Expert: Ivan Goldberg, M.D. - 3/28/2008

Question
Dr. Goldberg: I read an answer of yours on this website in which you stated "The symptoms of OCD when seen in someone with bipolar disorder most often are related to inadequately treated depression."  Ten years ago I was diagnosed with OCD and prescribed 40 mg of prozac. Recently, following a series of very rapid mood swings (among other things), I started seeing a new therapist and the posibility of my being bipolar was presented. The more I thought about this possibility the more it made sense (it runs in my family too), esp regarding those symtpoms I've had and just dealt with that do not fit into the OCD diagnosis. I have been on lamictal for just short of a week and so far so good. My psychiatrist indicated that he would like to get me to therapeutic levels of a mood stabilizer and then start weening me off the prozac. While I welcome and embrace the promise of getting closer to a correct treatment, and thus a better life, I am worried that pulling back off the prozac will usher in the violent/sexual obsessive thoughts that torture me for so many years. Could you please expand on your quote and point me to any related literature. Thank you very much!

Answer
Hi Nancy . . .

As pointed out in the abstract below, the usually pattern is that depression is associated with an increase in obsessive compulsive symptoms and mania with a decrease. While Prozac has both antidepressant and antiOCD activity, I have seen people with both OCD and bipolar disorder do well when treated with Lamictal.

Unfortunately, not a hell of a lot has been written about the Bipolar-OCD connection.

Rev Bras Psiquiatr. 2005 Jun;27(2):139-42. Epub 2005 Jun 13.

Clinical expression of obsessive-compulsive disorder in women with bipolar disorder.

Issler CK, Amaral JA, Tamada RS, Schwartzmann AM, Shavitt RG, Miguel EC, Lafer B.

Psychiatric Institute, Clinical Hospital, Medical School, Universidade de São Paulo, São Paulo, Brazil. cillykissler@yahoo.com.br

OBJECTIVE: To study clinical and psychopathological features of obsessive-compulsive disorder (OCD) in women with bipolar disorder (BD).

METHODS: Fifteen outpatients with concurrent bipolar disorder I (80.0%) or II (20.0%) and obsessive-compulsive disorder were studied. Most of them (80.0%) sought treatment for bipolar disorder. They were ascertained by means of the Structured Clinical Interview for DSM-IV (SCID/P), semi-structured interviews to investigate obsessions, compulsions and sensory phenomena that may precede compulsions and an additional module for the diagnosis of chronic motor and vocal tics. Severity of symptoms was assessed by the Yale-Brown Obsessive-Compulsive Rating Scale, Hamilton Depression Rating Scale and Young Mania Rating Scale.

RESULTS: Obsessive-compulsive disorder presented early onset (before the age of 10) in 9 (60%) cases, preceded bipolar disorder in 10 (66.7%) and displayed chronic waxing and waning course in 13 (86.7%) of them. There was wide overlap between types of obsessive-compulsive symptoms and all patients experienced sensory phenomena preceding the compulsions. There was no clear-cut impact of depressive and manic episodes on the intensity of obsessive-compulsive symptoms, which increased in depression and decreased in mania in 40.0% of the cases, had the opposite pattern in 26.7% of the patients and fluctuated inconsistently in the rest of them. Tics disorders were diagnosed in 5 (33.3%) patients.

CONCLUSIONS: Our results suggest that in women with comorbid bipolar disorder and obsessive-compulsive disorder the latter presents features that may be typical of the association of the two disorders, such as early onset and sensory phenomena preceding compulsions. A prospective controlled study is necessary to confirm these observations, due to some limitations of our study: small exclusively female sample, heterogeneity concerning the type of bipolar disorder and the disorder that determined sought of treatment and retrospective non-controlled design.

PMID: 15962140 [PubMed - indexed for MEDLINE]

Best regards . . .
Ivan
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