Byline: Bindu. Annigeri, Rajesh. Raman, Rashmi. Appaji
Obsessive compulsive features occurring in mania have been well documented. Though there have been some studies on obsessive compulsive disorder (OCD) comorbid with mania in the western countries, there are very few case reports and studies in India. Our aim is to report one such case here, who presented with OC features which are not typical of the symptom cluster of the OCD commonly seen with mania in earlier reports. Also, the comorbidities in OCD should be recognized as this can have important diagnostic and therapeutic implications.
Psychiatric disorders have been known to have various comorbidities. Obsessive compulsive disorder (OCD) too is one such disorder which can coexist with other anxiety disorders, mood and psychotic disorders. Of these, depressive symptoms are the commonest comorbidity. Mania in OCD can occur either as an independent comorbidity or as a result of an antidepressant-induced switch in a patient on anti-OCD drugs. Whatever the cause may be, this comorbidity implies that there can be a host of differences in the presentation, course, treatment guidelines and prognosis.
A 17-year-old first born male patient who was premorbidly of an easy temperament had a strong family history of mental illness. There was depression in the mother and OCD in the maternal uncle and cousin. His intellectual performance was average. He consulted a Psychiatrist for OCD of five years duration and was prescribed clomipramine 75 mg, fluoxetine 20 mg and risperidone 1 mg. A week after this consultation, he presented to our out patient department (OPD) with a history of obsessions of contamination, sexual images, compulsions of washing, checking, repetitions and ritualistic compulsions. It was of an insidious onset and a fluctuating course. There was no history of attention deficit hyperactivity disorder (ADHD) or Tourette's syndrome. He also had depressive symptoms i.e. sadness, suicidal behavior, decreased sleep and delusion of reference, which he said was of one month duration. Patient was admitted as he also had suicidal ideas and plans and was given fluoxetine 40 mg along with clomipramine 75 mg. His Hamilton rating scale for depression (HAM-D) and Y-Brown obsessive compulsive scale (Y-BOCS) scores were 42 and 32 respectively. During the stay in the hospital, he was found to have agitation and aggression, increased speech output, increased psychomotor activity, grandiose ideas about his physical power and sexual imagery regarding the treating staff and the nurses. Young mania rating scale (YMRS) score was 39. His OC symptoms persisted with the same severity. He was then started on divalproex sodium and dose built up to 1 500 mg, risperidone gradually increased to 12 mg, clonazepam 1 mg and parenteral antipsychotics. As there was no reduction in symptoms, quetiapine was started and the dose built to 400 mg. Despite the high dose of antipsychotics, there was no extra pyramidal side effects (EPS). Clomipramine and fluoxetine were stopped. Not finding an adequate response and due to the presence of suicidal ideas, he was started on electroconvulsive therapy and after one sitting of modified electro convulsive therapy (ECT), his manic symptoms worsened. His aggression and increased verbal output reduced minimally after increasing the dose of quetiapine to 600 mg and his YMRS scores reduced to 30. He was discharged on request with divalproex sodium 1 500 mg, risperidone 4 mg and quetiapine 600 mg and was advised regular follow-up. During the follow-up, he was found to have prominent symptoms of both mania and OCD, though he reported a 50% reduction of manic symptoms.
There are some differences from the available evidence that were found in above patient. The OC symptom cluster of this patient was not typical of that reported in this comorbidity. The bipolarity was of type I. An interesting finding was that both OCD and mania were prominent in intensity. …