Amerio, Andrea

Ghaemi, S. Nassir

Odone, Anna

TONNA, MATTEO

PubMed

Amerio A.

Tonna M.

Odone A.

Ghaemi S. N.

Archivio istituzionale della ricerca - Università di Genova

Comorbid bipolar disorder and obsessive-compulsive disorder: An old debate renewed

Archivio istituzionale della ricerca - Università di Modena e Reggio Emilia

To the Editor,Apparent comorbidity between bipolar disorder (BD) and anxiety disorders is a common condition in psychiatry with higher prevalence rates for generalised anxiety disorder, so-cial phobia, panic disorder.1Overlapping clinical criteria for many diagnoses, especially mood and anxiety disorders, produced by the Diagnostic and Statistical Manual of Mental Disorders (DSM) might lay be-hind these high prevalence rates.2 Using DSM, it is unclear whether concomitant diagnoses actually reflect the presence of distinct clinical entities or refer to multiple manifestations of a single clinical entity.With regard to anxiety disorders, one of the most difficult additional psychiatric diagnosis to manage in BD patients is obsessive-compulsive disorder (OCD).3,4 In our recent meta-analysis, the pooled prevalence of OCD in BD was 17.0%, which was comparable to the results reported by the pooled prevalence of BD in OCD (18.35%).5 In line with previous stud-ies,6 OCD prevalence rate was higher among BD children and adolescents (24.2%, compared to 13.5% in adults).The co-occurrence of symptoms of BD and OCD was noted 150 years ago by Morel,7 but the topic is insufficiently studied and the relationship between BD and OCD remains unclear.In agreement with Kraepelin’s thought a psychiatric diagno-sis is best established by its longitudinal course of illness, the evidence so far supports the view that, especially among pa-Print ISSN 1738-3684 / On-line ISSN 1976-3026OPEN ACCESS370  Copyright © 2016 Korean Neuropsychiatric Association  tients with a primary diagnosis of BD, the majority of comor-bid OCD cases appeared to be related to mood episodes.8 OC symptoms in comorbid patients appeared more often-and sometimes exclusively-during depressive episodes, and co-morbid BD and OCD cycled together, with OC symptoms of-ten remitting during manic/hypomanic episodes.Therefore, only a substantial minority of comorbid BD-OCD may represent “true” OCD independent of BD with OC symptoms that improve or worsen during mood episodes with-out being related to these.These findings are in line with Feinstein’s definition of co-morbidity, as “any distinct additional entity that has existed or may occur during the clinical course of a patient who has the index disease under study”.2 “True” OCD comorbid with BD would represent the random co-occurrence of two inde-pendent diseases, estimated by multiplication of prevalence rates, which are about 1% for each condition, and producing a very low expected true comorbidity of 0.1% in the general population.The treatment of BD-OCD patients remains a great chal-lenge, since the gold standard for one disease (serotonin reup-take inhibitors for OCD) can worsen the other (antidepres-sants can cause mania and/or more mood episodes in BD).The clinical features of comorbid BD-OCD patients would explain why OCD and BD symptoms respond to adequate mood stabilizer treatment.3 Only in a minority of comorbid patients with persistent OCD, despite improvement in mood episodes, addition of low doses of antidepressants could be considered while strictly monitoring emerging symptoms of mania or mixed states. Benefit with antipsychotics was also seen, although a few reports also exist of exacerbation of OC symptoms with neuroleptic agents.Considering the growing interest over the last decades into shared pathophysiologies across psychiatric disorders, stud-LETTER TO THE EDITORComorbid Bipolar Disorder and Obsessive-Compulsive  Disorder: An Old Debate Renewed Andrea Amerio1,2 , Matteo Tonna3, Anna Odone4, and S. Nassir Ghaemi2,51Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy2Mood Disorders Program, Tufts Medical Center, Boston, MA, USA3Department of Mental Health, Local Health Service, Parma, Italy4Department of Biomedical, Biotechnological and Translational Sciences, Unit of Public Health, University of Parma, Parma, Italy5Tufts University Medical School, Department of Psychiatry and Pharmacology, Boston, MA, USAReceived: October 7, 2015    Revised: November 22, 2015Accepted: November 22, 2015    Available online: March 23, 2016 Correspondence: Andrea Amerio, MDDepartment of Clinical and Experimental Medicine, University of Parma, c/o Ospedale Maggiore, Viale A. Gramsci 14, Parma 43126, ItalyTel: +39 0521 903594, Fax: +39 0521 347047E-mail: andrea.amerio@studenti.unipr.itcc  This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduc-tion in any medium, provided the original work is properly cited.http://dx.doi.org/10.4306/pi.2016.13.3.370Amerio A et al.    www.psychiatryinvestigation.org  371ies addressing neurobiological substrates are essential to illu-minate pathogenetic mechanisms that underlie comorbid BD-OCD. AcknowledgmentsThis research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.Conflicts of InterestDr. Amerio, Dr. Tonna, and Dr. Odone report no conflicts of interest. Dr. Ghaemi has provided research consulting to Sunovion and Pfizer, and has obtained a research grant from Takeda Pharmaceuticals. Neither he nor his family hold equity positions in pharmaceutical corporations.REFERENCES1. Boylan KR, Bieling PJ, Marriott M, Begin H, Young LT, MacQueen GM. Impact of comorbid anxiety disorders on outcome in a cohort of patients with bipolar disorder. J Clin Psychiatry 2004;65:1106-1113.2. Maj M. “Psychiatric comorbidity”: an artefact of current diagnostic sys-tems? Br J Psychiatry 2005;186:182-184.3. Amerio A, Odone A, Marchesi C, Ghaemi SN. Treatment of comorbid bipolar disorder and obsessive-compulsive disorder: a systematic re-view. J Affect Disord 2014;166:258-263.4. Amerio A, Odone A, Marchesi C, Ghaemi SN. Do antidepressant-in-duced manic episodes in obsessive-compulsive disorder patients rep-resent the clinical expression of an underlying bipolarity? Aust N Z J Psychiatry 2014;48:957.5. Amerio A, Stubbs B, Odone A, Tonna M, Marchesi C, Ghaemi SN. The prevalence and predictors of comorbid bipolar disorder and obsessive-compulsive disorder: a systematic review and meta-analysis. J Affect Disord 2015;186:99-109.6. Sala R, Axelson DA, Castro-Fornieles J, Goldstein TR, Goldstein BI, Ha W, et al. Factors associated with the persistence and onset of new anxiety disorders in youth with bipolar spectrum disorders. J Clin Psychiatry 2012;73:87-94.7. Morel BA. Traité des maladies mentales. Second Edition. Paris: Mas-son; 1860.8. Amerio A, Odone A, Liapis CC, Ghaemi SN. Diagnostic validity of co-morbid bipolar disorder and obsessive-compulsive disorder: a systemat-ic review. Acta Psychiatr Scand 2014;129:343-358.9. Ekman CJ, Lind J, Rydén E, Ingvar M, Landén M. Manic episodes are associated with grey matter volume reduction - a voxel-based mor-phometry brain analysis. Acta Psychiatr Scand 2010;122:507-515.    

Andrea Amerio

Matteo Tonna

Anna Odone

S. Nassir Ghaemi

Crossref

Psychiatry Investigation

Comorbid Bipolar Disorder and Obsessive-Compulsive Disorder: An Old Debate Renewed

AMERIO, Andrea

TONNA, Matteo

ODONE, Anna

Archivio istituzionale della Ricerca -  Università degli Studi di Parma

12 October 2022University of Parma Research RepositoryComorbid bipolar disorder and obsessive-compulsive disorder: An old debate renewed / Amerio, Andrea;Tonna, Matteo; Odone, Anna; Ghaemi, S. Nassir. - In: PSYCHIATRY INVESTIGATION. - ISSN 1738-3684. -13:3(2016), pp. 370-371. [10.4306/pi.2016.13.3.370]OriginalComorbid bipolar disorder and obsessive-compulsive disorder: An old debate renewedPublisher:PublishedDOI:10.4306/pi.2016.13.3.370Terms of use:openAccessPublisher copyright(Article begins on next page)Anyone can freely access the full text of works made available as "Open Access". Works made availableAvailability:This version is available at: 11381/2817704 since: 2016-11-09T21:17:10ZThis is the peer reviewd version of the followng article:To the Editor,Apparent comorbidity between bipolar disorder (BD) and anxiety disorders is a common condition in psychiatry with higher prevalence rates for generalised anxiety disorder, so-cial phobia, panic disorder.1Overlapping clinical criteria for many diagnoses, especially mood and anxiety disorders, produced by the Diagnostic and Statistical Manual of Mental Disorders (DSM) might lay be-hind these high prevalence rates.2 Using DSM, it is unclear whether concomitant diagnoses actually reflect the presence of distinct clinical entities or refer to multiple manifestations of a single clinical entity.With regard to anxiety disorders, one of the most difficult additional psychiatric diagnosis to manage in BD patients is obsessive-compulsive disorder (OCD).3,4 In our recent meta-analysis, the pooled prevalence of OCD in BD was 17.0%, which was comparable to the results reported by the pooled prevalence of BD in OCD (18.35%).5 In line with previous stud-ies,6 OCD prevalence rate was higher among BD children and adolescents (24.2%, compared to 13.5% in adults).The co-occurrence of symptoms of BD and OCD was noted 150 years ago by Morel,7 but the topic is insufficiently studied and the relationship between BD and OCD remains unclear.In agreement with Kraepelin’s thought a psychiatric diagno-sis is best established by its longitudinal course of illness, the evidence so far supports the view that, especially among pa-Print ISSN 1738-3684 / On-line ISSN 1976-3026OPEN ACCESS370  Copyright © 2016 Korean Neuropsychiatric Association  tients with a primary diagnosis of BD, the majority of comor-bid OCD cases appeared to be related to mood episodes.8 OC symptoms in comorbid patients appeared more often-and sometimes exclusively-during depressive episodes, and co-morbid BD and OCD cycled together, with OC symptoms of-ten remitting during manic/hypomanic episodes.Therefore, only a substantial minority of comorbid BD-OCD may represent “true” OCD independent of BD with OC symptoms that improve or worsen during mood episodes with-out being related to these.These findings are in line with Feinstein’s definition of co-morbidity, as “any distinct additional entity that has existed or may occur during the clinical course of a patient who has the index disease under study”.2 “True” OCD comorbid with BD would represent the random co-occurrence of two inde-pendent diseases, estimated by multiplication of prevalence rates, which are about 1% for each condition, and producing a very low expected true comorbidity of 0.1% in the general population.The treatment of BD-OCD patients remains a great chal-lenge, since the gold standard for one disease (serotonin reup-take inhibitors for OCD) can worsen the other (antidepres-sants can cause mania and/or more mood episodes in BD).The clinical features of comorbid BD-OCD patients would explain why OCD and BD symptoms respond to adequate mood stabilizer treatment.3 Only in a minority of comorbid patients with persistent OCD, despite improvement in mood episodes, addition of low doses of antidepressants could be considered while strictly monitoring emerging symptoms of mania or mixed states. Benefit with antipsychotics was also seen, although a few reports also exist of exacerbation of OC symptoms with neuroleptic agents.Considering the growing interest over the last decades into shared pathophysiologies across psychiatric disorders, stud-LETTER TO THE EDITORComorbid Bipolar Disorder and Obsessive-Compulsive  Disorder: An Old Debate Renewed Andrea Amerio1,2 , Matteo Tonna3, Anna Odone4, and S. Nassir Ghaemi2,51Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy2Mood Disorders Program, Tufts Medical Center, Boston, MA, USA3Department of Mental Health, Local Health Service, Parma, Italy4Department of Biomedical, Biotechnological and Translational Sciences, Unit of Public Health, University of Parma, Parma, Italy5Tufts University Medical School, Department of Psychiatry and Pharmacology, Boston, MA, USAReceived: October 7, 2015    Revised: November 22, 2015Accepted: November 22, 2015    Available online: March 23, 2016 Correspondence: Andrea Amerio, MDDepartment of Clinical and Experimental Medicine, University of Parma, c/o Ospedale Maggiore, Viale A. Gramsci 14, Parma 43126, ItalyTel: +39 0521 903594, Fax: +39 0521 347047E-mail: andrea.amerio@studenti.unipr.itcc  This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduc-tion in any medium, provided the original work is properly cited.http://dx.doi.org/10.4306/pi.2016.13.3.370Amerio A et al.    www.psychiatryinvestigation.org  371ies addressing neurobiological substrates are essential to illu-minate pathogenetic mechanisms that underlie comorbid BD-OCD. AcknowledgmentsThis research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.Conflicts of InterestDr. Amerio, Dr. Tonna, and Dr. Odone report no conflicts of interest. Dr. Ghaemi has provided research consulting to Sunovion and Pfizer, and has obtained a research grant from Takeda Pharmaceuticals. Neither he nor his family hold equity positions in pharmaceutical corporations.REFERENCES1. Boylan KR, Bieling PJ, Marriott M, Begin H, Young LT, MacQueen GM. Impact of comorbid anxiety disorders on outcome in a cohort of patients with bipolar disorder. J Clin Psychiatry 2004;65:1106-1113.2. Maj M. “Psychiatric comorbidity”: an artefact of current diagnostic sys-tems? Br J Psychiatry 2005;186:182-184.3. Amerio A, Odone A, Marchesi C, Ghaemi SN. Treatment of comorbid bipolar disorder and obsessive-compulsive disorder: a systematic re-view. J Affect Disord 2014;166:258-263.4. Amerio A, Odone A, Marchesi C, Ghaemi SN. Do antidepressant-in-duced manic episodes in obsessive-compulsive disorder patients rep-resent the clinical expression of an underlying bipolarity? Aust N Z J Psychiatry 2014;48:957.5. Amerio A, Stubbs B, Odone A, Tonna M, Marchesi C, Ghaemi SN. The prevalence and predictors of comorbid bipolar disorder and obsessive-compulsive disorder: a systematic review and meta-analysis. J Affect Disord 2015;186:99-109.6. Sala R, Axelson DA, Castro-Fornieles J, Goldstein TR, Goldstein BI, Ha W, et al. Factors associated with the persistence and onset of new anxiety disorders in youth with bipolar spectrum disorders. J Clin Psychiatry 2012;73:87-94.7. Morel BA. Traité des maladies mentales. Second Edition. Paris: Mas-son; 1860.8. Amerio A, Odone A, Liapis CC, Ghaemi SN. Diagnostic validity of co-morbid bipolar disorder and obsessive-compulsive disorder: a systemat-ic review. Acta Psychiatr Scand 2014;129:343-358.9. Ekman CJ, Lind J, Rydén E, Ingvar M, Landén M. Manic episodes are associated with grey matter volume reduction - a voxel-based mor-phometry brain analysis. Acta Psychiatr Scand 2010;122:507-515.    

English

Amerio Andrea

Tonna Matteo

Odone Anna

Ghaemi S. Nassir

Archivio Istituzionale della Ricerca - Università degli Studi di Pavia

https://air.unipr.it/bitstream/11381/2817704/2/Amerio%20et%20al%202016_PSYCH%20INVEST.pdf

Comorbid bipolar disorder and obsessive-compulsive disorder: An old debate renewed

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Archivio Istituzionale della Ricerca - Università degli Studi di Pavia