Expert: Ivan Goldberg, M.D. - 1/27/2008

Question
QUESTION: Hello. One of my children was diagnosed at age 3 with OCD. She is now
almost 7, and we have tried behaviour therapy alone for a long time. Last May
I finally gave in and said we could try medication. Since then, she has been on
and off of Zoloft, Lexapro, Risperdal, and Geodon. She reacted to all the SSRIs
by becoming extremely violent and angry, but the OCD symptoms did
improve. The Risperdal was intended to reduce the aggression, but it never
did that, even after discontinuing the SSRI. Then we tried Geodon alone. Her
reaction to that was swift. She couldn't sleep, and was extremely agitated.
Manic is the only way I could describe it, and her mood swings were abrupt
and rapid. So, they discontinued that med as well. Now her psychiatrist wants
to try Abilify, but I am quite concerned about how this may adversely effect
her. What is the likelihood that Abilify could help when the other medications
have yielded either little response (Risperdal) or disaster (the other three)?

ANSWER: Hi Laura . . .

It is impossible for me to evaluate the situation based on the information that your provide. While I am not a child psychiatrist I get to see a few children with hard to treat psychiatric syndromes. When it comes to children with the symptoms of OCD I am always VERY interested in the family  history going back as many generations as possible. OCD occurring in children with family histories positive for the presence of OCD react to treatment quite differently from children with the symptoms of OCD with family histories of mood disorders.

With very few exceptions, because of the danger of tardive dyskinesia and neuroleptic malignant syndrome, I limit the use of antipsychotic medications such as Risperdal and Abilify to the treatment of individuals with psychosis.

Has the possible use of clomipramine (Anafranil) been discussed?

Best regards . . .
Ivan




---------- FOLLOW-UP ----------

QUESTION: Hello, and thank you for your quick response. Anafranil has not been
considered. I believe she is still considered too young.

As for family history, there really isn't too much that we have found. There is
no history on my side as far as we can tell. Her paternal grandmother has
never been diagnosed, but we do believe she has OCD. My brother-in-law
has been diagnosed with OCD and Bi-polar disorder. Her father has a history
of depression. That is all that we know of going back as far as the great-
grandparents.

Is there any correlation between a manic response to anti-psychotics and bi-
polar disorder? The information I have found thus far only seems to address
this with the SSRIs.

Thank you again for your time.  

Answer
Hi, Laura . . .

I am not surprised to hear that there is bipolar disorder in your husband's family. People with medication-induced hypomania / agitation frequently have such histories.

The treatment of a child with OCD and a bipolar family history is obviously complex. When treating such children (or adults) I first start one of the anticonvulsant mood stabilizers such as Depakote, Tegretol, or Trileptal, and then add Anafranil.

Here are some citatrions on the use of anticonvulsant mood stabilizers in the treatment of individuals with OCD:

1: Clin Drug Investig. 2007;27(3):219-23.

Treatment of compulsive sexual behaviour with clomipramine and valproic acid.

Gulsun M, Gulcat Z, Aydin H.

Isparta Military Hospital, Isparta Asker Hastanesi Psikiyatri Servisi, Egridir
Yolu, Isparta, Turkey. mgulsun@gmail.com

The concepts of compulsive sexual behaviour or sexual addiction and treatment of the disorder have been argued over by many investigators. From a scientific point of view, both concepts are still not well established in psychiatric nomenclature. On the other hand, authors point out that compulsive sexual behaviour, obsessive-compulsive disorder and substance addiction show
similarities in symptomatology and response to treatment. In this article, the case of a 21-year-old female exhibiting compulsive sexual behaviour since childhood who was treated with a combination of clomipramine and valproic acid is presented and discussed in the light of the relevant literature.

Publication Types:
   Case Reports

PMID: 17305416 [PubMed - indexed for MEDLINE]

2: J Clin Psychopharmacol. 2003 Aug;23(4):419-20.

The interactive metabolism effect of oxcarbazepine coadministered with tricyclic antidepressant therapy for OCD symptoms.

Baird P.

Publication Types:
   Case Reports
   Letter

PMID: 12920423 [PubMed - indexed for MEDLINE]

3: J S C Med Assoc. 2002 Dec;98(8):316-20.

Successful treatment of obsessive compulsive disorder with oxcarbazepine. A case
report.

McMeekin H.

Publication Types:
   Case Reports

PMID: 12532658 [PubMed - indexed for MEDLINE]

4: Psychiatry Clin Neurosci. 2002 Apr;56(2):207-8.

Treatment of features of Obsessive-Compulsive Personality Disorder using
carbamazepine.

Greve KW, Adams D.

Publication Types:
   Case Reports
   Letter

PMID: 11952927 [PubMed - indexed for MEDLINE]

5: J Clin Psychiatry. 2000 Jul;61(7):528-9.

Carbamazepine augmentation of clomipramine in the treatment of refractory
obsessive-compulsive disorder.

Iwata Y, Kotani Y, Hoshino R, Takei N, Iyo M, Mori N.

Publication Types:
   Case Reports
   Letter

PMID: 10937614 [PubMed - indexed for MEDLINE]

6: J Clin Psychiatry. 1998 Feb;59(2):82.

Valproate monotherapy in an SRI-intolerant OCD patient.

Corá-Locatelli G, Greenberg BD, Martin JD, Murphy DL.

Publication Types:
   Case Reports
   Letter

PMID: 9501891 [PubMed - indexed for MEDLINE]

7: Ann Clin Psychiatry. 1997 Sep;9(3):171-3.

Response of obsessive compulsive disorder to carbamazepine in two patients with
comorbid epilepsy.

Koopowitz LF, Berk M.

Department of Psychiatry, University of the Witwatersrand Medical School,
Johannesburg, South Africa.

An association between epilepsy and obsessive compulsive disorder (OCD) has been noted. The response of two patients with OCD and comorbid epilepsy to carbamazepine is reported. It is hypothesized that obsessive compulsive symptoms may be a variant of epileptiform forced thinking in a subgroup of patients, and may be preferentially responsive to anticonvulsant therapy.

Publication Types:
   Case Reports

PMID: 9339883 [PubMed - indexed for MEDLINE]

8: Clin Neuropharmacol. 1988 Oct;11(5):478-81.

Carbamezapine in obsessive-compulsive disorder.

Khanna S.

Department of Psychiatry, National Institute of Mental Health and Neuro Sciences,
Bangalore, India.

Publication Types:
   Comparative Study

PMID: 3219680 [PubMed - indexed for MEDLINE]

9: Biol Psychiatry. 1987 Sep;22(9):1169-71.

Carbamazepine in obsessive-compulsive disorder.

Joffe RT, Swinson RP.

Department of Psychiatry, St. Michael's Hospital, Toronto, Ontario, Canada.

PMID: 3651536 [PubMed - indexed for MEDLINE]

Best regards . . .
Ivan
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