A Case of Obsessive-Compulsive Disorder With Fear of Contamination of Percutaneous Endoscopic Gastrostomy Tube

A Case of Obsessive-Compulsive Disorder With Fear of Contamination of Percutaneous Endoscopic Gastrostomy Tube

To the Editor: Obsessive-compulsive disorder (OCD) is frequently seen in older adults.1 Although geriatric OCD, like OCD in younger adults and children, benefits from standard OCD treatments,1 management of OCD in geriatric cases can be extremely difficult due to multiple comorbid medical conditions in this age group. We report a geriatric patient with chronic OCD who developed life-threatening complications due to comorbid subjective dysphagia that needed percutaneous endoscopic gastrostomy (PEG) tube placement. This case highlights the difficulties in the management of OCD in geriatric patients who have a PEG tube.

Case report. Ms A is a 77-year-old married white woman with a long history of OCD (DSM-5) who was admitted to the medical unit for malnutrition due to dysphagia. Although all results from medical workups were within normal limits, the patient had to have a PEG tube inserted due to severe malnutrition and cachexia. She was initially stable with the PEG tube and was discharged to a skilled nursing facility but soon was readmitted because she developed obsessive thoughts about PEG tube contamination. Since her diet mainly consisted of liquids, Ms A developed diarrhea, which exacerbated her obsessional fears of fecal contamination and refusal of tube feeds. Finally, she refused to eat or drink either orally or via PEG tube, leading to significant weight loss. She also developed psychotic symptoms such as auditory hallucinations, visual hallucinations, and paranoid thoughts. Additionally, Ms A presented with severe depressive symptoms including helplessness, hopelessness, anhedonia, depressed mood, and suicidal ideations with a plan of self-starving. In addition to fluoxetine, olanzapine and clonazepam were initiated to address her psychotic and anxiety symptoms. The fluoxetine dose was increased to 60 mg daily, olanzapine was titrated up to 15 mg daily, and the clonazepam dose was 0.5 mg twice daily. Furthermore, she was started on bedside supportive therapy sessions. Over a period of a few weeks, Ms A responded to these treatment interventions with reduction in obsessive thoughts and psychotic symptoms. She allowed PEG tube feedings and even tried oral feeds on occasion. Ms A regained weight and medical stability and was discharged home.

This case highlights several important issues and challenges. The first challenge was self-starvation, which put the patient in serious danger. Some studies2 have suggested an association between weight loss and OCD symptoms in anorexic patients; so excessive weight loss could even worsen OCD symptoms. Exacerbation of OCD symptoms after PEG tube placement was another challenge. Moreover, the existence of depressive, anxiety, and psychotic symptoms made the management of OCD even more challenging in this patient. In this case, the patient’s psychotic symptoms could be manifestations of delirium and associated depression. Treating malnutrition with a PEG tube was initially the focus of her treatment plan. As mentioned, olanzapine was used to address the psychotic symptoms, and the patient’s response to anxiolytics along with selective serotonin reuptake inhibitors for OCD and depression was promising.

There are studies3-5 advocating the use of atypical antipsychotics with serotonergic agents in treatment-resistant OCD. However, there are also studies that either show no benefit from using antipsychotic augmentation6 or show that atypical antipsychotics may even exacerbate OCD symptoms.7 Therefore, choosing the appropriate antipsychotic to either augment response to fluoxetine or treat psychotic symptoms needed to be done cautiously. Our treatment outcome provides evidence in favor of using atypical antipsychotics like olanzapine in severe, complicated treatment-resistant OCD patients with psychotic symptoms. Furthermore, the importance of bedside supportive therapy as an adjunct to the psychopharmacologic treatment was emphasized in this case.

References

1. Jones MK, Wootton BM, Vaccaro LD. The efficacy of exposure and response prevention for geriatric obsessive compulsive disorder: a clinical case illustration. Case Report Psychiatry. 2012;2012:394603. PubMed doi:10.1155/2012/394603

2. Mattar L, Thiébaud MR, Huas C, et al. Depression, anxiety and obsessive-compulsive symptoms in relation to nutritional status and outcome in severe anorexia nervosa. Psychiatry Res. 2012;200(2-3):513-517. PubMed doi:10.1016/j.psychres.2012.04.032

3. Maina G, Pessina E, Albert U, et al. 8-Week, single-blind, randomized trial comparing risperidone versus olanzapine augmentation of serotonin reuptake inhibitors in treatment-resistant obsessive-compulsive disorder. Eur Neuropsychopharmacol. 2008;18(5):364-372. PubMed doi:10.1016/j.euroneuro.2008.01.001

4. Bystritsky A, Ackerman DL, Rosen RM, et al. Augmentation of serotonin reuptake inhibitors in refractory obsessive-compulsive disorder using adjunctive olanzapine: a placebo-controlled trial. J Clin Psychiatry. 2004;65(4):565-568. PubMed doi:10.4088/JCP.v65n0418

5. Marazziti D, Pfanner C, Dell’ Osso B, et al. Augmentation strategy with olanzapine in resistant obsessive compulsive disorder: an Italian long-term open-label study. J Psychopharmacol. 2005;19(4):392-394. PubMed doi:10.1177/0269881105053299

6. Shapira NA, Ward HE, Mandoki M, et al. A double-blind, placebo-controlled trial of olanzapine addition in fluoxetine-refractory obsessive-compulsive disorder. Biol Psychiatry. 2004;55(5):553-555. PubMed doi:10.1016/j.biopsych.2003.11.010

7. Khullar A, Chue P, Tibbo P. Quetiapine and obsessive-compulsive symptoms (OCS): case report and review of atypical antipsychotic-induced OCS. J Psychiatry Neurosci. 2001;26(1):55-59. PubMed

Ali Najafian Jazi, MD, MSa

[email protected]

Shady S. Shebak, MDb

Bush Kavuru, MDa

aDepartment of Psychiatry, Carilion Clinic, Roanoke, Virginia

bDepartment of Psychiatry, Virginia Tech Carilion School of Medicine, Roanoke

Potential conflicts of interest: None.

Funding/support: None.

Published online: December 8, 2016.

Prim Care Companion CNS Disord 2016;18(6):doi:10.4088/PCC.16l01967

© Copyright 2016 Physicians Postgraduate Press, Inc.