Comorbidity of obsessive compulsive disorder in bipolar disorder

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Ai?-FECTIVE DISORDERS

ELSEVIER Journal of Affective Disorders 34 (1995) 117-120

Comorbidity of obsessive compulsive disorder in bipolar disorder

Stephanie Kriiger a,c, Robert G. Cooke b~c, * , Gary M. Hasey b,d, Thecla Jorna ‘, Emmanuel Persad f

a Westfulisches Zentrum fiir Psychiatric, Uniuersity of Bochum, Bochum, Germany b Department of Psychiatry, University of Toronto, Clarke Institute of Psychiatry, Toronto, Ontario, Canada

’ Bipolar Disorders Clinic, Clarke Institute of Psychiatry, Toronto, Ontario, Canada ’ Mood and Anxiety Unit, Clarke Institute of Psychiatry, Toronto, Ontario, Canada

e Department of Psychiatry, University of Toronto; Clarke Institute of Psychiatry, Toronto, Ontario, Canada ’ Department of Psychiatry, University of Western Ontario; London Psychiatric Hospital, London, Ontario, Canada

Received 21 July 1994; revised 13 October 1994; accepted 17 January 1995

Abstract

The comorbidity of OCD and bipolar disorder has not been systematically examined. Therefore, we determined the frequency of patients meeting DSM-III criteria for OCD syndrome in a sample of 149 inpatients with DSM-III major affective disorder who had received a clinically reviewed structured diagnostic interview. The frequency of OCD syndrome was not significantly different between subjects with major depression (35.2%, II = 105) and bipolar disorder (35.1%, n = 37). This suggests that OCD is equally common in bipolar as in unipolar patients.

Keywords: Major depression; Prevalence; OCD; Bipolar disorder; Comorbidity

1. Introduction

Several studies have indicated a high prevalence of major depressive disorder in patients with obsessive compulsive disorder (OCD), rang- ing between 13 and 15% (Rasmussen and Tsuang, 1986; Karno et al., 1988; Rasmussen and Eisen, 1992). Less attention has been paid to the relationship between OCD and bipolar disorder (BD)

* Corresponding author. Address: Bipolar Disorders Clinic, 11th Floor, Clarke Institute of Psychiatry, Toronto, Ontario M5T lR8, Canada. Fax: (1) (416) 979-6853.

and estimates of the prevalence of OCD in subjects with BD in the range of 5-6% appear not to have been based on systematic study (Winokur et al., 1969; Jenike and Rasmussen, 1990). These figures may reflect the notion that from a phe- nomenological viewpoint mania and OCD appear to be mutually exclusive (Kendell and Discipio, 1970). Nevertheless, reports of OCD symptoms in hypomanic patients date back to the 1940s (Stengel, 1945) and as early as the 19th century More1 (1860) had described patients with BD who had OCD symptoms during depressive episodes and during interepisodic intervals. More recently, several anecdotal reports describe OCD in patients with BD (Baer et al., 1985; Gordon and

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118 S. Kriiger et al. /Journal of Affective Disorders 34 (1995) II 7-120

Rasmussen, 1986; White et al., 1986, Keck et al., 1986; Vieta et al., 1991; Steiner, 1992) and Boyd and colleagues (Boyd et al., 1984) reported that the presence of either mania or depression increased the probability of the presence of OCD in patients in an epidemiologic sample.

The current study attempts to provide more systematic data on the comorbidity of BD and OCD. In it, we examined the prevalence of OCD in a sample of hospitalized patients with unipolar depression and BD.

2. Methods

The study sample was drawn from a cohort of 676 patients admitted during 1981-92 to a 12-bed clinical and research unit specializing in depression. The patient population comprised mainly depressed patients, including referrals directly from the hospital emergency department as well as tertiary referrals of patients with refractory depression from other psychiatrists and medical centres. During this period, the diagnostic interview schedule (DIS; Robins et al., 1979) was administered to 269 of these subjects, including those participating in specific research protocols on the unit, and to as many additional inpatients as staffing allowed. 224 subjects were diagnosed with a mood disorder. The results of each DIS interview were reviewed for reliability by two inpatient psychiatrists who were familiar with each patient and who made a final consensus DSM-III (American Psychiatric Association, 1980) diagnosis. The DIS interview was considered unreliable if the responses in the mood disorder section or in 2 2 other sections of the DIS were considered unreliable by the review team. After DSM-III conventions, the diagnosis of OCD was

Table 1

Prevalence of OCD syndrome in patients with affective disorders

not made by the clinicians in patients who had a primary diagnosis of mood disorder. Our princi- pal data analysis was carried out in the 149 cases in which the clinicians and the DIS agreed on the affective subtype, i.e., major depressive disorder, bipolar disorder (bipolar I in DSM-IV (American Psychiatric Association, 1994)) or atypical bipolar disorder (bipolar II in DSM-IV) but, since this represented a small proportion of the available cases, we carried out the same data analysis in all 224 subjects who received a DIS diagnosis of mood disorder. For the current study, we compared the lifetime prevalence of the OCD syndrome as determined by the DIS across the three affective subtypes and whether the diagnosis was based on the presence of obsessions, compulsions or both. Differences in prevalence were tested for significance at P < 0.05 by x2 analysis.

3. Results

Of the 149 subjects, 146 were depressed on admission and 3 were manic. The sample comprised 89 women and 60 men, the mean age + SD was 49 L- 12 years. 37 subjects had received a diagnosis of BD, 7 of atypical BD and 105 of major depression. Mean age at onset of the mood disorder was 26 + 7 years. There were no statisti- cally significant differences in age of onset for the three affective subtypes.

Table 1 outlines the distribution of the OCD syndrome and obsessional and compulsive symptoms across the three affective subtypes. Age at onset was 32 f 15.9 years for obsessions and 27 f 19.8 years for compulsions across all affective subtypes. There were no significant differences in gender, or duration or prevalence of the OCD syndrome, among patients with BD, atypical BD

Bipolar (n = 37) Atypical bipolar (n = 7) Major depression (n = 10.5)

Obsessions only a 16.2% (6) Compulsions only a 8.1% (3) 28.6% (2) Obsessions and compulsions a 10.8% (4) OCD syndrome a 35% (13) 28.6% (2)

a Prevalence rates not significantly different across all affective subtypes (x2 analysis).

20% (21)

7.6% (8)

7.6% (8)

35% (37)

S. Kriiger et al. /Journal of Affective Disorders 34 (1995) 117-120 119

or major depression. Essentially, the same results were found for the 224 patients who had received a DIS diagnosis of mood disorder (data not shown). While only 2/7 subjects with atypical bipolar disorder met criteria for OCD syndrome, the very small number of subjects does not allow final conclusions based on this finding.

4. Discussion

Our observation that the OCD syndrome occurs with equal frequency in bipolar and unipolar depressives challenges the earlier assertion that OCD occurs rarely in BD. Our findings are sup- ported by a growing body of literature suggesting a pathophysiological link between OCD and bipolar affective disorder: a number of case reports now describe the development of mania in re- sponse to treatment with a selective serotonin uptake-inhibiting antidepressant (SSRI) in OCD patients, some of whom had no prior history of bipolarity (Baer et al., 1985; Gordon and Ras- mussen, 1986; White et al., 1986; Keck et al., 1986; Vieta et al., 1991; Steiner, 1992). Further- more, Jefferson et al. (1991) reported a 25% manic switchover in fluvoxamine treated patients with OCD compared with only a 0.6% switchover incidence in patients with a mood disorder.

Evidence based on a single family pedigree (Dilsaver and White, 1986) suggests a genetic linkage between OCD and BD while other studies indicate increased incidence of obsessional traits in the offspring of bipolar probands (Klein and Depue, 1985). Coryell (1981) reported an equal incidence (2.3%) of mania in families of probands with OCD and in families with a bipolar disordered member.

Our data suggest an incidence of OCD in BD which is 6 x higher than previously thought. However, methodological issues may have con- tributed to these results. The presence of OCD was determined by the DIS, a standardized interview. There is evidence in the literature that the reliability of the DIS in diagnosing OCD is mod- erate when compared with a standardized DSM- III diagnosis made by a psychiatrist (Anthony et al., 1985) but there is no information on the

sensitivity of the DIS in discriminating true ego- dystonic obsessions from depressive ruminations. Thus, mislabelling of ruminations as obsessions might have produced a higher apparent prevalence of obsessions in our sample of depressed subjects. While this factor may have led to an overestimate of the prevalence of OCD in our subjects, it does not negate the findings of equiva- lent rates of OCD symptoms in patients with major depression and BD. Also, although the DIS was only administered to 40% of patients admitted to the unit, we have no reason to as- sume that this influenced our results in any way. Finally, it is possible that a selection bias may have influenced our findings. Our investigational unit was principally geared towards the treatment of refractory depression and, thus, our bipolar group may have included an overrepresentation of patients prone to episodes of severe or chronic depression as opposed to hypomania, mania or briefer or less severe depressive episodes. Bipolar disordered patients with predominantly depressive episodes are known to differ from those bipolar subjects with predominantly manic episodes with regard to age at onset, course and outcome parameters of the mood disorder (Angst, 1978) and, thus, might conceivably also have a higher frequency of lifetime OCD symptoms.

Based on the results of our study and its methodological drawbacks due to the presence of depression in our subjects, we suggest that further investigation should focus on the assessment of OCD in the interepisodic interval of BD. This would help to distinguish clinical features of bipolar patients with from those without OCD and would provide more reliable information on the comorbidity of both disorders.

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Comorbidity of obsessive compulsive disorder in bipolar disorder