The Role of Glutamatergic Dysfunction in Treatment-Resistant Obsessive-Compulsive Disorder: Treatment of an Adolescent Case with N-Acetylcysteine Augmentation

Abstract

[Author Affiliation]Kemal Utku Yazici. 1 Department of Child and Adolescent Psychiatry, Firat University Faculty of Medicine, Elazig, Turkey.Ipek Percinel. 2 Department of Child and Adolescent Psychiatry, Osmaniye State Hospital, Osmaniye, Turkey.Address correspondence to: Kemal Utku Yazici, Department of Child and Adolescent Psychiatry, Firat University Faculty of Medicine, Elazig 23023, Turkey, E-mail: dr.kemal.utku@outlook.comTo The Editor:Obsessive compulsive disorder (OCD) is a common, chronic, and treatment resistant neuropsychiatric disorder that frequently begins during childhood and adolescence (Jenike 2004; Heyman et al. 2006). The recommended treatment strategy for OCD in children and adolescents includes cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs), either individually or combined. However, treatment with SSRIs in addition to clomipramine and typical/atypical antipsychotic agents is recommended for cases that do not respond to normal OCD treatment (American Academy of Child and Adolescent Psychiatry 2012; Arumugham and Reddy 2013). Despite these various treatment approaches, the desired reduction in symptom severity is not always achieved, and, therefore, other treatment options must be considered (Abudy et al. 2011; Arumugham and Reddy 2013).N-acetylcysteine (NAC) is an antioxidant molecule that modulates glutamate (glu) transmission in the brain (Berk et al. 2013). Recent reports have indicated the importance of glutamatergic dysfunction in OCD pathophysiology and the influence of glutamatergic agents in OCD (Chakrabarty et al. 2005; Pittenger et al. 2011; Kariuki-Nyuthe et al. 2014), which has led to the increased use of NAC for the treatment of OCD (Lafleur et al. 2006; Afshar et al. 2012; Van Ameringen et al. 2013). Herein, we discuss the use of NAC to treat a 15-year-old girl with treatment-resistant OCD.Case ReportA 15-year-old female patient was brought to our clinic by her mother, who indicated that the girl had the following complaints: Fear of becoming ill, anxiety about becoming infected from touching strangers, frequent hand washing, staying in the bathroom for extended periods, checking and rechecking homework and school bags before going to school, and returning to check the door just after leaving the house. Based on the history reported by her and her mother, the patient's obsessive tendencies began ∼3 years ago, and she was diagnosed with OCD at that time by another child psychiatrist in a different center. First, she underwent CBT for 1 month, but had no reduction in her complaints. Therefore, in addition to the CBT, she was started on sertraline therapy, which was increased until the dose reached 150 mg/day. However, she reported that her obsessive thoughts and behaviors continued without any decrease, and over the next 2 years, she was treated with fluoxetine (40 mg/day), citalopram (60 mg/day), fluvoxamine (200 mg/day), clomipramine (150 mg/day), risperidone (3 mg/day) and aripiprazole (15 mg/day) for at least 16 weeks, either individually or combined. After a period of time, she refused to visit the doctor because she was not benefiting from the medication. She reported a minor reduction in her complaints while using citalopram alone, and, therefore, made her own decision to use only citalopram. However, she decided to seek medical treatment at our clinic as a result of family pressure, additional complaints of moodiness and unhappiness, and continued obsessive thoughts and behaviors, which were still severe. She had been using 60 mg/day of citalopram for ∼ 4 months when she came to our clinic. Her history had no indications of any mental or motor development problems. Her family history revealed that her aunt had received treatment for 10 years for OCD. Our psychological assessment revealed that the patient had contamination and pathological doubt obsessions, and checking/rechecking and frequent hand washing compulsions, but no depressive symptoms. …