To the Editor: Serotonin uptake inhibitors are the major pharmacological agents used in the treatment of obsessive-compulsive disorder (OCD). However, not all patients improve after such treatment, and it is questioned whether the disorder is in fact caused by abnormal serotonergic function. Moreover, it has been suggested that gonadal hormones might be involved in the pathophysiology of OCD (1). In fact, a few patients with OCD have been effectively treated with the antiandrogenic agent cyproterone acetate (2, 3).
I report the case of a man suffering from a severe form of OCD that greatly improved after treatment with a long-acting analogue of the gonadotropin-releasing hormone, which is known to reduce levels of circulating androgens to almost zero.
For Mr. A, age 42, the first symptoms of OCD had appeared at age 10, and he deteriorated during adolescence, when he developed severe rituals, obsessional slowness, cleaning compulsions, and obsessive thoughts. At the age of 20, he was given a disability pension, and since then no major improvement had been evident. For several years he was given adequate doses of clomipramine and extensive psychotherapy without any reduction in his symptoms. Mr. A was so tormented by the disorder that he raised the question of neurosurgical treatment.
On the basis of previous case reports (2, 3), he was given cyproterone acetate in ordinary doses for several months. Although he experienced a slight decrease in the intensity of his OCD symptoms, the effect was not obvious. Nevertheless, as a last resort and with Mr. A’s informed consent, treatment was started with monthly intramuscular injections of 3.75 mg of the long-acting gonadotropin-releasing hormone analogue triptorelin. In the first month he reported an increase in obsessions and compulsions. Such an effect is expected if androgenic hormones actually promote OCD symptoms, since plasma androgen concentrations are temporarily increased during the initial phase of treatment.
After 4 months, Mr. A claimed to be experiencing considerable relief. After 3 more months of treatment, only about 10% of his symptoms remained. He was no longer disabled by his illness, and he began study at the university level. The only side effect he noticed was a reduction in libido, which was less pronounced than it previously was when he was treated with clomipramine.
This observation supports the contention that OCD is associated with increased androgenic activity and that it can be effectively treated with pharmacological agents with antiandrogenic properties.