Seasonal obsessive-compulsive disorder

Abstract

A case of obsessive-compulsive disorder (OCD) with seasonal variation in symptoms of 10-years duration is reported because of its rarity. The phenomenology of the observed disorder was obsessions related to dirt and contamination resulting in washing compulsions with onset in October and complete resolution in April-May every year. The patient responded to phototherapy along with exposure and response prevention therapy and pharmacotherapy.

Seasonal variations in psychiatric symptoms have come into prominence following the description of seasonal affective disorder (SAD) which responds to treatment with bright artificial light.[1] A psychiatric epidemiologic study of 7,076 Dutch adults reported that panic disorder and generalized anxiety disorder were reported more frequently in winter than in other seasons, while obsessive-compulsive disorder (OCD) was reported more frequently in autumn than in summer.[2] Seasonal variations have also been reported in suicide, trichotillomania, bulimia, late luteal phase dysphoric disorder, and delayed sleep phase syndrome;[3,4,5] but reports of seasonal OCD are rare. Here we report a patient whose OCD had its onset during winter and remitted following summer. This is a unique case report from a tropical country like India showing winter onset OCD and responding to bright light therapy.

CASE REPORT

This 41-year-old housewife, educated up to sixth standard, hailing from middle socioeconomic status, with nil contributory family history, and suffering from hypertension and myopia in left eye (+0.75) and hypermetropia in right eye (−0.75), reported to outpatient clinic with history of 10-years duration characterized by unpleasant, frequent, and distressing doubts related to dirt and contamination. These resulted in performance of long, nonfunctional repetitive activities like cleaning and saying same words again and again. It was also reported both by husband and the patient herself that these symptoms have a seasonal pattern appearing in October and complete resolution in April-May. This seasonal pattern was so well-recognized that no treatment was taken for initial 3-4 years as they considered it an effect of change of season and that symptoms would disappear once the winter is over. No associated stress or precipitating factor was identified that might lead to reoccurrence of these symptoms every year in winter. Gradually over the years she noted that the severity of her illness increased and was causing socio-occupational dysfunctions. Therefore, this year she reported for psychiatric treatment at the beginning of October. On Mental State Examinations she had obsessions of contamination, compulsions for washing, and assurance seeking. The severity of symptoms was assessed by administrating Yale–Brown Obsessive Compulsive Scale (Y-BOCS).[6] The total Y–BOCS score was 30 (obsessions score 17 and compulsions score 13), other routine investigations were within normal limit. Other than OCD in subsequent follow-ups, patient was also diagnosed as having cervical spondylitis. She was on fluoxetine 20 mg once daily for 1month, but did not show much improvement. Therefore, keeping in view the seasonal variation in the pattern of OC symptoms, she was also considered for phototherapy. Phototherapy was carried out every day during 2 weeks with full spectrum bright light. The light was applied for 2 hours in day from 10 to 12 am. She was also taken up for exposure and response prevention (ERP) therapy twice a week for 1hour, where therapist assisted the patient in exposure. After a 14-day treatment there was a complete remission of OCD symptoms. Her Y-BOCS score came down to 8 (5 for obsession and 3 for compulsion) and she was discharged on fluoxetine 20mg once daily maintenance treatment. There was no relapse during the next 16months including onset of winter.

DISCUSSION

Epidemiological studies have found the prevalence rates of SAD to be generally higher in northern locations like North America and Europe, and generally lower in warmer, tropical countries.[1] However, the influence of latitude in prevalence of OCD is yet to be established by cross-sectional surveys from different countries. Studies also suggest that seasonal OCD is rare in prevalence and difficult to diagnose. One reason might be the requirement of long history with respect to seasonality is required for establishing diagnosis. In a large-scale study of children in United States aged 9-17 years, significant seasonal variations were found in overanxious disorder, OCD, separation anxiety disorder, social phobia, and major depressive disorder, with worsening of symptoms in August-October.[7] Similarly, a retrospective study of 34 patients with OCD found that 53% patients with OCD reported a marked seasonal variation in their symptoms.[8]

While the reasons for the seasonal variation in OCD symptoms is not known, alterations in monoaminergic neurotransmission in the brain are believed to be the reason for seasonal variations in mood disorders. In a study of 101 healthy men, it was found that the turnover of serotonin by the brain was lowest in winter. Moreover, the rate of production of serotonin by the brain was directly related to the duration of bright sunlight, and increase rapidly with greater duration of sunlight.[9] These findings are supportive of the notion that changes in release of serotonin by the brain may underlie seasonal variations in OCD. The alteration of brain serotoninergic systems in OCD supports the use of light therapy for the treatment of OCD. In fact, just like in the present case, a reduction in OC symptoms by bright light therapy has been reported earlier in a patient having seasonal variation in OCD.[10]

Our case raises certain questions. Can these variations in symptoms be solely attributed to climate (light) changes or there are factors that still remain unexplored. It is also questionable whether the response is because of anti-obsessional drugs or it was just a placebo effect of the drug therapy. A careful prospective study of seasonal pattern of OCD will help in understanding symptoms, course, and suitable treatment options in such cases. Different clinical course and treatment response indicates different and/or overlapping neurobiological basis for the seasonal OCD. Is seasonal variation of OCD different from OCD unrelated to seasons? Our case had contamination obsession and washing compulsion, but whether seasonal OCD manifest in other types like aggression, sexual, hoarding or symmetry, and whether it may be classified as ‘reactive’ or ‘autogenic’ subtypes as suggested by Lee and Kwon.[11] Further it can be speculated that, like SAD, seasonal OCD may be of some diagnostic value or can be taken as part of spectrum or a course specifier in nosology.