Treat the disease not the symptoms: Successful management of obsessive compulsive disorder in bipolar disorder with aripiprazole augmentation

To the Editor

Obsessive compulsive disorder (OCD) whether preceding or occurring during the course of bipolar disorder (BD) remains a matter of nosological and clinical confusion (Amerio et al., 2014a). Treatment is clinically challenging as antidepressants often cause mood switch. Current research evidence recommends optimal mood stabilization as primary aim (Amerio et al., 2014b).

The patient is a 30-year-old unmarried unemployed male whose symptoms started 4 years ago. He had obsessive pathological doubt resulting in walking cautiously out of fear of hurting some animal or insect. He would scan the road thoroughly and take a long time to reach his destination. There were symptoms of low mood, decreased interest and decreased drive. He presented after 4 months and was prescribed fluoxetine 100 mg. Minimal response prompted a trial of clomipramine. Within 3 weeks of treatment with clomipramine 100 mg, he had elated mood, became abusive and claimed to be of exalted birth. He showed adequate response to lithium 900 mg and clonazepam 2 mg and remained well for the next 2 years.

He again presented with obsessions of contamination and dusting and wiping compulsions of 2 months duration. Obsessions of pathological doubt forced him to check and recheck his activities for perfection and completeness. He had problems in activities of daily living. He met the diagnostic criteria of OCD as per Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) and his Yale–Brown Obsessive Compulsive Scale (YBOCS) score was 29.5. He also had a depressed mood and lack of interest and reduction in his interests and drives. His lithium dose was increased to 1200 mg/day which brought the serum levels to 0.89 mmol/L. Minimal improvement prompted the addition of 10 mg aripiprazole, which gradually increased to 20 mg/day. His obsessive compulsive (OC) symptoms resolved with his YBOCS score dropping to 8. He remained in remission for the next 6 months.

This case supports the view that symptoms of OCD are secondary to mood dysregulation in BD. The initial appearance of OC symptoms were working as a protective shell preventing the appearance of BD (Tonna et al., 2015). Clomipramine caused a manic switch which supports the bipolar nature of his illness. Episodes of OCD during the depressive phase and resolution on adequate mood stabilization add to the proposition.

Antiobsessional and mood stabilizing properties of aripiprazole resulted in improvement without a manic switch. This case further supports the contention that aim of treatment of OCD in BD should be disease management rather than symptom alleviation.