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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 39  |  Issue : 1  |  Page : 5-14

Bipolar disorder among patients with obsessive–compulsive disorder at Zagazig University Hospitals


Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission30-May-2017
Date of Acceptance15-Jun-2017
Date of Web Publication29-Jan-2018

Correspondence Address:
Wail Abouhendy
Professor of Psychiatry Zagazig University, Psychiatry Department, Faculty of Medicine, Zagazig University, 44511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejpsy.ejpsy_22_17

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  Abstract 


Background Comorbidity of bipolar disorder (BD) in obsessive–compulsive disorder (OCD) patients is a relevant phenomenon and has significant effect on expression of symptom, treatment, and complications of the disorder.
Objective The aim of this study was to find the frequency of BP in patients with OCD, determine the effect of BP occurrence on the clinical characteristics of OCD, and compare between OCD patients with and those without BP.
Patients and methods Sixty individuals with OCD diagnosed according to the Diagnostic and statistical manual for mental disorders, 5th ed., were subjected to screening using the Obsessive–Compulsive Symptoms Scale, the Yale–Brown Obsessive–Compulsive Scale, the Hamilton Depression Rating Scale, and Mood Disorder Questionnaire.
Results Fifteen percent of the OCD patients included in the study had additional lifetime diagnosis of BD. There was a statistically significant relation between comorbidity and episodic course of OCD, previous psychiatric hospitalization, and suicidal attempts.
Patients with comorbid BD comprised mainly male patients and urban residents with a high incidence of religious obsessions and compulsions, general compulsions (e.g. checking, ordering, and arranging), and repetition, but with no statistically significant difference.
Conclusion A better understanding of the clinical profile of individuals with a primary diagnosis of OCD with and those without BD helps in guiding the treatment of individuals.

Keywords: bipolar disorder, comorbidity, obsessive–compulsive disorder


How to cite this article:
Abouhendy W, Youssef UM, Salah El-Deen GM. Bipolar disorder among patients with obsessive–compulsive disorder at Zagazig University Hospitals. Egypt J Psychiatr 2018;39:5-14

How to cite this URL:
Abouhendy W, Youssef UM, Salah El-Deen GM. Bipolar disorder among patients with obsessive–compulsive disorder at Zagazig University Hospitals. Egypt J Psychiatr [serial online] 2018 [cited 2018 Feb 17];39:5-14. Available from: http://new.ejpsy.eg.net/text.asp?2018/39/1/5/224004




  Introduction Top


Obsessive–compulsive disorder (OCD) is considered one of the 10 most debilitating conditions among all physical and mental disorders all over the world (Murray and Lopez, 1996). According to the Diagnostic and statistical manual for mental disorders, 4th ed. (DSM-IV), the main clinical features of OCD are obsessions and/or compulsions.

Obsessions are persistent impulses, thoughts, or images that are experienced as inappropriate and intrusive and hence cause anxiety or distress. Compulsions are repetitive physical or mental acts performed in response to obsessions to prevent or lessen the distress or some feared outcome. It appears to be difficult to suppress such thoughts or behaviors in those afflicted with OCD often, despite usually knowing that the obsessions or compulsions are excessive and unreasonable (American Psychiatric Association, 1994).

Bipolar disorder (BD) is a mood disorder characterized by repeated episodes of depression and mania/hypomania (American Psychiatric Association, 2001). Patients with BD also experience substantial symptoms between episodes, in addition to multiple relapses of mood episodes (Benazzi, 2004; Paykel et al., 2006).

Psychiatric comorbidity is highly prevalent and complicates the course of BD (Schaffer et al., 2012). The most highly prevalent comorbidities associated with BD are anxiety disorders. Epidemiological studies reveal that a large number of individuals (74.9%) with BD have at least one anxiety disorder at some point in their lives (Merikangas et al., 2007).

Recent studies indicate that there is great comorbidity between OCD and BD, and that up to 7–21% of patients who suffer from BD have an additional diagnosis of OCD (Chen and Dilsaver, 1995; Krüger et al., 2000; Joshi et al., 2010; Magalhães et al., 2010). Moreover, the prevalence of BD in OCD patients was found to be 15–15.7% (Perugi et al., 1997; Joshi et al., 2010). This comorbidity seems to be very common in men, with a study showing that 69% of those with association are male (Zutshi et al., 2007). OCD is commonly comorbid with BD II (Perugi et al., 1999; Krüger et al., 2000).

Research indicates that patients with comorbid bipolar affective disorder experience a more episodic course of OCD. OCD symptoms are more severe in the depressive episode of BAD and tend to be less intense or absent during manic/ hypomanic episodes (Zutshi et al., 2007). A history of rapidly cycling bipolar affective disorder is most common in patients with comorbid OCD (Magalhães et al., 2010).

The importance of this link lies in the potential impacts of comorbidity on the phenotype of each condition and in the effect of the treatment. Moreover, it is important to look at the additional burden placed on healthcare resources.


  Patients and methods Top


Patients

This work included 60 patients with OCD diagnosed according to the Diagnostic and statistical manual for mental disorders, 5th ed. (DSM-5), diagnostic criteria. This sample had been selected within 6 months and patients were selected from both the inpatient ward and the outpatient clinic of Psychiatry Department, Zagazig University Hospitals, Sharkia, Egypt, using a systematic random sampling technique.
  1. First, the frequency of BP in patients with OCD was determined.
  2. Thereafter, the patients were divided into two groups:
    1. OCD patients with BP.
    2. OCD patients without BP.


Thereafter, a comparative study was carried out between the two groups to
  1. determine the effect of BP occurrence on the clinical characteristics of OCD and
  2. to find the similarities and differences between OCD patients with BP and those without BP.


Inclusion criteria

  1. Fulfilling DSM-5 criteria for OCD.
  2. Both sexes.
  3. Age range from 18 to 60 years.


Exclusion criteria

  1. Age below 18 years and above 60 years.
  2. Fulfilling DSM-5 criteria for intellectual disabilities and having low comprehension skills, severe physical disorders, organic brain disease, and history of drug/alcohol dependence.
  3. Currently being in active manic/ hypomanic episode.


Patients who met the inclusion criteria were selected using the systematic random sampling technique and asked to participate in the study after obtaining consent.

Methods

All patients were subjected to the following assessment procedures under the supervision of supervisors:
  1. Full psychiatric examination through semistructured interview including specific data as regards sociodemographic data using sheet of the Department of Psychiatry, Zagazig University (age, sex, marital state, education, occupation, residence, and family history of psychiatric disorders) and the clinical characteristics of the disorder (course of OCD, history of previous hospitalization, history of suicide, severity of OCD, and severity of comorbid depression).
    • The semistructured interview contained a full psychiatric sheet, which allowed each patient to receive psychiatric diagnosis by its end during which diagnosis of OCD was confirmed according to the DSM-5 criteria (American Psychiatric Association, 2000).
  2. General medical examination: general medical examination of patients was carried out to exclude the presence of severe physical disorders, organic brain disease.
  3. Psychometric assessment:
    • The following psychometric scales were administered:
    1. Obsessive–Compulsive Symptoms Scale (Moemen and Abohendy, 2006)
      • This self-rating scale consists of a group of questions (statements) (83) divided into subgroups, and each subgroup tests a dimension of obsession (e.g. ruminations, sexual obsessions, aggressive obsessions, religious obsessions, cleaning obsessions, impulsive obsessions, and obsessive pictures) and/or compulsions (e.g. general compulsions, religious compulsions, cleaning compulsions, slowness, repetition, and touch) and a subgroup of questions for dysfunction. Moreover, this scale was used to compare the severity of obsessions and compulsions between the two groups. This scale is suitable and applicable for Arabic cultures.
      • Each question (statement) is answered using the Likert scale; the score of each statement ranges between 5 and 1, 5 representing always and 1 representing never. To obtain the degree for each subscale we first correct each statement and add the points (scores) of each subscale to be changed to adjusted standardized degree.
      • To obtain the total score we add the preadjusted degree (score) of the submeasure and the total is changed to T degree. The total degree ranges from 31 to 85.
    2. Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) (Goodmanet al., 1989) (Arabic version; translated by Ain Shams Institute of Psychiatry)
      • The Y-BOCS is used to estimate the severity of symptoms of OCD.
      • The scale, which was designed by Goodmanet al.(1989), is used extensively in the field of research and clinical practice to asses both the severity of OCD obsessions and compulsions without being biased to the type of their content and the improvement during treatment. This scale measures obsessions and compulsions separately.
      • The scale is self-rating, which consists of 10 items, each item evaluated from 0 (no symptoms) to 4 (extreme symptoms), yielding a total score range from 0 to 40. The scale includes questions about the amount of time spent by the patient on obsessions, how much they get impaired or distressed, and how much they can resist and control these thoughts. The same is about compulsions as well. The results can be calculated according to the total score: 0–7 is subclinical; 8–15 is mild; 16–23 is moderate; 24–31 is severe; and 32–40 is extreme.
      • Patients having scores ranging from mild to higher levels are experiencing a significant negative impact on their quality of life and should consider professional help in alleviating OCD symptoms.
    3. Hamilton Depression Rating Scale (HDRS) (Hamilton, 1967) (Arabic version translated by Lotfy Fateem)
      • This is a clinician-rated scale and takes about 20–30 min to assess the severity of depressive symptoms in adults. The HDRS (also known as the Ham-D) is the most widely assessment tool used in depression. The original version contains 17 items (HDRS-17) related to depressive symptoms present over the past week. The HDRS was developed originally for hospital inpatients, emphasizing on depression symptoms (melancholic and physical).
      • Scoring of the HDRS-17 is as follows: a score of 0–7 is considered as being normal; a score of 8–16 suggests mild depression; a score of 17–23 indicates moderate depression; and scores over 24 indicate severe depression, with the maximum score being 52.
    4. Mood Disorder Questionnaire (MDQ) (Hirschfeldet al., 2000)


The MDQ was developed by a team of psychiatrists and researchers calling for to address an urgent need for the accurate diagnosis of BD, which can be fatal if left untreated. The questionnaire takes short time (about 5 min) to complete, and can give important insights into diagnosis and treatment.

Clinical trials have demonstrated that the MDQ has a high rate of accuracy; it can identify seven of every 10 individuals who have BD and screen nine of 10 individuals who do not. A recent National Depressive and Manic-Depressive Association (DMDA) survey revealed that about 70% of people having BD had received at least one misdiagnosis and many of them had waited more than 10 years from the onset of their symptoms to receive a correct diagnosis. National DMDA hopes that the MDQ will minimize this delay and help more people to receive the treatment they need, when they need it. The MDQ screens for spectrum of BD.

The patients have a positive screen if they answer as follows: first, ‘yes’ to seven or more of the 13 items in question number 1; second, ‘yes’ to question number 2; and third; ‘moderate’ or ‘serious’ to question number 3. This positive screen should be followed by a comprehensive medical evaluation for bipolar spectrum disorder.

In this study, MDQ was first translated into Arabic by an expert in English and then presented to three professors of psychiatry who accepted it as face validity. After that, MDQ was applied on five healthy medical students and then translated back to English by an expert in English in English center, and the original one and the one translated back to English were compared. After that, the total score of the Arabic version of the MDQ was compared with each part of it to test the internal consistency.

Administrative design

  1. Approval was obtained from the Institutional Review Board.
  2. Written informed consent was obtained from participants after discussing with them the aim of the study.
  3. The general principles that were explained for all those who participate in this study were as follows:
    1. Participation in this study is totally free and voluntary.
    2. Participation in this study does not imply a direct benefit for the participant, although data obtained could be useful for other people.
    3. Patients were informed that they may decide to exit from the study at any moment without giving any justification.
    4. The results of this study could be used as a scientific publication but the identity of the participant will be absolutely confidential and only researchers will know.



  Results Top


This study included 60 OCD patients: 29 (48.33%) were male and 31 (53.33%) were from rural areas. More than half majority (55%) of them were married and 50% had received middle school level education. Their mean age was 31.82±10.74 years (range: 18–60 years). Among the OCD patients, 34 (56.67%) were not working, 11 (18.33%) were employed, 10 (16.67%) were students, and five (8.33%) were manual workers. Nine (15%) of them had a family history of psychiatric disorders and nine (15%) of them had comorbid BD ([Table 1]).
Table 1 Demographic data of studied patients as a whole

Click here to view


There was no statistically significant difference between OCD patients without BD and those with BD as regards age, sex, marital status, education, occupation, residence, and family history of psychiatric disorders ([Table 2]).
Table 2 Comparison between obsessive–compulsive disorder patients without bipolar disorder and obsessive–compulsive disorder patients with bipolar disorder as regards sociodemographic data

Click here to view


OCD patients with BD were more likely to have episodic course, be more suicidal, and frequently hospitalized compared with OCD patients without BD, and there was a statistically significant difference between the two groups ([Table 3]).
Table 3 Clinical implications of bipolar disorder on the clinical characteristics of obsessive–compulsive disorder

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OCD patients with BD tend to have less rumination, sexual obsessions, aggressive obsessions, cleaning obsessions, impulsive obsessions, and obsessive images, but more religious obsessions compared with OCD patients without BD. However, there was no statistically significant difference ([Table 4]).
Table 4 Comparison between obsessive–compulsive disorder patients and obsessive–compulsive disorder patients with bipolar disorder as regards obsessions

Click here to view


OCD patients with BD tend to have less religious, cleaning, slowness, and touch compulsions and less dysfunction and tend to have more general compulsions and repetition compared with OCD patients without BD, but with no statistically significant difference ([Table 5]).
Table 5 Comparison between obsessive–compulsive disorder patients without bipolar disorder and obsessive–compulsive disorder patients with bipolar disorder as regards compulsions and dysfunction

Click here to view



  Discussion Top


Comorbidity between BD and OCD raises theoretical and practical problems. The theoretical importance lies in studying possible common underlying pathogenesis, course, complications, treatment management, and outcome. This is important in facing the controversial issue concerning the validity of diagnostic classification − namely, the categorical versus dimensional nature of mental illness.

OCD patients with comorbid BD have a number of indicators of more severe illness. The presence of a lower social quality of life and more anxiety symptoms may be more specific features of the bipolar–OCD comorbidity (Presta et al., 2003).

Frequency of bipolar disorder in obsessive–compulsive disorder patients

We found that 51 (85%) patients (23 male and 28 female) were diagnosed with OCD without BD, and about 15% (six male and three female) of OCD patients were found to have additional lifetime diagnosis of BD.

A study that focused on the reverse issue showed that, among OCD outpatients, 15.7% presented with bipolar comorbidity (Perugi et al., 1997). Moreover, in an epidemiological survey carried out on 453 OCD patients, it was found that 11% of patients had suffered from BD (DSM-IV mania or hypomania) (Hantouche et al., 2002).

Darby et al. (2011) in their study found that 16% of OCD patients were also diagnosed with bipolar affective disorder; of these 16%, 67% had bipolar disorder II.

Demographic data and comorbidity

Age distribution

In the current study, the mean age of OCD patients with comorbid BD was 36.56, which is higher than that of OCD patients without BD (30.84). However, there was in no statistical significance as regards age between the two groups (P=0.150).

Studies by Mahasuar et al. (2011) did not show any statistical difference between the two groups as regards age and this is in line with our study. Ozdemiroglu et al. (2015) also in their study demonstrated that OCD with the BD group and OCD without the BD group did not differ significantly in terms of age and is consistent with our results also.

Sex distribution

Our work revealed that comorbidity tended to be higher in male (66.7%) than in female (33.3%) patients but with no statistical significance as regards sex between the two groups (OCD with and OCD without BD) (P=0.203).

Some of the earlier studies found that male population represented the majority of OCD patients with BD (Zutshi et al., 2007). Moreover, Mahasuar et al. (2011) found that OCD with bipolar is more common in male population (67.65%) than in female population (32.35%), with no significant difference.

Marital status

Our results showed that the incidence of comorbidity was higher in married patients (66.7%), followed by single patients (33.3%); the percentage in those without BD was nearly equal, being 52.9% in married and 41.1% in single patients. Comparison between the two groups (OCD with and OCD without BD) revealed that there was no statistical significance as regards marital status (P=0.823). This finding is consistent with the results of Mahasuar et al. (2011) and Ozdemiroglu et al. (2015), and this shows that marital status has no role in comorbidity between OCD and BD.

Education distribution

This study revealed that the majority of OCD patients comorbid with BD were highly educated (44.4%) but those without BD had average qualification (52.9%). When we compared the two groups we found that there was no statistical significance as regards educational level (OCD and OCD with BD).

The study by Ozdemiroglu et al. (2015) revealed that there was no statistically significant difference as regards years of education between the two groups, which is consistent with our findings.

Occupation distribution

Our results showed that most of the OCD patients with BD were employed (44.4%), but most of the OCD patients without BD were unemployed (60.78%); however, there was no statistically significant difference between the two groups.

The findings of the comparative study by Mahasuar et al. (2011) are in line with our results as they found that most of the OCD patients with BD were self-employed/business/agriculture (33%), whereas most of the OCD patients without BD were unemployed (30%) with no statistical significance.

Residence

On analyzing the place of residence and its relation with comorbidity between OCD and BD, we found that most of the OCD patients with BD (66.7%) were living in urban area, whereas 43.1% of OCD patients without BD were living in urban areas. However, there was no statistical significance as regards residence (P=0.173).

Mahasuar et al. (2011) found that among the two groups most OCD patients with BD (56%) and those without BD (58%) were living in urban area, with no statistical significance as regards residence between the two groups.

Family history of psychiatric disorders

This work found that 15.7% of OCD patients without BD have positive family history of psychiatric disorders and about 11.1% was recorded in those with comorbid BD. There was no statistically significant difference as regards family history of psychiatric disorders between the two groups.

Mahasuar et al. (2011) found that a family history of any psychiatric illness was higher in OCD patients with BD (68%) than in those without BD (53%), with no statistically significant difference. Moreover, a comparison study between OCD and OCD with BD patients by Ozdemiroglu et al. (2015) also showed that there was no significant difference between the two groups as regards family history of OCD.

Findings of a study by Perugi et al. (1997) revealed the same. All previous studies mentioned are in line with our results and show that family history has no role in comorbidity between OCD and BD.

In contrast, some studies stated higher rates of mood disorder and OCD in relatives of bipolar–OCD patients (Hantouche et al., 2003; Angst et al., 2005; Zutshi et al., 2007), and this difference may be due to difference in sample size and methods used for assessment.

Course of obsessive–compulsive disorder

In our study, episodic course of OCD was recorded in about 77.8% of OCD patients with BD and in about 11.8% in those without BD. There was a higher incidence of continuous course of OCD recorded in OCD patients without BD (88.2%) than in OCD patients with BD (22.2%). There was a highly statistically significant difference between the two groups (P=0.000) as regards course of OCD. This finding consequently supports the argument that comorbidity with BD affects the course of OCD in a distinct manner.

In consistence to our finding, a study by Mahasuar et al. (2011) showed that OCD when associated with BD tends to have an episodic course regardless of whether or not the patients are primarily bipolar.

Moreover, other earlier studies showed that BD may contribute to a more episodic course for OCD, sometimes referred to as cyclothymic OCD (Perugi et al., 1997; Hantouche et al., 2003; Tükel et al., 2006; Zutshi et al., 2007; D’Ambrosio et al., 2010; Magalhães et al., 2010). Similarly studies by Ozdemiroglu et al. (2015) have found that the frequency of episodic course tended to be higher in OCD–BD patients (P=0.029) than in pure OCD patients. Consequently, BD–OCD patients are characterized by a more episodic course of OCD, higher rates of rapid cycling, and seasonality.

Perugi et al. (1997) stated that bipolarity should take precedence in diagnosis, course, and treatment considerations, when bipolar and OCD coexist.

Rate of suicide

In the current study, the rate of suicidality in OCD patients co-morbid with BD (44.4%) was higher than those without BD (7.8%), and this shows the role of comorbidity in increasing the risk for the disorder because of increased probability of suicide attempts either from OCD symptoms or from BD (manic or depressive episode).

In confirmation with our findings, Chen and Dilsaver (1995), Hantouche et al. (2003), and Angst et al. (2005) referred to an increased incidence of suicidality in the OCD with BD group.

Previous psychiatric hospitalization

Our results demonstrated an increased rate of hospitalization in patients diagnosed as OCD and BD (77.8%) than those without BD (2%) with high a statistically significant difference, and that is consistent with our results as regards previous suicidal attempts in both groups and increased risk for disorder with subsequent need for hospitalization.

In accordance with our study, Mahasuar et al. (2011) found that hospitalization was higher in OCD patients with BD. In the OCD with BD group, 70.6% were hospitalized (32% for manic episode and 38% for severe OCD), whereas in the OCD without BD group, 14% were hospitalized for severe OCD. Moreover, Ozdemiroglu et al. (2015) in their study found that the rate of previous hospitalizations was significantly lower in the OCD without comorbidity group compared with the other group (OCD and BD). Timpano et al. (2012) showed that the number of psychiatric hospitalizations has a great relation with comorbidity between OCD and BD.

Severity of obsessive–compulsive disorder

In our study, about half of the OCD patients with BD were associated with severe OCD symptoms during the time of assessment (55.6%), whereas the majority of those without BD (66.7%) were associated with severe OCD symptoms, but with no statistically significant difference between the two groups.

Timpano et al. (2012) in their study found that OCD patients with comorbid affective disorders, particularly BD, represent a clinically severe group compared with those without such comorbidity.

Improvement in OCD in the hypomanic /manic phases and worsening in depressed phases was observed in a study by Mahasuar et al. (2011). Similar observations made previously by Perugi et al. (1997) and Zutshi et al. (2007) support the argument that comorbidity with BD affects the course of OCD in a special manner.

Numerous studies stated that obsessions or compulsions in BD patients are common and severe during depressive and mixed episodes, or even during euthymia and remit during manic episodes (Gordon and Rasmussen, 1988).

Their results differ from ours (as we found severe OC symptoms in both groups); the difference may be attributed to different sample size as they included 605 patients and the difference in the methods used to assess impairment.

Severity of depression

Our findings show that the majority of OCD patients with and without BD also had severe depression (77.78% OCD with BD and 76.5% OCD without BD) (assessed using Hamilton scale). There was no significant difference between the two groups as regards severity of depression associated with the disorder.

In contrast, results by Mahasuar et al. (2011) showed that the total number of depressive episodes in general and severe depressive episodes and episodes of psychotic depression in special was significantly higher in the OCD patients with BD group. This is not consistent with our results due to the difference in sample size as they included 34 patients from the start diagnosed as OCD with BD but we chose our sample of OCD randomly and only nine patients were found to have additional diagnosis of BD.

Obsessions

Our study results showed that religious obsessions were higher in OCD patients with BD than in those without BD, but with no significant difference between the two both groups. The results according to mean of ruminations, sexual obsessions, aggressive obsessions, cleaning obsessions, and obsessive pictures showed that they occur more frequently in the group of OCD patients without BD than in OCD with BD with no statistically difference as regards them between the two groups.

These results is confirmed by Masi et al. (2004) and Hasler et al. (2005) who found religious obsessions were statistically significant higher in OCD patients & BD group than in OCD patients without BD; however, the significant difference may be due to their larger sample (102), different age group (children and adolescents), and inclusion of both inpatients and outpatients.

Previous studies by Perugi et al. (1997) found higher rates of sexual obsessions in the OCD and BD group and they were more likely to have aggressive obsessions and those with a philosophical, superstitious, or bizarre content, which is not in line with our study that proved that there was no statistical significance found as regards sexual or aggressive obsessions. Their data suggested that religious obsessions were found to be higher in the OCD and BD group, and that is consistent with our results but we revealed no statistical significance between the two groups.

Compulsions

Our results demonstrated that general compulsions including ordering and checking rituals appeared to occur higher in the OCD and BD group, but when we compared both groups we found that there was no significant difference recorded according to them in both groups.

Our results also showed that mean repetition was higher than that in the OCD and BD group than in OCD without BD but this numerical difference failed to find statistically significant difference between two groups. These results are in agreement with higher rates of repeating behaviors recorded by Maina et al. (2007) and Perugi et al. (1998), as well as higher rates of reassurance-seeking compulsions, which were found in a study by Hantouche et al. (2003) and Mahasuar et al. (2011).

In the study by Ozdemiroglu et al. (2015), at the time of assessment, the total (P=0.0001), obsession (P=0.0001), and compulsion (P=0.0001) subscales scores of the Y-BOCS were significantly higher in the OCD group compared with the BD–OCD group. This is in agreement with our results as we found that all obsessions except religious and all compulsions except repetition are higher in OCD patients without BD than in OCD with BD but with no statistically significant difference between the two groups.

The main limitations of this study were as follows:
  1. The relatively small sample size that could limit certain interpretations.
  2. The retrospective recall of some variables, which may certainly affect some results.
  3. We did not include BD patients who were in an active manic period to avoid the risk of mistaking acute affective symptomatology on some clinical variables.
  4. Despite these limitations, our study has an advantage by specifically comparing the patients with pure diagnosis of OCD and those with comorbid BD.


Recommendations

Clinical recommendations

  1. Psychometric assessment should be an integral part of any psychiatric examination.
  2. All OCD patients with comorbid BD should be taken seriously no matter how trivial their acts appear to be and should be subjected to comprehensive psychiatric examination with subsequent precautions as there would be a high rate of suicidal attempts and hospitalizations.
  3. Diagnosis of OCD with comorbid BD is very important as it would have clinical implications on clinical characteristic of OCD and on choice of the most appropriate treatment.


Research recommendations

  1. It would be worthy to explore this phenomenon in a community-based study and to compare them with patients of different psychiatric diagnoses.
  2. Long-term follow-up studies of OCD and BD patients are important to improve predictive ability and hence clinical management.
  3. Extensive epidemiological research on comorbidity between OCD and BD is needed to understand the extent of this phenomenon in Egypt.
[34]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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