Copyright ª Blackwell Munksgaard 2007

Bipolar Disorders 2007: 9: 722–729 BIPOLAR DISORDERS

Original Article

Bipolar obsessive-compulsive disorder and

personality disorders
Maina G, Albert U, Pessina E, Bogetto F. Bipolar obsessive-compulsive Giuseppe Maina, Umberto Albert,
disorder and personality disorders. Enrico Pessina and Filippo Bogetto
Bipolar Disord 2007: 9: 722–729. ª Blackwell Munksgaard, 2007
Department of Neuroscience, Anxiety and Mood
Disorders Unit, University of Turin, Turin, Italy
Objectives: Relatively few systematic data exist on the clinical impact
of bipolar comorbidity in obsessive-compulsive disorder (OCD) and no
studies have investigated the influence of such a comorbidity on the
prevalence and pattern of Axis II comorbidity. The aim of the present
study was to explore the comorbidity of personality disorders in a group
of patients with OCD and comorbid bipolar disorder (BD).

Methods: The sample consisted of 204 subjects with a principal

diagnosis of OCD (DSM-IV) and a Yale-Brown Obsessive-Compulsive
Scale (Y-BOCS) score ‡16 recruited from all patients consecutively
referred to the Anxiety and Mood Disorders Unit, Department of
Neuroscience, University of Turin over a period of 5 years (January
1998–December 2002). Diagnostic evaluation and Axis I comorbidities
were collected by means of the Structured Clinical Interview for DSM-IV
Axis I Disorders (SCID-I). Personality status was assessed by using the
Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II).
Socio-demographic and clinical features (including Axis II
comorbidities) were compared between OCD patients with and without a
lifetime comorbidity of BD.

Results: A total of 21 patients with OCD (10.3%) met DSM-IV criteria

for a lifetime BD diagnosis: 4 (2.0%) with BD type I and 17 (8.3%) with
BD type II. Those without a BD diagnosis showed significantly higher
rates of male gender, sexual and hoarding obsessions, repeating
compulsions and lifetime comorbid substance use disorders, when
compared with patients with BD/OCD. With regard to personality
disorders, those with BD/OCD showed higher prevalence rates of Cluster
A (42.9% versus 21.3%; p ¼ 0.027) and Cluster B (57.1% versus 29.0%;
p ¼ 0.009) personality disorders. Narcissistic and antisocial personality
disorders were more frequent in BD/OCD.
Conclusions: Our results point towards clinically relevant effects of
comorbid BD on the personality profiles of OCD patients, with higher
rates of narcissistic and antisocial personality disorders in BD/OCD
patients.
Key words: bipolar disorder – comorbidity –
obsessive-compulsive disorder – personality
disorders
Received 13 March 2005, revised and accepted for
publication 31 October 2006
Corresponding author: Prof. Giuseppe Maina,
Department of Neurosciences, Anxiety and Mood
Disorders Unit, University of Turin, Via Cherasco
11, 10126 Turin, Italy. Fax: + 39 011 673473;
e-mail: giuseppemaina@hotmail.com

Clinical and epidemiological studies in recent years
have suggested that comorbidity between obsessive-
compulsive disorder (OCD) and bipolar disorder
(BD) is highly prevalent. In BD patients, the lifetime
rates of comorbid OCD have been reported to range
The authors of this paper do not have any commercial associations
that might pose a conflict of interest in connection with this manu-
script.
between 3.2% and 35%, depending on the charac-
teristics of subjects included (with or without
psychotic features, BD type I or II or mixed
samples) (1–13). Conversely, the rate of lifetime
comorbid BD in clinical samples of OCD patients
ranges between 3.8% and 21.5%, with a higher
prevalence of BD type II (7.8–17.7%) (14–22).
When bipolar comorbidity was dimensionally ex-
plored by using soft bipolar spectrum criteria, rates

722

increased to 30% for lifetime hypomanic episodes
and almost 50% for cyclothymic traits (21).
Epidemiological studies in the community have
confirmed the existence of a significant comorbidity
between OCD and BD, suggesting that high rates
found in clinical samples are not simply a result of
clinical center bias. In the Epidemiologic Catch-
ment Area (ECA) Study, the lifetime rate of OCD
among patients with BD was 21% (23). A commu-
nity survey conducted in Italy found a lifetime rate
of 3.6% for manic, hypomanic or mixed episodes
among patients with a principal diagnosis of OCD,
and a lifetime rate of 11.1% for OCD among
subjects with a principal diagnosis of BD (24).
When using a wider concept of the bipolar spec-
trum in epidemiological studies (25), lifetime co-
morbidity rates increased significantly: 53.3% of
OCD cases manifested some hypomanic symptoms
and 30% qualified for BD type II diagnoses (26).
The clinical impact of BD/OCD comorbidity has
only recently been investigated. Bipolar disorder
patients with comorbid OCD are more frequently
males, more often suffer from a comorbid panic
disorder, have more suicidal attempts or ideation,
and spend less time in euthymia than BD patients
without such comorbidities (8, 13, 23). Subjects
with OCD and comorbid BD more frequently
report sexual, religious, aggressive and impulsive
obsessions and checking, ordering and hoarding
compulsions, compared to patients without such a
comorbidity; have an earlier age at onset (even in
prepubertal age), tend to show a gradual onset
and have an episodic course of OCD; have more
suicide attempts and more hospitalizations; and
show higher rates of panic disorder/agoraphobia,
substance use disorders and, in children and
adolescents, conduct disorders and attention-defi-
cit hyperactivity disorder (16, 22, 27–29).
Although comorbidity between personality dis-
orders and OCD appears to be a relevant phenom-
enon, with clinical and therapeutic implications
(30–33), none of the above-mentioned studies
investigated the influence of BD comorbidity on
the prevalence and pattern of Axis II comorbidity
in OCD.
The aim of the present study was to explore the
comorbidity of personality disorders in a group of
patients with OCD and comorbid BD.
Methods
Subjects
Subjects for this study were recruited from all
patients with a principal diagnosis of OCD con-
secutively referred to the Anxiety and Mood
Bipolar OCD and personality disorders
Disorders Unit, Department of Neuroscience, Uni-
versity of Turin (Italy) over a period of five years
(January 1998–December 2002). This is a tertiary
referral center mainly for patients from the
Piedmont and Aosta’s Valley regions of Italy,
located within the University General Hospital.
Patients are referred by general practitioners or
psychiatrists due to an anxiety or mood disorder
diagnosis (or hypothesized diagnosis), although a
few are self-referred (through information received
from other patients). Each referred patient is seen in
the outpatient service, and, if necessary, a decision
is then made regarding admission to the general
psychiatry inpatient unit. If a patient is judged to
have a principal diagnosis other than anxiety and/
or mood disorders, he or she is referred to another
unit within the same general hospital.
Inclusion criteria were: principal diagnosis of
OCD according to DSM-IV criteria and a
minimum total score of 16 on the Yale-Brown
Obsessive-Compulsive Scale (Y-BOCS) (34–35).
Furthermore, patients had to be at least 18 years
of age and willing to voluntarily participate in
the study. Informed consent from patients was
obtained after the procedure had been fully
explained.
Exclusion criteria were a current or previous
diagnosis of organic mental disorder, schizophre-
nia, schizophreniform or other psychotic disorder,
or an uncontrolled or serious medical condition.
Diagnostic and symptomatological evaluation
A systematic face-to-face interview that consisted
of structured and semi-structured components was
used to collect data. Diagnostic evaluation and
Axis I comorbidities were recorded by means of the
Structured Clinical Interview for DSM-IV Axis I
Disorders (SCID-I) (36).
All socio-demographic and illness characteristics
were obtained through the administration of a
semi-structured interview, developed and used in
previous studies (18, 37–39), with a format that
covered the following areas.
Socio-demographic data. Age, sex, marital status
(single, married, divorced, widowed), years of
education.
Onset and course of OCD. Disease onset was
indicated at the one-month period following the
first occurrence of obsessive and compulsive symp-
toms, and when at least one of these symptoms was
demonstrated by marked distress, was time-consu-
ming (more than one h per day) or interfered with
the person’s normal daily functioning (normal
routine, occupational and social activities). An
723
Maina et al.
attempt was made to date onset of OCD to within
a four-week period, but if there was any uncer-
tainty, a close relative of the patient was inter-
viewed and a range was plotted and its midpoint
used in the analysis. The onset was considered
abrupt when the symptoms reached clinically
significant intensity within one week of onset. All
other types of onset were considered insidious. If
an interval occurred, then the two time-points –
symptoms onset and disorder onset – were recorded
in the patient’s clinical history. In some cases
patients had an abrupt onset and therefore the
onset of symptoms and onset of disorder coin-
cided. The course of the disorder was considered
episodic when at least one circumscribed symptom-
free interval (six months) was present; all other
types of course were considered chronic, according
to a definition we used in previous studies (17, 40).
Obsessive-compulsive symptomatology. Up to three
primary obsessions and compulsions were listed for
each subject using the Y-BOCS Symptom Check-
list.
Personality disorders. Personality status was
assessed by using the Structured Clinical Interview
for DSM-IV Axis II Disorders (SCID-II) (41).
Assessment with the SCID-II was guided by items
previously confirmed by the subjects on the SCID-
Personality Questionnaire (SCID-PQ). Items not
verified on the SCID-PQ were assumed to be true
negatives. However, if an interviewer had any reason
to believe these were false negatives, further items
were assessed. This method is in accordance with
instructions for using the SCID-II, and enabled
personality disorder symptomatology to be based on
clinical contact combined with a structured clinical
interview. The raters for this interview were also
carefully instructed to challenge subjects, asking that
they be certain that such selected traits were unre-
lated to the symptomatology of the Axis I disorder.
In addition, the following rating scales were
included in the assessment of OCD patients: the
Hamilton Rating Scale for Anxiety (HAM-A) (42)
and the 17-item Hamilton Rating Scale for
Depression (HAM-D) (43).
The interview and all ratings were completed by
psychiatrists with at least four years of experience
with anxiety and mood disorders. High reliability
and diagnostic concordance have been documented
in previous reports (38, 44).
Statistical analysis
A statistical comparison between OCD patients
with and without a lifetime comorbidity of BD was
724
performed to examine whether there was any
difference in socio-demographic or clinical features
(including Axis I and II comorbidities). Our study
was designed to provide descriptive information;
therefore, primarily descriptive statistics were used
to analyze the data. Between-group comparisons of
categorical variables were made with Pearson’s
chi-square test. Continuous variables were com-
pared by using Student’s t-test for two-class
comparisons. Given the exploratory nature of our
study, we decided to use a two-tailed significance
level of p < 0.05.
Results
A total of 204 patients with a principal diagnosis of
OCD were enrolled in the study. Of these, 21
(10.3%) met DSM-IV (SCID) criteria for a lifetime
diagnosis of BD: 4 (2.0%) with BD type I and 17
(8.3%) with BD type II. Of the 21 subjects
diagnosed with BD, 15 (7.4%) had previously
received a BD diagnosis, while 6 (2.9%) patients
were newly diagnosed retrospectively according to
the results of the SCID. All of the newly diagnosed
BD subjects received a diagnosis of BD type II.
The mean age at onset of the first mood episode
for the 21 BD/OCD patients was 25.9 ± 7.4 years;
the onset of OCD preceded that of the first mood
episode in 8 patients (38.1%), was concomitant in
11 patients (52.4%) and followed the first mood
episode in 2 patients (9.5%). All patients whose
BD diagnosis was made prior to our assessment
(15 subjects) were already on a mood stabilizer
(lithium and/or antiepileptics and/or olanzapine);
the 6 newly diagnosed subjects were put on a mood
stabilizer prior to starting antidepressants in order
to prevent possible (hypo)manic switches.
Since there were only 4 patients with comorbid
BD type I, we performed all the comparisons
combining all BD patients.
The demographic and clinical characteristics of
the sample according to bipolar comorbidity are
presented in Table 1. The only statistically signif-
icant difference was in gender distribution: BD/
OCD subjects showed higher rates of male gender
than OCD patients without a diagnosis of BD.
Table 2 shows the phenomenology of OCD
according to the Y-BOCS Symptoms Checklist.
Patients with BD/OCD reported significantly high-
er rates of sexual and hoarding obsessions and
repeating compulsions.
Tables 3 and 4 report Axis I and II comorbid
disorders according to SCID-I and -II. Patients
with BD/OCD showed higher rates of substance
use disorders, at least one Cluster A personal-
ity disorder, at least one Cluster B personality
 Bipolar OCD and personality disorders

Table 1. Demographic and clinical characteristics: comparison between bipolar and non-bipolar subjects with obsessive-compulsive disorder

Statistics

Total (n ¼ 204) Bipolar (n ¼ 21) Non-bipolar (n ¼ 183) t or v2 df p

Index age, years, mean (±SD) 34.7 (12.1) 32.8 (13.0) 34.9 (12.0) 0.777 202 0.438
Educational level, years, mean (±SD) 12.1 (3.6) 11.6 (3.4) 12.2 (3.7) 0.701 202 0.484
Marital status, n (%)
Single 115 (56.4) 16 (76.2) 99 (54.1) 4.212 3 0.239
Married 77 (37.7) 5 (23.8) 72 (39.3)
Divorced 8 (3.9) 0 (0.0) 8 (4.4)
Widowed 4 (2.0) 0 (0.0) 4 (2.2)
Gender, n (%)
Male 102 (50.0) 16 (76.2) 86 (47.0) 6.423 1 0.011
Female 102 (50.0) 5 (23.8) 97 (53.0)
Age at onset, years, mean (±SD)
OCD 23.8 (9.5) 23.1 (10.4) 23.8 (9.4) 0.341 202 0.734
OCS 18.7 (9.9) 15.4 (8.2) 19.1 (10.1) 1.617 202 0.108
Type of onset, n (%)
Insidious 154 (75.5) 16 (76.2) 138 (75.4) 0.006 1 0.937
Abrupt 50 (24.5) 5 (23.8) 45 (24.6)
Type of course, n (%)
Chronic 165 (80.9) 19 (90.5) 146 (79.8) 1.393 1 0.238
Episodic 39 (19.1) 2 (9.5) 37 (20.2)
Y-BOCS, mean (±SD)
Total score 26.0 (6.3) 26.9 (6.2) 25.8 (6.4) )0.720 202 0.472
Obsession subscore 13.9 (3.2) 14.2 (3.0) 13.9 (3.2) )0.323 202 0.747
Compulsion subscore 12.0 (4.6) 12.7 (3.9) 11.9 (4.7) )0.721 202 0.472
HAM-D, mean (±SD) 11.5 (6.1) 10.4 (6.3) 11.6 (6.1) 0.820 202 0.413
HAM-A, mean (±SD) 12.9 (6.7) 10.7 (5.9) 13.2 (6.7) 1.661 202 0.098
Positive family history, n (%)
OCD 36 (17.6) 1 (4.8) 35 (19.1) 2.674 1 0.102
Other anxiety disorders 23 (11.3) 1 (4.8) 22 (12.0) 0.993 1 0.319
Mood disorders 44 (21.6) 7 (33.3) 37 (20.2) 1.915 1 0.166
Schizophrenia 3 (1.6) 0 (0.0) 3 (1.6) 0.349 1 0.554

SD ¼ standard deviation; OCD ¼ obsessive-compulsive disorder; OCS ¼ Obsessive-compulsive symptoms; Y-BOCS ¼ Yale-Brown
Obsessive-Compulsive Scale; HAM-D ¼ 17 item Hamilton Rating Scale for Depression; HAM-A ¼ Hamilton Rating Scale for Anxiety.

Table 2. Obsessive-compulsive phenomenology according to the Yale-Brown Obsessive-Compulsive Scale Symptoms Checklist: comparison between bipolar
and non-bipolar subjects with obsessive-compulsive disorder

Statistics

Total (n ¼ 204) Bipolar (n ¼ 21) Non-bipolar (n ¼ 183) v2 df p

Obsessions, n (%)
Aggressive 100 (49.0) 12 (57.1) 88 (48.1) 0.618 1 0.432
Contamination 104 (51.0) 12 (57.1) 92 (50.3) 0.356 1 0.551
Sexual 45 (22.1) 9 (42.9) 36 (19.7) 5.890 1 0.015
Hoarding/saving 27 (13.2) 7 (33.3) 20 (10.9) 8.234 1 0.004
Religious 49 (24.0) 6 (28.6) 43 (23.5) 0.266 1 0.606
Symmetry/order 89 (43.6) 8 (38.1) 81 (44.3) 0.291 1 0.589
Somatic 64 (31.4) 7 (33.3) 57 (31.1) 0.042 1 0.838
Miscellaneous 120 (58.8) 11 (52.4) 109 (59.6) 0.401 1 0.526
Compulsions, n (%)
Checking 121 (59.3) 13 (61.9) 108 (59.0) 0.065 1 0.799
Cleaning 103 (50.5) 10 (47.6) 93 (50.8) 0.077 1 0.781
Repeating 93 (45.6) 15 (71.4) 78 (42.6) 6.302 1 0.012
Ordering 57 (27.9) 5 (23.8) 52 (28.4) 0.198 1 0.656
Counting 37 (18.1) 6 (28.6) 31 (16.9) 1.717 1 0.190
Hoarding/collecting 25 (12.3) 5 (23.8) 20 (10.9) 2.907 1 0.088
Miscellaneous 109 (53.4) 10 (47.6) 99 (54.1) 0.318 1 0.573

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Maina et al.

Table 3. Lifetime Axis I comorbidities: comparison between bipolar and non-bipolar subjects with obsessive-compulsive disorder

Statistics

Lifetime comorbidity, n (%) Total (n ¼ 204) Bipolar (n ¼ 21) Non-bipolar (n ¼ 183) v2 df p

Anxiety disorders
Generalized anxiety disorder 51 (25.0) 5 (23.8) 46 (25.1) 0.018 1 0.894
Panic disorder 15 (7.4) 1 (4.8) 14 (7.7) 0.231 1 0.631
Social phobia 17 (8.3) 2 (9.5) 15 (8.2) 0.043 1 0.835
Simple phobia 33 (16.2) 6 (28.6) 27 (14.8) 2.652 1 0.103
At least one anxiety disorder 81 (39.7) 8 (38.1) 73 (39.9) 0.025 1 0.873
Depressive disorders
Major depressive disorder 51 (25.0) – 51 (27.9) – – –
Dysthymic disorder 11 (5.4) – 11 (6.0) – – –
Depressive disorder NOS 76 (37.2) – 76 (41.5) – – –
At least one depressive disorder 98 (48.0) – 98 (53.6) – – –
Other disorders
Anorexia nervosa 6 (2.9) 0 (0.0) 6 (3.3) 0.709 1 0.400
Bulimia nervosa 6 (2.9) 0 (0.0) 6 (3.3) 0.709 1 0.400
Eating disorder NOS 5 (2.5) 1 (4.8) 4 (2.2) 0.523 1 0.470
Substance use disorders 15 (7.4) 6 (28.6) 9 (4.9) 15.472 1 <0.001
Depersonalization disorder 8 (3.9) 2 (9.5) 6 (3.3) 1.950 1 0.163
Body dysmorphic disorder 13 (6.4) 1 (6.6) 12 (6.6) 0.102 1 0.750
Tic disorders 12 (5.9) 2 (9.5) 10 (5.5) 0.561 1 0.454
Kleptomania 2 (1.0) 0 (0.0) 2 (1.1) 0.232 1 0.630
Pyromania 1 (0.5) 0 (0.0) 1 (0.5) 1.115 1 0.734
Trichotillomania 4 (2.0) 0 (0.0) 4 (2.2) 0.468 1 0.494
Impulse-control disorders NOS 20 (9.8) 1 (4.8) 19 (10.4) 0.673 1 0.412
At least one comorbid disorder 159 (77.9) 14 (66.7) 145 (79.2) 1.731 1 0.188

NOS ¼ not otherwise specified.

disorder, and narcissistic and antisocial personality
disorders.
Discussion
The aim of the present study was to explore the
comorbidity of personality disorders in a group of
patients with OCD and comorbid BD.
Our findings are consistent with others suggesting
that BD is frequent in patients with OCD (14–22),
although this specific association seems to be
restricted to BD type II. The lifetime rate found
for BD type I was 2% in our sample, which is in the
range of lifetime prevalence rates for this disorder
found in the general population (1.6% for manic
episodes in the National Comorbidity Survey) (45),
while the lifetime rate for BD type II was 8.3%, and
thus higher than expected (46). Our result based on
an association between OCD and only BD type II is
in agreement with results from all studies which
specifically investigated lifetime comorbidity with
BD type I and II; these studies reported lifetime rates
for BD type II ranging from 7.8% to 17.7%,
compared to rates for BD type I ranging between
0.5% and 3.8% (15–17, 19, 21).
Given that we found only four subjects with a
lifetime diagnosis of BD type I, we performed all
statistical comparisons combining all patients with
726
comorbid BDs. Comorbid BD had a great impact
on the clinical characteristics of OCD: BD/OCD
patients were more likely to be male; showed a
distinct obsessive-compulsive symptomatological
profile; had more sexual and hoarding obsessions
and more repeating compulsions; and had higher
lifetime rates for substance use disorders. The
observation of a great impact of BD on the clinical
characteristics of OCD is in agreement with results
from other studies, which found a predominance of
male gender, a higher rate of sexual, religious,
aggressive and impulsive obsessions and checking,
ordering and hoarding compulsions, and higher
lifetime rates for substance use disorder (6, 27, 28).
Other authors found an earlier age at obsessive-
compulsive symptom onset in subjects with
comorbid BD, both in adult and adolescent sam-
ples (22, 29). In our study, BD/OCD patients
showed an earlier age at symptom onset (15 versus
19 years), although this difference did not reach
statistical significance. When we compared our
results with those from some of the above-men-
tioned studies (16, 21), we did not find either a
higher prevalence of episodic course or a higher
lifetime rate for panic disorder. This might be
due to differences in subjects enrolled in differ-
ent studies or in criteria used to collect informa-
tion (e.g., criteria used to diagnose comorbid
 Bipolar OCD and personality disorders

Table 4. Axis II comorbidities: comparison between bipolar and non-bipolar subjects with obsessive-compulsive disorder

Statistics

Total (n ¼ 204) Bipolar (n ¼ 21) Non-bipolar (n ¼ 183) v2 df p

Axis II comorbidity, n (%)

Paranoid 14 (6.9) 3 (14.3) 11 (6.0) 2.018 1 0.155
Schizoid 19 (9.3) 3 (14.3) 16 (8.7) 0.685 1 0.408
Schizotypal 19 (9.3) 4 (19.0) 15 (8.2) 2.626 1 0.105
Any Cluster A disorder 48 (23.5) 9 (42.9) 39 (21.3) 4.860 1 0.027
Antisocial 14 (6.9) 6 (28.6) 8 (4.4) 17.260 1 <0.001
Borderline 34 (16.7) 5 (23.8) 29 (15.8) 0.860 1 0.354
Histrionic 13 (6.4) 3 (14.3) 10 (5.5) 2.457 1 0.117
Narcissistic 19 (9.3) 7 (33.3) 12 (6.6) 15.991 1 <0.001
Any Cluster B disorder 65 (31.9) 12 (57.1) 53 (29.0) 6.891 1 0.009
Avoidant 48 (23.5) 5 (23.8) 43 (23.5) 0.001 1 0.975
Dependent 37 (18.1) 4 (19.0) 33 (18.0) 0.013 1 0.909
Obsessive-compulsive 63 (30.9) 4 (19.0) 59 (32.2) 1.536 1 0.215
Any Cluster C disorder 128 (62.7) 11 (52.4) 117 (63.9) 1.076 1 0.300
At least one personality disorder 174 (85.3) 17 (81.0) 157 (85.8) 0.352 1 0.553
More than one personality disorder 73 (35.8) 13 (61.9) 60 (32.8) 6.951 1 0.008

conditions). We also failed to find any statistically
significant difference between the two groups in
comorbidity rates for dysthymia, HAM-D total
scores and HAM-D suicidality mean scores. This
could be partly explained by the fact that our
patients were seen in an outpatient service. It is
plausible that severely ill patients with current
suicidal ideation would have been admitted to the
inpatient service. This limitation should be taken
into account when examining the results of our
study.
Taken together, the peculiar characteristics dis-
played by BD/OCD patients put these subjects at
higher risk of poorer response to or compliance
with common antiobsessional strategies, both
pharmacological and psychological (47, 48), sug-
gesting the need for alternative interventions for
these subjects.
To our knowledge, this is the first study to have
dealt with the impact of BD comorbidity on the
prevalence of Axis II disorders in OCD subjects,
and therefore comparisons with other studies are
not possible. Comorbid BD seems to affect the
personality profile of patients with OCD, since
BD/OCD subjects in our sample showed signifi-
cantly higher rates of at least a Cluster A or B
disorder, and, specifically, higher rates of narcis-
sistic and antisocial personality disorders. A BD
comorbidity, moreover, raises the frequency of
any personality disorder in OCD except obsessive-
compulsive personality disorder, although not
always with statistical significance. As for other
characteristics related to the BD/OCD comor-
bidity, the presence of a personality disorder
predicted poorer response to antiobsessional
treatments (40, 49, 50).
With regard to personality traits or disorders in
BD, there are multiple studies with differing views
[e.g., some authors have postulated that personal-
ity characteristics are core components of affective
disorders (51)] and several studies have indicated
that Cluster B personality disorders are more
frequent in BD (46, 52–54). This is in agreement
with our findings. It will be of interest to examine
whether some of the personality disorders found to
be associated with a BD/OCD comorbidity are
part of the clinical picture of the affective disorder
or represent independent entities, but this issue is
beyond the objectives of the present paper.
The findings of a higher than expected rate of
BD comorbidity in OCD and of the influence of
such a comorbidity on the clinical characteristics of
the disorder raises the question of whether obses-
sive-compulsive symptoms are part of bipolar
symptomatology rather than those of a distinct
entity; current knowledge does not permit the
drawing of definitive conclusions. However, the
fact that obsessive-compulsive symptoms are
present, at least in some cases, both in the
depressive and (hypo)manic phases of BD, suggests
that, at least in some cases, the hypothesis of two
distinct clinical entities may be true. Familial and
genetic studies, on one hand, and longitudinal
studies on the other, will give us an answer on this
fundamental question in the future.
A limitation of our study is that comorbidity
rates could have been inflated by specific help-
seeking patterns such as those that occur in a
tertiary psychiatric care setting. Since university
hospitals like ours specialize in treating complex
disorders, it is likely that patients referred to our
clinic have more than one Axis I comorbidity, as
727
Maina et al.
well as comorbid personality disorders. However,
higher rates of BD/OCD comorbidity have also
emerged from epidemiological studies, suggesting
that this phenomenon is not just the result of center
biases. It is, however, possible that the study
setting may have biased our result of a higher
comorbidity for personality disorders in subjects
with BD and OCD, and we are not aware of any
similar study performed in an epidemiological
setting.
The most important limitation is, however, the
small sample size of subjects with lifetime comor-
bid BD type I (only four patients), which obliged
us to perform comparisons combining all BD
patients, and prevented us from examining the
specific influence of BD subtypes on OCD. Future
studies should address this issue with greater
sample sizes.
Another limitation that must be taken into
account is the difficulty in diagnosing personality
disorders, which is even higher when instruments
such as the SCID-II are used in bipolar subjects.
Our results should then be viewed as restricted to
personality diagnoses as defined by DSM criteria
and cannot be compared to results of other studies
that used different conceptual frameworks and
instruments, such as Akiskal’s affective tempera-
mental model or Cloninger’s five-factor model of
personality disorder assessment.
In conclusion, our findings add to the literature
data indicating that bipolar comorbidity (mainly
BD type II) is a relevant phenomenon and has
clinically significant influence on the symptomato-
logical expression and complications of the disorder.
Furthermore, our results point towards a clinically
relevant effect of comorbid BD on the personality
profiles of OCD patients, with higher rates of
Cluster B personality disorders reported in BD/
OCD patients. The findings of specific differences
between OCD subjects with and without BD
comorbidity also point towards the possible identi-
fication of more homogeneous sub-groups of OCD
patients, whose conditions may differ etiologically,
and who may, in the future, benefit from specific
treatments.
The correct identification of BD/OCD comor-
bidity has relevant implications as far as treatment
outcome is concerned, since specific obsessive-
compulsive symptoms (such as hoarding symp-
toms), multiple comorbidity, alcohol or other
substance abuse and personality disorder comor-
bidity have a negative influence on compliance and
response to currently available antiobsessional
agents. Our study seems to suggest that a higher
Axis II comorbidity is related to the sub-group
with BD comorbidity.
728
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