Bipolar You

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Is There Such a Thing as Bipolar OCD Disorder?

The connection between bipolar disorder and obssessive compulsive symptoms

Technically, no; you won't find any such diagnosis in the American Psychiatric Association's DSM-IV (Diagnostic and Statistical Manual). That doesn't mean it doesn't exist. It's not at all uncommon that I hear obsessive compulsive (OC) symptoms as part of bipolar patients' descriptions of what happens when they are out of midrange mood.

First a brief description of Obsessive Compulsive Disorder (OCD): Obsessions are recurring thoughts that occur over and over again in the same form. Many of you probably have had the experience of getting a melody or a phrase of a song stuck in your head. Now imagine that same song being there for most of your waking hours for weeks on end and literally interfering with your ability to concentrate or to work. That's closer to an obsession. The range of obsessional thoughts that can be present with OCD is very broad - so much so that it's difficult to easily characterize them through brief description. The salient element is that the people with OCD feel that their obsessional thoughts often have control over their mind. They can't find the off switch.

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Compulsions are behaviors or sequences of behaviors that people must do repeatedly. They may fear some dreaded outcome if they don't carry through with the behavior (I'll die of a serious infection if I don't wash my hands after touching a doorknob). Or in the absence of specific fears, sometimes there's simply an intense need to carry through with the behavior for no clear or apparent reason. This need can be so intense that it preempts the progression towards other behaviors until the compulsion is enacted.

It's not uncommon that we find compulsions extending into the realm of organizing and/or cleaning: pictures must be precisely parallel; items on a desk must be perfectly aligned and equally spaced; things must be clustered in particular ways or in specific numbers. Again, the range of compulsive behaviors is as varied as are peoples' behaviors.

Some with OCD primarily experience obsessions; others may only experience compulsions. Many with the diagnosis experience both. And if you identify with some of this, that's not so uncommon either. There are many people with mild aspects of OCD. It's not a "disorder" but obsessional or compulsive elements are simply part of their personality style. Think of those people you know who consistently need neatness and order. They make lists, everything has its place, their closets are ordered and they adhere to routines. Essentially they do what they can do to assert control over their world. The presence of such need doesn't necessarily translate into having OCD. After all, planning, order and efficiency can be good things. But, if the presence of obsessions and/or compulsions is pervasive; when they literally get in the way of feeling emotionally comfortable; when you find your life is consumed by trying to manage your OC symptoms, then you may have crossed into the realm of psychological "disorder."

About 15% to 20% of adults with bipolar disorder also meet criteria for OCD. That means one out of every five to 6 adults with bipolar disorder (BD) also has OC symptoms. We know that BD involves mood variability including periods of depressed mood, midrange mood and elevated mood. During midrange mood, those with BD may find that most of their bipolar symptoms are absent. But if they're bipolar, in midrange and part of the 15% to 20% with OCD, then their obsessions or compulsions won't likely be absent. In other words, when bipolar symptoms are in remission and/or being well controlled through appropriate treatment, symptoms of OCD will likely still persist. The good news is that during midrange mood OC symptoms are at least not being exacerbated by mood instability. Midrange is good!

But what about those with BD whose OC symptoms are only present when their mood is outside of midrange? Do they have OCD? Technically, no. They have obsessive and/or compulsive symptoms that are caused by, or are secondary to, their bipolar disorder. And this typically means their symptoms are not part of a broader OCD diagnosis.

It's not uncommon that OC symptoms may accompany depressed mood, elevated mood or both. When people are depressed their thought process is often more ruminative than usual. On-line Miriam Webster defines ruminate: "To go over in the mind repeatedly or often casually and slowly." Indeed, the depressed individual is often preoccupied with painful thoughts that are recurrent. It only makes sense that depressive rumination can become fertile ground for true obsessions. As the continuum extends further, the casual thought process becomes painfully intense.

We see similar trends with elevated mood. But because the very essence of elevated mood involves increased energy and intense behavioral expression, it also makes sense that compulsive behaviors are often part of the hypomanic-manic continuum. One of the criteria for identifying bipolar elevated mood phase is increased goal directed activity. Again, we see a broad range of intensity and acuity. At the lower end of the continuum we may see a college student with BD immerse herself in an art project for several days to the exclusion of most of her other responsibilities. Moving up the hypomanic continuum we see a student cataloging, organizing, copying lyrics and downloading all the Beatles' songs from the band's first performance through its last. The end result may not have much utility but at some point he certainly felt like it was a good idea. And with full mania, we may see an individual only getting 2 to 3 hours sleep nightly for a full week while feverishly working on the next breakthrough alternative to Einstein's theory of relativity! Of course, by the end of that time the basics of quantum physics haven't been revised and the individual may possibly be headed towards manic psychosis and even psychiatric hospitalization.

Each of the three college students with elevated mood are examples of the connection between bipolar disorder and behavioral compulsions. The bipolar individual who is caught up in goal directed behavior can't simply step away from the goal he or she is trying to achieve. In essence the experience is not unlike the OCD person whose compulsive behaviors have a stronghold on his or her psyche.

A recurrent theme I hear from bipolar students is that once their hypomania gets rolling, so does their need to clean and organize. Twice this past week, I heard students speak of their elevated mood intensity directed towards their living environment. One spoke of his intensified focus on the efficiency and organization of his work space. In his words, "when I'm up, I'm like the lean, mean, efficiency machine." The second situation entailed a female's mood intensity being channeled towards her house cleaning. She was at it for a full day with the conclusion of each room's work readily flowing into to the next, and then the next. By midnight with several rooms still awaiting her sponge and vacuum, she recognized she was headed towards a night without any sleep and a probable depressive crash once her hypomanic energy was depleted. To her credit she wisely decided to take a strong dose of her sleeping medicine which successfully ended her compulsion and allowed her to return to mid-range mood after a solid 9 hour sleep. Now granted, two stories don't equal a trend, but it's noteworthy that the second account emerged during a weekly bipolar support group with eights student's present. As the female student's house cleaning story unfolded, I observed most of the other students nodding with some degree of identification.

If you also identify with these issues, what do you do with that information? First, if you do find that you also occasionally experience intense periods of elevated energy with goal directed behavior, you might consider seeking consultation from a mental health professional, particularly if you've got other elevated mood symptoms such as lessened need for sleep, racing thoughts, rapid speech, intense optimism and feelings of excitement.

I also want to offer a cautionary note here. If you do seek professional consultation, be sure to inquire if the professional has expertise with bipolar assessment. Sometimes when OC symptoms are readily identifiable a professional who is not well versed in bipolar assessment may overlook the underlying mood disorder and mistakenly diagnose OCD. The danger inherent in this error is that OC symptoms are usually treated pharmacologically with antidepressant medications, which can actually precipitate hypomania for those with BD unless a mood stabilizing medication has already been prescribed.

Now, let's say you're beyond consultation seeking; you've already been diagnosed with BD and you're discovering that you've also got episodic OC symptoms. What then? You need to work on developing the kind of self-observation where once you're drawn into the goal directed behavior, you can see it for what it is - an indication that you've commenced a hypomanic episode. If that's the case, it's a good idea to call your mental health provider and discuss what's occurring. Or perhaps as did the university coed with the now very clean house, you take some extra medicine to help slow things down and get some much needed sleep. If that works for you, then you've been able to successfully push the reset button without much negative consequence.

And as for the notion of bipolar OCD ...? I doubt we'll see it as established as a separate diagnosis, but it may be helpful if mental health professionals more commonly consider the OC issues as part of their specific bipolar diagnostic qualifiers, i.e. - "bipolar disorder, hypomanic type with OC symptoms."

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Russ Federman, Ph.D., ABPP is Director of Counseling and Psychological Services at the University of Virginia. He is also co-author of Facing Bipolar: The Young Adult's Guide to Dealing with Bipolar Disorder (New Harbinger Publications). www.BipolarYoungAdult.com

 

Russ Federman, Ph.D., A.B.P.P. is in private practice in Charlottesville, VA specializing in psychotherapy with individuals having bipolar disorder.

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