Pattern of Obsessive Compulsive Symptoms Among Patients With

essio epr n D an f d Rabie et al., J Depress Anxiety 2016, 5:3 o A l a n

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e DOI: 10.4172/2167-1044.1000229

y o J Journal of Depression & Anxiety ISSN: 2167-1044

ResearchResearch Article Article OpenOpen Access Access Pattern of Obsessive Compulsive Symptoms among Patients with Bipolar-I Disorder Menan A Rabie1*, Eman Shorub1, Ahmed K Al-awady2, Abdel-Nasser M Omar1 and Hisham A Ramy1 1Institute of Psychiatry, Ain Shams University, Cairo, Egypt 2Departement of Psychiatry, Al-Azhar University, Cairo, Egypt

Abstract Background: Clinicians have observed the occurrence of obsessive and/or compulsive symptoms within the course of bipolar disorder. However the pattern of their occurrence is not clearly delineated. This study aimed to explore this pattern. Method: A cross sectional study. All patients were assessed by the Structured Clinical Interview for DSM-IV (SCID I) to diagnose bipolar disorder (BD) and comorbid obsessive compulsive (OC) symptoms. The symptom severity was assessed by Young Mania Rating Scale (YMRS), Beck Depression Inventory II (BDI-II), Yale-Brown Obsessions and compulsions Scale (Y-BOCS). Results: Sixty two patients were classified into two groups: BD comorbid with OC symptoms (BD-OC) and BD with no comorbidity (BD). High rates of OC symptoms in BD patients (38.7%) with higher educational level in the BD- OC group, and higher rates of unemployment were noticed among patients of BD–OC group. The smoking was more prevalent in BD group than BD-OC group. The most common among BD-OC subjects were contamination, religious and aggressive obsessions and cleaning/washing and counting compulsions. Limitations: The prevalence rates are not to be generalized because of the small size of the sample. Most of the history was taken from the patients and their relatives depending on their memory. More experimental study designs about the effectiveness of different types of management strategies would be beneficial to the patients. Conclusion: Bipolar Patients with comorbid Obsessive and/or Compulsive symptoms showed higher educational levels, unemployment, greater functional impairment, and less smoking. Most common obsessions were contamination, religious and aggressive obsessions, cleaning and counting compulsions.

Keywords: Affective disorder; Obsessive compulsive disorder; administration in patients with OCD, higher rate of relapse of mood Comorbidity episodes, attempted suicide, and hospitalization, and also episodic course of OCD in bipolar disorder patients [1,9,10] and the efficacy of Introduction mood stabilizers to treat OCD in bipolar disorder patients [11]. The relationship of bipolar disorder (BD) and obsessive compulsive In a study by Angst et al. [12], of those with OCD, 53% had disorder (OCD) had been already emphasized by French psychiatrists hypomanic symptoms and 30% were given a Bipolar II diagnosis in the 19th century and has been demonstrated by different groups of [12]. Other studies have supported the increased prevalence of OCD researchers in the recent years [1]. OCD has a complex relationship with Bipolar II over Bipolar [13]. A study analyzing data from a large with bipolar disorder. Clinicians may see patients who start out looking nation-wide sample found that for those with either Bipolar I or II like they have classic OCD and end up looking like they have definite (although most had Bipolar II), 21% had comorbid OCD [14]. Patients bipolar disorder without OCD. Obsessive-compulsive disorder is the with comorbid OCD and affective disorders, particularly represent a most commonly seen comorbid anxiety disorder in bipolar patients. clinically severe group compared to those without such comorbidity Some genetic variants, neurotransmitters especially serotonergic [15]. An overlapping character between both disorders was found in systems and second-messenger systems are thought to be responsible some common genetic variants (e.g. the serotonin transporter gene for its etiology [2]. (SLC6A4), and the brain-derived neurotrophic factor (BDNF) gene) The analysis of the epidemiologic data of the ECA (Epidemiologic [16,17]. Catchment Area) showed the lifetime prevalence of OCD in bipolar In terms of the presentation of the disorders, Masi et al. [13] found disorder patients, unipolar depressive disorder patients, and general that the types of compulsions differ between those with comorbid population in the USA (1995) is 21%, 12.2%, and 2.5%, respectively [3]. Around one third of BP-I and II patients meet criteria for an anxiety disorder, most commonly social anxiety (22.0% lifetime; 12.7% *Corresponding author: Menan A Rabie, Faculty of Medicine, Institute of current), panic disorder with or without agoraphobia (17.3%; 8.0%), Psychiatry, Ain Shams University, Cairo, Egypt, Tel: 26831474(202); E-mail: obsessive-compulsive disorder [OCD] (9.9%; 5.7%) [4]. [email protected] March 03, 2016; May 13, 2016; May 16, 2016 Also, a research on a clinical sample found the frequency of OCD in Received Accepted Published bipolar and unipolar depressed patients 21.1% and 14.3%, respectively Citation: Rabie MA, Shorub E, Al-awady AK, Omar AM, Ramy HA (2016) Pattern [5]. On the other hand, assessing the reverse state to the fore mentioned of Obsessive Compulsive Symptoms among Patients with Bipolar-I Disorder. J Depress Anxiety 5: 229. doi: 10.4172/2167-1044.1000229 condition has yielded the significant frequency of individuals with bipolar disorders among cases with OCD [6-8]. The relationship of Copyright: © 2016 Rabie MA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted OCD and bipolar disorders has been discussed regarding different use, distribution, and reproduction in any medium, provided the original author and aspects; e.g., induction of (hypo)mania following antidepressant drugs source are credited.

J Depress Anxiety ISSN: 2167-1044 JDA, an open access journal Volume 5 • Issue 3 • 1000229 Citation: Rabie MA, Shorub E, Al-awady AK, Omar AM, Ramy HA (2016) Pattern of Obsessive Compulsive Symptoms among Patients with Bipolar-I Disor- der. J Depress Anxiety 5: 229. doi: 10.4172/2167-1044.1000229

Page 2 of 6 bipolar and OCD and those with just OCD. Those with pure OCD of substance abuse disorders, severe cognitive dysfunction (e.g., have more checking compulsions while those with comorbidity exhibit mental retardation, dementia), history of tic disorder (because of the more obsessions that are classified as “others” which they described association of this disorder and the specific OC symptoms (8), and as “existential, philosophical, and/or superstitious”. In general they those having a third psychiatric comorbidity other than BD and OCD found that although the amount of obsessions were equal whether were excluded. comorbid or not, those who also had bipolar disorder actually had fewer compulsions [13]. Procedures Those with comorbid bipolar disorder and obsessive-compulsive Outpatients and inpatients from the psychiatric hospital were disorder typically experience heightened feelings of distress over those recruited and their eligibility for participation in the study was with only one of the disorders. This is not unique to comorbid OCD determined. All of the selected patients were offered to sign a written and bipolar disorder; comorbidity in general is typically reflected by informed consent before being involved in the study. They were increased levels of distress and increased treatment [18]. For those with explained the aim of the study and its procedures. The participants comorbid OCD and bipolar disorder, there is also an increased risk for were informed that they have the right to withdraw from the study at alcohol and substance abuse [19]. any time without justification. Moreover, they were informed that this study could be used for scientific publication without the disclosure of A group of researchers has looked at how OCD and bipolar relate. the participants’ personal identity. They found that whereas unipolar depression was “incidental”, i.e. not clearly related to the OCD (although common) by contrast bipolar The patients who agreed to participate were subjected to medical disorder seemed to be more directly related to the OCD. For example, history and examination (general, and neurological examinations) and people with religious and sexual obsessions as part of their OCD were investigations (when needed) to confirm the absence of neurological or more likely than those with other obsessions to have bipolar disorder. chronic medical condition. The authors specifically recommend that bipolar disorder take A clinical psychiatric interview was conducted to all patients precedence over the OCD in terms of which is treated first [7]. according to the psychiatric sheet of ASUIP, which is designed to collect the demographic data (age, gender, education, occupation, social class, Hypothesis marital status, etc…), the psychiatric history (age at onset of BD or Patients with bipolar disorder have obsessive and/or compulsive OCD, age at 1st seeking professional help, history of drug or substance symptoms. The obsessive and/or compulsive symptoms have a specific intake, current medications) and the psychiatric examination. pattern (timing, type of obsession, or compulsion, relation to the The subjects were further assessed by the use of the Structured course of illness, etc). Clinical Interview for DSM-IV (SCID I) diagnostic tool to diagnose Aims of the work BD and comorbid OCD, if it is present, and to exclude other Axis I diagnosis according to DSM VI classification. The confirmation of the 1. To assess the occurrence of the obsessions and compulsions in diagnosis and the assessment of the symptom severity were done by the patients with Bipolar Disorder. use of Young Mania Rating Scale (YMRS), Beck Depression Inventory- 2. To Study the type of obsessions and compulsions if present, II (BDI-II), Yale-Brown Obsessions and compulsions Scale (Y-BOCS). and the time of their occurrence throughout the longitudinal Tools course of bipolar illness. Structured Clinical Interview for DSM-IV (SCID I) Subjects and Methods It is a semi-structured diagnostic interview which has been updated Site of the study for DSM-IV. It begins with a section on demographic information and Cases were selected from outpatient and inpatients of the Institute clinical background. Then there are 7 diagnostic modules, focused on of Psychiatry, Ain Shams University Hospitals. The Institute of different diagnostic groups: mood, psychotic, substance abuse, anxiety, Psychiatry, Ain Shams University Hospitals (ASUIP) is located in somatoform, eating and adjustment disorders. It is considered the Western Cairo, serves both urban and rural areas, including Greater standard interview to verify diagnosis in clinical trials and is extensively Cairo and other governorates as well. ASUIP provides services to used in other forms of psychiatric research [20]. patients with psychiatric disorders providing 80 beds for inpatient Young Mania Rating Scale (YMRS) management of various psychiatric disorders and 17 beds for inpatient substance abuse management. The Young Mania Rating Scale (YMRS) is one of the most frequently utilized rating scales to assess manic symptoms. The scale Study design has 11 items and is based on the patient’s subjective report of his or her It is a Cross sectional, observational study. clinical condition over the previous 48 hours. Additional information is based upon clinical observations made during the course of the Selection of cases clinical interview [21]. The sample was selected from the outpatient and inpatients in Beck Depression Inventory (II) ASUIP. All the patients fulfilling the inclusion criteria (diagnosed as having BD, males and females, Age range = 18-45 years, signing the Depressive symptoms were detected by the Beck Depression informed consent) were offered to participate in the study. The sample Inventory II (BDI-II). This is a 21-item self report instrument that was collected during the period from February to December 2010. The assesses the severity of depressive symptomatology in adults. It is patients’ age ranged between 18-65 years (adult population). Patients a revised version of the original BDI [22], updated to correspond to having history of medical, neurological disorders, lifetime diagnosis criteria from the Diagnostic and Statistical Manual of Mental Disorders

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[23]. Each of the 21 items measures the presence and the severity of Frequency % a somatic or cognitive symptom of depression, rated on a four-point No 38 61.3 scale ranging from 0 to 3. The ratings are summed, yielding a total score Only obsessions 12 19.4 that can range from 0 to 63. Severity scores are interpreted as follows: Valid Only compulsions 1 1.6 0–9, minimal; 10–16, mild; 17–29, moderate; and 30–63, severe. The Obsessions & compulsions 11 17.7 BDI-II has been validated as a sensitive, specific, and predictive tool for Total 62 100.0 measuring depression [24]. Despite the fact that the somatic symptoms Table 2: The distribution of bipolar cases regarding obsessions and compulsions. of pre-existing medical conditions may overlap those of depression, studies have shown that the somatic items do not interfere with the Statistical analysis discriminative capacity of the BDI-II in primary-care settings [25]. The BDI-II has also been shown to be sensitive and specific at any phase of The collected data was revised, coded, tabulated and introduced to a depressive disorder [26]. a PC using Statistical package for Social Science (SPSS 20). Data was presented and suitable analysis was done according to the type of data Yale-Brown Obsessions and compulsions Scale (Y-BOCS) obtained for each parameter. This rating scale is designed to rate the severity and types of Descriptive statistics symptoms in patients with obsessive and compulsive disorder (OCD). 1. It is intended for use as a semi-structured interview, the interviewer Mean, Standard deviation (± SD) and range for parametric numerical data, while Median and Interquartile range (IQR) for non- should assess the items in the listed order and use the questions provided. parametric numerical data. Ratings should be based primarily on reports and observations gained during the interview [27]. 2. Frequency and percentage of non-numerical data. All 19 items are rated, but only items 1-10 (excluding items 1b and Analytical statistics 6b) are used to determine the total score. The total Y-BOCS score is the sum of items 1-10 (excluding items 1b and 6b), whereas the obsession Student T Test was used to assess the statistical significance of the difference between two study group means. and compulsion subtotals are the sums of items 1-5 (excluding 1b) and 6-10 (excluding 6b), respectively. Item 11 (insight), and 12 (avoidance) Mann Whitney Test (U test) was used to assess the statistical may give useful clinical information. Items 17 (global severity) and significance of the difference of a non parametric variable between two 18 (global improvement) have been adapted from the Clinical Global study groups. Impression Scale [28]. Item 19, which estimates the reliability of the Chi-Square test was used to examine the relationship between two information reported by the patient, may assist in the interpretation qualitative variables. of scores on other Y-BOCS items in some cases of OCD. It was administered to evaluate the severity and types of obsessive and/or Fisher’s exact test: was used to examine the relationship between compulsive symptoms. two qualitative variables when the expected count is less than 5 in more than 20% of cells. Chi square Bipolar (62) test Results BD (38) OC-BD (24) Sixty two patients completed the SCID I, YMRS, BDI-II as well p value N % n % as Y-BOCS. According to the presence or absence of obsessive– compulsive disorder (OCD) symptoms, patients were classified into Male 27 71.1% 13 54.2% sex 0.18 two groups: Bipolar disorder co morbid with OC Disorder/symptoms Female 11 28.9% 11 45.8% (BD-OC group) and Bipolar disorder (BD group) with no comorbidity Technical educa- 34 89.5% 15 62.5% tion level with OC Disorder/symptoms. education 0.01* High education 4 10.5% 9 37.5% The demographic data studying revealed that male patients level constituted the majority 27 patients (71.1%) of BD group and 13 Unemployed 24 63.2% 22 91.7% occupa- patients (54%) of the BD-OC group. The BD-OC group (39.5%) Semi-skilled 13 34.2% 2 8.3% 0.03*a tion declared receiving high education more than (BD) group (10.5%). The Professional 1 2.6% 0 0.0% mean age among (BD) and (BD-OC) groups was 26.5 ± 7.4 and 23.1 ± Urban 27 71.1% 14 58.3% residency 0.30 4.6 years respectively (Table 1). Rural 11 28.9% 10 41.7% Single 25 65.8% 19 79.2% The number of patients who had OC symptoms was 34 patients (38.7%) Married 10 26.3% 4 16.7% of the studied sample. 19.4% had only obsessions, 17.7% had obsessions and marital 0.83 a Widow 1 2.6% 0 0.0% compulsions and only 1.6% had only compulsions (Table 2). Divorced 2 5.3% 1 4.2% The clinical picture of bipolar patients, Description of episodes and Yes 13 34.2% 20 83.3% smoking <0.001** time of obsession were studied and illustrated in (Table 3). Of the BD No 25 65.8% 4 16.7% group, 47.4% were during their depressive episodes, 42.1% had their Mean SD Mean SD p value Age manic episodes, 7.9% had mixed episodes and 2.6% were experiencing 26.5 7.4 23.1 4.6 0.031* hypomania. As regards the BD-OC group, 58.3%% were examined *significant results p <0.05 during their depressive episodes, 37.5% had their manic episodes, 4.2% **significant results p <0.01 had mixed episodes. a. Fisher’s exact test Table 1: Comparison regarding demographic data. The severity of depression evaluated by the BDI-II was higher in

Page 4 of 6 the BD-OC group, 8.3% had severe depression, 12.5% had moderate Cases(24) depression, and 25% had mild symptoms, while the BD group showed N % no severe depression, 7.9% moderate depression, and 7.9% mild Aggressive obsessions 17 70.8% depressive symptoms. Meanwhile the manic symptoms were more Contamination obsessions 17 70.8% severe in the group of BD (36.8%) rather than the BD-OC group (8.3%) Sexual obsessions 3 12.5% (Table 3). Hoarding/saving obsessions 14 58.3% Religious obsessions 17 70.8% While trying to monitor the chronological pattern of comorbidity Symmetry obsessions 7 29.2% of BD activity and OC symptoms, the study showed that 20.8% had Miscellaneous obsessions 8 33.4% their OC symptoms during the current episode, 12.5% experienced the Somatic obsessions 7 29.2% OC symptoms during their euthymic phase of the illness, and 66.7% Cleaning/washing compulsions 10 41.7% are having their OC symptoms all through the course of BD (Table 4). Checking compulsions 7 29.2% As regards the distribution of obsessions and compulsions in Repeating rituals compulsions 2 8.4% BD-OC group, the study revealed the most common types to be Counting compulsions 9 37.5% contamination, religious and aggressive obsessions and to a lesser extent Ordering/arranging compulsions 6 25% some sexual obsessions. As regards the compulsions, the most common Hoarding/collecting compulsions 0 0.0% compulsions were cleaning/washing and counting compulsions but no Miscellaneous compulsions 5 20.8% cases of hoarding/collecting were detected (Table 5). Table 5: Distribution of obsessions and compulsions in BD-OC group.

Discussion systematic review of 64 articles that studied the range of Lifetime comorbidity. It included results of three population based studies In an attempt to clarify the pattern of occurrence of obsessive and/ conducted in Italy and USA, reported lifetime prevalence rates of or compulsive symptoms in BD, the literature was revised to compare comorbid OCD in BD patients ranging between 11.1% and 21% [3,29- the results of the current study. 31].. Another study analyzing data from a large nation-wide sample Prevalence rates found that for those with either Bipolar I or II (although most had Bipolar II), 21% had comorbid OCD [14]. The study revealed high rates of comorbid OC symptoms among patients with bipolar disorder (38.7%). This is consonant with a These results are consistent with multiple hospital-based studies where the lifetime prevalence of comorbid OCD in BD patients ranged Fisher's exact between 1.8% and 35.1% depending on the features of the study test BD (38) BD-OC (24) population included [32,33]. Another study found that 21.9% of BD p value patients had obsession and/or compulsion symptoms [34]. When Depressive 47.4% 58.3% considering remitted patients, comorbidity prevalence rates were 35% Manic 42.1% 37.5% current episode 0.83 (OCD-BD) patients [35]. These studies suggest that OCD co-occur Hypomanic 2.6% 0.0% with bipolar disorder more often than expected. Mixed 7.9% 4.2% Minimal 84.2% 54.2% One study was inconsistent with these results, it showed a low Mild 7.9% 25.0% prevalence of co-morbidity of OCD in first-episode BD-I patients (one BDI-II scores 0.03* Moderate 7.9% 12.5% patient (1.8%) met DSM-IV criteria for OCD, and two (3.6%) met Severe 0.0% 8.3% criteria for sub-threshold OCD. and it indicated that the rate of OCD Non-Significant 63.2% 91.7% in the first-episode BD-I patients did not differ significantly from that YMRS scores 0.01*a Significant 36.8% 8.3% found in the general population. These findings are probably due to the *significant results p <0.05 small sample size and the inclusion of BD-I patients only [36]. a. Chi square test Table 3: Clinical picture of bipolar and Description of episodes and time of obsession. Demographic data The demographic data studying revealed male preponderance Timing of OC symptoms Type of the Episode among both groups of BD. The level of education in BD-OC group was in BD-OC higher than BD group with statistically significant difference (p value = N % Type N % 0.01). The majority of patients with BD-OC (91.7%) were unemployed, Current only 5 20.80% depressive 5 100% with a statistically significant difference from the BD group (p value = depressive 1 33.3% 0.03). The impact of comorbidity of BD-OC is probably reflected on the Past only 3 12.50% occupational status and functional performance. This is consistent with manic 2 66.7% the findings of many studies that found higher rates of unemployment and greater functional impairment among BD–OC group [37,38]. depressive 8 50% current& The degree of functional vocational impairment manifested by being 16 66.70% past manic 7 43.75% unemployed could be probably correlated to the earlier onset and higher severity of the bipolar illness noticed in the BD-OC group. mixed 1 6.25% depressive 14 58.33% Another interesting observation was that patients of the BD-OC Total 24 100% manic 9 37.50% group were younger than the BD group: their mean age was (23.1 ± mixed 1 4.17% 4.6), while the mean age in the BD group was (26.5 ± 7.4) (p value = 0.031). In a study by Angst et al. [12], it was reported that for those with Table 4: Timing of OC symptoms throughout the course of the BD.

Page 5 of 6 comorbid bipolar and OCD, the age of onset for OCD is earlier [12]. However, they are inconsistent with studies that showed lower rates This was inconsistent with another study which revealed no statistically of washing compulsions in subjects with BD-OC comorbidity [1,44]. significant differences between BD-OC and BD in terms of age, sex, It should be noted that some transcultural differences regarding OC education and marital status [33]. symptoms have been reported [1]. Smoking This study confirms the high comorbidity rates for OC symptoms in BD patients (38.7%). It also revealed a higher educational level in Interestingly, the number of smokers in BD-OC group was higher the BD-OC group than BD. Higher rates of unemployment and greater than those in BD group with high statistically significant difference (p functional impairment were found among patients of BD–OC group. value<0.001). This finding is consistent with other studies which found The smoking was more prevalent in BD group than BD-OC group. that BD-OC patients had an –over two times- higher likelihood to The total number of depressive episodes was higher in patients with be also diagnosed with nicotine, substance use disorders and alcohol BD-OC group than in BD group. The most common obsessions use disorders vs. non-comorbid patients [15,39]. This may be also were contamination, religious, and aggressive obsessions and the consonant with the findings of The ECA study, which confirmed most common compulsions were cleaning/washing and counting the higher rate of substance abuse in OCD-BD subjects versus non- compulsions. comorbid subjects [3]. Limitations Clinical data Although the study is revealing clinically interesting findings, While trying to monitor the chronological pattern of comorbidity however there are some limitations: The prevalence rates are not of BD activity and OC symptoms, the study showed that 20.8% had to be generalized because of the small size of the sample. More their OC symptoms during the current episode, 12.5% experienced the information about the details of the symptoms and their timing would OC symptoms during their euthymic phase of the illness, and 66.7% be enlightening if observed directly by the psychiatrists, however are having their OC symptoms although the course of BD. most of the history was taken from the patients and their relatives Most of the current episodes were depressive episodes in both depending on their memory. Further analysis and correlations would groups. The results of YMRS and BDI-II revealed more severe be done, but it may crowd the results, probably these will be presented depression in the BD-OC group with statistically significant difference in another research paper. More experimental study designs about (p value=0.03) and more severe manic symptoms in the BD group with the effectiveness of different types of management strategies would be statistically significant difference (p value=0.01). These findings are beneficial to the patients. consistent with many studies which revealed that the total number of Acknowledgment depressive episodes was higher in patients with OCD-BD comorbidity than in BD alone [40,41]. The authors are grateful to the help of Mr. Abdel-Gawad Khalifa, the clinical psychologist who helped with the assessment of patients, and to Dr. Mostafa El- In the current study, OC symptoms comorbidity with BD was Shahed who performed the statistical analysis. manifested more likely during depression and mixed episodes which Funding are consistent with other studies [42,43] which found a decrease in The authors did not receive any type of financial support. The research was OCD symptoms during mania and a flare during depressive episodes. sponsored by the authors themselves. Zutshi et al. [44] revealed that most BD-OCD patients (78%) either References had OCD confined exclusively to depressive episodes or reported worsening of OCD during depression. Improvement in OC symptoms 1. Shabani A, Alizadeh A (2008) The specific pattern of obsessive compulsive symptoms in patients with bipolar disorder. 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