Can intrusive thoughts ever be a sign of bipolar disorder?

Unwelcome and distressing mental images, ideas, or impulses that repeatedly enter our minds against our will are called intrusive thoughts, and research shows that they are extremely common. Almost as common is the ability to recognize intrusive thoughts for what they are: a weird glitch that comes with having a brain doing billions of computations each and every second. 

However, for some, these random thoughts aren’t easy to shrug off. The 1-2% of people who struggle with Obsessive-Compulsive Disorder (OCD) are in this category, as are some people with bipolar disorder (BD)—another serious mental disorder that 4.4% of US adults will experience at some point in their lives. It’s important to know that these two conditions co-occur pretty frequently, with one study estimating that OCD accounted for 21% of all comorbidities in BD. 

In this article, we’ll look at the nature of intrusive thoughts in both conditions, examine how they differ from one another, and discuss how these disorders can be treated when they occur in the same person at the same time.  

Intrusive thoughts and mental disorders

Whether you have a mental health disorder or not, intrusive thoughts can be disturbing, particularly when they center around violent or harmful acts and irrational doubts, as they often do. However, it’s only when these types of thoughts can’t be dismissed out of hand that they begin to present a real problem, leading people to question their moral character or causing them to feel anxious or guilty. 

These “sticky” intrusive thoughts are observed in several mental health conditions, including PTSD, anxiety disorders, and schizophrenia. That means that a diagnosis can’t be made from their presence alone, highlighting the need for a comprehensive analysis by a mental health care provider. Before we look at how intrusive thoughts can appear as a feature of OCD and BD, let’s take a high-level look at each condition. We’ll start with OCD, as intrusive thoughts are most often a core symptom of the condition. 

OCD: an overview

OCD is a mental health condition that affects tens of millions of people worldwide. As the name suggests, it’s characterized by two main components: obsessions and compulsions. 

Obsessions are intrusive, distressing, and unwanted thoughts, images, sensations, or urges that repeatedly enter a person’s mind, causing significant anxiety or discomfort. These intrusive triggers are beyond the person’s control and are often disturbing, violent, or taboo. They’re referred to as ego-dystonic, meaning they are inconsistent with a person’s core values or identity. A doting parent with OCD might have intrusive thoughts about harming their child, for example, precisely because they care so much, and the worst thing they can imagine would be to hurt their child.

The second group of core symptoms, compulsions, are repetitive behaviors or mental acts that people feel compelled to perform in response to their obsessions. Compulsions are done in an attempt to reduce the distress caused by intrusive thoughts, prevent feared events, or adhere to rigid rules. Although they might provide temporary relief, they train the brain to believe that obsessions are actually dangerous or threatening, contributing to a vicious cycle of increased anxiety and further compulsive behaviors that tends to grow over time, causing more & more distress & impairment along the way.

In people with OCD, intrusive thoughts typically manifest in specific themes, such as contamination fears, fears of harming others or oneself, concerns about symmetry or order, and excessive doubt or indecisiveness. Though often portrayed as a relatively benign quirk, the disorder can significantly interfere with daily life, relationships, work, and overall well-being. Left untreated, OCD can be debilitating, putting people at greater risk of developing other mental disorders and suicide. 

BD: an overview

Bipolar Disorder is a complex mental health condition characterized by extreme mood swings that include depressive episodes (overwhelming sadness, lack of energy, and feelings of worthlessness) and periods of mania (a mental state characterized by elevated mood, extreme energy, impulsivity, and a decreased need for sleep) or hypomania—a milder form of mania, featuring similar symptoms but with less severity and a lower impact on daily functioning.

Distinguishing bipolar disorder from other mental health disorders can be challenging due to overlapping symptoms. Conditions like major depressive disorder, borderline personality disorder, and schizophrenia can present with mood disturbances that mimic bipolar disorder. 

To receive a bipolar disorder diagnosis, a person must experience at least one episode of mania or hypomania accompanied by depressive episodes. The presence of these mood episodes is what distinguishes bipolar disorder from other mental health conditions.

Making matters slightly more complex is the fact there are several different types of BD: 

1. Bipolar I Disorder involves periods of mania that last at least seven days, often accompanied by severe depressive episodes.
2. Bipolar II Disorder is characterized by recurring episodes of major depression and hypomania but without full-blown manic episodes.
3. Cyclothymic Disorder is a milder form of bipolar disorder where people experience numerous periods of hypomania and mild depression over at least two years.
4. Bipolar with mixed features refers to when someone experiences depression and mania or hypomania simultaneously or in quick succession.
5. Bipolar with seasonal pattern refers to the time of year or seasons regularly affecting mood episodes.
6. Rapid Cycling Bipolar is when a person has experienced four or more depressive, manic or hypomanic, or mixed episodes within a year.
7. Bipolar Disorder Not Otherwise Specified (BP-NOS) is used when symptoms do not fit the criteria for the other types, but there are clear indications of bipolar mood disturbances.

“Intrusive thoughts can happen in all types of BD, but they’re most common in people with BD II,” explains Faran Asen, LICSW, a therapist with NOCD. “That’s because they are more common in depression than in mania, and BD II is typified by much less mania.” 

Asen adds that people with BD may experience hyperfixation and rumination, particularly during depressive states, often exacerbating their depression. Instead of a singular ongoing theme, as seen in OCD, individuals with bipolar disorder may get “stuck” on repetitive thoughts of minimal importance before transitioning to another thought. 

It’s also important to note that, while commonly reported among people with BD, intrusive thoughts are not one of its defining symptoms in the DSM-5.

The content and intensity of intrusive thoughts may vary during different phases of bipolar disorder. 

“During depressive episodes, intrusive thoughts may be more negative and self-critical, while during manic or hypomanic phases, they may be more euphoric and unrealistic,” says Asen. 

The link between intrusive thoughts and bipolar disorder is not yet fully understood. One possible explanation is that they may share similar neurobiological mechanisms. It’s also important to recognize that some cases of comorbid bipolar disorder and OCD may be misdiagnosed, leading to incorrect treatment approaches.

Importance of comprehensive assessment for accurate diagnosis

To avoid misdiagnosis and correctly identify the primary condition, clinicians must conduct a comprehensive evaluation that considers intrusive thoughts in addition to both mood-related and behavioral symptoms. This assessment will involve a detailed psychiatric history, clinical interviews, and standardized assessment tools.

Effective treatment for people with intrusive thoughts that result from bipolar disorder involves prioritizing the management of bipolar symptoms. Medications such as mood stabilizers, anticonvulsants, and antipsychotics are commonly used to stabilize mood and prevent episodes. Addressing BD with these medications may resolve intrusive thoughts, especially if they are not indicative of comorbid OCD.

If you suspect that you may have bipolar disorder, it’s crucial to contact a mental health professional, such as a psychiatrist, psychologist, or licensed therapist. They have the expertise to assess your symptoms, diagnose these conditions correctly, and prescribe effective treatment.

Co-occurring OCD and BD 

If OCD and BD are comorbid, treatment becomes more complex and requires a comprehensive approach. That’s because medications for treating OCD—primarily selective serotonin reuptake inhibitors (SSRIs)—can sometimes make BD symptoms worse or mask certain symptoms, leading to inaccurate diagnosis.

“With BD, medication is super important,” explains Asen. “It’s not one of the disorders where we’ll try to see if we can manage it with therapy alone. Luckily, in addition to being responsive to SSRIs, OCD is equally responsive to a form of therapy called exposure and response prevention (ERP). So when these two conditions are comorbid, treating the BD with a mood stabilizer—as opposed to an antipsychotic—while simultaneously undergoing ERP to treat OCD is an approach people may want to consider.” 

So what does ERP look like? Let’s get into it. 

Exposure and response prevention therapy (ERP)  

Developed in the 1960s and 70s, ERP helps people learn to accept obsessions or distressing thoughts while refraining from compulsive behaviors, leading to greatly reduced symptoms and greater management skills in a relatively short period of time. ERP works by exposing people in a controlled manner to situations or triggers that typically provoke anxiety, providing opportunities to deliberately resist the urge to engage in compulsions that only make obsessions worse over time, thereby interrupting the vicious cycle of OCD. By realizing that their distress will naturally dissipate when they don’t engage in compulsions or any other active coping skills, people actively break the OCD cycle.

ERP has proven to be highly effective in helping people manage OCD symptoms. Numerous studies have shown that it can significantly reduce the severity of obsessions and compulsions, leading to improved daily functioning and a better quality of life in around two-thirds of people with OCD, often in a few months of regular sessions and homework.

ERP typically involves several steps:

• Assessment: You’ll begin by working with a therapist who specializes in OCD treatment. They’ll assess your specific obsessions, compulsions and how they impact your life. Understanding your unique triggers is crucial for creating a personalized ERP plan. 
• Exposures: The core component of ERP involves exposure to situations, thoughts, or objects that trigger your OCD-related distress. This can be challenging at first, but a crucial step as your brain learns that these triggers are not as threatening as they seem.
• Response prevention: During exposure, you’ll also practice response prevention—as you may have guessed from the approach’s name. This means refraining from engaging in your usual compulsive behaviors or rituals. 
• Gradual progression: ERP is usually conducted in a graded manner. You’ll start with exposures that evoke mild anxiety and gradually move up the exposure hierarchy to more challenging situations. This step-by-step approach helps build confidence and resilience over time.
• Homework: ERP often includes homework assignments to practice outside of therapy sessions. These assignments reinforce what you’ve learned and help apply your skills to real-life situations. 
• Monitoring progress: You and your therapist will regularly review your progress toward the goals you initially set. This evaluation helps make adjustments to the treatment plan if needed. If you’re among most people who benefit from ERP, it’ll also show you how far you’ve come. 

ERP is a brave step towards regaining control over your life and finding relief from OCD symptoms—whether your OCD is comorbid with BD or not. Your therapist will be there to support you until you’ve mastered your toolbox and resumed living life on your own terms. 

Getting the help you need

If you think your intrusive thoughts are a result of OCD and want to learn how ERP can treat them, I encourage you to learn about NOCD’s accessible, evidence-based approach to treatment with the NOCD Care team to discover how we can help you. 

All of our therapists specialize in OCD and receive ERP-specific training. You can also get 24/7 access to personalized self-management tools built by people who have been through OCD and successfully recovered.