Clinical and neurocognitive changes with modafinil in obsessive–compulsive disorder: a case report

Abstract

There are limited treatment options for co-occurring sleep disorders and obsessive–compulsive disorder (OCD). We postulated that Modafinil (Provigil) [2-{(diphenylmethyl) sulfinyl acetamide}], a non-amphetamine wakefulnesspromoting agent, might be of value in patients with excessive daytime sleepiness (EDS). Randomized double-blind placebo-controlled depression trials have investigated the effects of modafinil co-administered with selective serotonin re-uptake inhibitors (SSRIs) and found improvement in clinical global scores, and aside from effects on sleep and mood, modafinil has exhibited cognitive enhancing effects in some subjects (Minzenberg and Carter 2008). In a doubleblind placebo-controlled crossover challenge, Turner et al. (2004) demonstrated decreased motor impulsivity as measured on laboratory tests in adult attention-deficit/ hyperactivity disorder patients treated with single doses of modafinil (100 mg and 200 mg). To date, studies examining the neuropsychological effects of treatment are rare in OCD and have generally failed to show a positive effect of SSRI treatment on cognition (Nielen and den Boer 2003). In this context, we considered a new approach for treating neurocognitive impairments in treatment-resistant OCD. Modafinil’s effects on clinical symptoms and on a selected range of neurocognitive functions previously reported to be impaired in OCD (Chamberlain et al. 2005) are examined. We report the case of a patient with treatment-resistant OCD and EDS treated with adjunctive modafinil. DW is a 33-year-old unemployed man with a 13-year history of aggressive obsessions, panic anxiety, low mood, and EDS. Past treatment with dothiepin, venlafaxine, and several SSRIs had produced little benefit. A primary diagnosis of SSRI-resistant, DSM-IV OCD (defined as less than 25% improvement on the Yale-Brown Obsessive– Compulsive Scale (Y-BOCS) despite adequate treatment trials) was made, with DSM-IV panic disorder and DSM-IV dysthymia as subsidiary diagnoses. His sleep schedule was chaotic, with sleeping periods during the day, though he tended to get up at 8 am irrespectively. At initiation of modafinil, DW (right-handed, no sensory impairments) had been receiving escitalopram (40 mg) for at least 12 weeks being administered unchanged throughout the trial. A single morning dose of modafinil (100 mg) was prescribed and increased after 3 weeks to 200 mg (in two divided doses), and after 4 weeks to 400mg (in two divided doses). Treatment adherence was checked verbally. Clinical assessments were W. H. Dittrich (*) Medical School, Office of the Dean, Goethe-University Frankfurt am Main, Haus 15B, Zi. 418, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany e-mail: winand.dittrich@kgu.de