Muhammad H Burki
MBBS, PhD
MD Sexual Health Institute of Pakistan
Lahore Punjab Pakistan
Muhammad Z Mukhthar
MSc psychology
Director AZM hospital
Sargodha Punjab Pakistan
There was no financial support from any agency
This case study has not been presented previously
No disclaimer
Corresponding Author
Muhammad Haris Burki
Sexual Health Institute of Pakistan
885/A Block E St # 1 Nadra bad Badian Road Cantt Lahore Punjab Pakistan
Haris_burki@yahoo.com
Phone :923004214795, 923334701061
Case History
N 29 year old unmarried female, from lower socio economic class presented with complaints of obsessions and compulsions with rituals, paranoid delusions, insomnia, avoidance, isolation, and withdrawal from daily life for last 15 years. Obsession about cleanliness dominated clinical picture which started with onset of menstruation. She felt that her body is contaminated with urine and her clothes are dirty. She specifically used to avoid touching her clothes with her hand. She used to request to get her hands tied up, this helped her to relieve anxiety. She refused to eat with her own hands .She reduced water intake for fear of going to washroom and getting contaminated. Patient had feeling as if she were not wearing clothes. During course of illness she developed some delusions about magic. Patient did not agree to get married and consequently withdrew and isolated from society,even her own family. DSM IV was used for diagnosis. Patient full filled criterion of OCD.
Patient was referred to clinical psychologist for CBT and started with clomipramine but, beyond 100mg she could not tolerate due to side effects. Then she was switched over fluvoxamine up to 200mg .There was only moderate respose. Fluvoxamine was augmented with clonezepam. haloperidole, buspiron, for 3 months .Later on clomipramine was also added.and haloperidole was replaced by olanzapine .However response was not satisfactory yet. Fluoxtine 60mg replaced fluvoxamine in next 3 months. For few weeks sodium divolprate and tramadol were also tried with no positive results. Eventually antipsychotics were stopped and bromocriptine was added to existing medicines .Started from 2.5 mg it was titrated to 7.5mg .Within 4 week tangible response was noticed .She started eating with her own hands, now she could go to wash room .She resumed her activities of knitting .She is ready to get married. .Her confidence level and eye contact has shown remarkable improvement.
Discussion
Resistance in OCD treatment is not uncommon. [1.2,3] Serotonin is key neurotransmitter implicated in treatment of OCD [4,5]. Possible role played by dopamine in treatment of OCD has not been fully considered [1.,6] .Theoretically dopamine can play role in management of OCD. It can be argued that OCD patient are over cautious and they try to minimize risk in their lives. Repetition and Rituals are exercised to increase their satisfaction level. Dopamine on other hand promotes risk taking behavior [7]. It can be seen in case of bipolar patients where dopamine play key role. This can be seen in effects of dopaminergic drugs like cocaine and amphetamines[7]. .Use of dopamine agonist like pramipexole ropinirole and cabergoline can induce pathological gambling [8]. . Important feature of OCD is its excessive self consciousness. One of effects of dopamine is that it transcend one beyond self. In some of dopaminergic events like sex arousal, orgasm, euphoria OCD symptoms although temporarily tend to get abated. In orgasm and drug induced euphoria reward center is stimulated by dopaminergic nerve ending [9,10]. . During sexual arousal one crave to get connected to other. In drug induce euphoria and orgasm one feels connected to universe. So improving dopaminergic transmission can be beneficial for OCD treatment.
There are various strategies to augment effects of SSRIs, like adding low dose antipsychotic, clomipramine , buspiron, benzodiazepines ,N acetyl cystine , [1,2,3,11]. and etc. Some of these strategies virtually increase dopaminergic transmission.For example low dose antipsychotic actually block auto receptor of dopamine resulting in improved dopaminergic flow. [12]. Buspiron which acts on 5HT1A increases dopamine activity. SSRIs,like setraline and fluvoxamine which are considered drug of choice for OCD exert some effect on dopamine [13]. This can be possible cause of their superior efficacy in OCD. dopamine agonist was considered for treatment of resistant OCD. [6]. . When bromocriptine was added, it directly increased activity of dopamine that resulted in desirable response in the patient.
Conclusion
Dopaminergic medication may be tried in resistant cases of OCD.
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