher test and multivariate logistic regression.

RESULTS

Data regarding 585 individuals were collected. 14.2% (N = 83) of our sample had an episodic course. Bipolar I comorbid disorder, abrupt onset, lower severity of illness and lower rates of repeating compulsions were associated with the likelihood of having an E-OCD.

CONCLUSIONS

Our findings confirm that a significant proportion of OCD patients have an episodic course and that E-OCD could represent a specific endophenotype.

Insight in patients with bipolar disorder: Findings from the bipolar disorder course and outcome study from India (BiD-CoIN study)

Background

There are limited number of studies evaluating insight among patients with bipolar disorder (BD).

Aim

This study aimed to examine insight and its correlates in BD using the data from the multicenter BD course and outcome study from India (BiD-CoIN). The additional aim was to evaluate the insight in patients with BD using different scales and understand the correlates of insight.

Materials and Methods

773 BD patients presently in clinical remission were evaluated on the Insight Scale for Affective Disorders (ISAD), insight items of the Hamilton Depression Rating Scale (HDRS), and the Young Mania Rating Scale (YMRS).

Results

The assessment scales influenced the prevalence of poor insight. Poorer insight irrespective of the assessment scale was consistently associated with higher residual depressive and manic symptoms, and a higher level of cognitive impairment and disability. Poor insight as assessed by ISAD was associated with a higher number of episodes in the lifetime, shorter duration of current remission, a higher number of depressive episodes, a higher amount of time spent in depressive episodes, higher depressive affective morbidity, a higher number of manic episodes, and higher residual depressive and manic symptoms.

Conclusion

Poor insight in BD is consistently associated with higher residual depressive and manic symptoms and a higher level of cognitive impairment and disability. However, in terms of course variables, the correlates vary depending on the assessment method.

Comorbidities in Youth with Bipolar Disorder: Clinical Features and Pharmacological Management

BACKGROUND

Bipolar Disorder (BD) is a highly comorbid condition, and rates of cooccurring disorders are even higher in youth. Comorbid disorders strongly affect clinical presentation, natural course, prognosis, and treatment.

METHODS

This review focuses on the clinical and treatment implications of the comorbidity between BD and Attention-Deficit/Hyperactivity Disorder, disruptive behavior disorders (Oppositional Defiant Disorder and/or Conduct Disorder), alcohol and substance use disorders, Autism Spectrum Disorder, anxiety disorders, Obsessive-Compulsive Disorder, and eating disorders.

RESULTS

These associations define specific conditions which are not simply a sum of different clinical pictures, but occur as distinct and complex combinations with specific developmental pathways over time and selective therapeutic requirements. Pharmacological treatments can improve these clinical pictures by addressing the comorbid conditions, though the same treatments may also worsen BD by inducing manic or depressive switches.

CONCLUSION

The timely identification of BD comorbidities may have relevant clinical implications in terms of symptomatology, course, treatment and outcome. Specific studies addressing the pharmacological management of BD and comorbidities are still scarce, and information is particularly lacking in children and adolescents; for this reason, the present review also included studies conducted on adult samples. Developmentally-sensitive controlled clinical trials are thus warranted to improve the prognosis of these highly complex patients, requiring timely and finely personalized therapies.

The global assessment of OCD

Obsessive Compulsive Disorder (OCD) is a common mental disorder that often causes great sufferance, with substantial impairment in social functioning and quality of life and affects family and significant relationships. Notwithstanding its severity, OCD is often not adequately diagnosed, or it is diagnosed with delay, leading often to a long latency between onset of the OCD symptoms and the start of adequate treatments. Several factors contribute to the complexity of OCD's clinical picture: early age of onset, chronic course, heterogeneity of symptoms, high rate of comorbidity with other psychiatric disorders, slow or partial response to therapy. Therefore, it is of primary importance for clinicians involved in diagnosing OCD, to assess all aspects of the disorder. This narrative review focuses on the global assessment of OCD, highlighting crucial areas to explore, pointing out the clinical features which are relevant for the treatment of the disorder, and giving an overview of the psychometric tools that can be useful during the screening procedure.

Obsessive-compulsive symptoms in major depressive disorder correlate with clinical severity and mixed features

Obsessive-compulsive symptoms (OCS) are often reported in patients with bipolar disorder. The aim of this study was to investigate OCS and their related clinical features in major depressive disorder (MDD). The analysis involved 482 outpatients with MDD collected within the Combining Medications to Enhance Depression outcomes trial, who were assessed with scales for depression, suicidality, irritability, hypomanic symptomatology, and other comorbid psychiatric manifestations. OCS were reported in 27% of the sample. Patients with MDD experiencing OCS were found to differ from those not experiencing OCS by a greater severity of depression (d = 0.41, P = 0.0001), more hypomanic symptoms (d = 0.48, P < 0.0001) and mixed features (22% vs. 10%, P = 0.001), increased levels of suicidal thoughts (d = 0.40, P = 0.0001), a lower likelihood of achieving remission after antidepressant treatment (19% vs. 33%, P = 0.0109), as well as more comorbid anxiety disorders (i.e. panic disorder: d = 0.98, P < 0.0001; generalized anxiety disorder: d = 0.74, P < 0.0001; social phobia: d = 0.71, P < 0.0001), and post-traumatic stress disorder (d = 0.81, P < 0.0001). In light of these findings, clinicians should pay more attention to the occurrence of OCS in MDD, as these symptoms may reflect greater clinical severity, poorer treatment outcome, and increased risk for bipolarity.

Quetiapine for Bipolar Depressive Episode in Obsessive-Compulsive Disorder Patients Maintained on Selective Serotonin Reuptake Inhibitor Treatment

OBJECTIVES

A meaningful proportion of patients with obsessive-compulsive disorder (OCD) develop symptoms of bipolar depression (BP-D). In the present investigation, we aimed to determine whether quetiapine is efficacious in OCD patients who despite continuous treatment with a selective serotonin reuptake inhibitor developed an acute episode of BP-D.

METHODS

We analyzed 68 charts of Diagnostic and Statistical Manual of Mental Disorders Fifth Edition OCD patients from our outpatient clinic and identified 15 patients who in addition met Diagnostic and Statistical Manual of Mental Disorders Fifth Edition criteria for bipolar II disorder, depressive episode. Eleven (7 men and 4 women, aged 24-54 years) patients for whom quetiapine was added to treat the index episode of BP-D were included. Treatment response was assessed retrospectively and defined as a score of "much improved" or "very much improved" on the Clinical Global Impression-Improvement scale.

RESULTS

Quetiapine was added for treatment of BP-D in a dose range of 150 to 400 mg (mean, 273 mg). Eight (73%) of the 11 study patients fulfilled the criterion of response, that is a score of "much improve" (4 patients) and "very much improved" (4 patients) on the Clinical Global Impression-Improvement scale. Notably, quetiapine was associated with additional improvement of OCD symptoms in 6 of 8 study responders. Quetiapine was well tolerated. The most frequently detected side effects were drowsiness (5 patients), constipation (4 patients), and orthostatic hypotension (2 patients).

CONCLUSIONS

The revealed beneficial effect of quetiapine addition for acute episode of BP-D in OCD patients maintained on selective serotonin reuptake inhibitor treatment merits further controlled investigation.

Suicide attempts and suicidal ideation in patients with obsessive-compulsive disorder: A systematic review and meta-analysis

INTRODUCTION

There is controversy on the magnitude of suicide risk in OCD and on the psychopathological features that raise the risk. This systematic review and meta-analysis aims to estimate the pooled prevalence of suicide attempts and suicidal ideation (current/lifetime) in subjects with OCD and identify sociodemographic and clinical factors associated with greater risk.

METHODS

We conducted a literature search in PubMed/Medline, PsycINFO, Web of Science and CINAHL databases up to June 20, 2019, according to PRISMA guidelines. Stata statistical software (Version 15) was used to obtain forest plots, execute subgroup analyses and perform univariate and multivariate meta-regressions.

RESULTS

We found 61 eligible studies including OCD patients: 52 investigated suicide attempts and reported a pooled prevalence of 0.135 (95% CI 0.123-0.147); 26 explored current suicidal ideation and reported a pooled prevalence of 0.273 (95% CI 0.214-0.335); 22 researched lifetime suicidal ideation and reported a pooled prevalence of 0.473 (95% CI 0.397-0.548). Severity of obsessions, comorbid substance use and depressive/anxious symptoms increased the risk, whereas compulsions had a comparatively protective effect.

LIMITATIONS

Owing to the small number of studies reporting completed suicide rates, this metric was not included in the meta-analysis. The degree of heterogeneity between the studies was high.

CONCLUSION

Clinicians should keep in mind that one out of ten patients with OCD attempts suicide during his/her lifetime, about one third has current suicidal ideation and about half has had suicidal ideation in the past. Several clinical features are associated with increased risk and should be factored into clinical risk management.

Lifetime bipolar disorder comorbidity and related clinical characteristics in patients with primary obsessive compulsive disorder: a report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS)

INTRODUCTION

Bipolar disorder (BD) and obsessive compulsive disorder (OCD) are prevalent, comorbid, and disabling conditions, often characterized by early onset and chronic course. When comorbid, OCD and BD can determine a more pernicious course of illness, posing therapeutic challenges for clinicians. Available reports on prevalence and clinical characteristics of comorbidity between BD and OCD showed mixed results, likely depending on the primary diagnosis of analyzed samples.

METHODS

We assessed prevalence and clinical characteristics of BD comorbidity in a large international sample of patients with primary OCD (n = 401), through the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS) snapshot database, by comparing OCD subjects with vs without BD comorbidity.

RESULTS

Among primary OCD patients, 6.2% showed comorbidity with BD. OCD patients with vs without BD comorbidity more frequently had a previous hospitalization (p < 0.001) and current augmentation therapies (p < 0.001). They also showed greater severity of OCD (p < 0.001), as measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS).

CONCLUSION

These findings from a large international sample indicate that approximately 1 out of 16 patients with primary OCD may additionally have BD comorbidity along with other specific clinical characteristics, including more frequent previous hospitalizations, more complex therapeutic regimens, and a greater severity of OCD. Prospective international studies are needed to confirm our findings.

The Features of Comorbidity of Childhood ADHD in Patients With Obsessive Compulsive Disorder

Objective: Our aim is to investigate the impact of childhood ADHD comorbidity on the clinical features of obsessive compulsive disorder (OCD). Method: Ninety-five adult outpatients with a diagnosis of OCD were assessed by using the Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version, ADHD module, and the Yale-Brown Obsessive Compulsive Scale. Patients with or without childhood ADHD were compared in terms of the sociodemographic and clinical features, psychiatric comorbidities, and rating scales. Results: The rate of episodic course of OCD (p < .001), religious and sexual obsessions (p = .009, p = .020, respectively), lifetime comorbidity of bipolar disorder (BD), social anxiety disorder (SAD; p = .001, p = .009, respectively), and tic disorder (TD) comorbidity (p < .001) were higher in the OCD + ADHD group than in the OCD without ADHD group. Conclusion: Childhood ADHD may be associated with higher rates of BD, SAD, and TD comorbidity and episodic course of OCD as well as higher frequency of certain types of obsessions.

Suicide Risk in Obsessive-Compulsive Disorder and Exploration of Risk Factors: A Systematic Review

BACKGROUND

Historically, OCD has been considered to be associated with a relatively low risk of suicide. Recent studies, on the contrary, revealed a significant association between OCD and suicide attempts and ideation. A huge variation in prevalence rates, however, is reported.

OBJECTIVE

To estimate prevalence rates of suicide attempts and suicidal ideation in individuals with OCD, and to identify predictors of suicide risk among subjects with OCD.

METHODS

We systematically reviewed the literature on suicide risk (ideation and/or attempts) and OCD. We included studies with appropriate definition of OCD, cross-sectional or prospective design, separating clinical samples from epidemiological studies, that employed a quantitative measure of suicidality and/or reported an outcome measure of the association between suicidality and OCD or examined factors associated with suicidality.

RESULTS

In clinical samples, the mean rate of lifetime suicide attempts is 14.2% (31 studies: range 6- 51.7%). Suicidal ideation is referred by 26.3-73.5% of individuals (17 studies, mean 44.1%); current suicidal ideation rate ranges between 6.4 and 75% (13 studies, mean 25.9). Epidemiological studies found that OCD increases significantly the odds of having a lifetime suicidal ideation as compared to the general population (OR: 1.9-10.3) and a history of lifetime suicide attempts (OR: 1.6- 9.9). Predictors of greater suicide risk are severity of OCD, the symptom dimension of unacceptable thoughts, comorbid Axis I disorders, severity of comorbid depressive and anxiety symptoms, past history of suicidality and some emotion-cognitive factors such as alexithymia and hopelessness.

CONCLUSION

Overall, suicidality appears a relevant phenomenon in OCD.

Obsessive-compulsive Disorder with Comorbid Bipolar Disorders: Clinical Features and Treatment Implications

BACKGROUND

Obsessive-compulsive disorder (OCD) symptoms within the context of a bipolar disorder (BD) have been described since the 19th century. Interestingly, the existence of a relevant overlap between the aforementioned psychiatric syndromes has been confirmed by a number of recent epidemiological and family studies.

AIMS

The aim of the present paper is to review the clinical features and the therapeutic implications of the OCD-BD comorbidity.

DISCUSSION

In the last two decades, the frequent association between OCD and BD has been earning a growing interest given its relevant nosological and therapeutic implications. Usually patients suffering from OCD-BD comorbidity show a peculiar clinical course, characterized by a larger number of concomitant depressive episodes and episodic course. In these cases, the treatment with antidepressants is more likely to elicit hypomanic or manic switches, while mood stabilizers significantly improve the overall clinical picture. Moreover, OCD-BD patients are frequently comorbid with a number of other psychiatric disorders, in particular anxiety disorders, social phobia, and different substance abuses, such as alcohol, nicotine, caffeine and sedatives.

CONCLUSIONS

BD-OCD comorbidity needs further investigations in order to provide more solid evidences to give patients a more precise clinical diagnosis and a more targeted therapeutic approach.

Bipolar disorder comorbidity in patients with obsessive-compulsive disorder: Prevalence and predictors

BACKGROUND

Patients with obsessive-compulsive disorder (OCD) often present with comorbidities, mainly anxiety and affective disorders, which may influence OCD course, help-seeking and treatment response. Some authors have studied bipolar disorder (BD) comorbidity in patients with OCD, but usually in small samples. The objective was to estimate the lifetime prevalence of BD in a large clinical sample of OCD patients, and to compare demographic and clinical features of patients with and without BD comorbidity.

METHOD

This cross-sectional study with 955 adult OCD patients from the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (C-TOC) used several assessment instruments, including the Yale-Brown Obsessive-Compulsive Scale, the Dimensional Yale-Brown Obsessive-Compulsive Scale, the Beck Depression and Anxiety Inventories, and the Structured Clinical Interview for DSM-IV Axis I Disorders. Descriptive and bivariate analyses were followed by logistic regression.

RESULTS

The lifetime prevalence of BD was 7.75% (N = 74). The variables that were independently associated with BD comorbidity were: panic disorder with agoraphobia, impulse control disorders, and suicide attempts.

LIMITATIONS

The cross-sectional design does not permit causal inferences; the external validity may be limited, as the participants were from tertiary services. Despite the large sample size, some analyses may have been underpowered due to the relatively low prevalence of the outcome and of some explanatory variables.

CONCLUSIONS

Patients with OCD comorbid with BD have some clinical features indicative of greater severity, including higher suicide risk, and require a careful therapeutic approach for the appropriate treatment of both disorders.

Course and outcome of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is generally believed to follow a chronic waxing and waning course. The onset of illness has a bimodal peak - in early adolescence and in early adulthood. Consultation and initiation of treatment are often delayed for several years. Studies over the past 2-3 decades have found that the long-term outcomes in OCD are not necessarily bleak and that at least half the treatment-seeking patients with OCD show symptomatic remission over long term. A short duration illness, of low severity that is treated early and intensively, with continued maintenance treatment over long term possibly has a good outcome. Recent studies have also identified neuroimaging and neuropsychological correlates of good outcome, but these need further replication. This paper presents an overview of conceptual issues and studies on long-term outcome of OCD and predictors of outcome.

Obsessive-compulsive disorder comorbid with schizophrenia and bipolar disorder

Obsessive Compulsive Disorder (OCD) and Obsessive Compulsive Symptoms (OCS) are known to be highly comorbid with bipolar disorder and schizophrenia. Comorbid OCD/OCS influences the course of schizophrenia and bipolar disorder. There is also some evidence to suggest that a diagnosis of OCD may be associated with elevated risk for later development of psychosis and bipolar disorder. Comorbid OCD/OCS is associated with a greater severity of schizophrenia phenotype and poorer prognosis. In addition, certain atypical antipsychotics, clozapine in particular are known to induce or worsen OCS in schizophrenia. OCD when comorbid with bipolar disorder mostly runs an episodic course with worsening and improvement of OCD/OCS in depressive and in manic/hypomanic phases respectively. There is limited systematic data on the treatment of OCD in schizophrenia and bipolar disorder. When OCD presents in the context of schizophrenia, management may include treatment with atypical antipsychotics with limited serotonergic properties, changing the antipsychotic, reduction in the dose of the antipsychotic, addition of cognitive-behavior therapy (CBT), or a specific serotonin reuptake inhibitor (SSRI). When OCD is comorbid with bipolar disorder, mood stabilization is the priority. CBT may be preferred over SSRIs to treat OCD/OCS that persist in between the mood episodes because SSRIs may induce a switch or worsen the course of bipolar disorder. SSRIs when indicated have to be used judiciously under the cover of adequate mood stabilization.

Clinical and familial profile of bipolar disorder with and without obsessive-compulsive disorder: an Indian study

Abstract Introduction Comorbid obsessive-compulsive disorder (OCD) is common in bipolar disorder (BD). Clinical characteristics, functionality and familial pattern of this comorbidity are largely understudied. Objective To assess clinical profile, familial loading of psychiatric disorders and level of functioning in remitted BD patients who have comorbid OCD and to compare results with those of remitted BD patients without OCD. Methods Remitted BD-I subjects were assessed using the Structured Clinical Interview for DSM-IV Axis I Disorders, Global Assessment of Functioning Scale (GAF), Hamilton Depression Rating Scale (HDRS), Young Mania Rating Scale (YMRS), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and Family Interview for Genetic Studies (FIGS). BD patients with and without OCD were compared. Group differences were analyzed using the chi-square test and the independent samples t test. Values <0.05 were considered statistically significant. Results Of the 90 remitted BD-I patients, 35.5% (n=32) had obsessive-compulsive symptoms/OCD. The BD-OCD group showed significantly lower GAF scores, higher rates of suicidal attempts, hospitalizations, manic and depressive episodes compared to the group with BD only (p<0.05). In addition, first and second-degree relatives had higher rates of BD-OCD and OCD, but not of BD. Conclusions BD-OCD is characterized by more severe BD, more dysfunction and higher familial loading of BD-OCD and OCD. Larger studies involving relatives of probands will help to confirm our findings and to delineate nosological status of BD-OCD comorbidity.

Bipolar disorder comorbidity in patients with a primary diagnosis of OCD

OBJECTIVE

Bipolar disorder (BD) is considered to be a common comorbid condition in subjects with obsessive-compulsive disorder (OCD), but there is limited literature on the prevalence of BD and its clinical correlates in those with a primary diagnosis of OCD.

METHODS

We studied the prevalence of BD in a sample of consecutively registered outpatients attending a specialty OCD clinic in India over a period of 13 months. One hundred and seventy-one patients with a primary diagnosis of OCD were assessed systematically using structured and semi-structured instruments.

RESULTS

The prevalence of lifetime BD in OCD was 4%. The OCD + BD group had an episodic course of OCD and higher rate of lifetime suicide attempts.

CONCLUSIONS

BD may not be as highly prevalent in OCD as reported in literature. Those with OCD seem to have only a marginally higher risk for developing BD than the general population. A diagnosis of BD seems to have a pathoplastic effect on the course of OCD. Patients with OCD-BD comorbidity have to be specifically assessed for suicide risk.

Management of obsessive-compulsive disorder comorbid with bipolar disorder

Obsessive-compulsive disorder (OCD) is one of the most common comorbidities in bipolar disorder (BD). Clinicians often get perplexed in making treatment decisions when encountering comorbid OCD and BD as treatment of OCD by pharmacotherapy may induce or exacerbate mood instability and psychotherapeutic approaches for OCD may not be feasible in acute manic or depressive state of BD. In this study, we reviewed literature, whether existing guideline-based treatments of BD may be effective in OCD and whether newer agents will be of use for treating this comorbidity. We could find that treatment of such comorbid disorder is largely understudied. Adjuvant topiramate or olanzapine- selective serotonin reuptake inhibitor/clomipramine combination along with mood stabilizer is found to be effective for treating OCD in BD. Use of other conventional pharmacological agents and psychotherapy for treating comorbid OCD in BD lacks evidence and is limited to case reports. Our review also highlights the need for further studies regarding the treatment strategies in this highly prevalent comorbid disorder.

Heredity in comorbid bipolar disorder and obsessive-compulsive disorder patients

Partly due to the overlap of symptom groupings in DSM, psychiatric comorbidity is extremely common. One of the most common and difficult to manage comorbid conditions is the co-occurrence of bipolar disorder (BD) and obsessive compulsive disorder (OCD). However, the key nosological question about this condition - whether they are two distinct disorders or a subtype of one of the disorders - remains unresolved. In order to help address this unanswered question, we updated our recent systematic review, searching the electronic databases MEDLINE, Embase, and PsycINFO to specifically investigate the heredity in BD-OCD patients. We identified a total of 8 relevant papers, the majority of which found that, compared to non-BD-OCD patients, BD-OCD patients were more likely to have a family history for mood disorders and less likely to have a family history for OCD. These results support the view that the majority of cases of comorbid BD-OCD are, in fact, BD cases. If confirmed in larger, more focused studies, this conclusion would have important nosological and clinical implications.

Comorbid obsessive-compulsive disorder with bipolar disorder: A distinct form?

We examined whether the patients with Bipolar Disorder (BD) and Obsessive-Compulsive Disorder (OCD) comorbidity may represent a distinct form of BD. The subjects diagnosed with BD (n=48), OCD (n=61), and BD with OCD (n=32) were compared in terms of several socio-demographic and clinical characteristics. Previous history of suicidal attempts was more likely to be higher in BD-OCD group compared to the other two groups. A more episodic course of OCD, higher rates of rapid cycling, and the seasonality were found in BD-OCD patients. The frequency of bipolar II and NOS subtypes was more prevalent in patients with BD-OCD than in OCD patients. The first diagnosed illness was BD in the majority of BD-OCD cases. It was found that first affective episode was major depression in half of BD-OCD patients. Age at onset of BD was found to be earlier in BD-OCD group compared to pure BD patients. Bipolarity may not have a specific effect on the phenomenology of OC symptoms. The episodic course of OCD, seasonality, rapid cycling, earlier onset of BD, and impulsivity in BD-OCD patients may be indicative for a distinct form of BD.

Think twice: Impulsivity and decision making in obsessive-compulsive disorder

BACKGROUND AND AIMS

Recent studies have challenged the anxiety-avoidance model of obsessive-compulsive disorder (OCD), linking OCD to impulsivity, risky-decision-making and reward-system dysfunction, which can also be found in addiction and might support the conceptualization of OCD as a behavioral addiction. Here, we conducted an exploratory investigation of the behavioral addiction model of OCD by assessing whether OCD patients are more impulsive, have impaired decision-making, and biased probabilistic reasoning, three core dimensions of addiction, in a sample of OCD patients and healthy controls.

METHODS

We assessed these dimensions on 38 OCD patients and 39 healthy controls with the Barratt Impulsiveness Scale (BIS-11), the Iowa Gambling Task (IGT) and the Beads Task.

RESULTS

OCD patients had significantly higher BIS-11 scores than controls, in particular on the cognitive subscales. They performed significantly worse than controls on the IGT preferring immediate reward despite negative future consequences, and did not learn from losses. Finally, OCD patients demonstrated biased probabilistic reasoning as reflected by significantly fewer draws to decision than controls on the Beads Task.

CONCLUSIONS

OCD patients are more impulsive than controls and demonstrate risky decision-making and biased probabilistic reasoning. These results might suggest that other conceptualizations of OCD, such as the behavioral addiction model, may be more suitable than the anxiety-avoidance one. However, further studies directly comparing OCD and behavioral addiction patients are needed in order to scrutinize this model.

Comorbid bipolar disorder and obsessive-compulsive disorder

Obsessive-compulsive symptoms are common in patients with bipolar disorders. This comorbid condition complicates the clinical treatment of the two disorders, so identifying these individuals is important. We discuss the comorbid occurrence of obsessive-compulsive disorder and bipolar disorder, introduce possible etiological mechanisms that could result in this common comorbid condition, discuss recent research advances in the area, and propose some clinical principles for managing such patients.

Obsessive compulsive symptoms in bipolar disorder patients: a comorbid disorder or a subtype of bipolar disorder?

Over the last decade increasing attention has been focused on individuals that simultaneously meet the criteria of two or more mental disorders. One of these comorbid conditions, comorbid bipolar disorder and obsessive compulsive disorder, is relatively common among patients with a primary diagnosis of bipolar disorder. But there is little research about the diagnosis and treatment of this comorbid condition, particularly in China. The available studies are primarily cross-sectional studies with small samples, so they are of limited use in understanding the etiology and course of this combined condition. A review of the limited literature suggests that this is a relatively severe, refractory subtype of bipolar disorder that only occasionally merits being considered a comorbid disorder. Larger prospective studies are needed to clarify the etiology, prognosis, and appropriate treatment for this comorbid condition.

Suicidality in obsessive compulsive disorder (OCD): a systematic review and meta-analysis

Although a growing number of studies have examined the frequency of suicidal thoughts and behaviors in individuals with obsessive compulsive disorder (OCD), there is controversy about the frequency and burden of suicidality in OCD. This is the first systematic review aimed at examining the association between suicidality and OCD and at providing evidence about psychological mechanisms that may underlie suicidality in those with OCD. Five electronic bibliographic databases were searched up to April 2014: Medline, PsycINFO, Embase, Web of Science and CINAHL. Meta-analysis using random effects models was conducted. Forty-eight studies were included in the systematic review. The pooled effect size across 30 independent comparisons revealed a moderate to high, significant association between suicidality and OCD (Hedges' g=0.66, 95% confidence interval 0.49-0.82) which persisted across different types of suicidality including suicidal ideation and suicide attempts. Comorbid Axis I disorders, increased severity of comorbid depressive and anxiety symptoms, increased severity of obsessions, feelings of hopelessness and past history of suicide attempts were associated with worsening levels of suicidality in OCD. There was no indication for publication bias but the methodological quality of the studies was low. The theoretical, research and clinical implications of these findings are emphasized.

Diagnostic validity of comorbid bipolar disorder and obsessive-compulsive disorder: a systematic review

OBJECTIVE

At least 50% of bipolar disorder (BD) patients have an additional diagnosis, one of the most difficult to manage being obsessive-compulsive disorder (OCD). Defining the nosology of BD-OCD comorbidity has important clinical implications, given that treatments for OCD can worsen BD outcomes.

METHOD

A systematic review was conducted on: i) BD-OCD comorbidity lifetime prevalence and ii) on standard diagnostic validators: phenomenology, course of illness, heredity, biological markers, and treatment response. Relevant papers published through March 30th 2013 were identified searching the electronic databases MEDLINE, Embase, PsycINFO, and the Cochrane Library.

RESULTS

Sixty-four articles met inclusion criteria. Lifetime comorbidity prevalence was 11-21% in BD patients and 6-10% in OCD patients. Compared to non-comorbid subjects, BD-OCD has a more episodic course of OC symptoms (up to 75% vs. 3%), typically with worsening during depression (78%) and improvement during mania/hypomania (64%), as well as a higher total mean number of depressive episodes (8.9±4.2 vs. 4.1±2.7) and perhaps more antidepressant-induced mania/hypomania (39% vs. 9%).

CONCLUSION

In this first systematic review of BD-OCD comorbidity, it appears that OC symptoms are usually secondary to BD, rather than representing a separate disease.

Comorbid obsessive-compulsive symptoms in schizophrenia: contributions of pharmacological and genetic factors

A large subgroup of around 25% of schizophrenia patients suffers from obsessive-compulsive symptoms (OCS) and about 12% fulfill the diagnostic criteria of an obsessive-compulsive disorder (OCD). The additional occurrence of OCS is associated with high subjective burden of disease, additional neurocognitive impairment, poorer social and vocational functioning, greater service utilization and high levels of anxiety and depression. Comorbid patients can be assigned to heterogeneous subgroups. One hypothesis assumes that second generation antipsychotics (SGAs), most importantly clozapine, might aggravate or even induce second-onset OCS. Several arguments support this assumption, most importantly the observed chronological order of first psychotic manifestation, start of treatment with clozapine and onset of OCS. In addition, correlations between OCS-severity and dose and serum levels and duration of clozapine treatment hint toward a dose-dependent side effect. It has been hypothesized that genetic risk-factors dispose patients with schizophrenia to develop OCS. One study in a South Korean sample reported associations with polymorphisms in the gene SLC1A1 (solute carrier family 1A1) and SGA-induced OCS. However, this finding could not be replicated in European patients. Preliminary results also suggest an involvement of polymorphisms in the BDNF gene (brain-derived neurotrophic factor) and an interaction between markers of SLC1A1 and the gene DLGAP3 (disc large associated protein 3) as well as GRIN2B (N-methyl-D-aspartate receptor subunit 2B). Further research of well-defined samples, in particular studies investigating possible interactions of genetic risk-constellations and pharmacodynamic properties, are needed to clarify the assumed development of SGA-induced OCS. Results might improve pathogenic concepts and facilitate the definition of at risk populations, early detection and monitoring of OCS as well as multimodal therapeutic interventions.