Q:  Are My Impulses/Urges/Images More due to Bipolar or OCD?

I understand there is a relationship between Bipolar and OCD and had a question in regards to that.  I was recently diagnosed with Bipolar II, with rapid (ultradian) cycling.  I am taking 150 mg Lamictal and Ativan as needed.  2 years ago I was put on SSRI's (Zoloft and then Lexapro) for a misdiagnosed unipolar depression (with very adverse side effects that sent me into rapid cycling with hypomania).  After 6 months on Zoloft I switched to Lexapro.  About 3 months later, I started to have obsessions which consisted of images or impulses/urges that were violent, aggressive, or sexually inappropriate.  Mind you, pre-SSRI treatment, I did not have any of these thoughts!  I also get an "out of control" feeling inside my body where I feel like my body is going to do things against my will like poke myself in the eye with a pencil.  The obsessions have a cyclical quality to them like my moods, for 3 days there could be nothing, and then 1 day of obsessing, etc.  Here's where it becomes complicated: After going off Lexapro, (I was nothing like this on it) I have had a few extreme rage attacks where I scream and sob in my car, want to drive recklessly, feel like I want to run someone over, want to stab at someone or something, or just hurt myself violently in general.  I have thrown mirrors and plates to the ground to shatter them....this is completely out of character for me. My computer wouldn't work and in anger I have both the image and the urge to smash it to the ground. The more enraged I get, the more I have images of doing violent things.  I understand that in OCD, you are not in danger of acting on these urges.  However, does having obsessions in the way I experience it and Bipolar put one in greater danger of acting on the impulses, since Bipolar can include a problem of impulse control (or does it)?  I recently had a rage attack and at the same time imaged myself stabbing..instead I took a ballpoint pen and stabbed it onto my bed several times to get my rage out. ... I am wondering if the violent and aggressive or loss of control impulses/urges/images I have are more due to Bipolar or OCD?  Could they be 2 separate entities bouncing off each other, distinctly separate, or part of the same thing? Any way to tell?  They seemed to start simultaneously.

Dear Kristen --

 You have a very complicated situation, and I'll have to be careful about over-interpreting what you have written. For starters, it is important to recognize that sometimes OCD is "co-morbid" with bipolar disorder, a jargon term in my business (a rather unfortunate term) meaning that the two conditions are both present. That is the way you have been diagnosed so far, it sounds like. It is also recognized that sometimes what looks like OCD is actually part of the bipolar disorder -- the good news there is being that sometimes you just have to focus on treating the one and the other will resolve, i.e. treat the bipolar disorder and the OCD symptoms may disappear. That may not be the case for you, but if it were true, that would be nice.

I start with that thought because many of the symptoms you are describing, these episodes of intense anger and frustration and rage, could be interpreted as "manic symptoms". Neither lamotrigine (Lamictal) nor lorazepam (Ativan) is recognized as having strong anti-manic effects. So it is quite conceivable that you simply need to add a strong anti-manic agent (perhaps replacing lorazepam to keep from expanding the number of medications, as it might serve a similar function) to get the symptoms under control. They are frightening you, and therefore warrant some pretty quick action -- like calling your psychiatrist and describing them, and wondering if there might be some anti-manic treatment that could get them under control. This will probably lead to a consideration of several options such as Zyprexa, which works very fast and very strongly but can cause weight gain if used for more than a few days; and lithium, even though that idea scares a lot of people, which is unfortunate as it is one of our best options and not limited just to people with severe mania; and Seroquel, which is not as fast as Zyprexa but causes less weight gain and glucose increases, but although those still have to be monitored closely.

Therefore your concern about whether you might be in danger of acting on these urges can be made rather moot, you see: you need to treat the symptom whether or not it represents some real danger to you or not. From what you describe I cannot really comment on whether this danger is significant or not: the range of possibilities goes all the way from quite likely to very unlikely. But what matters is to focus on getting those symptoms treated, which will address the issue whether there is danger or not.

One more thought that might be relevant, and perhaps somehow useful: although most psychiatrists, in my experience talking with them, do not know this, there is a phenomenon called "antidepressant-discontinuation induced mania" (Ali 2003 review). 

I hope that proves useful.

Dr. Phelps