Relevance of electroconvulsive therapy in acute and maintenance phase management of obsessive-compulsive disorder: A case study

Dear Editor,

Obsessive-compulsive disorder (OCD) is a common psychiatric disorder with variable course and outcomes as reported in different follow-up studies.[1] Serotonergic agents, cognitive behavior therapy, and behavioral interventions like exposure and response prevention are the mainstays of treatment in OCD.[1,2] OCD significantly interferes with the quality of life.[3] Electroconvulsive therapy (ECT) is one non-invasive neuromodulation technique used in the management of OCD very infrequently and the evidence is sparse about its efficacy. This case report describes a 26-year-old female patient with a history of psychosis and unusual obsessions (recurring thoughts of lizards falling on her) who responded well to ECT.

A 26-year-old married woman, a graduate and homemaker from a rural area, sought treatment at the psychiatry department in a tertiary center. She reported recurring thoughts of disgust stemming from a fear of lizards falling on her, along with six years of disturbed sleep. These thoughts began without any prior negative experiences with lizards or other reptiles. Her symptoms first appeared two weeks before seeking treatment from a private psychiatrist, and she showed improvement while on medication for two years. In 2020, she experienced a second relapse five months after getting married but responded well to daily sertraline at 150 mg. She did not experience symptoms for the next 14 months. However, around five months after childbirth, in late 2023, she began experiencing a worsening of symptoms, such as suspicion toward her family, auditory hallucinations, and disrupted sleep, which lasted for around five months. These symptoms improved after taking loxapine 50 mg/day for two weeks. She remained well for the next 20 days. The patient has been experiencing repetitive thoughts of lizards falling on her, which has caused extreme fear and senseless thoughts. She has attempted to leave her home due to fear of lizards and has been increasingly irritable and suspicious for the past three months. The patient’s illness began with disrupted sleep and distressing recurring thoughts of lizards falling on her. She feels intense disgust at the idea of skin contact with a lizard and has taken measures to prevent this, such as wearing a veil on her head and checking for lizards in the house. She has minimal control over these thoughts and experiences extreme anxiety. There have been no reports of other symptoms such as delusions, disorganized behavior, or auditory hallucinations. Her maternal uncle had a history of well-managed psychosis, and there was no relevant past or family history of other psychiatric or medical illnesses. During a mental status examination, her affect was anxious, and psychomotor agitation was evident. Her thinking revealed an obsession with the fear of a lizard falling on her. She was diagnosed with Other non-organic psychotic disorders (F28) with OCD, predominantly obsessional thoughts or ruminations (F42.0) as per ICD-10 diagnostic criteria. The patient’s symptom severity score on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was 32. Initially, the patient was prescribed 10 mg of olanzapine and 20 mg of fluoxetine. The fluoxetine dose was gradually increased to 80 mg per day, while the olanzapine dosage remained at 10 mg/day. As her symptoms worsened and she became suicidal, ECT was considered. Following one session of ECT, the patient experienced a significant reduction in her intrusive thoughts. After three additional ECT sessions, the patient achieved remission. A total of four ECT sessions were administered, and the patient’s medication regimen remained unchanged. During a two-week follow-up period, the patient’s symptoms worsened (with a YBOCS score of 28), prompting six more ECT sessions in conjunction with ongoing pharmacological treatment. Again, the patient achieved remission. Subsequently, the patient underwent maintenance ECT weekly for a month. The plan moving forward includes spacing out ECT sessions gradually while closely monitoring for any signs of symptom relapse and maintaining the patient on the same dose of serotonergic medications.

There are several unique features in this patient (obsession with coming into contact with a lizard, a history of psychosis which resolved, and the presence of depressive symptoms and suicidal behavior, which resolved completely with ECT, remerged following discontinuation of ECT and again controlled with ECT). The affective symptoms, suicidal behavior that was unmanageable with a higher dose of serotonergic agent (fluoxetine 80 mg/day), improved significantly with a single session of ECT. Additionally, the YBOCS score also reached zero from a baseline score of 32. Considering the re-emergence of symptoms of OCD following discontinuation of ECT, it was reconsidered again. After the acute management of symptoms, weekly maintenance sessions of ECT were given and the symptoms of OCD remained well controlled with this strategy. Existing evidence about the use of ECT in the management of OCD is mostly limited to case studies, retrospective chart reviews or small sample quasi-experimental study.[4,5,6,7,8,9,10,11,12,13] The outcomes in the existing research are mixed, with some reporting minimal improvement in OCD symptoms following ECT and others reporting significant improvement in OCD symptoms; however, a consistent finding in most of the published research is improvement in co-morbid depressive symptoms following administration of ECT. A study conducted by Li et al. (2022)[5] reported that the presence of depression or psychosis as comorbidity with OCD is associated with poor response to ECT. However, another study by Liu et al. (2014),[7] reported patients of OCD with prominent depressive symptoms responded well to ECT. In our case, comorbid depressive symptoms, suicidal behavior, and psychosis were associated and the patient responded well to ECT. ECT can be an effective intervention in the management of OCD, though it is not routinely recommended. Inadequate trial with serotonergic medications and cognitive behavior therapy has been reported in patients of OCD responding to ECT.[14] Similarly, past and family history of mood disorder, severe form of OCD, and the presence of sexual obsessions may be associated with good response to ECT.[4,7,14,15]

ECT may improve core symptoms of OCD, affective symptoms, and suicidal behavior in some patients. Larger studies are needed to confirm these findings and to establish the relevance of maintenance ECT in preventing relapse. Further research will guide clinicians on the potential role of ECT in severe and difficult-to-treat cases of OCD.

Ethical statement

Informed consent was taken from the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.