Journal of Affective Disorders 174 (2015) 367371

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Brief report

Comorbid obsessive compulsive disorder in patients

with bipolar-I disorder
M. Shashidhara, B.R. Sushma, Biju Viswanath, Suresh Bada Math, Y.C Janardhan Reddy n
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore 560029, India

art ic l e i nf o

a b s t r a c t

Article history:
Received 23 October 2014
Received in revised form
4 December 2014
Accepted 4 December 2014
Available online 13 December 2014

Background: Limited numbers of studies have examined the prevalence of OCD systematically in
consecutively sampled adult bipolar disorder type I (BD-I) patients. We examined the frequency of
OCD in a large number (n 396) of consecutively hospitalized patients with BD-I and identied sociodemographic and clinical correlates of BD-I with and without OCD.
Method: BD-I patients (n 396) were assessed using the Mini International Neuropsychiatric Interview
for Bipolar Disorder Studies, the Structured clinical interview for (Axis II) DSM-IV, the Family interview
for genetic studies, the YaleBrown ObsessiveCompulsive Scale, the Young Mania Rating Scale, the
Hamilton Rating Scale for Depression, the Global Assessment of Functioning (GAF) and the Clinical Global
Impression scale. Patients with and without OCD were compared in terms of various socio-demographic
and clinical variables.
Results: Thirty (7.6%) of the 396 inpatients studied had OCD and 15 (3.8%) had subclinical OCD. BDOCD
group had signicantly lower GAF scores, higher rates of unemployment, and lower incidence of
psychotic symptoms. In addition, BDOCD group had higher rates of comorbid social anxiety and anxious
avoidant personality disorder (AAPD) and OCD in rst-degree relatives. Those with clinical and
subclinical OCD did not differ on functioning and severity measures.
Limitations: Retrospective design and recruitment of patients from inpatient services of a tertiary
psychiatric hospital.
Conclusion: OCD is not an uncommon comorbid disorder in BD-I and appears to be associated with
greater functional disability. BD-I with comorbid OCD is associated with greater family history of OCD,
comorbidities of social phobia and AAPD and less of psychotic symptoms.
& 2014 Elsevier B.V. All rights reserved.

Keywords:
Bipolar disorder
Obsessive compulsive disorder
Anxiety disorder
Co-morbidity

1. Introduction
Bipolar disorder (BD) is a recurrent illness associated with high
rates of comorbid disorders and suicide risk (Goodwin and
Jamison, 2007). Anxiety disorders are common comorbid disorders
and may have an impact on the outcome of the illness (Henry
et al., 2003; Perugi et al., 2002; Sareen et al., 2005). There is even a
suggestion that anxiety disorders and BD may have shared
pathophysiology (Freeman et al., 2002).

Abbreviations: BD, Bipolar disorder; OCD, Obsessive compulsive disorder; MINIBIPOLAR, Mini International Neuropsychiatric Interview for Bipolar Disorder
Studies; SCID-II, Structured Clinical Interview for DSM-IVAxis II disorders; FIGS,
Family Interview for Genetic Studies; YMRS, Young Mania Rating Scale; CGI, Clinical
Global Impression; GAF, Global Assessment of Functioning; Y-BOCS, YaleBrown
ObsessiveCompulsive Scale; AAPD, Anxious avoidant personality disorder.
n
Corresponding author. Tel.: 91 80 26995278, 91 80 26995306;
fax: 91 80 26564822.
E-mail address: ycjreddy@gmail.com (Y. Janardhan Reddy).
http://dx.doi.org/10.1016/j.jad.2014.12.019
0165-0327/& 2014 Elsevier B.V. All rights reserved.

Obsessivecompulsive disorder (OCD) is one of the commonest

anxiety disorders associated with BD (Altindag et al., 2006;
DellOsso et al., 2011; Tamam and Ozpoyraz, 2002; Zutshi et al.,
2006). Epidemiological studies indicate that the rates of OCD in
patients with BD are signicantly higher (520%) than in general
population (23%) (Angst et al., 2005; Chen and Dilsaver, 1995).
Conversely, studies have also found high rate of BD in patients
with OCD, ranging from 10% to 20% (Perugi et al., 1997, 2002).
Familial factors play an important role in the BDOCD comorbidity,
as evidenced by familial aggregation with OCD in BD pedigrees
(Goes et al., 2012).
Among the clinic-based studies, the prevalence of OCD in BD
patients varies considerably, ranging from 2% to 39% (Boylan et al.,
2004; DellOsso et al., 2011;Henry et al., 2003; Kruger et al., 2000;
Magalhaes et al., 2010; Simon et al., 2004; Strakowski et al., 1998).
Such wide variation is possibly a function of methodological
differences, especially those related to sampling. A recent systematic review reported 1121% rate of comorbid OCD in BD
patients and 610% of BD in OCD patients (Amerio et al., 2014a).

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M. Shashidhara et al. / Journal of Affective Disorders 174 (2015) 367371

BD when comorbid with OCD has been associated with episodic

course (Strakowski et al., 1998), greater disability and poorer quality
of life (Boylan et al., 2004), rapid cycling (Magalhaes et al., 2010),
increased risk of suicide (Simon et al., 2004), comorbid dysthymia
(Kruger et al., 2000), substance abuse and eating disorders (DellOsso
et al., 2011). A recent study examined 318 inpatients and found
comorbid OCD to be related to depressive temperament and poorer
response to anticonvulsants (Henry et al., 2003). The review by
Amerio et al. concluded that OCD is mostly secondary to mood
episodes, depression in particular and that the course of OCD is
episodic with worsening in depressive phases and improvement/
remission in manic phases (Amerio et al., 2014a).
In this study, we examined the frequency of occurrence of OCD
in a large number (n 396) of consecutively hospitalized patients
with BD type I (BD-I) and attempted to identify socio-demographic
and clinical correlates of BD-I with and without OCD.

2. Method
Sample consisted of all consecutive adult (418 years) patients
with DSM-IV-TR (APA, 2000) diagnosis of BD-I admitted to the
inpatient services of the National Institute of Mental Health and
Neuro Sciences (NIMHANS), Bangalore, India from July 2010 to July
2011. Patients with mental retardation, schizophrenia, schizoaffective
disorder, epilepsy and other neurological disorders were excluded.
Among the 456 such patients, 38 refused consent whereas 22 were
excluded as they had a comorbid neurological disorder (epilepsy and
stroke). Hence, the nal study sample included 396 BD-I patients.
Participants voluntarily gave written informed consent. The NIMHANS Ethics Committee approved the study for its ethical aspects.
Patients fullling the inclusion criteria underwent a structured
evaluation using the Mini International Neuropsychiatric Interview for Bipolar Disorder Studies (MINI-BIPOLAR) (Sheehan et al.,
1998) and Structured Clinical Interview for DSM-IVAxis II disorders (SCID-II) (First et al., 1995). Socio-demographic and clinical
variables were obtained from the medical records/charts and from
the interviews of the subjects and their immediate family members. Life charting of the course of bipolar illness and its relationship to OCD was completed for each patient based on the
information available from all the sources i.e., clinical charts,
personal interviews with index patient and an immediate family
member (Roy-Byrne et al., 1985). Family history of major psychiatric illnesses (psychoses, affective disorders, alcohol/substance
abuse, and suicide) in rst-degree relatives was obtained from
the index patient and at least one other family member who lives
with the patient using a semi-structured interview, the Family
Interview for Genetic Studies (FIGS) (Maxwell, 1992). A family
history of OCD was conrmed by asking questions from the OCD
section of the MINI since the FIGS do not have a section on OCD.
The Young Mania Rating Scale (YMRS) (Young et al., 1978) and the
Hamilton Rating Scale for Depression (HAM-D) (Hamilton, 1960)
were used for the assessment of the severity of mania and depression
respectively. For the global assessment of the severity of illness and
functional impairment, we used the Clinical Global Impression (CGI)
(Guy, 2010) scale and the Global Assessment of Functioning (GAF)
(Endicott et al., 2010) scale, respectively. Severity of OC symptoms
was evaluated using the YaleBrown ObsessiveCompulsive Scale
(Y-BOCS), (Goodman et al., 1989). Obsessions were differentiated
from depressive ruminations based on their phenomenological
property. Depressive ruminations are typically about negative events
in life and reect self-criticism, failures, guilt, regret and pessimism.
They are mood-congruent, and are not necessarily experienced as
intrusive and distressing and are not associated with compulsions as
in OCD. Similarly, accelerated thoughts in mania are not perceived by

the individual as intrusive and are not associated with distress and
compulsions.
All the assessments were performed by the rst and second
authors who were trained to administer the instruments by senior
clinicians of the team (SBM/YCJR). Diagnosis of BD-I and OCD and
other clinical features including the longitudinal course of BD-I
was determined by consensus of the rst two authors. Assessments
were performed mostly within a week of the hospitalization when
patients were cooperative for detailed assessment. However, no
formal reliability exercises were carried out. Predominant polarity
was determined by the International Society for Bipolar Disorders
(ISBD) denition (Tohen et al., 2009). Course is considered predominantly depressed (PD) or predominantly manic (PM) by having at
least two-thirds of lifetime episodes of one polarity or the other.
2.1. Statistical analysis
The comparisons between the groups were carried out by Chisquare/Fisher's exact test for categorical variables and independent
sample t-test for continuous variables. A po0.05 was considered
statistically signicant. Bonferroni correction was not used because
of the exploratory nature of the study. Backward stepwise logistic
regression (Wald) was used to identify signicant variables in differentiating the groups. All variables which were signicant in the
univariate comparisons (psychotic symptoms, occupational status,
functioning scores, family history of OCD, comorbid social phobia,
and anxious avoidant personality disorder) were included in the
regression analysis. In addition, clinically signicant variables (age at
assessment, gender, and age of onset of BD-I) were also included.

3. Results
A total of 396 patients with BD-I were recruited out of which 30
(7.6%) had comorbid OCD (Y-BOCS415 and fullling criteria for
DSM-IV OCD). Fifteen subjects reported subclinical OC symptoms on
the Y-BOCS checklist (Mean7SD2.270.8). Of the 30 OCD patients,
28 were in mania, 1 was in mixed episode and one was in depression.
OCD ante-dated BD in 13; post-dated in 12; almost simultaneous
onset in 4; and not clear information in 1 patient. In 26 subjects, OCD
ran a continuous course (clinically ill, fullling criteria for DSM-IV
clinical diagnosis) and in the remaining 4 an episodic course. Of the
30 OCD patients, 20 reported worsening during manic phases and
3 during depression. No patients reported improvement in mania.
The Y-BOCS total, obsession and compulsion subscale scores
(Mean7SD) for the sample with OCD was respectively 26.772.8,
13.371.4 and 13.471.6.
There were no statistically signicant differences between patients
with and without OCD in terms of age (30.6711.9 years vs. 31.8711.1
years, t0.55, p0.59), sex (37% women vs. 42% women, 2 0.33,
p0.56) and background (60% urban vs. 47% urban, 2 1.8, p0.18).
A signicantly higher proportion of BDOCD subjects were unemployed when compared to the other group (10% vs. 5%, 2 8.52,
p0.04).
Those with clinical (n 30) and subclinical OCD (n15) did not
differ signicantly with respect to the GAF (35.83714.14 vs. 297
10.03, t 1.668, p0.103), the HAM-D (2.0376.38 vs. 1.7376.71,
t  0.146, p0.884), the YMRS (37.1377.3 vs. 40.0675.02, t
1.391, p0.171), CGI-S (bipolar disorder) (4.371.26 vs. 4.8671.42,
t 1.425, p0.161) and the number of hospitalizations (2.7672.06
vs. 271, t  1.356, p0.182).
Table 1 shows comparison of clinical correlates between BD-I and
BDOCD groups. No signicant differences were found between the
groups in terms of percentage time spent in episodes and polarity of
the most recent episode. The BDOCD group when compared to BD-I
alone had lower GAF score, and less of psychotic symptoms.

M. Shashidhara et al. / Journal of Affective Disorders 174 (2015) 367371

369

Table 1
Clinical prole of bipolar disorder with/without obsessive compulsive disorder.
Variable

Age at onset of BD
Illness duration in years
Number of hospitalizations
HAM-D score
YMRS score
CGI-BD
Global assessment of functioning
No. of episodes
Mania
Hypomania
Depression
Mixed
% time spent in episodes
Psychotic symptoms current
Psychotic symptoms lifetime
Current suicide risk
Family history
OCD
BD
Depression
Polarity of index episode
Mania
Depression
Mixed
Predominant Polarityn
Mania
Depression
Mixed
Unclear

BD without OCD
n 366
n (%)/Mean (SD)
22.9
8.8
2.9
3.5
33.4
4.2
41.9

( 7 8.1)
( 7 8.1)
( 7 2.2)
( 7 9.4)
( 7 12.4)
( 7 1.2)
( 7 15.6)

4.32
0.02
1.93
1.00
18.81
196
222
36

( 7 8.24)
( 7 0.20)
( 7 8.14)
( 7 0.43)
( 7 27.29)
(53.6)
(60.7)
(9.8)

BD with OCD
n 30
n (%)/Mean (SD)

t/Chi-square value

22.2
8.6
2.8
2.1
37.1
4.3
35.8

( 7 8.4)
( 7 7.6)
( 7 2.1)
( 7 6.4)
(7.3)
( 7 1.3)
( 7 14.2)

0.65
0.17
0.25
0.83
 1.62
 0.36
2.05

0.60
0.86
0.80
0.41
0.11
0.72
0.04

3.80
0.07
0.60
0.13
22.44
9
13
3

( 7 4.38)
( 7 0.37)
( 7 1.16)
( 7 0.43)
( 7 32.2)
(30.0)
(43.3)
(10)

0.34
 1.11
0.89
0.43
 0.69
6.16
3.45
0.01

0.57
0.51
0.37
0.67
0.49
0.01
0.06
0.98

1 (0.3)
80 (21.9)
35 (9.6)

2 (6.7)
6 (20.0)
4 (13.3)

0.44

0.02a
1.00a
0.51

314 (85.8)
41 (11.2)
11 (3.0)

28 (93.3)
1 (3.3)
1 (3.3)

1.81

0.40

265
36
18
47

18
2
4
6

5.48

0.14

(72.4)
(9.8)
(4.9)
(12.8)

(60.0)
(6.7)
(13.3)
(20.0)

a
Fisher's exact test; BD Bipolar disorder; OCD Obsessive compulsive disorder; CGI Clinical global impression; YMRS Young mania rating scale; HAM-D Hamilton
rating scale for depression.
n
Inter-episodic syndromic recovery was reported in 200 (51%) subjects and the two groups did not differ signicantly.

Signicantly higher proportion of the BDOCD group had a

family history of OCD as compared to BD only group. Prev1alence
of family history of other disorders was not signicantly different
between the groups.
Table 2 shows the comparison of comorbidities between the
groups. Social phobia was more in the OCDBD group, whereas
alcohol and substance dependence was more in the BD-I without
OCD group. Among axis II diagnoses, anxious avoidant personality
disorder (AAPD) had a signicantly higher prevalence in the
BDOCD group.
With respect to type of drugs used for the treatment of index
episodes, lithiumatypical antipsychotics was the commonest
(n168, 42%) followed by valproateatypical antipsychotics (n51,
13%), typical antipsychotics alone (n43, 11%), and atypical antipsychotics alone (n 29, 7%). The remaining received various combinations of mood stabilizers and antipsychotics. However, the pattern of
use of various medications and their combinations did not differ
signicantly between those who had OCD and those who did not.
None of the OCD patients received antidepressants during the index
mood episodes for which they were hospitalized.
We compared the BDOCD and BD-I groups with respect to
percentage of time on antipsychotics (30% vs. 21%, t 1.7, p 0.08),
mood stabilizers (24.4% vs. 14.9%, t1.8, p 0.09) and antidepressants (3.7% vs. 4.2%, t0.92, p 0.8) during the course of illness
but found no signicant differences. Although the percentage of
time spent on antidepressants during the course of illness was
low, antidepressant use itself in combination with mood stabilizers/antipsychotics was seen in 98 subjects (25%) and there was no
signicant difference between those who had OCD (n 7, 23%) and
those who did not (n 91, 25%).

Table 2
Comorbidity in BD with OCD vs. BD without OCD.
Variable

Axis I disorder
Any axis I diagnosis
Panic disorder
Agoraphobia
Social phobia
Generalized anxiety
disorder
Alcohol/Substance
dependence
Personality disorder (PD)
Any PD
Anxious avoidant PD
Obsessive compulsive PD
Passive aggressive PD
Paranoid PD
Schizoid PD
Borderline PD
Antisocial PD
a

BD without
OCD
n 366
n (%)

BD with
OCD
n 30
n (%)

Chi-square
value

78
1
0
5
4

5 (16.7)
0
1 (3.3)
3 (10.0)
0

0.65
1.00a
0.08a
0.02a
1.00a

72 (19.7)

2 (6.7)

0.09

77
10
1
9
4
3
12
42

10 (33.3)
8 (26.7)
0
0
0
1 (3.3)
0
1 (3.3)

2.45

0.12
o 0.001a
1.00a
1.00a
1.00a
0.27a
0.61a
0.23a

(21.3)
(0.3)
(0)
(1.4)
(1.1)

(21.0)
(2.7)
(0.3)
(2.5)
(1.1)
(0.8)
(3.3)
(11.5)

Fisher's exact test.

In regression analysis, a lower GAF score ( 0.02, OR0.94,

p0.002), unemployment status ( 0.24, OR1.7, p 0.03), less
psychotic symptoms ( 0.51, OR0.18, p0.001) and the presence
of anxious avoidant personality disorder ( 0.66, OR12.33,
po0.001) predicted BDOCD and explained 64% of the variance.

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M. Shashidhara et al. / Journal of Affective Disorders 174 (2015) 367371

4. Discussion
Of 396 patients with BD-I, 7.6% had comorbid OCD, which is
comparable to previous literature. Studies that have systematically
looked at inpatient population have reported rates ranging from 3%
to 7% (Henry et al., 2003; Kruger et al., 2000; Strakowski et al., 1998).
Kruger et al. (1995) reported a high rate of 35% OCD comorbidity, but
as reported by the authors themselves, the study's limitations were
that the majority of subjects were depressed and depressive ruminations could have been mislabeled as obsessions. Previous studies on
community (Angst et al., 2005; Kessler et al., 1997; Mitchell et al.,
2004) and outpatient populations (Boylan et al., 2004; DellOsso et
al., 2011; Magalhaes et al., 2010; Simon et al., 2004) have reported a
prevalence ranging from 5% to 21% and 4% to 12% respectively. In a
previous study from this center (Zutshi et al., 2007), a high
prevalence of OCD (35%) was noted in remitted BD patients. However, this sample was predominantly outpatient. A previous study
has also reported that the comorbidity between OCD and bipolarity
is very low in BD-I and highly prevalent in soft bipolar spectrum
(Hantouche et al., 2003). A recent systematic review noted the
variability in prevalence of OCD in BD patients depending upon the
nature of the sample, sample size, bipolar type and status of
remission and concluded that in larger samples prevalence of OCD
in BD-I was around 15%, whereas the population prevalence was
between 11% and 20% (Amerio et al., 2014a). In the current study,
patients were symptomatic, mostly in their mania phase, which
may have contributed to under-reporting of OCD (Table 1). It is well
known that OCD is more common in depressive phases of BD
(Amerio et al., 2014a).
In line with the systematic review of treatment of OCD in BD,
none of our patients received antidepressants for treatment of
OCD during the index episode (Amerio et al., 2014b), although
nearly a quarter of patients with bipolar disorder had received
antidepressants some time during the course of illness. However,
the percentage of time exposed to antidepressants during the
course of illness was very low (about 4%). The review, based on the
limited data, emphasizes the need to avoid antidepressants to
treat OCD because of the ability of the antidepressants to worsen
the course of BD and points out that in most patients, OCD
symptoms disappear with aggressive treatment of mood episodes
with mood stabilizers alone or in combination with atypical
antipsychotics (Amerio et al., 2014b).
In BDOCD group, the OCD ran a continuous course in a
majority (26 out of 30) with worsening in mania. This is counterintuitive and not in accordance with the published literature. A
recent review concluded that OCD in BD runs an episodic course
with worsening in depression and improvement in manic phases
(Amerio et al., 2014a). The disparity seems to be related the nature
of the sample in our study: a majority was in mania phase. It is
possible that those subjects who did not experience OCD during
the index episode of mania simply did not report of OCD in their
euthymic and depressive phases resulting in possible underestimation of OCD and also its episodic nature.
Patients in BDOCD group had lower GAF score and higher
rates of unemployment. This is consistent with previous studies
which have reported higher rates of unemployment (Zutshi et al.,
2006) and lower functioning (Simon et al., 2004) indicating higher
disability in these patients.
The groups did not differ with respect to number and type of
mood episodes, but psychotic symptoms were less in the BDOCD
group. Only few studies have looked into this aspect. Zutshi et al.
(2006) reported that bipolar patients with anxiety disorders have
more psychotic episodes, while Koyuncu et al. (2010) reported no
difference between BDOCD and BD-I alone group with regard to
prevalence of psychotic symptoms. This nding of lower prevalence of psychotic symptoms in this group needs special mention.

OCD could be a protective factor against psychosis in these

patients as has been previously reported in patients with schizophrenia and OCD comorbidity (Guillem et al., 2009; Poyurovsky
et al., 1999; Zink et al., 2008).
Patients in the BDOCD group had higher prevalence of comorbid
social phobia, which is consistent with previous studies (Tukel et al.,
2006; Zutshi et al., 2007). A high rate of AAPD in BDOCD patients is
also consistent with ndings from previous studies (Maina et al.,
2007). Higher co-morbidity of substance abuse in the BDOCD group,
as reported in previous studies (DellOsso et al., 2011), was not found.
Family history of OCD was signicantly greater in the BDOCD
group. This is consistent with high rates of family history of OCD,
anxiety states and depression in BD patients with OCD reported
previously (Angst et al., 2005). A recent study using BD pedigrees
found BDOCD comorbidity to be mediated at least partly by
familial factors (Goes et al., 2012).
There is some evidence from the schizophrenia literature that
subclinical OCD may have a positive effect on functioning whereas
clinical OCD may have a negative effect on functioning (De Haan
et al., 2013). In this study, those with OCD did not differ from those
with subclinical OCD with respect to global functioning, severity of
depressive and manic symptoms, and number of hospitalizations.
This is possibly because those with subclinical OCD had very low
mean Y-BOCS total score of 2.2 (SD 0.8), a score closer to general
population mean (Johansen and Dittrich, 2013).
Strengths of our study include large sample size, use of structured
assessments, and collection of information from multiple sources
such as clinical charts, patients, and family members. Limitations of
this study include retrospective design and recruitment of patients
from inpatient services of a tertiary psychiatric hospital. Follow-up
data on these patients would have been invaluable, but could not be
collected.

5. Conclusions
Our study has demonstrated that OCD comorbidity is not uncommon in BD-I. BD-I with co-morbid OCD is associated with greater
functional disability. OCD seems to have a protective effect against the
occurrence of psychotic symptoms in BD-I. BDOCD is also associated
with greater comorbidity of social phobia, AAPD and more likelihood
of a family history of OCD. This study stresses the need for detailed
evaluation for OCD in patients with BD-I. Unrecognized OCD in BD-I
can lead to more functional disability. Future research should focus on
examining the impact of comorbid OCD on treatment response and
long-term course of BD-I.

Role of funding source

None.

Conict of interest
None.

Acknowledgments
Dr. BV is funded by the INSPIRE (IFA12-LSBM-44) faculty fellowship of the
Department of Science and Technology, Government of India.

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