OCD and Bipolar Disorder: Comorbidity and Diagnosis
When a client presents with intrusive thoughts and mood instability, clinicians face a diagnostic puzzle: Is this OCD, bipolar disorder, both, or something else entirely? Understanding the relationship between these two conditions is crucial for accurate diagnosis and effective treatment.
The Comorbidity Picture
Research indicates that approximately 11% of individuals with bipolar disorder also meet criteria for OCD at some point in their lifetime.¹ To put this in perspective: people with bipolar disorder are more than four times as likely to have OCD compared to the general population. When we look at current (rather than lifetime) rates, the picture is even more striking—individuals with bipolar disorder are seven times more likely to be experiencing OCD at any given time than the general population.
The comorbidity isn't random. Both conditions involve dysregulation in overlapping brain circuits,²,³ particularly those involving the orbitofrontal cortex and striatum.
Why the Confusion Happens
Several factors contribute to diagnostic confusion between OCD and bipolar disorder:
Racing thoughts vs. obsessions. Manic episodes feature rapid thought flow that feels exciting or productive, while OCD obsessions are repetitive, unwanted, and anxiety-provoking. However, in mixed episodes or when insight is limited, this distinction becomes murkier.
Compulsions vs. impulsive behaviors. Both involve repetitive actions that can seem irrational to observers. The key difference: compulsions are driven by distress reduction and feel obligatory (ego-dystonic), while manic impulsivity can feel pleasurable or goal-directed in the moment (ego-syntonic).
Mood-dependent symptom fluctuation. Some individuals experience worsening OCD symptoms during mood episodes, which can mask the presence of two distinct conditions.
Key Differentiators
Understanding these distinctions helps clarify the diagnostic picture:
Ego-syntonicity. As discussed in my recent post on ego-dystonic thoughts, OCD obsessions often feel alien and distressing. During mania, thoughts typically feel congruent with an elevated sense of self—grandiose, exciting, or mission-driven rather than threatening.
The role of distress. While OCD obsessions often trigger anxiety, OCD is fundamentally about intrusive thoughts and compulsive responses to reduce distress or prevent feared outcomes. The DSM-5 reclassified OCD into its own category—Obsessive-Compulsive and Related Disorders—recognizing that anxiety is a common result of OCD, not its defining feature. In bipolar mania, elevated mood, energy, and goal-directed activity are central,⁴ with anxiety typically not being the primary emotional experience.
Response to neutralization. People with OCD engage in compulsions specifically to reduce distress or prevent feared outcomes. Manic behaviors aren't performed to neutralize distress—they're expressions of elevated mood and energy.
Temporal patterns. OCD symptoms are typically chronic and relatively stable (though they may wax and wane). Bipolar disorder involves distinct episodes with clear changes from baseline functioning.
When Both Are Present
For individuals with comorbid OCD and bipolar disorder, the clinical picture becomes more complex:
OCD symptoms may intensify during mood episodes. Mania can reduce insight into OCD, making obsessions feel more believable or compulsions more justified. Depression can amplify the distress of intrusive thoughts and make compulsions feel more necessary.
Some clients describe their OCD as "background noise" during euthymic periods, but during mood episodes, it demands center stage. Others experience their conditions as relatively independent, with OCD symptoms remaining stable regardless of mood state.
Treatment Implications
Accurate diagnosis matters tremendously for treatment planning:
Medication considerations. SSRIs are first-line for OCD but can potentially trigger mania in vulnerable individuals. Mood stabilizers are essential for bipolar disorder but don't directly address OCD symptoms. When both conditions are present, careful medication management⁵—often involving both a mood stabilizer and an SSRI—is necessary.
Therapy sequencing. Exposure and Response Prevention (ERP), the gold standard for OCD, requires emotional stability to be effective. If someone is in a manic or deeply depressed episode, mood stabilization typically takes precedence before intensive ERP begins.
Safety planning. Harm obsessions in OCD are ego-dystonic and not associated with actual risk, while impulsivity during mania can lead to genuine safety concerns. This distinction is critical for appropriate risk assessment.
Clinical Vignettes
(All clinical vignettes are fictional and any resemblance to a real person is strictly coincidental.)
Kara presents with intrusive thoughts about contamination and spends hours washing her hands. She also describes periods where she sleeps only 3-4 hours, feels "on top of the world," and starts multiple ambitious projects she never finishes. Between these episodes, her contamination fears persist but feel more manageable. Kara likely has both OCD and bipolar disorder.
Marcus comes to therapy describing blasphemous thoughts about harming religious figures that horrify him. During periods of elevated mood, these thoughts intensify, but he describes them as "messages" he must act on rather than intrusions he wants to resist. Marcus may have bipolar disorder with psychotic features rather than OCD, or the mania may be reducing his insight into ego-dystonic OCD thoughts.
Alex has persistent intrusive thoughts about her house burning down, leading her to check appliances repeatedly. Recently, she's been sleeping less, spending impulsively, and feeling irritable. She describes the intrusive thoughts as "always there," but her recent behaviors feel "out of character" and started suddenly three weeks ago. Alex has OCD with a possible emerging mood episode that warrants careful assessment.
Red Flags for Clinicians
Several warning signs suggest you may be dealing with comorbidity or misdiagnosis:
Your client's "OCD" symptoms dramatically worsen or improve in sync with mood changes. The content of intrusive thoughts shifts from ego-dystonic to ego-syntonic during certain periods. Your client describes feeling good or energized by behaviors you initially conceptualized as compulsions. Standard OCD treatment isn't working, and you notice mood instability you hadn't initially assessed for.
Moving Forward
As clinicians, our responsibility is to look beyond surface presentations and understand the underlying mechanisms driving our clients' experiences. The overlap between OCD and bipolar disorder reminds us that psychiatric conditions don't always arrive in neat, separate packages.
Thorough assessment, including detailed history of mood episodes and careful attention to the ego-syntonic versus ego-dystonic nature of thoughts and behaviors, helps us provide the most accurate diagnosis and effective treatment. When in doubt, consultation with trained colleagues or referral for psychiatric evaluation can clarify complex presentations.
Want to strengthen your foundation in OCD assessment and treatment? I offer continuing education trainings on core topics like recognizing OCD, understanding differential diagnosis, and working with challenging presentations like harm OCD and suicidal ideation.
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References
Amerio, A., Stubbs, B., Odone, A., Tonna, M., Marchesi, C., & Ghaemi, S. N. (2015). The prevalence and predictors of comorbid bipolar disorder and obsessive-compulsive disorder: A systematic review and meta-analysis. Journal of Affective Disorders, 188, 99–109.
Graybiel, A. M., & Rauch, S. L. (2000). Toward a neurobiology of obsessive-compulsive disorder. Neuron, 28(2), 343–347.
Phillips, M. L., & Swartz, H. A. (2014). A critical appraisal of neuroimaging studies of bipolar disorder: Toward a new conceptualization of underlying neural circuitry and a road map for future research. American Journal of Psychiatry, 171(8), 829–843.
Phillips, M. L., & Swartz, H. A. (2014). A critical appraisal of neuroimaging studies of bipolar disorder: Toward a new conceptualization of underlying neural circuitry and a road map for future research. American Journal of Psychiatry, 171(8), 829–843.
Amerio, A., Odone, A., Marchesi, C., & Ghaemi, S. N. (2014). Treatment of comorbid bipolar disorder and obsessive-compulsive disorder: A systematic review. Journal of Affective Disorders, 166, 258–263.
