Worsening of Obsessive-Compulsive Symptoms Following Treatment With Olanzapine
TO THE EDITOR: We report a case of olanzepine-induced worsening of obsessive-compulsive symptoms in a patient who had a similar response to both clozapine and risperidone in previous trials. Although the current literature on atypical antipsychotic drug induction of obsessive-compulsive symptoms consists of 16 case studies, one retrospective report, and a small prospective investigation (1, 2), to our knowledge this is the first such report involving olanzapine. We undertook the current trial with this patient following the report by Baker et al. (3), who suggested that olanzapine did not cause de novo obsessive-compulsive symptoms in inpatients with schizophrenia following a 6-week trial.
Mr. A was a 35-year-old man who lived with his parents and suffered from partially responsive schizophrenia and comorbid obsessive-compulsive disorder (OCD). He had previously experienced clozapine- and then risperidone-induced worsening of obsessive-compulsive symptoms. Before treatment with olanzapine and at 4-week intervals, obsessive and compulsive symptoms were identified and rated with the Yale-Brown Obsessive Compulsive Scale (scale range=0–40). In the past 5 years Mr. A's best level of functioning was attained on a regimen of haloperidol, 25 mg/day, plus some combination of antiobsessional drug (Yale-Brown scale score=20). The most recent antiobsessional drug was fluvoxamine, 200 mg/day. On this regimen, before the olanzapine trial, Mr. A's symptoms included compulsive hand washing and his sentinel somatic delusion of “muscles breaking up.”
Olanzapine was started at a dose of 10 mg/day concurrent with Mr. A's other medications, and over a 2½-week period haloperidol was tapered and discontinued. Between weeks 3 and 4 of olanzapine treatment (1 week after discontinuation of haloperidol), accompanied by his mother, Mr. A presented with gross worsening of his OCD symptoms (Yale-Brown scale score=23). His mother stated, “I can't keep him supplied with all of the paper products!” referring to Mr. A's increased hand washing and drying and preference for disposable paper towels and toilet tissue. At week 4 fluvoxamine was increased to 300 mg/day, which was the maximum tolerated. The increase in fluvoxamine, however, did not alter the frequency, duration, or quality of Mr. A's OCD symptoms, and the dose was returned to 200 mg/day at week 10.
Despite the more severe OCD symptoms (Yale-Brown scale score=30 at weeks 12 and 16), Mr. A had a global subjective report of improvement and stated, “I feel more like myself.more awake and energetic.” He expressed interest in continuing the olanzapine trial, and he suggested “behavioral” treatments for his OCD. Adjunctive behavioral treatment had been suggested or attempted for many years without benefit, primarily because of Mr. A's unwillingness to accept this form of treatment. Although his parents were frustrated with the return of previously controlled OCD symptoms, they also agreed with and supported continuation of olanzapine treatment. Mr. A reported increased motivation, and after months of indecision he decided to join a health club (week 11) and entertained the idea of part-time work or school. His psychotic symptoms, including the somatic delusion, remained at a stable baseline.
This case is one of several to suggest that atypical antipsychotic drugs as a group may share the potential of uncovering or increasing obsessive-compulsive symptoms in patients with schizophrenia or with schizophrenia and comorbid OCD. We undertook the present trial on the basis of a controlled clinical investigation suggesting that olanzapine, despite its pharmacologic resemblance to clozapine and risperidone (i.e., 5-HT2 antagonism), did not show an association with the emergence of obsessive or compulsive symptoms in patients with schizophrenia (3). All patients in this trial had either no or slight obsessions or compulsions at baseline (i.e., before olanzapine treatment). Therefore, there may be a biological predisposition to developing atypical antipsychotic drug-induced obsessions or compulsions, and this may be prominent in schizophrenic patients with comorbid OCD or in schizophrenic patients with a strong obsessional component. Finally, this report highlights the significance (to the patient) of unrecognized negative or dysphoric symptoms related to use of typical antipsychotic drugs. Although Mr. A did not complain of classic extrapyramidal symptoms or akathisia or have obvious parkinsonian symptoms, he had a fairly robust subjective feeling of improvement and general well-being following discontinuation of haloperidol.
1 Baker RW, Bermanzohn PC, Wirshing DA, Chengappa KNR: Obsessions, compulsions, clozapine, and risperidone. CNS Spectrums 1997; 2:26-36Google Scholar
2 Dodt JE, Byerly MJ, Cuadros C, Christensen RC: Treatment of risperidone-induced obsessive-compulsive symptoms with sertra~line (letter). Am J Psychiatry 1997; 154:582Medline, Google Scholar
3 Baker RW, Ames D, Umbricht DSG, Chengappa KNR, Schooler NR: Obsessive-compulsive symptoms in schizophrenia: a comparison of olanzapine and placebo. Psychopharmacol Bull 1996; 32:89-93Medline, Google Scholar
