Obsessive-Compulsive Disorder Driven by Aspects of Ritual Addiction: A Case Report and Review of Literature

Case History

A 33-year-old woman who presented to the emergency room with an intentional overdose of benzodiazepines and was voluntarily admitted to the inpatient psychiatric service to manage her major depressive disorder episode (MDD) and severe obsessive-compulsive disorder (OCD). The patient has a past psychiatric history notable for severe OCD, MDD, and anorexia nervosa, restrictive type and family history significant for OCD in her father and daughter. Her current admission was triggered by increasing domestic issues in her relationship. The patient has fairly adequate insight of her own condition, realizing how difficult it is for others to live with her. She would like better control of her behaviors through medication reconciliation, as they are causing continued significant functional impairment and distress.

Symptomatology

Her OCD has profoundly behavioral addiction characteristics; the patient describes herself as a workaholic, working over seventy hours a week between two occupations. She exhibits more prototypical compulsions and obsessions such as showering and cleaning the house multiple times a day and having her home organized in an incredibly specific manner. Her relationship with these compulsions, however, is riddled with signs of addiction. She is unable to fathom discontinuing these actions, as it fuels her desire to have control. She has struggled with eating disorders, namely anorexia nervosa, and she heavily restricts her diet. The patient endorses calorie counting and only eats very specific foods, and is unable to waver from these behaviors, as well. The patient also follows her exercise regimen and hyper-exercises as a means of control, stating that she used to run 7–10 miles daily, and now is down to 3 miles daily. She endorses that if she was exposed to opiates, she would be susceptible to addiction, but she does not have a history of SUD currently.

Diagnosis

During this admission, the patient’s diagnoses included: OCD, MDD, recurrent, severe, and without psychosis, and suicide attempt.

Treatment

Prior to admission, the patient was seen by a nurse practitioner regularly and was controlled on fluvoxamine 150 mg once daily, lamotrigine 150 mg once daily, which she believes has been the only medication regimen that has benefited her. She had tried multiple pharmacologic treatment regimens, but it is unclear whether she reached the maximum dose on these medications for a duration of 12 weeks. Therefore, she may not be truly treatment resistant. The patient, when eventually discharged, was placed on her outpatient dose of lamotrigine, fluvoxamine, and is on a waitlist for an inpatient OCD treatment facility. Given the complexity and severity of her disease, the patient was also set up with an outpatient psychiatrist in addition to her nurse practitioner.

Discussion

Obsessive-compulsive disorder is defined by the presence of obsessions and compulsions, where obsessions are defined as intrusive thoughts, images, or urges usually causing marked distress and compulsions are acts a person feels they must perform in response to the obsession.¹ SUD is defined as a spectrum of disorders related to the use of a drug of abuse.¹ The pathophysiology of OCD can be incredibly similar to that of substance use disorder (SUD) and addiction, where both disease processes share their compulsive natures. Some researchers identify that compulsions can be identified as “behavior addictions.”¹¹ While the only recognized form of behavior addiction is gambling addiction, many other forms exist such as shopping, internet gaming, and sexual intercourse. Furthermore, compulsions such as repeated and persistent handwashing, showering, and general inability to stop rituals, can reasonably be seen as a form of an addiction to very specific behaviors and more generally, the addiction to having and maintaining control.

Because there are no specific reported cases of patients with OCD exhibiting overt signs of addictive tendencies towards their compulsions, we believe that it is important to highlight the different manners in which this may manifest. We believe that the addictive qualities of our patient’s OCD may have made her treatment that much more difficult, causing the cycling of multiple different regimens since childhood and the progression of her comorbid MDD. The typical initial assessment of OCD includes the Yale-Brown Obsessive-Compulsive Scale and the Dimensional Obsessive-Compulsive Scale, to define the severity of the disorder and characterize the symptoms. Management is centered on cognitive behavior therapy (CBT), pharmacotherapy (selective serotonin reuptake inhibitors (SSRI) being first line), and deep brain stimulation for refractory cases. Newer studies have shown efficacy and promise of ketamine in untreated individuals, as well as glutaminergic medications such as N-acetylcysteine, memantine, riluzole, and minocycline.^2–6 However, none of these agents are supported by empirical data as strong as the support for SSRIs, CBT, or augmentation with antipsychotics.

The assessment of substance use disorder begins with establishment of what substance(s) have been used. For each substance, it is important to delineate patterns of use, frequency, amount, and last use. Additionally, the existence of co-morbid mental health and mood disturbances with SUD is well known and screening for these diseases is a part of the assessment. Management is multidisciplinary and can involve inpatient, residential, and outpatient care depending on physician and patient preference.

The similarity between SUD and OCD has been delineated in neurochemistry, in addition to clinical anecdotes. Studies in both disorders have shown alterations in the reward processing networks consisting of the mesolimbic and mesocortical pathways. These pathways include the ventral tegmental area, amygdala, nucleus accumbens, prefrontal cortex, and hippocampus. OCD patients have shown altered nucleus accumbens activation when anticipating rewards, which would support the conceptualization of compulsive behavior in OCD as a disorder of behavior addiction.⁷ Brain imaging studies in patients with OCD have also shown reduced prefrontal cortex activity and enhanced basal ganglia activity; alcohol use disorder and dependence show similar neuroanatomical findings.⁸ Furthermore, compulsivity in OCD and addictions is associated with attenuated dopamine release in the ventral tegmental area, leading to impaired reward and punishment processing. There are findings of diminished serotonergic signaling in the prefrontal cortex, causing cognitive and behavioral inflexibility, as seen in our patient.⁹

The continued concordance between the neuroanatomy and neurochemical changes found in both OCD and SUD only solidifies the thought that patients who may exhibit more addiction-type characteristics in their OCD symptomatology may benefit from alternate modes of treatment. For example, patients exhibiting addictive qualities may be controlled on agents used to reduce cravings, such as naltrexone, or modulate the cortico-mesolimbic dopamine pathways, serotonin, opioid, glutamate, and y-aminobutyric acid systems. Patients who wish to make lifestyle and habit changes may benefit from agents for the reduction and prevention of relapse.¹⁰ Identifying and confirming the similarities between OCD, substance use disorder, and globally addiction can provide additional treatment options for patients with severe OCD which has been refractory to multiple traditional treatment modalities and allow for better control of symptoms and quality of life.