OCD, Bipolar Disorder And The Link Between The Two

Obsessive-compulsive disorder and bipolar disorder are both serious conditions that can have a negative effect on your life. OCD results in uncontrollable recurring thoughts that often lead to repetitive behaviors, while bipolar disorder causes mood swings or shifts between manic (high energy) and depressive (low energy) episodes. 

Is it possible to have both of these conditions at the same time, and if so, how do they interact and connect with each other?

Can you have OCD and bipolar disorder?

The short answer is yes: About 15 to 20% of¹ people with bipolar disorder also meet the criteria for OCD. This comorbidity has not been well-studied, but there are some interesting factors present when these two disorders occur simultaneously.

First, the two conditions appear to interact. During depressive episodes, OCD symptoms tend to worsen, and during mania, they often, but not always, improve. This results in a cyclical presentation in which OCD may appear to go into remission and then return.

In addition, those with both conditions are more likely to have a family history of mood disorders and less likely to have a family history of OCD. This has led to a theory that the combination of these conditions may indicate bipolar disorder, which is manifesting in a way that mimics OCD.

This might not be true in all cases, of course, but it appears to be a likely explanation for many situations in which the two conditions appear to overlap.

Can OCD be mistaken for bipolar disorder?

It is more likely the reverse. Bipolar disorder is sometimes misdiagnosed as OCD. This can cause issues because the medication used to treat OCD, namely selective serotonin reuptake inhibitors (SSRIs), can cause an increased risk of mania when not paired with a mood stabilizer. While this risk is higher with tricyclic antidepressants, it can still happen with SSRIs.

Additionally, when OCD symptoms are caused by bipolar disorder, the typical treatment for OCD is likely to be ineffective. Meanwhile, using mood stabilizers to treat bipolar disorder can resolve OCD symptoms.

Mood stabilizers, however, are not a treatment for OCD on their own. The key difference is that when OCD and bipolar exist together, OCD tends to cycle with mood episodes, indicating that it is secondary to mood episodes. In some cases, this might appear to be a period of remission of OCD, especially if the mood cycles are longer.

Another clue to OCD being part of bipolar disorder is that obsessive thinking often falls outside the typical OCD obsessions, such as contamination, religion, or losing control. Bipolar people experiencing hypomania can also engage in behavior that resembles stereotypical OCD, such as alphabetizing all of their books in a single episode or downloading all music by Queen and copying the lyrics.

How is the combination of OCD and bipolar disorder treated?

In some cases, treating bipolar disorder can make OCD symptoms go away. Therefore, doctors are likely to start treatment with a mood stabilizer to see if this causes the OCD symptoms to remit. 

This requires you to stay on your bipolar medication, which is often an issue because non-compliance with medication is strongly associated with bipolar disorder. Women are more likely to go off their medication than men, although the reasons are unclear.

If OCD symptoms do not resolve with the treatment of bipolar disorder, then the recommended treatment is exposure and response prevention (ERP) therapy, which is the first-line treatment for OCD. This is typically preferred over an SSRI, which can cause issues with bipolar disorder treatment.

What is the outlook for bipolar disorder and OCD?

If the treatment for bipolar disorder also reduces or eliminates OCD symptoms, then the outlook is good as long as you adhere to your medication regimen and get checked regularly by your doctor. However, resistance to medication treatment does happen, which may require another type of medication. 

This may involve an atypical antipsychotic, such as clozapine or aripiprazole, but it may also be an anticonvulsant, glutamatergic agent, or anticholinesterase. SSRIs can sometimes induce mania but might still be used in people with concurrent OCD.

OCD symptoms that do not resolve when bipolar symptoms are treated have a similar outlook to regular OCD. ERP therapy can cause lasting remission that remains after treatment is stopped, making it more effective than medication.

Both conditions can be debilitating and have a negative impact on your quality of life and relationships. It's important to take any prescribed medication, even if you are feeling better, and follow your care team's instructions.

Can OCD and bipolar disorder be cured?

There is no cure for either condition. However, both can be managed with proper treatment. If you are on medication for bipolar disorder, you should not discontinue it without talking to your doctor. 

Bipolar medication is typically taken for life, even if you have sustained remission of symptoms. Some people fall into the trap of thinking that if they have sustained remission, it means their bipolar is cured, and they can stop taking their meds. However, if they do, a relapse is very likely.

Although ERP therapy can have lasting effects after treatment, it is still not a cure. Rather, it is a toolkit for dealing with your symptoms and keeping them from interfering with your life.

The lowdown

There is a strong apparent overlap between bipolar disorder and OCD. In many cases, however, the OCD goes into remission when the bipolar disorder is treated. OCD frequently cycles with mood, indicating that it is secondary to bipolar disorder.

This means that, in some cases, OCD that appears cyclical and does not respond to treatment may be bipolar disorder. If you have both, your doctor will prioritize treating the bipolar disorder in the hope that it will also resolve the OCD. If it does not, you may need therapy to deal with the OCD symptoms.

It is important to discuss bipolar disorder with your doctor if you also have periods of depression and/or if your OCD seems to come and go over time.