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Year : 2012  |  Volume : 34  |  Issue : 3  |  Page : 279-282  

Comorbid bipolar affective disorder and obsessive compulsive disorder in childhood: A case study and brief review

1 Department of Psychiatry, KPC Medical College and Hospital, Kolkata, India
2 Department of Psychiatry, Kasturba Medical College, Manipal, Karnataka, India
3 Department of Psychiatry and Head of Center for Child and Adolescent Psychiatry, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India

Date of Web Publication14-Jan-2013

Correspondence Address:
Samir Kumar Praharaj
Department of Psychiatry, Kasturba Medical College, Manipal, Karnataka - 576 104
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0253-7176.106036

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Obsessive compulsive disorder and bipolar affective disorder in the pediatric population show a bidirectional overlap. Few studies that have addressed this issue show that the prevalence of obsessive compulsive disorder in bipolar affective disorder patients ranges from 0 to 54%, and 1.85 to 36% of the obsessive compulsive disorder patients have a comorbid bipolar affective disorder. We report a case of a patient with an onset of obsessive compulsive disorder at two-and-a-half years of age, who developed mania after exposure to escitalopram. We suggest that in pediatric obsessive compulsive disorder cases, antidepressants be used with caution, especially in cases with a positive family history of bipolar affective disorder.

Keywords: Bipolar affective disorder, childhood, obsessive compulsive disorder

How to cite this article:
Jana AK, Praharaj SK, Sinha VK. Comorbid bipolar affective disorder and obsessive compulsive disorder in childhood: A case study and brief review. Indian J Psychol Med 2012;34:279-82

How to cite this URL:
Jana AK, Praharaj SK, Sinha VK. Comorbid bipolar affective disorder and obsessive compulsive disorder in childhood: A case study and brief review. Indian J Psychol Med [serial online] 2012 [cited 2020 May 29];34:279-82. Available from:

   Introduction Top

Childhood mental disorders are known for their associated comorbidities; childhood bipolar affective disorder and obsessive compulsive disorder are no different. They are marked with multiple comorbid anxiety disorders, mood disorders, and disruptive behavior disorders. It was once considered that bipolar comorbidity in obsessive compulsive disorder was rare and a systematic investigation in this area was not done until recently. [1] Even today, there is a dearth of literature in this area, when childhood population is considered. We report the case of a child presenting with obsessive compulsive disorder and bipolar disorder at a very young age. A review of the relevant literature has been undertaken, to compile the information on comorbidity of bipolar disorder and obsessive compulsive disorder in childhood. A Pubmed search was done using the keywords, 'childhood', 'adolescent', 'obsessive compulsive disorder', 'bipolar disorder', 'antidepressant-induced mania / hypomania,' and relevant articles were retrieved supplemented with a manual search of cross-references.

   Case Report Top

The index patient, a four-year-old male, from a rural background of eastern India, presented with irritability for 18 months. He would frequently gesticulate as if he was brushing something off his clothes. He would say, "chhiya gaya hai" (local dialect of Hindi, meaning: "there's filth on my clothes and body") whenever someone would touch him and would be irritated. In the seven months prior to presentation he used to urge his family members to wash his dresses with detergent repeatedly. After being touched by someone he would insist on getting bathed, using an unusually excessive amount of water, and taking a long time before he would let the attendant take him out of the bathroom. He would also repeatedly touch the private parts of the female members of the family. Another noted feature was his habit of repeatedly hitting himself or biting his body parts. On asking about these he would not provide any explanation, but would say that he did not like doing these. There was a family history of bipolar disorder in the maternal grandfather. However, the birth, prenatal, postnatal, and developmental history was unremarkable. When admitted in hospital, there were few occasions of tearfulness. He would often demand that the bed sheets and linens be washed several times a day, as they were not satisfactorily clean. The self-injurious behaviors also continued. Entertaining a diagnosis of obsessive compulsive disorder he was started on escitalopram 5 mg per day and behavioral intervention was done for the self-injurious behaviors. He showed improvement in his overall condition and was discharged on that regime. At follow-up after four months, he showed increased goal-directed behaviors, an unusual cheerful mood, and the parents reported increased socialization. The diagnosis of obsessive compulsive disorder with mania was made; he was re-admitted, escitalopram was stopped and tablet lithium 600 mg per day was started, and was increased to 750 mg (serum level 0.92 mmol / l) along with tablet risperidone 1 mg per day. On this regime the manic symptoms improved significantly. Risperidone was reduced to 0.5 mg for increased sedation. He was discharged on lithium 750 mg and risperidone 0.5 mg per day.

   Discussion Top

Childhood bipolar affective disorder is different from the adult counterpart for its different clinical presentation (protracted irritability with frequent violent outbursts, confusing the picture with disruptive behavior disorder) and course (chronic and continuous rather than acute and episodic). It is also marked with frequent comorbidities and anxiety disorders, it often shows a bidirectional overlap. [2] There have been few studies investigating the comorbidities of anxiety disorder in childhood and adolescent bipolar disorder, which are summarized in [Table 1]. [1],[3],[4],[5],[6],[7],[8] These studies show that the prevalence of obsessive compulsive disorder in bipolar affective disorder cohorts, range from 0 to 54%. Among other comorbidities, separation anxiety disorder, generalized anxiety disorder, and attention deficit/hyperactivity disorder figure, prominently. However, most of the studies were flawed by the selection and referral bias and the recall bias of patients and their guardians. Also, there have been studies in pediatric obsessive compulsive disorder patients, where comorbid bipolar disorder has been assessed, which are summarized in [Table 2]. [9],[10],[11],[12],[13],[14] Among the primary obsessive compulsive disorder cases, bipolarity has been seen in 1.85 - 36% of the patients, and in those patients, the overall severity is higher, they respond poorly to medications, and in them, the age of onset of obsessive compulsive disorder is earlier than in the cases of pure obsessive compulsive disorder patients.{Table 1}{Table 2}

Antidepressant-induced manic / hypomanic switches in primary obsessive compulsive disorder cases have been very rare, especially in the pediatric population. [15],[16] The selective serotonin reuptake inhibitors (SSRIs) impose a lower risk in inducing a manic / hypomanic switch, compared to other antidepressants. [17] Cyclothymic and episodic variants of obsessive compulsive disorder have been described in adults, which are pointers toward latent bipolarity. [18],[19],[20],[21] However, there has been no study addressing these issues in children or in the adolescent population. In our case the age of onset of obsessive compulsive disorder was two-and-a-half years. To the best of the authors' knowledge this is one of the youngest patients with obsessive compulsive disorder ever reported. He also developed mania around four months after exposure to escitalopram. A positive family history of bipolar disorder has been seen in our case, which might have paved the way for the onset of bipolarity in this case of a child who initially presented with obsessive compulsive disorder.

Bipolar affective disorder and obsessive compulsive disorder comorbidity is not uncommon in children or the adolescent population, although studies addressing this issue have been scarce. In our opinion, an index of suspicion for bipolarity is always required in childhood obsessive compulsive disorder cases with a family history of bipolar disorder, and the use of antidepressants in these cases has to be judicious.

   References Top

1.Masi G, Perugi G, Toni C, Millepiedi S, Mucci M, Bertini N, et al. Obsessive-compulsive bipolar comorbidity: Focus on children and adolescents. J Affect Disord 2004;78:175-83.  Back to cited text no. 1
2.Biederman J. Early-onset bipolar disorders. In: Sadock BJ, Sadock VA, editors. Comprehensive Textbook of Psychiatry. Philadelphia: Lipincott Williams & Wilkins; 2005.p. 3274-9.  Back to cited text no. 2
3.Lewinsohn PM, Klein DN, Seeley JR. Bipolar disorders in a community sample of older adolescents: Prevalence, phenomenology, comorbidity, and course. J Am Acad Child Adolesc Psychiatry 1995;34:454-63.  Back to cited text no. 3
4.Masi G, Toni C, Perugi G, Mucci M, Millepiedi S, Akiskal HS. Anxiety disorders in children and adolescents with bipolar disorder: A neglected comorbidity. Can J Psychiatry 2001;46:797-802.  Back to cited text no. 4
5.Tillman R, Geller B, Bolhofner K, Craney JL, Williams M, Zimerman B. Ages of onset and rates of syndromal and subsyndromal comorbid DSM-IV diagnoses in a prepubertal and early adolescent bipolar disorder phenotype. J Am Acad Child Adolesc Psychiatry 2003;42:1486-93.  Back to cited text no. 5
6.Masi G, Toni C, Perugi G, Travierso MC, Millepiedi S, Mucci M, et al. Externalizing disorders in consecutively referred children and adolescents with bipolar disorder. Compr Psychiatry 2003;44:184-9.  Back to cited text no. 6
7.Masi G, Perugi G, Toni C, Millepiedi S, Mucci M, Bertini N, et al. Attention-deficit hyperactivity disorder - bipolar comorbidity in children and adolescents. Bipolar Disord 2006;8:373-81.  Back to cited text no. 7
8.Masi G, Perugi G, Toni C, Millepiedi S, Mucci M, Bertini N, et al. The clinical phenotypes of juvenile bipolar disorder: toward a validation of the episodic-chronic-distinction. Biol Psychiatry 2006;59:603-10.  Back to cited text no. 8
9.Leonard HL, Swedo SE, Lenane MC, Rettew DC, Hamburger SD, Bartko JJ, et al. A 2- to 7-year follow-up study of 54 obsessive-compulsive children and adolescents. Arch Gen Psychiatry 1993;50:429-39.  Back to cited text no. 9
10.Geller DA, Biederman J, Griffin S, Jones J, Lefkowitz TR. Comorbidity of juvenile obsessive-compulsive disorder with disruptive behavior disorders. J Am Acad Child Adolesc Psychiatry 1996;35:1637-46.  Back to cited text no. 10
11.Reddy YC, Reddy PS, Srinath S, Khanna S, Sheshadri SP, Girimaji SC. Comorbidity in juvenile obsessive-compulsive disorder: A report from India. Can J Psychiatry 2000;45:274-8.  Back to cited text no. 11
12.Masi G, Millepiedi S, Mucci M, Bertini N, Milantoni L, Arcangeli F. A naturalistic study of referred children and adolescents with obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry 2005;44:673-81.  Back to cited text no. 12
13.Masi G, Millepiedi S, Mucci M, Bertini N, Pfanner C, Arcangeli F. Comorbidity of obsessive-compulsive disorder and attention-deficit / hyperactivity disorder in referred children and adolescents. Compr Psychiatry 2006;47:42-7.  Back to cited text no. 13
14.Masi G, Perugi G, Millepiedi S, Toni C, Mucci M, Pfanner C, et al. Bipolar co-morbidity in pediatric obsessive-compulsive disorder: Clinical and treatment implications. J Child Adolesc Psychopharmacol 2007;17:475-86.  Back to cited text no. 14
15.Go FS, Malley EE, Birmaher B, Rosenberg DR. Manic behaviors associated with fluoxetine in three 12- to 18-year-olds with obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 1998;8:73-80.  Back to cited text no. 15
16.Diler RS, Avci A. SSRI-induced mania in obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry 1999;38:6-7.  Back to cited text no. 16
17.Gijsman HJ, Geddes JR, Rendell JM, Nolen WA, Goodwin GM. Antidepressants for bipolar depression: A systematic review of randomized, controlled trials. Am J Psychiatry 2004;161:1537-47.  Back to cited text no. 17
18.Goodwin DW, Guze SB, Robins E. Follow-up studies in obsessional neurosis. Arch Gen Psychiatry 1969;20:182-7.  Back to cited text no. 18
19.Perugi G, Akiskal HS, Gemignani A, Pfanner C, Presta S, Milanfranchi A, et al. Episodic course in obsessive-compulsive disorder. Eur Arch Psychiatry Clin Neurosci 1998;248:240-4.  Back to cited text no. 19
20.Swartz CM, Shen WW. Is episodic obsessive compulsive disorder bipolar? A report of four cases. J Affect Disord 1999;56:61-6.  Back to cited text no. 20
21.Hantouche EG, Angst J, Demonfaucon C, Perugi G, Lancrenon S, Akiskal HS. Cyclothymic OCD: A distinct form? J Affect Disord  Back to cited text no. 21

This article has been cited by
1 Comorbidity in pediatric bipolar disorder: Prevalence, clinical impact, etiology and treatment
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[Pubmed] | [DOI]


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