Filippo Bogetto Andrea Aguglia

Disturbo bipolare e disturbo

ossessivo-compulsivo

The shift from an obsession to a

delusion may take either:

an affective form a paranoid form

delusional guilt to have

contaminated others

delusion to be persecuted as if

one had actually committed

some reprehensible act

Insel and Akiskal, Am J Psychiatry 1986

1. Prevalenza

!2. Impatto clinico

!3. Implicazioni terapeutiche

Il paziente con disturbo bipolare e

disturbo ossessivo-compulsivo

N=61.392

0

4,5

9

13,5

18

Bipolar Spectrum BD I BD II Subthreshold BD

10,111,8

17,7

12,5

OR=5.7

OR=9.0

OR=6.4

OR=4.1

p = .02

Merikangas et al., Arch Gen Psychiatry 2011; 68: 241-251

0

5

10

15

20

PD Social Phobia OCD

Unipolar Bipolar Sub-bipolar

p=.028

Faravelli et al. J Affect Disord, 2006; 94: 111-119

%

Lifetime comorbidity for anxiety disorders in bipolar,

sub threshold bipolar and unipolar disorder: the

Sesto Fiorentino study

Amerio et al, 2014

Adults: 1.8% - 35.1% !Children and adolescents: 20.7% - 48.5% !Sample size greater than 250 patients: 3% – 13.6%

Amerio et al., Acta Psychiatr Scand 2014; 129: 343-358

Lifetime prevalence rates of OCD in

bipolar patients: clinical studies

Current OCD comorbidity

0

5

10

15

20

All Bipolar Bipolar disorder I Bipolar disorder II

14,8

9,1

12,4

%

Albert et al. J Affect Disord 2008; 105: 297-303

OCD in Bipolar Disorder during euthymic phase

Cederlof et al., Schizophr Bull 2015; in press

OCD=19.814, BD=48.180, SCHZ=58.336, SCHA=14.904

Initial diagnosis of OCD Risk to develop BD or SCHZ or SCHA

Risk to develop OCD Initial diagnosis of BD or SCHZ or SCHA

SCHZ !BP !SCHA

Holma et al. J Clin Psychiatry 2008; 69: 1267-1275

Holma et al. J Clin Psychiatry 2008; 69: 1267-1275

Survival curve of time to diagnostic switch from

unipolar depression to bipolar disorder

%

Serie 1

0

25

50

75

100

OCD Social phobia Agoraphobia PD PTSD

57,9

73,777,8

85,790,5

N=413

Sala et al. J Clin Psychiatry 2012; 73: 87-94

Persistence of anxiety disorders in youth bipolar

patients: a five-years follow-up

1. Prevalenza

!2. Impatto clinico

!3. Implicazioni terapeutiche

Il paziente con disturbo bipolare e

disturbo ossessivo-compulsivo

Maina et al. Psychiatry Res, 2008; 158: 217-225

0

3,5

7

10,5

14

Bipolar I Bipolar II

Early-onsetLate-onset

p=.039

N=148

Early onset for Bipolar - OCD

0

20

40

60

80

Sexual obs Hoarding obs Repeating comp

Bipolar-OCD OCD

p<0,015

p<0,004

p<0,012

% o

f sp

ecifi

c O

C s

ympt

oms

Maina et al., Bipolar Disord 2007; 9: 722-729

N=204

OC symptoms and bipolar disorder

Tukel et al., Depress Anxiety 2006

Comparison of percentage of Bipolar disorder

in episodic and chronic OCD

Episodic course of OCD

0

5

10

15

20

25

4

21 Episodic (N=24) Chronic (N=104)

p=.01

Zutshi et al., Compr Psychiatry 2007; 48: 247-251

m/M

D

improvement of OC symptoms

in 64% of patients

worsening of OC symptoms

in 78% of patients

Perugi et al. J Affect Disord 2001; 67: 199-206

Obsessive-compulsive disorder (N=54)

0

10

20

30

40

50

60

Absent Present

47,852,2

%

current psychotic symptoms

0

15

30

45

60

Bipolar Bipolar - OCD

30

53,6

p = .01

Shashidhara et al., J Affect Disord 2015; 174: 367-371

%

N=396

Maina et al., Bipolar Disord 2007; 9: 722-729

0

20

40

60

80

Cluster A personality Cluster B Personality More than one Personality disorder

32,829,0

21,3

61,957,0

42,9

BD-OCD OCD

p = .009

%

N=204

p = .027

p = .008

Simon et al, Am J Psychiatry 2004; 161: 2222-2229

OCD comorbid reduces euthymic period

Results from STEP-BD

20

40

60

80

100

Thought of death Thought of suicide Wants to die Attempted suicide

Without OCD With OCD

* P<.05

** P<.01

%

*

*

*

**

Chen & Dilsaver. Am J Psychiatry 1995; 152: 280-282

OCD comorbid increases suicidality

OCD comorbid increases suicidality

Results from STEP-BD

Simon et al, Am J Psychiatry 2004; 161: 2222-2229

0

10

20

30

40

lifetime SUD

4,9

28,6

BD+OCD OCD

p<.001

OR=5.83

Maina et al., Bipolar Disord 2007; 9: 722-729

N=204

OCD-BD increases Substance use disorders

0

20

40

60

80

Rapid cycling History suicide attempts Lifetime alcohol dependence

no comorbidity anxiety comorbidity OCD comorbidity

Magalhaes et al., Compr Psychiatry 2010; 51: 353-356

%

Centorrino et al. Hum Psychopharmacol Clin Exp 2006; 21: 189–193

0

0,6

1,2

1,8

2,4

Re - hospitalizations/year

2,292,23

0,78

OCD BPD BPD + OCD

*

***

* * *

There is additional impairment due to anxiety in mood disorders

SF-36

N=105

*p≤.05 **p≤.005

Impact of Anxiety Disorder comorbidity on Quality of Life in Euthymic Bipolar Disorder Patients: all bipolar

Albert et al., J Affect Disord 2008; 105: 297-303

*p≤.05 **p≤.005

SF-36

N=61

Impact of Anxiety Disorder comorbidity on Quality of Life in Euthymic Bipolar Disorder Patients: bipolar II

Albert et al., J Affect Disord 2008; 105: 297-303

1. Prevalenza

!2. Impatto clinico

!3. Implicazioni terapeutiche

Il paziente con disturbo bipolare e

disturbo ossessivo-compulsivo

Raja and Azzoni, Bipolar Disord 2004; 6(3): 264-270

100% 42,8% 87,5%

These cases suggest herarchical priority to a bipolar

disorder diagnosis

Clinical management of obsessive-compulsive bipolar

comorbidity: a case series

Offidani et al., Psychother Psychosom 2013; 82: 132-141

Excessive mood elevation and behavioural activation with antidepressant

treatment of juvenile depressive and anxiety disorders: a systematic review

0

4

9

13

17

T0 T6 T12

Olanzapina

0

5

9

14

18

T0 T6 T12

Lamotrigina

HAM

-A s

core

s

HAM

-Asc

ores

N = 24 N = 23

p<0.05 p<0.05

Maina et al., J Clin Psychiatry 2008; 69: 609-614

Schaffer et al, Ann Clin Psychiatry 2012; 24: 6-22

OCD

The initial goal of in pharmacologic management of patients with bipolar and co-occurring OCD is

mood stabilization

BD

In a minority of BD patients with refractory OCD,

addition of low doses of antidepressants might also be considered

while strictly monitoring emerging symptoms of (hypo)mania

Amerio et al., Acta Psychiatr Scand 2014; 166: 258-263

Deckersback et al., Am J Psychiatry 2014; 171: 178-186

Deckersback et al., Am J Psychiatry 2014; 171: 178-186

Obsessive-compulsive disorder

Amerio et al, 2014

BD-OCD is a critical issue in psychiatry;

!

OC symptoms usually are manifestations of depressive or (hypo)manic

mood episodes and persist during euthymic phase;

!

BD-OCD may respond better to mood stabilizers and atypical

antipsychotic: antidepressants should be used only in a minority of

refractory OCD.

Conclusions

Amerio et al., J Affect Disord 2014; 166: 258-263

Duffy et al., Br J Psychiatry 2014; 204: 122-128

Clinical stages in the evolution of bipolar disorder based on high risk studies