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Obsessive-compulsive disorder successfully treated with trazodone
CASE REPORT
R. BRUCE LYDIARD. Ph.D., M.D.
Obsessive-compulsive disorder successfully treated
with trazodone Obsessive-compulsive disorder (OCD) is a relatively infrequent but potentially crippling anxiety disorder. It has been notoriously resistant to treatment of all kinds. I but phannacotherapy has shown some promise in recent years. 2 Two fairly recent reports'" suggested that OCD responds to the antidepressant trazodone. This article details the treatment of an additional patient with OCD who responded to this agent. C8sereport An 18-year-old single man was evaluated for anxiety associated with persistent intrusive thoughts that had begun two years earlier during a stressful period. He was plagued by an intrusive concern that his favorite rock group was involved in devil worship. and that he had been unwittingly influenced by this and would become a devil worshipper. He had had no prior thoughts of devil worship and was repulsed by the idea. He reported no other obsessions or rituals. There was no evidence of psychotic thought processes. He experienced only mild depressive symptoms, including dysphoric mood. sleep disturbance. and appetite disturbance that followed the onset of the obsessional thoughts. He ultimately was unable to function in school or at work because of the intrusive thoughts. He sought psychiatric treatment and received amitriptyline. 25 mg/d. for several weeks with no effect. Lorazepam. 0.5 mg one to two times a day. had a minimal beneficial effect but was discontinued. About six months after the onset Dr. Lydiard is assistant professor at the Medical University of South Carolina. Reprint requests to him in the Department ofPsychiatry and Behavioral Sciences. Medical University of South Carolina. 171 AshleyAve.. Charleston. SC 29425.
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of the obsessive symptoms. he required hospitalization for increased depressive symptoms and was treated with trazodone in increasing doses up to 350 mg/d. He received this dosage for a maximum of two weeks. over which time his depressed mood began to improve and his obsessions improved slightly. He was then discharged. Shortly thereafter he developed a urinary tract infection. and all medications were discontinued. Over the next few months his mood returned to normal. but the obsessive thoughts persisted unimproved for a year and a half. He avoided any situation in which the devil might be mentioned or brought to his attention. because of resulting intensification of his obsessive thoughts. He denied any history of panic attacks or other psychiatric history. His family psychiatric history was markedly positive; agoraphobia with panic attacks (maternal aunt). depression (mother. maternal great aunt, paternal aunt and uncle). and alcoholism (father). Treatment with desipramine was attempted with dosages up to 150 mg/d. This was discontinued after two weeks because of intolerable anticholinergic effects. Trazodone was prescribed in dosages increasing from 25 mg/d. Because of marked sedation, the patient was initially able to tolerate only low doses. As they were gradually increased to 100 mg/d over two months. his obsessive thoughts began to subside gradually. and diminished to the point that they no longer interfered substantially with his functioning at work. The avoidance behavior subsided completely. He remained stably Improved for SIX months. after which the dosage was decreased to 50 mg/d because of continued complaints about sedation. The obsessive thoughts began to recur after about one month at the decreased dosage. The dosage was increased to 150 mg/d over three months. and the symptoms again subsided and have remained in remission for eight months. The sedation lessened gradually over time.
PSYCHOSOMATICS
Discussion A variety of psychophannacologic approaches to the treatment of OCD have included use of monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants, antipsychotics, lithium carbonate, or benzodiazepines. In some reports, 5. 7 the OCD patients responding best to phannacologic treatment were persons with a history of panic attacks and phobic avoidance behavior. While this patient had no history of panic attacks, his family history was positive for panic disorder. A majority of patients with panic disorder and phobic anxiety have obsessional thoughts (80% in one report), 8 and obsessional symptomatology is reduced by treatment of panic disorder and agoraphobia with tricyclics or MAOIs. These preliminary findings suggest a potential link between panic disorder, agoraphobia, and OCD. Of all the psychophannacologic treatments, clomipramine, a potent serotonin neuronal reuptake blocker, has been the most vigorously studied and has shown the most favorable outcome in OCD" Clomipramine's serotonin-po-
tentiating action may play an important role in its anti-obsessional effects.'· Trazodone is also a selective serotonin reuptake blocker. II In addition to the reports'" of efficacy in OCD, it may be useful for panic disorder and agoraphobia, 12 although the latter is not a universal finding (D. Charney, M.D., oral communication, December 1984). The return of symptoms following dosage decrease and the improvement after subsequent increase suggests that the patient described above had not experienced a spontaneous remission. The failure of the obsessive symptoms to respond initially to 350 mg/d oftrazodone may possibly have resulted from an inadequate duration of treatment. This report adds support to the suggestion'" that trazodone may have a place in treating anxiety disorders. particularly OCD. Controlled studies of the possible efficacy of trazodone in treating OCD, panic, and other anxiety disorders would be of great interest. 0 The author thanks James Ballenger. M.D., for his helpful comments.
REFERENCES 1. Salzman L. Thaler FH: Obsessive-compulsive disorders: A review of the literature AmJ Psychiatry 138:286-296.1981. 2. Insel TR, Murphy Dl: Psychopharmacological treatment of obsessivecompulsive disorder: A review. J Clin Psychopharmacology 1:304-315, 1981 3 Prasad AJ: Obsessive-compulsive disorder and trazodone, letter. Am J Psychiatry 31 :612-613,1985. 4. Baxter LR: Two cases of OCD with depression responsive to trazodone. J Nerv Ment Dis 173:432-433, 1985. 5. Jenike ME, Surman OS. Cassem NH, et al: Monoamine oxidase inhibitors and obsessive-compulsive disorder. J Clin Psychiatry 34: 131-132. 1983. 6. Jain VK, Swinson RP, Thomas JG: Phenelzine in obsessive neurosis. Br J Psychiatry 117:237-238, 1970. 7. Annelsley PT: Nardil response in a chronic obsessive compulsive. Br J Psychiatry 117:748,1969.
DECEMBER 1986· VOL 27· NO 12
8. Sheehan DV, Ballenger J, Jacobson G: Treatment of endogenous anxiety with phobic hysterical and hypochondriacal symptoms. Arch Gen Psychiatry37:51-57,1980. 9. Insel TR, Murphy DL. Cohen RN. et al: Obsessive-compulsive disorder. A double-blind trial of clomipramine and clorgyline. Arch Gen Psychiatry 40:605-612,1983. 10. Thoren P, Asberg M, Bertilsson L, et al: Clomipramine treatment of obsessive-compulsive disorder II. Biochemical aspects. Arch Gen Psychiatry 37:1289-1294,1980. 11. Georgotas A. Forsell TL. Mann J, et al: Trazodone hydrochloride: A widespectrum antidepressant with a unique pharmacological profile. Pharmacotherapy 2:255-265, 1982. 12. Sheehan DV: Current views on the treatment of panic and phobic disorder. Drug Therapy (Hospital Edition) 7:74-93, 1982
859
R. BRUCE LYDIARD. Ph.D., M.D.
Obsessive-compulsive disorder successfully treated
with trazodone Obsessive-compulsive disorder (OCD) is a relatively infrequent but potentially crippling anxiety disorder. It has been notoriously resistant to treatment of all kinds. I but phannacotherapy has shown some promise in recent years. 2 Two fairly recent reports'" suggested that OCD responds to the antidepressant trazodone. This article details the treatment of an additional patient with OCD who responded to this agent. C8sereport An 18-year-old single man was evaluated for anxiety associated with persistent intrusive thoughts that had begun two years earlier during a stressful period. He was plagued by an intrusive concern that his favorite rock group was involved in devil worship. and that he had been unwittingly influenced by this and would become a devil worshipper. He had had no prior thoughts of devil worship and was repulsed by the idea. He reported no other obsessions or rituals. There was no evidence of psychotic thought processes. He experienced only mild depressive symptoms, including dysphoric mood. sleep disturbance. and appetite disturbance that followed the onset of the obsessional thoughts. He ultimately was unable to function in school or at work because of the intrusive thoughts. He sought psychiatric treatment and received amitriptyline. 25 mg/d. for several weeks with no effect. Lorazepam. 0.5 mg one to two times a day. had a minimal beneficial effect but was discontinued. About six months after the onset Dr. Lydiard is assistant professor at the Medical University of South Carolina. Reprint requests to him in the Department ofPsychiatry and Behavioral Sciences. Medical University of South Carolina. 171 AshleyAve.. Charleston. SC 29425.
8S8
of the obsessive symptoms. he required hospitalization for increased depressive symptoms and was treated with trazodone in increasing doses up to 350 mg/d. He received this dosage for a maximum of two weeks. over which time his depressed mood began to improve and his obsessions improved slightly. He was then discharged. Shortly thereafter he developed a urinary tract infection. and all medications were discontinued. Over the next few months his mood returned to normal. but the obsessive thoughts persisted unimproved for a year and a half. He avoided any situation in which the devil might be mentioned or brought to his attention. because of resulting intensification of his obsessive thoughts. He denied any history of panic attacks or other psychiatric history. His family psychiatric history was markedly positive; agoraphobia with panic attacks (maternal aunt). depression (mother. maternal great aunt, paternal aunt and uncle). and alcoholism (father). Treatment with desipramine was attempted with dosages up to 150 mg/d. This was discontinued after two weeks because of intolerable anticholinergic effects. Trazodone was prescribed in dosages increasing from 25 mg/d. Because of marked sedation, the patient was initially able to tolerate only low doses. As they were gradually increased to 100 mg/d over two months. his obsessive thoughts began to subside gradually. and diminished to the point that they no longer interfered substantially with his functioning at work. The avoidance behavior subsided completely. He remained stably Improved for SIX months. after which the dosage was decreased to 50 mg/d because of continued complaints about sedation. The obsessive thoughts began to recur after about one month at the decreased dosage. The dosage was increased to 150 mg/d over three months. and the symptoms again subsided and have remained in remission for eight months. The sedation lessened gradually over time.
PSYCHOSOMATICS
Discussion A variety of psychophannacologic approaches to the treatment of OCD have included use of monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants, antipsychotics, lithium carbonate, or benzodiazepines. In some reports, 5. 7 the OCD patients responding best to phannacologic treatment were persons with a history of panic attacks and phobic avoidance behavior. While this patient had no history of panic attacks, his family history was positive for panic disorder. A majority of patients with panic disorder and phobic anxiety have obsessional thoughts (80% in one report), 8 and obsessional symptomatology is reduced by treatment of panic disorder and agoraphobia with tricyclics or MAOIs. These preliminary findings suggest a potential link between panic disorder, agoraphobia, and OCD. Of all the psychophannacologic treatments, clomipramine, a potent serotonin neuronal reuptake blocker, has been the most vigorously studied and has shown the most favorable outcome in OCD" Clomipramine's serotonin-po-
tentiating action may play an important role in its anti-obsessional effects.'· Trazodone is also a selective serotonin reuptake blocker. II In addition to the reports'" of efficacy in OCD, it may be useful for panic disorder and agoraphobia, 12 although the latter is not a universal finding (D. Charney, M.D., oral communication, December 1984). The return of symptoms following dosage decrease and the improvement after subsequent increase suggests that the patient described above had not experienced a spontaneous remission. The failure of the obsessive symptoms to respond initially to 350 mg/d oftrazodone may possibly have resulted from an inadequate duration of treatment. This report adds support to the suggestion'" that trazodone may have a place in treating anxiety disorders. particularly OCD. Controlled studies of the possible efficacy of trazodone in treating OCD, panic, and other anxiety disorders would be of great interest. 0 The author thanks James Ballenger. M.D., for his helpful comments.
REFERENCES 1. Salzman L. Thaler FH: Obsessive-compulsive disorders: A review of the literature AmJ Psychiatry 138:286-296.1981. 2. Insel TR, Murphy Dl: Psychopharmacological treatment of obsessivecompulsive disorder: A review. J Clin Psychopharmacology 1:304-315, 1981 3 Prasad AJ: Obsessive-compulsive disorder and trazodone, letter. Am J Psychiatry 31 :612-613,1985. 4. Baxter LR: Two cases of OCD with depression responsive to trazodone. J Nerv Ment Dis 173:432-433, 1985. 5. Jenike ME, Surman OS. Cassem NH, et al: Monoamine oxidase inhibitors and obsessive-compulsive disorder. J Clin Psychiatry 34: 131-132. 1983. 6. Jain VK, Swinson RP, Thomas JG: Phenelzine in obsessive neurosis. Br J Psychiatry 117:237-238, 1970. 7. Annelsley PT: Nardil response in a chronic obsessive compulsive. Br J Psychiatry 117:748,1969.
DECEMBER 1986· VOL 27· NO 12
8. Sheehan DV, Ballenger J, Jacobson G: Treatment of endogenous anxiety with phobic hysterical and hypochondriacal symptoms. Arch Gen Psychiatry37:51-57,1980. 9. Insel TR, Murphy DL. Cohen RN. et al: Obsessive-compulsive disorder. A double-blind trial of clomipramine and clorgyline. Arch Gen Psychiatry 40:605-612,1983. 10. Thoren P, Asberg M, Bertilsson L, et al: Clomipramine treatment of obsessive-compulsive disorder II. Biochemical aspects. Arch Gen Psychiatry 37:1289-1294,1980. 11. Georgotas A. Forsell TL. Mann J, et al: Trazodone hydrochloride: A widespectrum antidepressant with a unique pharmacological profile. Pharmacotherapy 2:255-265, 1982. 12. Sheehan DV: Current views on the treatment of panic and phobic disorder. Drug Therapy (Hospital Edition) 7:74-93, 1982
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