The Link Between OCD And Bipolar Disorder

What is OCD?

The difference is that those without OCD might think an intrusive thought is weird, but then they let it pass and don’t think much else about it. Someone with OCD will dwell on an intrusive thought. It will cause them great anxiety. They might feel that their thought means they are a bad person or that something terrible will happen as a result of it. This is what makes an intrusive thought an obsession for someone with OCD.

Obsessions can centre around a wide variety of themes, such as sexual, religious, harm, contimatination, and more. One person might struggle with more than one type of obsession.

Obsessions cause very high anxiety and distress for the individual. They’re often filled with shame and terrified of what will happen as a result of their obsessions.

The individual with OCD will then feel desperate to do something to lessen this anxiety and to cope with their obsessions: this when compulsions come into play. Compulsions are repetitive or ritualistic actions which the individual with OCD carries out to try to deal with their obsessions. Just like obsessions, there are a variety of types of compulsions and one person may experience more than one type of compulsions.

Obsessions and compulsions may seem to ‘fit’ together or be related, such as contamination obsessions and cleaning compulsions. However, they can also seem completely unrelated, but will be intrinsically tied together in the individual’s mind. They may carry out compulsions to ‘prevent’ something bad happening as a result of their obsessions. They might do so because they feel their compulsions are stopping them from acting on their obsessions. Fundamentally, they’re carrying out these actions to try to lessen the anxiety and severe emotional distress caused by their obsessions.

Compulsions can take up many hours of the day. They can be very disruptive and distressing. Even if the individual knows that their compulsions are not based in logic, they will feel driven to carry them out nonetheless for fear of what will happen if they don’t. Although compulsions may initially ease the anxiety slightly, it will soon come back and often much stronger. This is the vicious cycle of OCD.

OCD is very common, with 1.2% of the population experiencing the disorder. It can affect anyone, in any walk of life. OCD can be a debilitating disorder, infiltrating almost every aspect of your life. Thankfully, OCD can be effectively treated and managed so that those with the disorder can live a full, happy life. We’ll discuss treatment later on in this article.

What is bipolar disorder?

Someone with bipolar disorder might also experience psychotic symptoms when they’re having a high or low mood. Psychosis can be defined as, “when you perceive or interpret reality in a very different way from people around you. You might be said to ‘lose touch’ with reality.” Someone experiencing psychosis might be very confused. They might have what’s known as disorder thinking and confused speech. They may also experience hallucinations. This can be very frightening for the individual and those around them.

Living with bipolar disorder can be very difficult. It can impact every area of an individual’s life and can be overwhelming at times. The disorder is more common than you might think, with 1 in 100 people having bipolar disorder. Bipolar disorder is a lifelong condition, meaning it can’t be cured. However, it can be effectively treated and symptoms can be managed just like with OCD, so that the individual can live a full life.

Mania/hypomania

Mania and hypomania are both mood states where the individual’s mood is high or elated. Mania is a more severe type of high mood. During mania, an individual will experience a range of symptoms which make it incredibly hard to function. Some people with mania also experience psychosis. Severe states of mania can be dangerous and may require the individual to stay in hospital until they are stable.

The symptoms of mania are shown below. It’s important to note that not everyone will experience all of these symptoms, and one individual may experience varying symptoms each time they are in a manic state.

• Feeling extremely happy and euphoric
• Feeling very excited with very high energy levels
• Talking very fast and often not making sense to others around you
• Feeling irritable and frustrated, especially when others ‘can’t keep up’ with you
• Increased sex drive and sometimes in approriate sexual behaviour
• Inability to concentrate
• Feeling extremely confident
• Feeling like you are invincible and can’t be hurt
• Feeling as though you can do everything better than you usually can
• Feeling as though you can see, hear, and understand things that other people can’t
• Saying or doing things that are out of character
• Acting inappropriately
• Doing things which put you at serious risk
• Sleeping very little or not at all
• Spending money recklessly
• Misusing drugs or alcohol
• Potential psychosis

Hypomania is a less severe, more manageable form of mania. However, this by no means suggests it is not very distressing, disruptive and difficult to manage. Symptoms of hypomania are shown below. Some may mirror those of mania as they do share many similarities, but as mentioned they tend to be less severe.

• Feeling very happy or euphoric
• Feeling very excited and full of energy
• Having racing thoughts
• Speaking very fast
• Feeling irritable if others can’t ‘keep up’
• Being easily distracted
• Feeling very confident
• Increased sex drive and potentially risky sexual behaviour
• Having great and grand ideas
• Making decisions which you wouldn’t usually make
• Sleeping very little
• Spending money recklessly
• Engaging in risky behaviour
• Acting out of character

After a manic or hypomanic episode it’s common to feel really ashamed of how you behaved, as it’s not how you would normally act. It’s also common to feel guilty for what you put loved ones through. Many people feel exhausted and drained, and may need a few days to rest and recover. It’s also common to have made commitments or taken actions which feel unmanageable or distressing once you’re stable again.

Depression

Bipolar depression is an all encompassing feeling of sadness, despair, and often pure exhaustion. For many people, depressive episodes can be harder to deal with than mania or hypomania. As we mentioned previously, the severity and how long these episodes last depends on many factors.

Symptoms of bipolar depression include:

• A very low mood
• Feeling very upset and tearful
• Severe lack of energy
• Low confidence and self esteem
• Feeling guilty and worthless
• Being very hard on yourself
• Feeling agitated, frustrated, and tense
• Withdrawing socially
• Not finding pleasure in things you usually enjoy
• Being unable to sleep or sleeping too much
• Eating too little or too much
• Misusing drugs or alcohol
• Lack of hope for the future
• Self-harm behaviours
• Suicidal feelings, ideation, and potentially actions

Mixed episodes

Mixed episodes or mixed states cause the individual to experience symptoms of both depression and mania or hypomania at the same time. This can be very distressing and often dangerous. It can be more difficult to figure out what you’re feeling or to manage your symptoms and get things back under control. These states can be unpredictable and can lead to people being more likely to act on suicidal thoughts and feelings.

Types of bipolar disorder

There are three main types of bipolar disorder:

• Bipolar 1: Those with bipolar 1 will have experienced at least one manic episode which lasted longer than a week. They may have also have experienced depressive episodes, although this is not required for the diagnosis.
• Bipolar 2: Those with bipolar 2 will have experienced at least one episode of hypomania and one episode of depression.
• Cyclothymia: Those with cyclothymia will have experienced both hypomania and depression but the symptoms are not severe enough to meet a bipolar 2 diagnosis.

Someone who has the symptoms of bipolar disorder but does meet the criteria for one of these three diagnoses, might be diagnosed with bipolar disorder ‘not otherwise specified’.

You might also hear about rapid cycling, although this is not a separate diagnosis of bipolar disorder. Rapid cycling simply means that the mood changes happen more quickly. While typical mood episodes will last days or weeks at a time, someone who experiences rapid cycling may find their mood shifting within the same day or hour. An individual may be classed as experiencing rapid cycling if they experience four or more bipolar mood changes within a year.

Bipolar and OCD comorbidity: differences and similarities

Similarities

Both disorders are life long and require active management to keep symptoms under control. Likewise, both disorders have symptoms which can make life very challenging and which can interrupt regular functioning.

There are a number of symptoms which display similarities between the two disorders:

• Intrusive thoughts and obsessional thinking

  As we mentioned earlier, we all experience intrusive thoughts. However, those with bipolar and OCD find these thoughts more distressing than those without the disorders. For someone with OCD, their intrusive thoughts become obsessions. For someone with bipolar disorder, they may experience a range of intrusive thoughts relating to self harm and suicide, or something they are worried about. This is more likely when they are in a depressed mood state. In both disorders these intrusive thoughts are distressing, unwanted, and persistent.

  In fact, someone with bipolar disorder may also experience obsessional thinking, wherein their intrusive thoughts or even a random everyday topic becomes stuck in their mind, playing over and over again. The magazine BPHope explains that a fifth of people who are bipolar experience some form of obsessional thinking.

• Rumination

  Rumination refers to excessively focusing on a negative thought or concern. This study on the topic of rumination and bipolar describes rumination as, “responding to negative affect or depressed mood by focusing on self and symptoms of distress, without actively engaging in active problem solving.” The study also explains that rumination is common in those with bipolar disorder, especially during depressive episodes. Interestingly, during manic or hypomanic states bipolar patients tend to ruminate on positive thoughts.

  Similarly, rumination is a driving factor in the cycle of OCD. Ruminating on obsessions makes them stronger and more distressing. Many people with OCD spend a great deal of time ruminating on their obsessions to figure out whether they’re ‘true’ or ‘untrue’, and attempting to understand them. Sometimes compulsions will center around rumination, such as repetitively checking or going over their thoughts.

• Anxiety

  Of course anxiety is a significant symptom in OCD, as this is one of the main symptoms which drives the OCD cycle. However, it’s also common to experience symptoms of anxiety with bipolar disorder. When anxiety symptoms become more pronounced in a bipolar patient, this is when a separate diagnosis of an anxiety disorder tends to be explored.

• Depression and hopelessness

  We’ve mentioned that for those with bipolar disorder depressive episodes play a major part in the disorder. People with OCD also often find themselves with a low mood, sometimes sinking into depression as a result of the effect their OCD symptoms have had on their life.

  Both disorders are incredibly hard to live with and often knowing that they are life long can make you lose hope for the future. A sense of hopelessness is a symptom often experienced in both disorders. Depression and lack of hope means that both disorders can put sufferers at higher risk of suicide.

• Social withdrawal

  During a depressive episode it’s common for those with bipolar to withdraw socially. Likewise, someone with OCD is likely to avoid social interaction. This may be because they fear being out socially will trigger their obsessions. It may also be that their time is so overtaken by compulsions that they don’t have the time to be social. It’s also possible that the depression experienced by someone with OCD could lead to them withdrawing from loved ones.

Differences

Despite their similarities both disorders are distinctly different in many ways. The main differences between the two include:

• Different mood states

  Although someone with OCD may experience general changes in their mood and struggle with depression, they do not experience the significant and severe changes in mood states which occur with bipolar disorder. An individual with OCD doesn’t experience mania, hypomania, or mixed states.

• Psychosis

  While someone with OCD could experience psychosis, this isn’t a symptom of OCD as it can be with bipolar disorder. Psychosis is noted as a symptom of bipolar disorder, in particular bipolar type 1. If someone with OCD was to experience psychosis, this would be a separate issue than their OCD.

• Obsessions and compulsions

  Someone with bipolar disorder might experience obsessive thinking and intrusive thoughts, but they do not experience the obsessions and compulsions which are a hallmark of OCD. An individual with OCD experiences a vicious cycle of obsessions and compulsions which are not a symptom of any other mental illness.

The impact of living with both disorders

How OCD can impact bipolar symptoms

Having OCD along with bipolar disorder can impact the severity of bipolar symptoms. Since depression is also common with OCD, and of course since living with two disorders at once becomes even more challenging, bipolar depressive symptoms can increase. As OCD is an anxiety based disorder, the anxiety which usually comes with bipolar disorder can be markedly worsened

The obsessional thinking and rumination we mentioned earlier which occur as a result of bipolar disorder can be worsened by the obsessions experienced with OCD. This can also contribute to more self-doubt and reduced confidence in general. We know that stress can be a trigger for mood changes for someone with bipolar disorder. Since living with OCD is inherently stressful, this can trigger more frequent and severe changes in mood states. This article explains that someone with both disorders will experience, “more chronic depressive and manic episodes and residual mood symptoms than people with just bipolar disorder.”

It’s important to note that a vital part of managing bipolar symptoms is being self aware so that you can identify triggers, as well as notice mood changes early on and deal with them as effectively as possible. Research suggests that having both disorders can cause less insight and self awareness of bipolar symptoms, actively making the disorder harder to manage. This article from Psychiatry Advisor states: “Patients who suffered from both disorders had poorer insight, experienced more frequent sensory phenomena, and had greater severity of anxiety and depressive symptoms.”Overall, OCD can make it much more difficult to keep bipolar symptoms managed and your mood stable.

How bipolar disorder can impact OCD symptoms

Having bipolar disorder can worsen OCD symptoms and interestingly, also change obsessions and compulsions in some ways. Bipolar depression can understandably worsen the depression and hopelessness that often accompanies OCD. Likewise, having bipolar disorder can increase anxiety levels. For someone with OCD, an increase in anxiety can lead to increased prevalence of obsessions and increased need to carry out compulsions. This can significantly worsen OCD symptoms and result in compulsions taking even more time out of the day.

These worsening OCD symptoms can lead to further problems with functioning, potentially leading to issues with work, social engagements, self-care, and other daily commitments. Social withdrawal may increase, causing isolation and further perpetuating depression. The combination, if left untreated, can be debilitating.

Interestingly, research suggests that someone with both disorders is more likely to experience obsessions and compulsions related to sexual or religious themes. They are also likely to experience lower rates of checking compulsions than someone who only has OCD. James Phelps, MD states that studies show that the majority of the time, “OCD symptoms worsen during depression and improve during mania.” So when the individual is in a bipolar depressive episode, their OCD symptoms are likely to be much worse. When their mood is stable and bipolar symptoms are under control, their OCD symptoms will still be present. When they are experiencing hypomania or mania, their OCD symptoms are likely to be less severe.

Increased risk

Having both disorders greatly increases a patient’s risk of engaging in harmful behaviours, such as acting in a way which is out of character and may put their safety in jeopardy. There is a significantly increased risk of patients abusing alcohol or drugs if they have both bipolar disorder and OCD. Those who do abuse these substances tend to do so more frequently and to more dangerous extents.

Patients with both disorders report an increased occurrence of self harm, along with suicidal feelings and ideation. They are also far more likely to actively plan and attempt suicide. Due to these high risk factors, it’s important that someone with both disorders seeks treatment and is treated with specific strategies to help them cope and reduce their risk.

Potential other comorbidities

Research shows that individuals with both OCD and bipolar disorder also have very high rates of other mental illnesses. However, the reason for this prevalence in comorbidities is not fully understood. In particular, they are more likely to develop other anxiety disorders. This includes disorders like generalized anxiety disorder, panic disorder, agoraphobia, social anxiety, and other phobias. They are also more likely to develop disorders which center around issues with impulse control.

This article explains that findings show people with disorders, “were more likely to have eating disorders; impulse control disorders such as pathologic gambling, compulsive buying, compulsive sexual disorder, and skin picking; alcohol abuse and dependence; body dysmorphic disorder; and attention-deficit/hyperactivity disorder.”

What causes the link?

Genetics

Scientists have not been able to pinpoint one specific gene which causes the link between bipolar disorder and OCD. However, they have been able to identify a number of genes which are shared by both disorders. This means that your genes could make you predisposed to developing both OCD and bipolar disorder.

Family history

Research has shown that family history can play a part in making an individual more likely to develop bipolar disorder or OCD. If you have a relative who has one of the disorders, you may be more likely to develop it in later life. This is similar for the co-occurrence of both disorders, although interestingly it’s been shown if you have both disorders you’re more likely to have a family member with a mood disorder. This article explains: “Combination bipolar disorder–OCD patients are more likely to have a family history of mood disorders and less likely to have a family history of OCD.”

Intrusive thoughts and obsessive thinking

As we mentioned earlier, both disorders have a focus on intrusive thoughts and some form of obsessive thinking. It may be that personality traits or specific genes which lead to the development of these patterns of thinking, contribute to the link between the two disorders.

Anxiety

Likewise both disorders feature symptoms of anxiety, as well as a tendency to develop other comorbid anxiety disorders. It’s possible that there are personality traits or a genetic predisposition for anxiety in people who develop both disorders.

Poor verbal memory

Some research has demonstrated that patients with both disorders display a decrease in some types of verbal memory. Verbal memory refers to the ability to read or hear information and be able to recall it and use it at a later date. Essentially any memory processes related to words and language could be categorized as verbal memory.

There are different types of verbal memory. In particular, patients with both disorders have shown poor long-delayed free recall. This means that they struggle to recall words or phrases they have been given, after a longer period of time has passed. This study on the topic discovered: “Compared with control subjects, both BP-I and OCD participants showed impaired performance in long-delayed free recall and verbal organization strategies during learning.” These results suggest that it’s possible that neural mechanisms controlling this area of memory and free recall, could also be implicated in the co-occurrence of bipolar disorder and OCD.

Diagnosis

Potential misdiagnosis

As the two conditions can occur together and have many overlapping symptoms, there is a fairly high potential for misdiagnosis. The wrong mental health diagnosis and the wrong treatment can be harmful and worsen your mental health. If you feel that you have been misdiagnosed or that you haven’t been assessed properly, you have the right to advocate for yourself. A thorough, long term psychological assessment by a qualified mental health professional should help to give you the correct diagnoses.

You can advocate for yourself by keeping a clear note of your symptoms to help your doctor get a clearer picture of what you’re going through. You can do research to get as informed as possible. You can be clear, calm, and persistent in asking questions which are worrying you and in putting across your point of view. Ensure that you have been referred to a mental health professional for a proper evaluation: if not, it’s worth advocating for this. You may also be able to access a patient advocate through a mental health charity: you can do an internet search to find out what might be available near you.

The diagnostic process

Once you have been referred to see a mental health professional, they will carry out an in depth evaluation. This will initially involve talking to you about what you’ve been experiencing. It can help to take notes or a record of your symptoms with you to ensure you give your doctor as much information as possible. The more clear a picture they have, the more accurately they will be able to diagnose you.

You may be asked a range of specific questions. Some of these might seem ‘strange’ or very personal, but ensure you answer as open and honestly as possible. They’re asking you these questions to help evaluate you. If you’re unsure or uncomfortable with a question, feel free to speak up. You can always ask your own questions at any point if there’s something on your mind.

You may be asked to fill out some forms or questionnaire type documents. These ask you to rate the severity of symptoms you might be experiencing, and again, help to give the doctor more in depth information. The doctor should also conduct a physical exam and potentially some tests, such as blood tests, to help them gather more evidence.

It’s unlikely you’ll be given a definitive diagnosis after an initial appointment, especially if the symptoms you are experiencing indicate the potential that you have more than one disorder. It’s more common for the mental health doctor to keep seeing you regularly, to monitor you and see how things process. This allows them to get to know you better and to make a more informed diagnosis.

In the meantime you may be referred for psychological therapy, or potentially offered medication if they feel sure enough about your symptoms. They’ll monitor the results of these treatments to see if the outcomes line up with the diagnosis they have in mind. You might hear the term ‘working diagnosis’. This simply refers to the diagnosis they feel most consistently suits your symptoms, but they are still gathering more information before they give a definite answer. This can sound worrying but it’s actually a good thing: it means they’re taking their time to ensure they give you the right diagnosis and the right treatment.

Treatment

We’ll take a look at how each disorder is treated individually, then follow up with differences in treatment when treating both disorders at once.

Treating bipolar disorder

Once you have been diagnosed with bipolar disorder (or are given a working diagnosis of bipolar), you should regularly see a psychiatrist or another mental health professional. They should monitor your symptoms, be there to support you, and keep track of how any treatments are going so they make adjustments where necessary.

Medication

A form of medication will typically be offered to help to stabilize your moods and reduce other symptoms. Sometimes a combination of medications will be used to get the best results. Medication is very much a trial and error process to see what works for you. It’s important side effects are taken into account.

You should be monitored closely when trying out any new medication. If any side effects you’re experiencing are unmanageable, or the medication is not reducing your bipolar symptoms, after a few weeks it’s likely another medication will be tried.

A range of medications are available including:

• Antipsychotics

  A number of antipsychotics are approved for use in bipolar disorder. These medications can help to stabilize your mood and help to control any psychotic symptoms.

• Anticonvulsants

  Anticonvulsants are used to control seizures, however some are licensed to treat bipolar disorder. These medications act as mood stabilizers, helping to even out your mood.

• Antidepressants

  Antidepressants can be used to tackle depression, however they can be dangerous for someone with bipolar disorder as they can cause mania. Therefore they should only be used in conjunction with a mood stabilizer or when a specific type is known to be safe.

• Lithium

  Lithium is a mood stabilizer which can be prescribed for long term management of bipolar disorder.

Psychological therapy

Typically a psychological therapy, also known as a talking therapy, will be offered alongside medication. There are a range of therapies which may be offered depending on your needs and what’s available in your area. Some of the main therapies offered include:

• Psychoeducation

  This teaches you about bipolar disorder so that you can understand your disorder and learn to recognise triggers.

• Cognitive behavioural therapy (CBT)

  CBT focuses on helping to identify negative thought patterns and behaviours. You’ll learn to replace them with more positive, helpful thoughts and behaviours. This better equips you to deal with your symptoms and manage them effectively.

• Interpersonal therapy

  Interpersonal therapy focuses on how your disorder may impact your relationships with other people and teaches you how to strengthen these connections. The charity Mind explains that this type of therapy, “focuses on your relationships with other people and how your thoughts, feelings and behaviour are affected by your relationships, and how they affect your relationships in turn.”

• Family-focused therapy

  Family therapy helps your family members to better understand your disorder and how to help you. You’ll learn together how to manage your symptoms, improve communication, and create stronger family connections.

Crisis treatment

Since the safety of those with bipolar disorder is at risk during a severe mood state (also known as experiencing a mental health crisis), crisis treatment should be offered. You may have a phone number for a crisis team, who will evaluate you if you feel you are in crisis and offer any care you may need. If your symptoms are particularly severe, you may need to be admitted to hospital so that you can be kept safe and given the care you need until your mood is stabilized.

Treating OCD

The primary form of OCD treatment is psychological therapy to break the OCD cycle. Sometimes medication will be used alongside therapy to bring the best results for patients. If you’re under the care of a mental health professional, you should also get regular monitoring and guidance as you engage in treatment.

Medication

The primary form of medication used to treat OCD are antidepressants known as Selective Serotonin Reuptake Inhibitors (SSRIs). SSRIs help to tackle symptoms of depression as well as lessen anxiety, which can help patients with OCD. Patients with OCD are not typically prescribed medication alone: they are usually used in conjunction with psychological therapy.

Psychological therapy

Psychological therapies focus on helping to break the cycle of OCD and giving patients greater control over their emotions. A number of therapies may be used to treat OCD. Aspects of different therapies are often combined to produce the best results for the patient.

• Cognitive Behaviour Therapy (CBT)

  As we mentioned earlier, CBT teaches you to replace negative thought patterns and behaviours with positive thoughts and helpful behaviours. This helps you to gain better control over your emotions, to lessen anxiety, and to break thought patterns which perpetuate OCD.

• Exposure and Response Prevention (ERP)

  ERP is the primary therapy recommended in treating OCD. ERP is a form of CBT which helps you to face your obsessions without reacting with compulsions. This is done in a gradual, manageable way. As you see that nothing bad happened when you didn’t react with a compulsion, your anxiety will lessen and the OCD cycle will actively be broken.

• Acceptance and Commitment Therapy (ACT)

  ACT focuses on accepting your thoughts rather than trying to change them, and committing to positive, helpful behaviours. The therapy helps you to understand how your thoughts may be influencing your behaviours. For some people, ACT may be a better fit than CBT.

• Mindfulness

  Mindfulness techniques are all about being present in the moment, promoting relaxation and stress relief. This can be very beneficial in reducing anxiety for someone with OCD. Techniques may include breathing exercises, guided meditation, and guided visualization.

Treating both disorders together

When both disorders occur together, research shows that treating the bipolar disorder and getting the patient’s mood stable should be the priority. This study on the topic concluded: “When bipolar and obsessive–compulsive disorders co-exist, bipolarity should take precedence in diagnosis, course and treatment considerations.” This order of treatment is because evidence shows that treating OCD would not be successful if an individual’s bipolar disorder symptoms were not under control.

Bipolar treatment may involve medication and psychological therapy as we’ve discussed. The medication may be able to treat both conditions at once, and this is something that should be taken into account by your mental health professional. It’s also important to note that antidepressants should not be prescribed to treat the OCD if you are not already on a mood stabilizer for your bipolar disorder, or this could increase the risk of mania or hypomania. Some antidepressants are safer for use in bipolar patients and carry a low risk of mania.

Some of the psychological therapies we’ve mentioned may be able to treat both bipolar and OCD at once, such as CBT, mindfulness, and family counselling. Once the bipolar disorder is well managed, the OCD should then become a priority. The treatments we previously covered are all still valid and can be very effective in treating the disorders, even when both occur together.

Since having both disorders increases the risk of substance abuse, risky behaviours, and suicide, it’s important that patients are monitored more closely. You should have access to crisis services if they are needed, and your increased risk should be taken into account during treatment.

It’s important to remember that even though living with two mental illnesses can be very difficult, it doesn’t have to stop you from living your life. With the right treatments you can live the happy, healthy life you want.

References

Owen Kelly, PhD, (2019), “The Link Between OCD and Bipolar Disorder”. Very Well Mind.

Mind, (2018), “Bipolar disorder”.

Mind, (2020), “Psychosis”.

NHS, (2019), “Bipolar disorder”.

Robin L. Flanigan, (2020), “Bipolar Disorder and Grappling with Obsessive Thinking”. BP Hope.

Ghaznavi, S., & Deckersbach, T. (2012). “Rumination in bipolar disorder: evidence for an unquiet mind.” Biology of mood & anxiety disorders, 2, 2.

Erica Cirino, (2019), “Can You Have Bipolar Disorder and OCD?” Healthline.

Laurel Ranger, (2019), “Greater Disease Severity With Comorbid OCD, Bipolar Disorder”. Psychiatry Advisor.

James Phelps, MD, (2016), “Bipolar Plus OCD: Which to Treat First?” Psychiatric Times.

Giulio Perugi, Hagop S Akiskal, Chiara Pfanner, et al, (1997), “The clinical impact of bipolar and unipolar affective comorbidity on obsessive–compulsive disorder”. Journal of Affective Disorders

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Thilo Deckersbach, Cary R Savage, Noreen Reilly-Harrington, et al, (2004), “Episodic memory impairment in bipolar disorder and obsessive-compulsive disorder: the role of memory strategies”. Bipolar Disord. 2004 Jun;6(3):233-44.