OCD and BDD Successfully Treated With ECT: Case Report From China
Out on Pubmed, from clinicians in China, is this case report:
Case Report: Effect of Electroconvulsive Therapy on Obsessive-Compulsive Disorder Comorbid With Body Dysmorphic Disorder.
Front Psychiatry. 2021 Aug 2;12:706506. doi: 10.3389/fpsyt.2021.706506. eCollection 2021. PMID: 34408682
The pdf is here.
An 18-year-old male high school student with an established
diagnosis of OCD presented in our department accompanied by
his parents after cutting off a small piece of his nose with scissors.
A year and a half earlier, he had decided that his nose was ugly
and started picking and prodding his nose repeatedly until it
was bleeding and painful. Psychiatric treatment had been sought
nearly a year before the current presentation. At that time, he was
started on fluvoxamine 200mg twice daily for 12 weeks and then
in combination with CBT for a further 12 weeks. However, his
symptoms worsened and he was spending increasing amounts
of time picking at his nose. The fluvoxamine was switched to
fluoxetine, another SSRI, which was started at a dose of 20mg and
increased gradually to 50mg over 2 weeks, and then combined
with aripiprazole 10 mg/day and alprazolam 0.8 mg/day for 12
weeks. However, the patient continued to pick at his nose.
On admission, the patient was unstable, irritable, and still
repeatedly picking at his injured nose, despite being aware that he
should not be doing so. He was in severe pain but still repeatedly
checking his nose in a mirror. He was in obvious distress with low mood, even though he knew rationally there was nothing abnormal about his nose. On examination, he met the ICD-10 diagnostic criteria for comorbid OCD and BDD. In view of the
poor efficacy of the first-line and second-line treatments, we
opted for a non-pharmacological treatment in this patient.
ECT has been used successfully as a treatment for mood and
psychotic disorders. Although there is no mention of ECT as
a treatment modality for OCD in the guidelines (9), there are
a few reports of ECT being an effective treatment for severe
OCD. After a full assessment of the severity of the patient’s
condition and the risk of self-injury, ECT was considered as
a treatment for this patient. A thorough physical examination
(including measurement of blood pressure, heart rate, and
respiratory function and a neurological assessment), laboratory
investigations (including hematology and biochemistry), and
chest radiography revealed no obvious abnormalities. Written
informed consent to treatment with modified ECT under general
anesthesia was obtained from the patient after he had been
provided with a detailed explanation about the course of
treatment and the potential risks.
Modified ECT was performed using a Thymatron System
IV (America Somatics LLC, Lake Bluff, IL, USA). All doses of
psychotropic drugs were reduced, fluoxetine and aripiprazole
was reduced to 40mg and 5 mg/d, respectively, on the day
before modified ECT. Alprazolam was discontinued the day
before modified ECT. The patient was fasted for at least 8 h
before ECT, and his temperature, weight, and blood pressure
were measured 30 min before treatment.
The modified ECT procedure is performed as follows. After venipuncture with a
20–30-cm plastic needle, 10 ml of 25% glucose solution are
injected to confirm successful puncture. The following agents are
then injected sequentially: atropine sulfate 0.5–1.0mg, diluted
to 2ml with water for injection; etomidate 0.2–0.3 mg/kg,
administered intravenously until loss of the eyelash reflex; 100%
pure oxygen with pressure ventilation at a frequency of 20–
30 tt/m, until the recovery of spontaneous breathing; and
succinylcholine chloride (2mM; 100mg in glycerin) diluted
to 5ml with water for injection. Approximately 30–60 s after
intravenous injection of succinylcholine chloride 0.8–1 mg/kg,
when fasciculations in the muscle fibers of the face and limbs
have stopped, a muscle relaxant is administered.Mask ventilation
is used throughout the procedure with careful monitoring for
airway patency and reflux aspiration and insertion of an oral
protector. Frontotemporal electrodes are then placed on both
sides. The stimulation parameters are as follows: charge, 101.1
millicoulombs; pulse width, 0.5ms; frequency, 20Hz; current
intensity, 0.9A; and stimulus duration, 5.6 s. A voltage of 110V
is then applied for 2–3 s. Mask ventilation was used until
spontaneous respiration resumes. Finally, airway patency and
thoracic movements are assessed and aspiration and auscultation
are performed. Spontaneous respiration usually resumes within
5–10min, after which the intravenous needle is removed.
Our patient underwent 12 sessions of modified ECT over
3 weeks with a maximum of three sessions per week and a
minimum interval between sessions of 48 h. Seizure monitoring
included two-lead electroencephalography (EEG) and oximetry.
The two-lead EEG electrodes were placed on the left and right
frontopolar points and over the ipsilateral mastoid processes
(FP1-A1 and FP2-A2 according to the International 10Y20
system). The patient did not report any adverse reactions, such
as dizziness or headache, after the sessions.
Psychiatric symptoms were assessed using the Hamilton
Anxiety Scale (HAM-A), Hamilton Depression Scale (HAMD),
and Yale Brown Obsessive Compulsive Scale (Y-BOCS)
before and 2 and 4 weeks after completion of the course of
modified ECT.
Before treatment, the HAM-A, HAM-D, and YBOCS
scores were 25, 14, and 26, respectively. After 2 weeks of
treatment, there was a marked decrease in the frequency of nosepicking.
The HAM-A, HAM-D, and Y-BOCS scores decreased to
17, 9, and 19, respectively, after 2 weeks of treatment and to 14, 6,
and 10 at 4 weeks. At the end of the treatment course, the patient’s
clinical symptoms were significantly improved. Although he
remained anxious about having what he perceived to be an
unattractive nose, he stopped picking at it.
I have chosen to feature this case report on the blog today to again bring up the use of ECT for refractory OCD, in this case comorbid with body dysmorphic disorder (BDD). There are several errors in the details of the ECT and ECT anesthesia (possibly related to language issues, or poor editing), but the case is clinically compelling and worth reading. BDD is a fascinating, debilitating variant of OCD and very difficult to treat.
There is much more literature about ECT or OCD than referenced here and the lack of longitudinal follow up of the patient is another deficiency of the report. Please see also blog post of August 27th.
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