OCD & Bipolar: Understanding the Connection

What Is OCD?

Obsessive-compulsive disorder (OCD) is a mental health condition characterized by cycles of unwanted intrusive thoughts, images, or urges and mental or behavioral compulsions.³ These cycles of obsessions and compulsions can take up an individual’s time and energy, severely affecting their quality of life and relationships. The World Health Organization lists OCD as one of the top ten leading causes of disability worldwide.³

The lifetime prevalence of OCD is 1.6% to 2.3% in the general population.³ Around 50% of people experience symptoms beginning in childhood or adolescence.³ OCD appears to have a genetic component, meaning that your risk of diagnosis increases if you have a family member who also has OCD.³ Although males present with symptoms earlier on, females make up the bulk of adult individuals with OCD.

What Is Bipolar Disorder?

Bipolar disorder is characterized by alternating episodes of hypomania and mania with episodes of depression.⁴ Risks and potential causes of bipolar include a mix of a family history of bipolar disorder and environmental factors.⁵ Having a family member with bipolar increases the risk of diagnosis.⁵ Certain stressful life events have links to developing BD, including childhood trauma, disability, divorce, unemployment, childbirth, and early parental loss.⁵

There are two main types of bipolar disorder: bipolar I and bipolar II. Type I bipolar can be differentiated from type II by the severity and intensity of symptoms, including the presence of mania instead of hypomania.⁴ Cyclothymic disorder is a bipolar spectrum disorder that includes bipolar symptoms that do not meet the criteria for hypomania and major depressive disorder.⁴

How Are OCD & Bipolar Connected?

Researchers have two main theories around the co-occurrence of bipolar and OCD.⁶ One theory is that OCD and bipolar are two independent conditions that sometimes occur together, and another theory is that OCD is a subtype of bipolar.⁶ Since OCD symptoms peak and wane depending on mood episodes, this suggests that the disorders may come from similar biological causes.⁴

OCD and bipolar disorder may also share some similar risk factors for development. Both disorders have high heritability rates, meaning that you are more likely to develop them if you have a family history of the conditions. Some shared environmental factors that have links to the development of OCD and bipolar include childhood trauma, certain viral infections, and anxiety around uncertainty.^{3, 4}

How Common Is It to Have Both Bipolar & OCD?

Having a diagnosis of both bipolar and OCD is relatively rare, although it is pretty common for those with bipolar disorder to have obsessive-compulsive (OC) tendencies. OCD is diagnosed in around 1.6-2.3%, whereas bipolar disorder is diagnosed in 4.4% of U.S. adults.^{3, 11} Around 21% of individuals diagnosed with bipolar disorder will also have an OCD diagnosis.¹⁰ OCD is more commonly diagnosed in those with Type II bipolar disorder at around a rate of 75%.²

Can Bipolar Disorder Cause OCD Symptoms?

Sometimes, either a manic or depressive episode shift can cause obsessive-compulsive (OC) tendencies as a coping mechanism in those with non-OCD bipolar. Some research supports OCD as having an onset before BD, with rates as high as 54%.⁷ One study found that it was much more common to receive an OCD diagnosis prior to receiving a bipolar diagnosis and less common to receive a bipolar diagnosis first.⁸

Overlapping compulsions can include compulsive sorting, checking, controlling, repeating, washing, counting, and reassurance-seeking.¹ These compulsions tend to occur more during depressive episodes or mixed states.

Challenges of Diagnosing OCD Vs. Bipolar Disorder

One of the main challenges presented when diagnosing OCD versus bipolar is that some features of the disorders overlap. For example, both OCD and bipolar can present with episodes of obsessions and rumination, mood shifts, and compulsive behaviors. One study identified that individuals with bipolar ruminate both in depressive and manic states.⁹ Rumination is also a common mental compulsion for those with OCD.

Additionally, bipolar disorder cycles and OCD cycles can be confused with one another, which can contribute to challenges with diagnosis as patients can seek care during different peaks or wanes in episodes. For example, if someone with OCD seeks out care during a stressful period of life where compulsions are intense, they may appear manic. Or, someone with bipolar who seeks care during a mixed episode might be engaging in more OCD-like tendencies to cope with mood shifts.

Can OCD Be Mistaken For Bipolar?

OCD is sometimes mistaken for bipolar when symptoms overlap or follow episodic patterns. Obsessive-compulsive symptoms tend to pop up during either depressive episodes or in the time periods between depressive and manic episodes of bipolar disorder.⁶ Obsessive-compulsive symptoms also tend to improve during hypomanic and manic phases.⁶ Sometimes, these symptoms can be missed or misattributed to another disorder.

Bipolar can also be mistaken for OCD when symptoms overlap, such as intrusive thoughts, dramatic mood shifts, or repetitive compulsive behaviors. Obsessions in OCD can sometimes look a lot like ruminative depressive episodes in BD. Compulsions can sometimes look a lot like the goal-directed activity that is found in mania and hypomania.

Particularly for individuals with bipolar, sometimes self-reporting of symptoms is also not as accurate during hypomanic or manic episodes.

Impact of Having Both OCD & Bipolar

The World Health Organization includes both bipolar and OCD as the top most disabling conditions worldwide. Those who have both OCD and bipolar tend to have more intense symptoms, longer episodes, less willingness to stay medicated, and show overall less response to medications.¹ Additionally, medication management can be difficult when there are certain medications commonly prescribed for OCD, which can exacerbate symptoms of mania.

One study documented worsening of OCD symptoms during depression for those with OCD and bipolar.⁷ Having both conditions also puts a person at risk for other disorders like depression, social phobia, and generalized anxiety disorder.⁷ Those who have bipolar OCD are also documented as having less severe OCD than their non-bipolar counterparts.⁷

Treatment for OCD & Bipolar Disorder

Treating a dual diagnosis of OCD and bipolar can be difficult because selective serotonin reuptake inhibitors (SSRIs), which are often the first line of treatment for OCD, can induce manic symptoms in BD.¹¹ Most experts agree that mood stabilization should be the initial focus of treatment.¹³ Psychotherapy has been shown to have positive effects when used in addition to medication.¹³

Medication

Having comorbid OCD and BD can complicate medication management. Selective serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed medication for OCD. However, SSRIs are also known to exacerbate manic symptoms in BD.¹

Research supports the use of mood stabilizers and antipsychotics as the primary sources of treatment, with antidepressants only being used in a minority of cases.¹² One review of research found that mood stabilizers combined with topiramate or olanzapine combined with clomipramine can be effective in the treatment of bipolar OCD.¹¹ Long-term bipolar medication management often requires continual monitoring, changing, and reevaluation.⁴

Psychotherapy

Once mood stabilization has occurred through medication management, psychoeducation of the disorders can be an initial step into psychotherapy. Through psychotherapy, people with OCD and bipolar can learn to recognize signs and symptoms of mania and depressive episodes.¹³ They can also learn to appreciate the importance of adhering to treatment and strategies for preventing fluctuations in mood.¹³

Cognitive behavioral therapy (CBT) is supported as an effective treatment for both bipolar and OCD.¹³ CBT can be adapted to address the interplay of thoughts, emotions, and behaviors that occur with changes in bipolar mood episodes and flares in OCD obsessions and compulsions. Additionally, exposure and response prevention (ERP), which is a type of CBT that is the gold standard treatment for OCD, can be used to address OCD symptoms or tendencies in bipolar OCD.¹⁴

How to Cope With OCD & Bipolar Disorder

Although there is no cure for OCD and bipolar, learning to manage symptoms can help you still have a good quality of life. Identifying and tracking symptoms can be helpful through using a diary or app, which you can share with your treatment team during appointments. Recommended daily coping includes lifestyle modifications, building and maintaining a support network, and following your prescribed treatment plan.

Here are some tips for how to cope with OCD and bipolar disorder:

Lifestyle Modifications

Since OCD and bipolar symptoms can negatively impact mood, attention, and energy levels, it is important to establish positive habits and routines through lifestyle changes. Both disorders often have cyclical patterns to symptoms, and learning to track your symptoms can help you plan for any exacerbations. It is important to share any self-reporting observations with your treatment team.

One helpful strategy is to explore self-care techniques using a self-care wheel, or similar activity. By exploring and noting coping strategies for your OCD and bipolar when symptoms are stable, you can better prepare for mood fluctuations during a crisis by having your coping mechanisms written out. Stress reduction techniques and mindfulness practices can also help by keeping your body in a more relaxed and stable state.

Building a Support System

Both the quality and quantity of a person’s support system can affect someone’s quality of life.¹⁵ Positive coping with OCD and bipolar might involve reevaluating, building, strengthening, or cutting certain friend and family relationships.

Building a supportive network might include exploring new opportunities for relationships, such as support groups for bipolar and OCD. The Depression and Bipolar Support Alliance can help you find a support group for bipolar symptoms. The International OCD Foundation can help locate OCD support and treatment groups local to you.

Following the Treatment Plan

Individuals with OCD or bipolar sometimes struggle to follow through with treatment plans due to fluctuating mood episodes and shame around obsessions. Maintaining a therapy routine, following medication schedules, and reporting any side effects to your treatment team are the best ways to manage bipolar and OCD. Although there is no cure, these lifestyle changes can help manage symptoms and improve your quality of life.

When to Seek Professional Support

It may be time to find professional support if symptoms interrupt your ability to fulfill personal and professional responsibilities. Especially if obsessions are centering around suicidal thoughts, professional support and treatment are needed. An online therapist directory or online therapy platform can help you look for a therapist who treats OCD and bipolar, while online psychiatrist options can support you through medication management.