Copyright ª Blackwell Munksgaard 2007

Bipolar Disorders 2007: 9: 722–729 BIPOLAR DISORDERS

Original Article

Bipolar obsessive-compulsive disorder and

personality disorders
Maina G, Albert U, Pessina E, Bogetto F. Bipolar obsessive-compulsive Giuseppe Maina, Umberto Albert,
disorder and personality disorders. Enrico Pessina and Filippo Bogetto
Bipolar Disord 2007: 9: 722–729. ª Blackwell Munksgaard, 2007
Department of Neuroscience, Anxiety and Mood
Disorders Unit, University of Turin, Turin, Italy
Objectives: Relatively few systematic data exist on the clinical impact
of bipolar comorbidity in obsessive-compulsive disorder (OCD) and no
studies have investigated the influence of such a comorbidity on the
prevalence and pattern of Axis II comorbidity. The aim of the present
study was to explore the comorbidity of personality disorders in a group
of patients with OCD and comorbid bipolar disorder (BD).

Methods: The sample consisted of 204 subjects with a principal

diagnosis of OCD (DSM-IV) and a Yale-Brown Obsessive-Compulsive
Scale (Y-BOCS) score ‡16 recruited from all patients consecutively
referred to the Anxiety and Mood Disorders Unit, Department of
Neuroscience, University of Turin over a period of 5 years (January
1998–December 2002). Diagnostic evaluation and Axis I comorbidities
were collected by means of the Structured Clinical Interview for DSM-IV
Axis I Disorders (SCID-I). Personality status was assessed by using the
Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II).
Socio-demographic and clinical features (including Axis II
comorbidities) were compared between OCD patients with and without a
lifetime comorbidity of BD.

Results: A total of 21 patients with OCD (10.3%) met DSM-IV criteria

for a lifetime BD diagnosis: 4 (2.0%) with BD type I and 17 (8.3%) with
BD type II. Those without a BD diagnosis showed significantly higher
rates of male gender, sexual and hoarding obsessions, repeating Key words: bipolar disorder – comorbidity –
compulsions and lifetime comorbid substance use disorders, when obsessive-compulsive disorder – personality
compared with patients with BD/OCD. With regard to personality disorders
disorders, those with BD/OCD showed higher prevalence rates of Cluster
A (42.9% versus 21.3%; p ¼ 0.027) and Cluster B (57.1% versus 29.0%; Received 13 March 2005, revised and accepted for
p ¼ 0.009) personality disorders. Narcissistic and antisocial personality publication 31 October 2006
disorders were more frequent in BD/OCD.
Corresponding author: Prof. Giuseppe Maina,
Conclusions: Our results point towards clinically relevant effects of Department of Neurosciences, Anxiety and Mood
comorbid BD on the personality profiles of OCD patients, with higher Disorders Unit, University of Turin, Via Cherasco
rates of narcissistic and antisocial personality disorders in BD/OCD 11, 10126 Turin, Italy. Fax: + 39 011 673473;
patients. e-mail: [email protected]

Clinical and epidemiological studies in recent years between 3.2% and 35%, depending on the charac-
have suggested that comorbidity between obsessive- teristics of subjects included (with or without
compulsive disorder (OCD) and bipolar disorder psychotic features, BD type I or II or mixed
(BD) is highly prevalent. In BD patients, the lifetime samples) (1–13). Conversely, the rate of lifetime
rates of comorbid OCD have been reported to range comorbid BD in clinical samples of OCD patients
ranges between 3.8% and 21.5%, with a higher
The authors of this paper do not have any commercial associations prevalence of BD type II (7.8–17.7%) (14–22).
that might pose a conflict of interest in connection with this manu- When bipolar comorbidity was dimensionally ex-
script. plored by using soft bipolar spectrum criteria, rates

722
 Bipolar OCD and personality disorders

increased to 30% for lifetime hypomanic episodes Disorders Unit, Department of Neuroscience, Uni-
and almost 50% for cyclothymic traits (21). versity of Turin (Italy) over a period of five years
Epidemiological studies in the community have (January 1998–December 2002). This is a tertiary
confirmed the existence of a significant comorbidity referral center mainly for patients from the
between OCD and BD, suggesting that high rates Piedmont and Aosta’s Valley regions of Italy,
found in clinical samples are not simply a result of located within the University General Hospital.
clinical center bias. In the Epidemiologic Catch- Patients are referred by general practitioners or
ment Area (ECA) Study, the lifetime rate of OCD psychiatrists due to an anxiety or mood disorder
among patients with BD was 21% (23). A commu- diagnosis (or hypothesized diagnosis), although a
nity survey conducted in Italy found a lifetime rate few are self-referred (through information received
of 3.6% for manic, hypomanic or mixed episodes from other patients). Each referred patient is seen in
among patients with a principal diagnosis of OCD, the outpatient service, and, if necessary, a decision
and a lifetime rate of 11.1% for OCD among is then made regarding admission to the general
subjects with a principal diagnosis of BD (24). psychiatry inpatient unit. If a patient is judged to
When using a wider concept of the bipolar spec- have a principal diagnosis other than anxiety and/
trum in epidemiological studies (25), lifetime co- or mood disorders, he or she is referred to another
morbidity rates increased significantly: 53.3% of unit within the same general hospital.
OCD cases manifested some hypomanic symptoms Inclusion criteria were: principal diagnosis of
and 30% qualified for BD type II diagnoses (26). OCD according to DSM-IV criteria and a
The clinical impact of BD/OCD comorbidity has minimum total score of 16 on the Yale-Brown
only recently been investigated. Bipolar disorder Obsessive-Compulsive Scale (Y-BOCS) (34–35).
patients with comorbid OCD are more frequently Furthermore, patients had to be at least 18 years
males, more often suffer from a comorbid panic of age and willing to voluntarily participate in
disorder, have more suicidal attempts or ideation, the study. Informed consent from patients was
and spend less time in euthymia than BD patients obtained after the procedure had been fully
without such comorbidities (8, 13, 23). Subjects explained.
with OCD and comorbid BD more frequently Exclusion criteria were a current or previous
report sexual, religious, aggressive and impulsive diagnosis of organic mental disorder, schizophre-
obsessions and checking, ordering and hoarding nia, schizophreniform or other psychotic disorder,
compulsions, compared to patients without such a or an uncontrolled or serious medical condition.
comorbidity; have an earlier age at onset (even in
prepubertal age), tend to show a gradual onset
Diagnostic and symptomatological evaluation
and have an episodic course of OCD; have more
suicide attempts and more hospitalizations; and A systematic face-to-face interview that consisted
show higher rates of panic disorder/agoraphobia, of structured and semi-structured components was
substance use disorders and, in children and used to collect data. Diagnostic evaluation and
adolescents, conduct disorders and attention-defi- Axis I comorbidities were recorded by means of the
cit hyperactivity disorder (16, 22, 27–29). Structured Clinical Interview for DSM-IV Axis I
Although comorbidity between personality dis- Disorders (SCID-I) (36).
orders and OCD appears to be a relevant phenom- All socio-demographic and illness characteristics
enon, with clinical and therapeutic implications were obtained through the administration of a
(30–33), none of the above-mentioned studies semi-structured interview, developed and used in
investigated the influence of BD comorbidity on previous studies (18, 37–39), with a format that
the prevalence and pattern of Axis II comorbidity covered the following areas.
in OCD.
The aim of the present study was to explore the Socio-demographic data. Age, sex, marital status
comorbidity of personality disorders in a group of (single, married, divorced, widowed), years of
patients with OCD and comorbid BD. education.
Onset and course of OCD. Disease onset was
indicated at the one-month period following the
Methods first occurrence of obsessive and compulsive symp-
toms, and when at least one of these symptoms was
Subjects
demonstrated by marked distress, was time-consu-
Subjects for this study were recruited from all ming (more than one h per day) or interfered with
patients with a principal diagnosis of OCD con- the person’s normal daily functioning (normal
secutively referred to the Anxiety and Mood routine, occupational and social activities). An
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Maina et al.

attempt was made to date onset of OCD to within performed to examine whether there was any
a four-week period, but if there was any uncer- difference in socio-demographic or clinical features
tainty, a close relative of the patient was inter- (including Axis I and II comorbidities). Our study
viewed and a range was plotted and its midpoint was designed to provide descriptive information;
used in the analysis. The onset was considered therefore, primarily descriptive statistics were used
abrupt when the symptoms reached clinically to analyze the data. Between-group comparisons of
significant intensity within one week of onset. All categorical variables were made with Pearson’s
other types of onset were considered insidious. If chi-square test. Continuous variables were com-
an interval occurred, then the two time-points – pared by using Student’s t-test for two-class
symptoms onset and disorder onset – were recorded comparisons. Given the exploratory nature of our
in the patient’s clinical history. In some cases study, we decided to use a two-tailed significance
patients had an abrupt onset and therefore the level of p < 0.05.
onset of symptoms and onset of disorder coin-
cided. The course of the disorder was considered
Results
episodic when at least one circumscribed symptom-
free interval (six months) was present; all other A total of 204 patients with a principal diagnosis of
types of course were considered chronic, according OCD were enrolled in the study. Of these, 21
to a definition we used in previous studies (17, 40). (10.3%) met DSM-IV (SCID) criteria for a lifetime
diagnosis of BD: 4 (2.0%) with BD type I and 17
Obsessive-compulsive symptomatology. Up to three (8.3%) with BD type II. Of the 21 subjects
primary obsessions and compulsions were listed for diagnosed with BD, 15 (7.4%) had previously
each subject using the Y-BOCS Symptom Check- received a BD diagnosis, while 6 (2.9%) patients
list. were newly diagnosed retrospectively according to
the results of the SCID. All of the newly diagnosed
Personality disorders. Personality status was BD subjects received a diagnosis of BD type II.
assessed by using the Structured Clinical Interview The mean age at onset of the first mood episode
for DSM-IV Axis II Disorders (SCID-II) (41). for the 21 BD/OCD patients was 25.9 ± 7.4 years;
Assessment with the SCID-II was guided by items the onset of OCD preceded that of the first mood
previously confirmed by the subjects on the SCID- episode in 8 patients (38.1%), was concomitant in
Personality Questionnaire (SCID-PQ). Items not 11 patients (52.4%) and followed the first mood
verified on the SCID-PQ were assumed to be true episode in 2 patients (9.5%). All patients whose
negatives. However, if an interviewer had any reason BD diagnosis was made prior to our assessment
to believe these were false negatives, further items (15 subjects) were already on a mood stabilizer
were assessed. This method is in accordance with (lithium and/or antiepileptics and/or olanzapine);
instructions for using the SCID-II, and enabled the 6 newly diagnosed subjects were put on a mood
personality disorder symptomatology to be based on stabilizer prior to starting antidepressants in order
clinical contact combined with a structured clinical to prevent possible (hypo)manic switches.
interview. The raters for this interview were also Since there were only 4 patients with comorbid
carefully instructed to challenge subjects, asking that BD type I, we performed all the comparisons
they be certain that such selected traits were unre- combining all BD patients.
lated to the symptomatology of the Axis I disorder. The demographic and clinical characteristics of
In addition, the following rating scales were the sample according to bipolar comorbidity are
included in the assessment of OCD patients: the presented in Table 1. The only statistically signif-
Hamilton Rating Scale for Anxiety (HAM-A) (42) icant difference was in gender distribution: BD/
and the 17-item Hamilton Rating Scale for OCD subjects showed higher rates of male gender
Depression (HAM-D) (43). than OCD patients without a diagnosis of BD.
The interview and all ratings were completed by Table 2 shows the phenomenology of OCD
psychiatrists with at least four years of experience according to the Y-BOCS Symptoms Checklist.
with anxiety and mood disorders. High reliability Patients with BD/OCD reported significantly high-
and diagnostic concordance have been documented er rates of sexual and hoarding obsessions and
in previous reports (38, 44). repeating compulsions.
Tables 3 and 4 report Axis I and II comorbid
disorders according to SCID-I and -II. Patients
Statistical analysis
with BD/OCD showed higher rates of substance
A statistical comparison between OCD patients use disorders, at least one Cluster A personal-
with and without a lifetime comorbidity of BD was ity disorder, at least one Cluster B personality
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Table 1. Demographic and clinical characteristics: comparison between bipolar and non-bipolar subjects with obsessive-compulsive disorder

Statistics

Total (n ¼ 204) Bipolar (n ¼ 21) Non-bipolar (n ¼ 183) t or v2 df p

Index age, years, mean (±SD) 34.7 (12.1) 32.8 (13.0) 34.9 (12.0) 0.777 202 0.438
Educational level, years, mean (±SD) 12.1 (3.6) 11.6 (3.4) 12.2 (3.7) 0.701 202 0.484
Marital status, n (%)
Single 115 (56.4) 16 (76.2) 99 (54.1) 4.212 3 0.239
Married 77 (37.7) 5 (23.8) 72 (39.3)
Divorced 8 (3.9) 0 (0.0) 8 (4.4)
Widowed 4 (2.0) 0 (0.0) 4 (2.2)
Gender, n (%)
Male 102 (50.0) 16 (76.2) 86 (47.0) 6.423 1 0.011
Female 102 (50.0) 5 (23.8) 97 (53.0)
Age at onset, years, mean (±SD)
OCD 23.8 (9.5) 23.1 (10.4) 23.8 (9.4) 0.341 202 0.734
OCS 18.7 (9.9) 15.4 (8.2) 19.1 (10.1) 1.617 202 0.108
Type of onset, n (%)
Insidious 154 (75.5) 16 (76.2) 138 (75.4) 0.006 1 0.937
Abrupt 50 (24.5) 5 (23.8) 45 (24.6)
Type of course, n (%)
Chronic 165 (80.9) 19 (90.5) 146 (79.8) 1.393 1 0.238
Episodic 39 (19.1) 2 (9.5) 37 (20.2)
Y-BOCS, mean (±SD)
Total score 26.0 (6.3) 26.9 (6.2) 25.8 (6.4) )0.720 202 0.472
Obsession subscore 13.9 (3.2) 14.2 (3.0) 13.9 (3.2) )0.323 202 0.747
Compulsion subscore 12.0 (4.6) 12.7 (3.9) 11.9 (4.7) )0.721 202 0.472
HAM-D, mean (±SD) 11.5 (6.1) 10.4 (6.3) 11.6 (6.1) 0.820 202 0.413
HAM-A, mean (±SD) 12.9 (6.7) 10.7 (5.9) 13.2 (6.7) 1.661 202 0.098
Positive family history, n (%)
OCD 36 (17.6) 1 (4.8) 35 (19.1) 2.674 1 0.102
Other anxiety disorders 23 (11.3) 1 (4.8) 22 (12.0) 0.993 1 0.319
Mood disorders 44 (21.6) 7 (33.3) 37 (20.2) 1.915 1 0.166
Schizophrenia 3 (1.6) 0 (0.0) 3 (1.6) 0.349 1 0.554

SD ¼ standard deviation; OCD ¼ obsessive-compulsive disorder; OCS ¼ Obsessive-compulsive symptoms; Y-BOCS ¼ Yale-Brown
Obsessive-Compulsive Scale; HAM-D ¼ 17 item Hamilton Rating Scale for Depression; HAM-A ¼ Hamilton Rating Scale for Anxiety.

Table 2. Obsessive-compulsive phenomenology according to the Yale-Brown Obsessive-Compulsive Scale Symptoms Checklist: comparison between bipolar
and non-bipolar subjects with obsessive-compulsive disorder

Statistics

Total (n ¼ 204) Bipolar (n ¼ 21) Non-bipolar (n ¼ 183) v2 df p

Obsessions, n (%)
Aggressive 100 (49.0) 12 (57.1) 88 (48.1) 0.618 1 0.432
Contamination 104 (51.0) 12 (57.1) 92 (50.3) 0.356 1 0.551
Sexual 45 (22.1) 9 (42.9) 36 (19.7) 5.890 1 0.015
Hoarding/saving 27 (13.2) 7 (33.3) 20 (10.9) 8.234 1 0.004
Religious 49 (24.0) 6 (28.6) 43 (23.5) 0.266 1 0.606
Symmetry/order 89 (43.6) 8 (38.1) 81 (44.3) 0.291 1 0.589
Somatic 64 (31.4) 7 (33.3) 57 (31.1) 0.042 1 0.838
Miscellaneous 120 (58.8) 11 (52.4) 109 (59.6) 0.401 1 0.526
Compulsions, n (%)
Checking 121 (59.3) 13 (61.9) 108 (59.0) 0.065 1 0.799
Cleaning 103 (50.5) 10 (47.6) 93 (50.8) 0.077 1 0.781
Repeating 93 (45.6) 15 (71.4) 78 (42.6) 6.302 1 0.012
Ordering 57 (27.9) 5 (23.8) 52 (28.4) 0.198 1 0.656
Counting 37 (18.1) 6 (28.6) 31 (16.9) 1.717 1 0.190
Hoarding/collecting 25 (12.3) 5 (23.8) 20 (10.9) 2.907 1 0.088
Miscellaneous 109 (53.4) 10 (47.6) 99 (54.1) 0.318 1 0.573

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Table 3. Lifetime Axis I comorbidities: comparison between bipolar and non-bipolar subjects with obsessive-compulsive disorder

Statistics

Lifetime comorbidity, n (%) Total (n ¼ 204) Bipolar (n ¼ 21) Non-bipolar (n ¼ 183) v2 df p

Anxiety disorders
Generalized anxiety disorder 51 (25.0) 5 (23.8) 46 (25.1) 0.018 1 0.894
Panic disorder 15 (7.4) 1 (4.8) 14 (7.7) 0.231 1 0.631
Social phobia 17 (8.3) 2 (9.5) 15 (8.2) 0.043 1 0.835
Simple phobia 33 (16.2) 6 (28.6) 27 (14.8) 2.652 1 0.103
At least one anxiety disorder 81 (39.7) 8 (38.1) 73 (39.9) 0.025 1 0.873
Depressive disorders
Major depressive disorder 51 (25.0) – 51 (27.9) – – –
Dysthymic disorder 11 (5.4) – 11 (6.0) – – –
Depressive disorder NOS 76 (37.2) – 76 (41.5) – – –
At least one depressive disorder 98 (48.0) – 98 (53.6) – – –
Other disorders
Anorexia nervosa 6 (2.9) 0 (0.0) 6 (3.3) 0.709 1 0.400
Bulimia nervosa 6 (2.9) 0 (0.0) 6 (3.3) 0.709 1 0.400
Eating disorder NOS 5 (2.5) 1 (4.8) 4 (2.2) 0.523 1 0.470
Substance use disorders 15 (7.4) 6 (28.6) 9 (4.9) 15.472 1 <0.001
Depersonalization disorder 8 (3.9) 2 (9.5) 6 (3.3) 1.950 1 0.163
Body dysmorphic disorder 13 (6.4) 1 (6.6) 12 (6.6) 0.102 1 0.750
Tic disorders 12 (5.9) 2 (9.5) 10 (5.5) 0.561 1 0.454
Kleptomania 2 (1.0) 0 (0.0) 2 (1.1) 0.232 1 0.630
Pyromania 1 (0.5) 0 (0.0) 1 (0.5) 1.115 1 0.734
Trichotillomania 4 (2.0) 0 (0.0) 4 (2.2) 0.468 1 0.494
Impulse-control disorders NOS 20 (9.8) 1 (4.8) 19 (10.4) 0.673 1 0.412
At least one comorbid disorder 159 (77.9) 14 (66.7) 145 (79.2) 1.731 1 0.188

NOS ¼ not otherwise specified.

disorder, and narcissistic and antisocial personality comorbid BDs. Comorbid BD had a great impact
disorders. on the clinical characteristics of OCD: BD/OCD
patients were more likely to be male; showed a
distinct obsessive-compulsive symptomatological
Discussion
profile; had more sexual and hoarding obsessions
The aim of the present study was to explore the and more repeating compulsions; and had higher
comorbidity of personality disorders in a group of lifetime rates for substance use disorders. The
patients with OCD and comorbid BD. observation of a great impact of BD on the clinical
Our findings are consistent with others suggesting characteristics of OCD is in agreement with results
that BD is frequent in patients with OCD (14–22), from other studies, which found a predominance of
although this specific association seems to be male gender, a higher rate of sexual, religious,
restricted to BD type II. The lifetime rate found aggressive and impulsive obsessions and checking,
for BD type I was 2% in our sample, which is in the ordering and hoarding compulsions, and higher
range of lifetime prevalence rates for this disorder lifetime rates for substance use disorder (6, 27, 28).
found in the general population (1.6% for manic Other authors found an earlier age at obsessive-
episodes in the National Comorbidity Survey) (45), compulsive symptom onset in subjects with
while the lifetime rate for BD type II was 8.3%, and comorbid BD, both in adult and adolescent sam-
thus higher than expected (46). Our result based on ples (22, 29). In our study, BD/OCD patients
an association between OCD and only BD type II is showed an earlier age at symptom onset (15 versus
in agreement with results from all studies which 19 years), although this difference did not reach
specifically investigated lifetime comorbidity with statistical significance. When we compared our
BD type I and II; these studies reported lifetime rates results with those from some of the above-men-
for BD type II ranging from 7.8% to 17.7%, tioned studies (16, 21), we did not find either a
compared to rates for BD type I ranging between higher prevalence of episodic course or a higher
0.5% and 3.8% (15–17, 19, 21). lifetime rate for panic disorder. This might be
Given that we found only four subjects with a due to differences in subjects enrolled in differ-
lifetime diagnosis of BD type I, we performed all ent studies or in criteria used to collect informa-
statistical comparisons combining all patients with tion (e.g., criteria used to diagnose comorbid
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 Bipolar OCD and personality disorders

Table 4. Axis II comorbidities: comparison between bipolar and non-bipolar subjects with obsessive-compulsive disorder

Statistics

Total (n ¼ 204) Bipolar (n ¼ 21) Non-bipolar (n ¼ 183) v2 df p

Axis II comorbidity, n (%)

Paranoid 14 (6.9) 3 (14.3) 11 (6.0) 2.018 1 0.155
Schizoid 19 (9.3) 3 (14.3) 16 (8.7) 0.685 1 0.408
Schizotypal 19 (9.3) 4 (19.0) 15 (8.2) 2.626 1 0.105
Any Cluster A disorder 48 (23.5) 9 (42.9) 39 (21.3) 4.860 1 0.027
Antisocial 14 (6.9) 6 (28.6) 8 (4.4) 17.260 1 <0.001
Borderline 34 (16.7) 5 (23.8) 29 (15.8) 0.860 1 0.354
Histrionic 13 (6.4) 3 (14.3) 10 (5.5) 2.457 1 0.117
Narcissistic 19 (9.3) 7 (33.3) 12 (6.6) 15.991 1 <0.001
Any Cluster B disorder 65 (31.9) 12 (57.1) 53 (29.0) 6.891 1 0.009
Avoidant 48 (23.5) 5 (23.8) 43 (23.5) 0.001 1 0.975
Dependent 37 (18.1) 4 (19.0) 33 (18.0) 0.013 1 0.909
Obsessive-compulsive 63 (30.9) 4 (19.0) 59 (32.2) 1.536 1 0.215
Any Cluster C disorder 128 (62.7) 11 (52.4) 117 (63.9) 1.076 1 0.300
At least one personality disorder 174 (85.3) 17 (81.0) 157 (85.8) 0.352 1 0.553
More than one personality disorder 73 (35.8) 13 (61.9) 60 (32.8) 6.951 1 0.008

conditions). We also failed to find any statistically With regard to personality traits or disorders in
significant difference between the two groups in BD, there are multiple studies with differing views
comorbidity rates for dysthymia, HAM-D total [e.g., some authors have postulated that personal-
scores and HAM-D suicidality mean scores. This ity characteristics are core components of affective
could be partly explained by the fact that our disorders (51)] and several studies have indicated
patients were seen in an outpatient service. It is that Cluster B personality disorders are more
plausible that severely ill patients with current frequent in BD (46, 52–54). This is in agreement
suicidal ideation would have been admitted to the with our findings. It will be of interest to examine
inpatient service. This limitation should be taken whether some of the personality disorders found to
into account when examining the results of our be associated with a BD/OCD comorbidity are
study. part of the clinical picture of the affective disorder
Taken together, the peculiar characteristics dis- or represent independent entities, but this issue is
played by BD/OCD patients put these subjects at beyond the objectives of the present paper.
higher risk of poorer response to or compliance The findings of a higher than expected rate of
with common antiobsessional strategies, both BD comorbidity in OCD and of the influence of
pharmacological and psychological (47, 48), sug- such a comorbidity on the clinical characteristics of
gesting the need for alternative interventions for the disorder raises the question of whether obses-
these subjects. sive-compulsive symptoms are part of bipolar
To our knowledge, this is the first study to have symptomatology rather than those of a distinct
dealt with the impact of BD comorbidity on the entity; current knowledge does not permit the
prevalence of Axis II disorders in OCD subjects, drawing of definitive conclusions. However, the
and therefore comparisons with other studies are fact that obsessive-compulsive symptoms are
not possible. Comorbid BD seems to affect the present, at least in some cases, both in the
personality profile of patients with OCD, since depressive and (hypo)manic phases of BD, suggests
BD/OCD subjects in our sample showed signifi- that, at least in some cases, the hypothesis of two
cantly higher rates of at least a Cluster A or B distinct clinical entities may be true. Familial and
disorder, and, specifically, higher rates of narcis- genetic studies, on one hand, and longitudinal
sistic and antisocial personality disorders. A BD studies on the other, will give us an answer on this
comorbidity, moreover, raises the frequency of fundamental question in the future.
any personality disorder in OCD except obsessive- A limitation of our study is that comorbidity
compulsive personality disorder, although not rates could have been inflated by specific help-
always with statistical significance. As for other seeking patterns such as those that occur in a
characteristics related to the BD/OCD comor- tertiary psychiatric care setting. Since university
bidity, the presence of a personality disorder hospitals like ours specialize in treating complex
predicted poorer response to antiobsessional disorders, it is likely that patients referred to our
treatments (40, 49, 50). clinic have more than one Axis I comorbidity, as
727
Maina et al.

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