The emergence of obsessive compulsive and compulsive buying symptomatology after acute stress and short-term use of ribavirin: case reports

Introduction

Neuropsychiatric side-effects have been reported in up to 60% of patients undergoing treatment with antiviral agents [Evon et al. 2009]. Most of them (48%) were depressive disorders. More rarely, signs and symptoms associated with anxiety, sleep, memory and attention disorders were observed [Lochet et al. 2003; Ward and Curtin, 2006]. Ribavirin, an antiviral agent, has also been reported to cause some psychiatric syndromes, however it is stressed that these effects are often enhanced by the psychiatric side-effects of the other antiviral agents (such as interferon alpha) which are often used together [Reichard et al. 1997; Martin-Santos et al. 2008]. We would like to report a case of single-agent ribavirin-induced compulsive buying.

The purpose of this case report is to draw attention to obsessive compulsive spectrum disorders (OCSDs) such as compulsive buying, which, although not defined as a disorder by the DSM and ICD, may cause clinically significant disability, and also to its etiology of biological and psychological explanations.

A 34-year-old woman presented to our clinic with obsessive fears of becoming contaminated by microbes whenever she touches any item, continuous thoughts of having forgotten to turn the lights off and close windows and doors, uncontrolled repetitive behaviors in the form of a compulsive need to constantly check the doors or lights or continuously wash her hands. She also had sudden and intense desires to shop and purchase things needlessly. When she postponed the desire to shop, she experienced severe discomfort and restlessness. She gained relief by buying unnecessary things, hence she faced economical problems due to excessive expenditure, resulting in regret and anxiety feelings.

Three weeks prior to her application, she received a prophylaxis treatment consisting of 1000 mg/day oral ribavirin applied for 7 days since she had pricked her finger with a syringe that had been used on a patient with Crimean-Congo hemorrhagic fever disease. During the medication usage she had no complaint other than a feeling of dizziness and lack of concentration. The prophylaxis treatment for Crimean-Congo hemorrhagic fever disease was completed and the disease did not appear. The aforementioned psychiatric symptoms and complaints started a week after the completion of this treatment with ribavirin.

It was determined via psychiatric examination that she was in an anxious–angry mood, her thoughts included suspicion and contamination obsessions, control and washing compulsions, and intense desire to go shopping; her behavior of purchasing unnecessary things was noted and, after purchasing, she experienced thoughts of guilt. Routine hematological and biochemical parameters were normal. Tests also revealed a Beck Depression Inventory score of 6, Beck Anxiety Inventory score of 7, Yale–Brown Obsessive Compulsive Scale score of 15, Brief Symptom Inventory overall average symptom score of 0.51, obsessive–compulsive symptoms subscale score of 1.3, and interpersonal sensitivity subscale score of 0.66.

The patient had received 6 months’ treatment with paroxetine 20 mg/day for the diagnosis of depressive disorder after her father’s death in 2004. She recovered after this treatment and had not had any psychiatric complaints since then. She had no other medical disease. Her aunt was receiving treatment for a diagnosis of obsessive–compulsive disorder (OCD).

As a result of these signs and symptoms, cognitive–behavioral treatment was planned with this patient, diagnosed with ribavirin-induced subthreshold OCD and compulsive buying (an impulse control disorder not otherwise specified [ICD-10 F63.9]).

A decrease in obsessive–compulsive complaints was seen in the second week. Behavioral recommendations were given for compulsive buying (make a list before shopping, take only enough cash for the items on the list, do not use a credit card, do not go shopping alone). After 1 month of treatment the obsessive–compulsive symptoms disappeared completely but, although at a decreased level, the patient’s complaints of compulsive buying still continued.

Discussion

With this case, besides discussing the position of compulsive buying in psychiatry practice and its relationship with OCDs, the possibility of immunological and psychological mechanisms in its etiology is also discussed.

Compulsive buying can be evaluated as a separate clinical entity or may take place in the category of impulse control disorders [Schlosser et al. 1994; McElroy et al. 1995]. Also, in this case, the symptoms of compulsive buying were intertwined with subclinical OCD. Besides this association (comorbidity), these similarities, which are held responsible for the etiology in the properties of neurotransmitter dysregulation, demographic, clinical and treatment response, cause these clinical entities to be considered in the same spectrum [Ravindran et al. 2009].

As with the other OCSDs, together with theetiology of compulsive buying not being clear, developmental, neurobiological, cultural andpsychological factors are thought to be effective [Aboujaoude and Koran, 2010]. There are studies in OCSD that demonstrate disruptions in the corticostriatal system and also there are similarities in the hypotheses related to the etiology of OCD [Hounie et al. 2007; Fontenelle et al. 2011]. The effect of the immune system in the etiology of OCD and therefore OCSD has been observed [Swedo et al. 1989; Montgomery, 1994; Sasson and Zohar, 1996]. It is thought that the natural immune response and immune cytokines affect the monoamine system in general, having a particular influence on the serotoninergic and dopaminergic systems, and therefore can cause affective, cognitive and behavioral changes [Kronfol and Remick, 2000; Dantzer et al. 2008; Miller, 2009].

There are reports related to some drugs that also include antiviral agents that caused OCD and OCSD [Jonkers and De Haan, 2002; Voon et al. 2007; Alexander, 2009; Di Nicola et al. 2010]. Ribavirin is a broad-spectrum antiviral drug that is not widely used and therefore its psychiatric side effects are not known [Sidwell et al. 1972]. In some case reports, where ribavirin was used in conjunction with other agents such as interferon-alpha, it has been reported that psychiatric side effects occurred, including depression, fatigue, anxiety symptoms, cognitive impairment and a decrease in quality of life [Maddock et al. 2005; Abdel-Salam, 2006]. The mechanism behind the neuropsychiatric side-effects occurring due to ribavirin is not understood. It is thought that many drugs induce the production of antidrug antibodies at a finite rate. Although these antibodies do not usually cause clinical symptoms, they can rarely cause severe degrees of clinical cases [Shankar et al. 2008]. As far as we know, there is no data about the formation of antibodies related to the usage of ribavirin.

Independent of its antiviral effect, ribavirin is an agent that reduces the necro-inflammatory response and synthesis of proinflammatory cytokines [Hoofnagle et al. 2003; Barnes et al. 2004]. It also has immunomodulatory and reinforcing effects on T helper 1 (Th1) cells, and it causes modulation or immunosuppression in cytokine profiles and lymphocyte differentiation patterns [Hultgren et al. 1998; Tam et al. 1999; Fang et al. 2000; Lavrnja et al. 2008]. It can be speculated that the effects of ribavirin on the immune system, as argued in previous studies of OCD immune theory, may cause a delay in corticostriatal activity.

A large number of neurobiological and psychological studies have been conducted on the psychopathological consequences of acute stress. The relationship between stress and post-traumatic stress disorder is particularly well known and, as in OCD, there are common features, such as repetitive intrusive cognition [Rachman and Hodgson, 1980; Marks, 2001].

Acute stress can cause quantitative and functional changes in the cortisol, involving dihydroepiandrosterone, corticotropin-releasing hormone (CRH), locus coeruleus and norepinephrine systems, neuropeptide Y, galanin, dopamine, serotonin, benzodiazepine, GABA, gonadal steroids, antibody production and suppressor/cytotoxic and natural killer (NK) cell populations [Cohen et al. 2001; Marsland et al. 2001; Charney, 2004; Hasler et al. 2010].

In compulsive situations, people respond with a variety of coping strategies [Hareven and Adams, 1982]. Especially intense negative emotions can lead to problematic behaviors such as alcohol or psychotropic substance use and gambling, self-injurious behavior and compulsive buying [O’Guinn and Faber, 1989; Marks, 2001; Miltenberger et al. 2003; Nock and Prinstein, 2004; Selby et al. 2008]. Hirschman mentioned that the stress of self-concept can result in a search for various types of symbolic self-complement [Hirschman, 1992]. In this way, compulsiveconsumption temporary helps the repair of self-concept [Rindfleisch et al. 1997]. At the same time, compulsive buying, with the advantage of euphoria, can be considered as a coping strategy during the depression or other negative emotions [Faber and Christenson, 1996; Dittmar and Drury, 2000].

We have contributed to the biological and psychological literature in the field of psychiatry for many years and, ultimately, this has lead us to the formation of the concept of ‘biopsychosocial’. In the etiology of psychiatric disorders, biological (in this case, the possible immunological effects of drugs), psychological (in this case, the effect of trauma on emotions, thoughts and behaviors), or biopsychosocial (in this case, the effect of possible structural or immunologic changes caused by psychological trauma on emotions, thoughts and behaviors) explanations are important in determining the correct treatment approaches.

Although it was a constraint that the necessary immunological research could not be made in this case, we think that the compulsive buying that occurred in this patient, who has a familial predisposition to OCD, was triggered by the usage of ribavirin or a psychological stressor. Therefore, whether the effects of ribavirin or psychological stressor on the immune system caused disruption in corticostriatal activity and/or created the ground for OCSD is worthy of controlled clinical and immunological studies.