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| LETTER TO THE EDITOR |
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| Year : 2022 | Volume
: 1
| Issue : 3 | Page : 146-147 |
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Treatment-resistant obsessive-compulsive disorder and multimodal augmentation: a case study
Shreya Verma1, Shubhajeet Roy1, Vaibhav Singh2, Amit Singh2, Sujita Kumar Kar2
1 King George’s Medical University, Lucknow, Uttar Pradesh, India
2 Department of Psychiatry, King George’s Medical University, Lucknow, Uttar Pradesh, India
| Date of Submission | 18-Jul-2022 |
| Date of Decision | 15-Aug-2022 |
| Date of Acceptance | 20-Aug-2022 |
| Date of Web Publication | 29-Sep-2022 |
Correspondence Address:
Sujita Kumar Kar
Department of Psychiatry, King George’s Medical University, Lucknow, Uttar Pradesh, India
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/2773-2398.356526
How to cite this article:
Verma S, Roy S, Singh V, Singh A, Kumar Kar S. Treatment-resistant obsessive-compulsive disorder and multimodal augmentation: a case study. Brain Netw Modulation 2022;1:146-7 |
How to cite this URL:
Verma S, Roy S, Singh V, Singh A, Kumar Kar S. Treatment-resistant obsessive-compulsive disorder and multimodal augmentation: a case study. Brain Netw Modulation [serial online] 2022 [cited 2023 Dec 2];1:146-7. Available from: http://www.bnmjournal.com/text.asp?2022/1/3/146/356526 |
Dear Editor,
Obsessive-compulsive disorder (OCD) is a common psychiatric disorder, and a large number of patients become resistant to conventional treatments during their illness. No responses to dose optimization often warrant augmentation with psychotherapy, pharmacological agents or neuromodulation (Reddy and Arumugham, 2020). In OCD, a more than 35% reduction in symptom severity from baseline is considered a response and a score of < 12/40 on the Yale-Brown Obsessive Compulsive Scale (YBOCS) is considered remission (Reddy and Arumugham, 2020). In 40-60% of patients with OCD, although serotonergic treatment does not respond adequately, augmentation strategies are required to optimize therapeutic outcomes (Arumugham and Reddy, 2013). Various neuromodulation strategies have been tried as augmentation strategies in the management of OCD. In this case study, we discussed the adoption of multiple augmentations strategies together in a young female with OCD. The practice and research implications were discussed along with the literature review.
A 34-year-old female presented to the psychiatry outpatient department with chief complaints of recurrent repetitive thoughts of contamination and repetitive hand washing and cleaning acts for the past 6 years. Initially, she would wash her hands 5-6 times a day, but the symptoms had worsened over the past few years. At the time of reporting, it had reached up to eight to nine times a day, with a frequency of 6-8 times each time. As per the informant, the patient also started to take more time to finish bathing, which initially would take up to 10 to 15 minutes but later it had increased up to 2 hours. The patient consulted various general practitioners within 3 years, with the primary treatment being tablet fluoxetine up to 60 mg/d and tablet fluvoxamine up to 100 mg/d. She was partially responsive to this therapy. However, she became non-adherent to treatment due to the lockdown caused by the coronavirus disease 2019 pandemic. After 10 months of lapse, her symptoms deteriorated again. The patient had begun to experience anxiety due to not being able to control the urge to wash her hands. She felt anxious and worried endlessly about her recurrent thoughts of contamination. There was no history of blasphemy, sexual thoughts, religious rituals, or need for symmetry. There was no history of hoarding behavior, recurrent skin pricking, or hair pulling. There was no history of any psychiatric illness in the family. The patient also had no history of psychiatric illnesses. Pre-morbidly, she was well adjusted to life. Precipitating factors or stressors could not be elicited. The patient also had a pelvic inflammatory disease, for which she started treatment from the Department of Obstetrics and Gynaecology. On general examination, the patient was well-nourished and average-built. Her weight was 60 kg, height was 148 cm, body mass index was 27.4 kg/m2, blood pressure was 122/84 mmHg, and pulse rate was 88 beats/min. All the general and systemic examinations were unremarkable. Baseline investigations, including complete blood count, liver function test, and renal function test, were done, all of which were within normal limits. On mental status examination, the patient’s predominant anxious affect and thinking revealed obsessional thoughts with unsuccessfully resisted acts regarding contamination. A diagnosis of OCD with mixed obsessional thoughts and acts with pelvic inflammatory disease under the 10th edition of the International Classification of Diseases (ICD-10) criteria was made. The patient was started on fluvoxamine 100 mg/d, aripiprazole 5 mg/d and clonazepam 0.25 mg/d. After 2 months, clomipramine 50 mg/d was added, which had to be stopped as the patient was reporting constipation; however, the patient was reporting only some improvement on the treatment, and her symptoms continued to interfere with day-to-day activities. After 2 months, the patient was admitted for proper evaluation and management then she was continued with fluvoxamine 300 mg/d, aripiprazole 5 mg/d, and clonazepam 0.25 mg/d as and when required, with the above pharmacotherapy. At hospitalization, her severity of symptoms was evaluated (her score on YBOCS was 25/40). Behavior therapy in the form of exposure and response prevention was done and 16 sessions of transcranial direct current stimulations (tDCS) were given. In tDCS, a current of 2 mA for 20 minutes was given twice a day and the cathode was placed on the supplementary motor area and the anode was placed on the left dorsolateral prefrontal cortex. During her 10 days of stay, her symptoms improved markedly, and she was discharged with advice to follow up. At the time of discharge, her score on YBOCS was reduced to 11/40 (56% reduction of symptoms). During a follow-up visit at 6 weeks, her improvement was sustained and clonazepam was stopped.
Conventionally, a single augmentation strategy is recommended to optimize therapeutic outcomes. However, many patients are more in need of multiple augmentation strategies. In a previous report, a multimodal augmentation strategy (pharmacological, behavior therapy, and tDCS) was effective in a patient with OCD with a comorbid seizure disorder and depression (Kar et al., 2022). There was a 69.23% reduction in YBOCS score within 18 days of hospitalization (Kar et al., 2022). In this current case, a 56% reduction in YBOCS score happened over 8 days of hospitalization. The patient did not report any side effects due to any of these treatment modalities used in combination.
Previously, researchers have also used tDCS for the treatment of OCD with co-morbid schizophrenia (Verma et al., 2018). A recent systematic review evaluated the potential role of tDCS as an augmentation strategy to manage OCD with acceptable safety features (Brunelin et al., 2018). Considering the safety, efficacy, and rapid reduction of symptoms, the multimodal augmentation strategy may be considered a reliable management strategy in the management of OCD. To substantiate the evidence, there is a need for larger studies on various combinations of augmentation strategies and different settings (non-clinical and clinical settings to limit the biases). Moreover, it is also required to monitor the durability of the beneficial response through follow-up studies. Informed consent was obtained from the patient.
Open access statement: This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
| References | |  |
| 1. | Arumugham SS, Reddy JY (2013) Augmentation strategies in obsessive-compulsive disorder. Expert Rev Neurother 13:187-202; quiz 203.  |
| 2. | Brunelin J, Mondino M, Bation R, Palm U, Saoud M, Poulet E (2018) Transcranial direct current stimulation for obsessive-compulsive disorder: a systematic review. Brain Sci 8:37. |
| 3. | Kar SK, Kumari B, Singh A (2022) Multimodal augmentation approach with transcranial direct current stimulation in management of obsessive-compulsive disorder with depression and comorbid seizure disorder: a case report. Indian J Psychol Med doi: 10.1177/02537176221084875. |
| 4. | Reddy YCJ, Arumugham SS (2020) Are current pharmacotherapeutic strategies effective in treating OCD? Expert Opin Pharmacother 21:853-856. |
| 5. | Verma R, Kumar N, Mahapatra A, Shah B (2018) Effectiveness of tDCS augmentation for co-morbid obsessive compulsive disorder in chronic schizophrenia: A case report. Asian J Psychiatr 38:9-11. |
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