Abstract
Rathi Mahendran, Institute of Mental Health, Woodbridge Hospital, Singapore:
Olanzapine-induced worsening of obsessive–compulsive (OC) symptoms has been reported [1]. We have not found reported cases of OC symptoms arising de novo with olanzapine treatment and would like to report this case.
The patient, a 53-year-old, single, Asian male with chronic schizophrenia for 34 years had no past history of OC symptoms and no relevant family history. Over the years, he exhibited abnormal behaviour such as mumbling and smiling to himself and had poor socio-occupational functioning. He was on regular treatment with depot injection fluphenazine decanoate 50 mg six weekly but defaulted two appointments and was admitted for increasingly disturbed and hostile behaviour. He was hallucinated, thought disordered and deluded at admission. Despite electroconvulsive therapy and addition of sulpiride, the improvement in his mental state was short-lived. After 4 weeks, he was again unwell, thought disordered and hallucinated.
He was switched to Olanzapine, which was gradually titrated to 20 mg per day over 23 days. After 14 days at this dose, ward staff noted that he began to count chairs repeatedly. If stopped, he would put up a struggle and restart the count. He then began to count toothbrushes every morning, greet staff repeatedly and began to adjust his T-shirt in a particular pattern. This would be repeated 2–3 times before he responded to questions. He could not explain the behaviour except that he ‘had to do it’ and felt uncomfortable and distressed if he resisted. There were no passivity symptoms.
On the Y-BOCS Symptom Checklist (9/89) [2], the principal symptoms noted were: checking compulsions, repeating rituals, counting compulsions, ordering/arranging compulsions and miscellaneous compulsions. Other behaviours noted included repeatedly checking nametags of the nursing staff, checking light switches and counting patients in the ward sometimes till midnight.
The score on the Y-BOCS Compulsion Rating Scale [2] was 14 on Day 10 and rose to 16 on Day 17. Olanzapine was decreased to 15 mg per day and Clomipramine was started at 50 mg per day after 2 weeks. He actually appeared to worsen and so Clomipramine was increased to 75 mg per day and Olanzapine discontinued a week later. He was then prescribed Quetiapine starting at 25 mg per day and increasing to 100 mg per day by 2 weeks. There was significant reduction in the compulsive symptoms. The Clomipramine was reduced to 25 mg per day. He continued to count chairs but could be discharged home. His family reported this continued for about a week more at home and since then, over the last six months, there have been no symptoms.
Newly emergent OC symptoms have been reported with Risperidone and Clozapine but have not been demonstrated with Olanzapine [3]. An open-label trial has even suggested that Olanzapine may be effective in augmenting SSRI treatment for OCD refractory patients [4]. To our knowledge, this is the first report of compulsive symptoms arising de novo with Olanzapine treatment.