Husband-BP or OCD?
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Husband's diagnosis: OCD or BP? (Laura)

Q: This question is regarding my husband. he has always battled with ups, downs, anxiety, etc. he currently has a dx of ocd,
gad and depression. he has taken 2 antidepressants, that are doing nothing except he says making him more anxious. our 8 year
old daughter was just dxd as bp recently and i have done very extensive research. i have has my husband read alot about bp
and he agrees very much that alot of what he is reading sounds like him. he mentioned this to his psych but he kind of blew him
off. he gets very odd, violent thoughts ,which is attributed to his ocd, but i have also read that some bp people also have these
thoughts. how can we be sure and how can we get his dr to listen to us. thank you, laura

Dear Laura -- 
First, there is clearly a relationship between "OCD" and bipolar that goes beyond their occurrence together more than OCD
occurs alone in the general population (i.e. it is estimated at 3% in the population, but occurs -- or something that "looks" like
OCD, exactly as you describe -- at a higher rate in people with bipolar disorder; I've not seen a number recently but would
guess more like 6-10%). So, firstly, it should not be a mystery to us to see "OCD" and bipolar together.

However, secondly, I have seen this "mistaking" bipolar for OCD all the time. "Mistaking" is much too strong a word because
these symptoms are complex and subtle and how one sees them depends a lot on one's prior orientation: if from experience is
one looking for bipolar, one can certainly "see" more that way, because one looks very closely for clues to support it. I admit
to that bias but defend it: heck, bipolar is one of the most treatable diagnoses out there; it has one of the best prognoses,
perhaps especially if caught early; it can get worse if mistaken for something that is treated with antidepressants (read: anxiety,
OCD, depression); and the risks of the medications for bipolar if used properly are not a great deal higher than the risks of
antidepressant medications (especially if you count sexual dysfunction!). 

So much for that rant. Third: I have seen at least 2 patients where OCD was absolutely and classically present, yet later
"metamorphosed" into clear-cut, rapid-cycling bipolar with hypomania even my reluctant colleagues would call manic
symptoms. So there may be some way that OCD can change over time. The "bottom line" of all this is that the diagnostic
distinction between OCD and bipolar is not at all clear. 

And now for what this all means: your husband has something that sounds pretty symptomatic. If it gets better on treatment for
OCD, fine. There is unfortunately no way to "be sure" about the diagnosis, so eventually it comes down to treatment. If
something works, great (and it doesn't necessarily "prove" the diagnosis for which that's the usual treatment either; there are
other ways to explain these results -- so no gloating, is the point). If treatment is not working, we doc's are taught to
re-examine the diagnosis as the first step in deciding what to do next. Maybe his doc hasn't reached that point yet. 

You could even try referring his doc' to my website to see for himself what you and your husband are reading and finding
convincing. Sometimes this has to be done very respectfully and gently and supportively (hint hint); it's hard to know what kind
of pressures this doc' is operating under, but they could be massive and mean he has little time for dealing with people's
impressions of their diagnosis -- even though you may be very right. 

Dr. Phelps 

Published October, 2000

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