Cases That Test Your Skills

Obsessive and inattentive

Current Psychiatry. 2012 March;11(3):43-47

References

1. Goodman WK, Price LH, Rasmussen SA, et al. The Yale-Brown Obsessive Compulsive Scale: I. Development, use and reliability. Arch Gen Psych. 1989;46(11):1006-1011.

2. Goodman WK, Price LH, Rasmussen SA, et al. The Yale-Brown Obsessive Compulsive Scale: II. Validity. Arch Gen Psych. 1989;46(11):1012-1016.

3. Geller DA, Biederman J, Faraone S, et al. Re-examining comorbidity of obsessive compulsive and attention-deficit hyperactivity disorder using an empirically derived taxonomy. Eur Child Adolesc Psychiatry. 2004;13(2):83-91.

4. Freeman RD. Attention deficit hyperactivity disorder in the presence of Tourette syndrome. Neurol Clin. 1997;15(2):411-420.

5. Geller DA. Obsessive-compulsive and spectrum disorders in children and adolescents. Psychiatr Clin North Am. 2006;29(2):353-370.

6. Eapen V, Fox-Hiley P, Banerjee S, et al. Clinical features and associated psychopathology in a Tourette syndrome cohort. Acta Neurol Scand. 2004;109(4):255-260.

7. Kano Y, Ohta M, Nagai Y, et al. Association between Tourette syndrome and comorbidities in Japan. Brain Dev. 2010;32(3):201-207.

8. Grados M, Riddle M. Do all obsessive-compulsive disorder subtypes respond to medication? Int Rev Psychiatry. 2008;20(2):189-193.

9. Lipkin PH, Goldstein IH, Adesman AR. Tics and dyskinesias associated with stimulant treatment in attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med. 1994;148(8):859-861.

10. Castellanos FX, Giedd JN, Elia J, et al. Controlled stimulant treatment of ADHD and comorbid Tourette’s syndrome: effects of stimulant and dose. J Am Acad Child Adolesc Psychiatry. 1997;36(5):589-596.

11. Gadow K, Sverd J, Sprafkin J, et al. Long-term methylphenidate therapy in children with comorbid attention-deficit hyperactivity disorder and chronic multiple tic disorder. Arch Gen Psychiatry. 1999;56(4):330-333.

12. Gadow KD, Sverd J, Nolan EE, et al. Immediate-release methylphenidate for ADHD in children with comorbid chronic multiple tic disorder. J Am Acad Child Adolesc Psychiatry. 2007;46(7):840-848.

13. Tourette’s Syndrome Study Group. Treatment of ADHD in children with tics: a randomized controlled trial. Neurology. 2002;58(4):527-536.

14. Lyon GJ, Samar SM, Conelea C, et al. Testing tic suppression: comparing the effects of dexmethylphenidate to no mediation in children and adolescents with attention-deficit/hyperactivity disorder and Tourette’s disorder. J Child Adolesc Psychopharmacol. 2010;20(4):283-289.

15. Gadow KD, Sverd J, Sprafkin J, et al. Efficacy of methylphenidate for attention-deficit hyperactivity disorder in children with tic disorder. Arch Gen Psychiatry. 1995;52(6):444-455.

16. Bloch MH, Panza KE, Landerso-Weisenberger A, et al. Meta-analysis: treatment of attention-deficit/hyperactivity disorder in children with comorbid tic disorders. J Am Acad Child Adolesc Psychiatry. 2009;48(9):884-893.

17. McDougle CJ, Goodman WK, Price LH. Dopamine antagonists in tic-related and psychotic spectrum obsessive compulsive disorder. J Clin Psychiatry. 1994;55(suppl):24-31.

18. Wilens TE, Morrison NR. The intersection of attention-deficit/hyperactivity disorder and substance abuse. Curr Opin Psychiatry. 2011;24(4):280-285.

19. Kollins SH. A qualitative review of issues arising in the use of psycho-stimulant medications in patients with ADHD and co-morbid substance use disorders. Curr Med Res Opin. 2008;24(5):1345-1357.

20. Schubiner H. Substance abuse in patients with attention-deficit hyperactivity disorder: therapeutic implications. CNS Drugs. 2005;19(8):643-655.

21. Stahl SM. The prescriber’s guide. Stahl’s essential psychopharmacology. 3rd ed. New York NY: Cambridge University Press; 2009.

22. Jain R, Segal S, Kollins SH, et al. Clonidine extended-release tablets for pediatric patients with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2011;50(2):171-179.

23. Hedderick EF, Morris CM, Singer HS. Double-blind crossover study of clonidine and levetiracetam in Tourette syndrome. Pediatr Neurol. 2009;40(6):420-425.

24. Joffe RT, Swinson RP, Levitt AJ. Acute psychostimulant challenge in primary obsessive-compulsive disorder. J Clin Psychopharmacol. 1991;11(4):237-241.

25. Insel TR, Hamilton JA, Guttmacher LB, et al. D-amphetamine in obsessive-compulsive disorder. Psychopharmacology (Berl). 1983;80(3):231-235.

TREATMENT: Weighing options

Clinical Point

Psychostimulants could exacerbate obsessions or compulsions in some patients because of their dopaminergic properties

To manage impaired attention and executive function difficulties secondary to ADHD, we offer Mr. C several options, including bupropion, modafinil, and memantine augmentation. Mr. C asks for a psychostimulant because exam week is approaching and he wants a treatment with quick therapeutic effect. We discuss with Mr. C the potential for dopaminergic agents, such as psychostimulants, to exacerbate tics or OCD symptoms. Ultimately, we prescribe immediate-release MAS, 20 mg/d.

Two days later, Mr. C says he has taken 3 MAS doses and describes a marked reduction in obsessions, significant decrease in frequency of “triggers,” and greater capacity to use CBT saying, “when I am [triggered], I am able to move past the urges without doing any compulsions.” Daily time spent “stuck on” obsessions or compulsions decreases from 5 to 6 hours per day to “about 2 and a half minutes.”

Mr. C reports a modest increase in the prevalence of tics, experienced as “little throat clears and quick stuttering of breath.” He notes that, although in the past such tics would be followed by urges for “perfecting the tic and making it feel just right,” he presently “had no desire to do so.”

Clinical Point

Diversion of psychostimulants is a risk inherent in the use of these agents, particularly among college-age patients

OUTCOME: Sharper focus

Increasing MAS immediate release from 20 mg/d to 30 mg/d suppresses Mr. C’s obsessions and compulsions for 8 hours. On the 19th day of treatment, MAS immediate release was replaced with an extended release formulation, 30 mg/d, which preserves therapeutic effect and tolerability for 16 weeks. Repeat Y-BOCS yields 9 total, 3 on obsessions subscale, and 6 on compulsions subscale scores.

One month later, Mr. C reports that his symptoms have been “improving ever since” the previous appointment. He continues to be able to access skills for managing his OCD and is doing well in his 2 accelerated summer courses, saying “I focus really well” in 3-hour class sessions. On exam, tic behaviors are nearly absent. Mr. C describes occasional bouts of anxiety associated with urges to engage in tic behaviors, in turn arising from fear of symptomatic recurrence as he worked toward stopping smoking as advised by his primary care physician and psychiatrist.

The authors’ observations

The results of the repeat Y-BOCS are consistent with improvement in obsessions but possible worsening of compulsions since Mr. C was discharged from residential treatment. Alternatively, compulsions may have worsened immediately after discharge and declined again with introduction of MAS.

A substantial body of literature describes the challenges associated with treating ADHD with comorbid tics, including the relative degree of risk of tic exacerbation associated with treating ADHD with psychostimulants. The range of FDA-approved pharmacologic options for treatment of this comorbidity is limited (Table 2),²¹ particularly given the risk for tardive dyskinesia associated with the typical antipsychotics haloperidol and chlorpromazine. Data support using the α-2 agonist clonidine to treat hyperactivity associated with ADHD²² and TD²³ and an extended-release preparation of this medication is FDA-approved for the former but not the latter indication (an α-2A receptor subtype agonist, guanfacine, also is FDA-approved for ADHD in pediatric patients). Mr. C’s experience of robust, sustained reduction in obsessions, if not compulsions, after treatment with MAS is consistent with the few studies of stimulant use in ADHD with comorbid OCD.^24,25

Effective treatment of ADHD may help Mr. C better access CBT strategies and thereby potentiate treatment of comorbid OCD.

Table 2

FDA-approved medications for ADHD, OCD, and TD

Disorder	Medications
ADHD	Amphetamine (racemic), atomoxetine, chlorpromazine (hyperactivity), clonidine extended release, dexmethylphenidate, dextroamphetamine, guanfacine extended release, haloperidol (hyperactivity, second-line), lisdexamfetamine, methylphenidate (racemic)
OCD	Clomipramine, fluoxetine, fluvoxamine, paroxetine, sertraline
TD/Tourette’s syndrome	Haloperidol (Tourette’s), pimozide (Tourette’s)
ADHD: attention-deficit/hyperactivity disorder; OCD: obsessive-compulsive disorder; TD: tic disorder Source: Reference 21

Related Resources

Clinical Point

Data support using the α-2 agonist clonidine to treat hyperactivity associated with ADHD and TD

Pliszka SR. Treating ADHD and comorbid disorders: psychosocial and psychopharmacological interventions. New York, NY: The Guilford Press; 2011.
Pollak Y, Benarroch F, Kanengisser L, et al. Tourette syndrome-associated psychopathology: roles of comorbid attention-deficit hyperactivity disorder and obsessive-compulsive disorder. J Dev Behav Pediatr. 2009;30(5):413-419.

Drug Brand Names

Atomoxetine • Strattera
Bupropion • Wellbutrin, Zyban
Chlorpromazine • Thorazine
Clomipramine • Anafranil
Clonidine extended release • Kapvay
Dexmethylphenidate • Focalin
Dextroamphetamine • Dexedrine
Escitalopram • Lexapro
Fluoxetine • Prozac
Fluvoxamine • Luvox
Guanfacine • Intuniv, Tenex
Haloperidol • Haldol
Lisdexamfetamine • Vyvanse
Memantine • Namenda
Methylphenidate • Methylin, Ritalin
Modafinil • Provigil
Pimozide • Orap
Quetiapine • Seroquel
Risperidone • Risperdal

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.