Q:  Bipolar Disorder or Depression with OCD Features?

Dear Dr. Phelps,
 
Since I've been 18 years old, my emotional state has been a turbulent roller-coaster with many highs and lows. Last year, just before I turned 31 years old (I am now 32) I was diagnosed with bipolar II depression, albeit without hypomania. I was taking effexor sr 75mg at the time, and though I generally felt well, there were some symptoms not going away. (i.e. tendency to talk fast, flight of ideas, anxiety) 
 
The doctor at the time added risperdal, 1.0-1.5 mg/day, and the results were AWFUL. I have never felt so terrible in my life! The feeling was that the antidepressants on their own might be inducing hypomania, but after a month on risperdal, I felt extremely depressed, suffered from crying spells, and protracted severe anxiety. I even tried increasing my AD to 225 mg/day, but still felt depressed while on the risperdal.
 
I have since discontinued the risperdal, (based on the advice of a psychiatrist) and tapered my effexor xr from 225 mg to 150 mg. I feel a lot better than when I was on the risperdal (no crying spells, less anxiety, more optimistic outlook) but still do not feel totally right. I sleep in way too much, and feel somewhat irritable. That said, the situation is better than when I was on risperdal.
 
I should note, also, that one of my most disturbing symptoms has been obsessive thoughts that do not go away. (My most recent diagnosis is for OCD). Before I was ever prescribed ADs, I would ruminate over the same thoughts endlessly and resist compulsions. (i.e. I was convinced that I had to call certain girls during my early 20s and couldn't let go of the thoughts) I also went on a trip back when I was 17 to visit the Nazi concentration camps to commemorate the holocaust and obsessed on end that I had PTSD. (i have been told by numerous psychiatrists that while I might have had a mild transient PTSD, that I do not suffer from a chronic form of the disorder)
 
Based on what I have told you (and I know it's a lot) should I speak to a doctor about adding a mood stabilizer such as Lamictal? Does my description of symptoms sound like a mild bipolar disorder or more likely depression with OCD features? 
 
I should note, too, that I am currently undergoing CBT therapy with modest to somewhat impressive results.

Please advise. I appreciate your help.
 
Warm regards,
 
 
PS- I am an aspiring lawyer- I have completed my articling ( a 10 month internship required to be called to the bar in Ontario, Canada) and must now successfully complete my bar exams. (which I failed previously in part due to my psychological status)

 

Dear Mr. R. --

First of all, I appreciate the confidence placed in me to be invited to to address this question. As you can probably imagine, especially with your legal training, it would be inappropriate for me to offer a diagnosis, or even come close to that, in this setting and based on limited information. But I can translate your query into some more fundamental questions as follows.

Does an experience like the one that you had on risperidone (Risperdal) increase the likelihood of a bipolar component such as that treatment with something like lamotrigine (Lamictal) might turn out to be useful? Well, the experience you describe is not common. I have seen risperidone make people with bipolar disorder worse, in ways that might be somewhat similar: I have seen it induce hypomania and mixed states and for these reasons I generally mistrust it as a mood stabilizer (although most of the rest of the "mood stabilizers" has a case report or two describing hypomania, I have seen this kind of reaction much more commonly with risperidone; I think it is far more likely to do this than the rest). Your symptoms could be construed as a "mixed state".

As you may have learned, there is some controversy about the diagnosis of OCD relative to bipolar disorder. Bipolar disorder can certainly produce "obsessive thoughts". Indeed, this is really very common. Many of my patients describe getting ideas stuck in their head that they cannot get rid of. They are unable to focus on anything else. The idea can be relatively innocent, or very troubling -- but either way, the persistence of that thought and the inability to use one's brain as a result, it is extremely frustrating (to put it mildly). 

So simply having a particular ideas stuck in your head is certainly not necessarily "OCD". One of my patients even described getting stuck like this with a certain advertising jingle. And that illustrates the second point here, which is that OCD tends to have some very characteristic obsessions: fear of contamination; fear that something important has not been done correctly, such as locking the door or some other issue regarding safety (e.g. turning off the stove, or the hairdryer); excessive concerns about symmetry, either in the world or in one's body, or even in numbers. Here is a fact sheet from the Association for Behavioral and Cognitive Therapies (ABCT; formerly the American Association of Behavior Therapy, AABT) in which you will see that same idea. In my opinion, having to call a certain girl is not at all characteristic of OCD, and is much more characteristic of the kinds of things I hear from my patients with bipolar disorder.  However, you could easily find an OCD specialist who would disagree with that. 

Either way, cognitive therapy could be useful, although difficult (difficult because, very much as in OCD, the relentless thoughts in bipolar manic states -- which can include mixed states with significant dysphoria -- are not going to stop me when one handles them using a particular cognitive technique.  Instead, one would have to keep using that technique over and over again, although this is supposed to end up being preferable to just going with the thought, which in OCD can lead to ritual compulsions, and in bipolar disorder, to increasing personal distress (e.g. when the thought is a highly negative one, about oneself, which is unfortunately quite common, indeed almost typical.)

I hope that much might be of some use to you.  It certainly would not be unreasonable to discuss this with your psychiatrist.

Dr. Phelps