Introduction
Traditionally it is thought that electroconvulsive therapy (ECT) lacks efficacy in obsessive compulsive disorder (OCD) and a literature search revealed only isolated case reports demonstrating benefit in patients who have depression and comorbid OCD (Hussain et al., Reference Hussain, Lewis and Thorton1993; Casey and Davis, Reference Casey and Davis1994; Thomas and Kellner, Reference Thomas and Kellner2003; Mishra et al., Reference Mishra, Saddichha and Baikunthanath2007; Dell'Osso et al., Reference Dell'Osso, Altamura, Mundo, Marazziti and Hollander2007). One small prospective trial (Khanna et al., Reference Khanna, Gangadhar, Sinha, Rajendra and Channabasavanna1988) reported that ECT improved OCD symptoms in non-depressed subjects, but after the cessation of ECT, there was a relapse in symptoms. One case report described ECT treating purely obsessional symptoms (Mellman and Gorman, Reference Mellman and Gorman1984). Only two studies described ECT in older women, both of whom had had a long history of OCD (Hussain et al., Reference Hussain, Lewis and Thorton1993; Casey and Davis, Reference Casey and Davis1994). This report describes a case of late-onset OCD, which was treatment resistant but which responded to ECT. The patient provided informed consent for publication of this case report.
Case history
The patient was an 81-year-old married female of Caucasian origin living independently with her husband. She had no previous psychiatric history. Following a right macular hemorrhage and acute loss of vision in her right eye, the patient developed increasing concerns about losing the sight in her left eye and anxious ruminations about a range of physical problems. Approximately one month prior to admission she was diagnosed with OCD following the development of prominent and distressing intrusive thoughts of being contaminated by germs and contaminating others. Subsequently she developed a compulsion to wash her hands excessively, and became avoidant of touching items such as taps. OCD is diagnosed by the presence of either obsessions (recurrent and persistent thoughts, impulses or images that are experienced as intrusive, distressing and cause anxiety, which are recognized as being a product of the patient's own mind) or compulsions (repetitive patterns of behavior or actions in response to an obsession), which cause marked distress and significantly interfere with the person's normal routine functioning (American Psychiatric Association, 2004). Although the patient also described mild depressive symptoms especially in the morning, these were congruent to the thoughts of contamination. She experienced tearfulness and agitation, but denied pervasive depressed mood, lack of energy, amotivation, guilt and suicidal ideation. Her symptoms profile did not qualify for a comorbid diagnosis of a major depressive disorder (American Psychiatric Association, 2004).
During admission to hospital, an extensive organic screen was performed including review by a consultant geriatrician, blood investigations, CT and MRI brain. All investigations were reported as normal. Neuropsychological testing (performed post ECT, after symptoms resolution) did not reveal any significant cognitive deficits such as problems with short- or long-term memory, attention, concentration or frontal lobe impairment. Various high-dose selective serotonin reuptake inhibitors were trialed without benefit, including sertraline 200 mg for four weeks, mirtazapine 60 mg for four weeks and venlafaxine XR 300 mg for four weeks. Psychotherapeutic interventions were unsuccessful due to the acute distress of the patient.
Following discussion with the patient and her family, she consented to a course of ECT. The thymatron IV machine was used. Propofol (80 mg) and suxamethonium (40 mg) were used as the induction and muscle relaxant agents respectively. The electrodes were positioned using the d'Elia configuration (Tiller and Lyndon, Reference Tiller and Lyndon2003). After initial stimulus dose titration (10%, 20%, 50%), she was given a course of a total of six right unilateral ECT (subsequent ECT was given at 60%; the last two treatments were given at 70% and 80%). Electroencephalographic (EEG) monitoring revealed post-ictal suppression of more than 80% for the first three treatments; however, the last three treatments had a post-ictal suppression less than 80%. Six effective generalized motor or electrographic seizures were administered three times a week for a fortnight (motor seizures ranged from 14 seconds to 25 seconds, and thecorresponding EEG seizures ranged from 15 seconds to 45 seconds). There was observed clinical improvement of the patient's symptoms and mental state after her third ECT. She had minimal side effects following each ECT treatment.
The patient was discharged to home on citalopram 40 mg mane and quetiapine 100 mg bd. The quetiapine was utilized for anxiolysis. However, six months later, her symptoms recurred and she was subsequently readmitted for a further course of ECT. Similar to her initial course of ECT, her symptoms began to improve after the third ECT. Following this second course of treatment, she received maintenance right unilateral ECT (charge 90%) every three weeks as an oupatient, with ongoing remission of OCD symptoms.
This case report is of interest for a number of reasons. First, this is a case which illustrates ECT causing a clear and demonstrable improvement in obsessive and compulsive symptoms in a case of OCD, without a comorbid major depressive disorder. It is of particular interest that this patient had a diagnosis of late-onset OCD, without any previous psychiatric history, and without underlying organic pathology. The patient's ongoing functional improvement with maintenance ECT also suggests ECT may have ongoing benefit in late-onset OCD. The mechanism behind this remains largely unknown; however, some research has implicated the role of serotonin in the pathoneurophysiology of OCD (Cybulska, Reference Cybulska2006) and it has been suggested that ECT may cause an increase in neuronal serotonin uptake binding sites in the frontal cortex (Hayakawa et al., Reference Hayakawa, Okamoto, Shimizu, Nishida, Motohashi and Yamawaki1995).
Conflict of interest
None.
Description of authors’ roles
S. Loi collected the data and wrote the paper. R. Bonwick assisted with writing the paper.
