Tormenting Thoughts and Secret Rituals Page 12

  The truly significant side effects of the SRIs—all affecting only a minority of patients—are nausea, nervousness, sexual problems, irritability, and nightmares.

  Gastrointestinal Symptoms

  Nausea, and sometimes vomiting or diarrhea, are among the most common side effects of SRIs: 20–30 percent of people experience them in the first one to two weeks of treatment. These side effects usually respond to either dose reduction or taking medications with food; often, however, they are the reason patients stop treatment with a given agent. These side effects are most troublesome with sertraline (Zoloft) and fluvoxamine (Luvox).

  Nervousness, Headaches, and Insomnia

  These side effects, affecting 15–20 percent of people taking the SRIs, are all related to an activating effect of these medications that some patients describe as being like the “caffeine jitters.” Such reactions are strongest with fluoxetine (Prozac) and are, indeed, the most common reason why people stop that medication. These side effects usually last only a few months, and then the body adjusts to them. After that, they are sometimes replaced by their opposites, apathy and sleeping too much. All respond immediately to lowering the dose of medication. All can also be effectively treated by the addition of an antianxiety medication such as clonazepam (Klonopin) or lorazepam (Ativan).

  Interference with Sexual Functioning

  This side effect—most often either an inability to attain orgasm or a loss of interest in sex—was underreported at first, but it is now clear that it occurs in fully 30–40 percent of people taking SRIs. This side effect, too, usually responds to dose reduction. A number of my patients on short-acting SRIs, such as paroxetine (Paxil), sertraline (Zoloft), and fluvoxamine (Luvox), have reported that skipping medication for two days allows a return of full sexual function without a loss of antiobsessional effect. Two recent studies have supported this observation. Adding medications of various types to an SRI can also reverse sexual side effects, and yohimbine (Yocon), buspirone (Buspar), buproprion (Wellbutrin), trazodone (Desyrel), and cyproheptadine (Periactin) have all been tried in this regard. In my practice, however, these counteractive drugs have proved disappointing. Only Yocon and Desyrel have worked at all, and those in only a few patients.

  Irritability and Nightmares

  Since the data are strong that the neurotransmitter serotonin plays a role in regulating anger (for instance, violent criminals have low levels of serotonin metabolites in the spinal fluid), it is not surprising that SRIs have an effect on irritability. Fortunately, this is usually a positive effect. Typical is the story of an eighteen-year-old woman who had been kicked off sports teams, run away from home, and been punished by her parents since age six for her short fuse and overly aggressive behaviors. After three months on an SRI she told me, “I’m much calmer now. I think before I act. For the first time ever, I sat down and talked to my sister for a full hour.” A study at Harvard in 1991 looking at outbursts of anger among people on SRIs found that outbursts went down in 71 percent of patients and up in 6 percent.

  The increased irritability that does occur in a small number of people can, it must be admitted, be a problem. I have had several patients, all with prior histories of hostile behaviors, who had to stop SRIs because of marked increases in anger. One patient, for instance, who had served time for assault and battery, had to stop his SRI because, as he put it, “It made me feel like when I was on steroids: say hello and I snap out.” I should add, however, that I have never had a patient who acted harmfully because of the effects of these medications.

  A larger problem with the SRIs is the occurrence of nightmares, often of physical harm. Rather than the 0–5 percent reported in clinical trials, perhaps 10–15 percent of my patients are bothered by vivid, troublesome dreams. These patients respond to decreasing the dose of medication, or changing to a different SRI.

  Other Side Effects

  Tremor and sleeping excessively can occasionally become problems after many months of treatment with an SRI. Patients so affected usually respond to a lowered dosage. Allergic reactions, primarily rash, occur in about 3 percent of people taking SRIs. Because teratogenic effects (adverse consequences of drugs on the developing fetus) have not been well studied, SRIs should be stopped, if possible, during pregnancy. Large numbers of pregnant women have taken SRIs, however, and so far there have been very few problems reported.

  Dry mouth, constipation, drowsiness, and memory loss occur as a group and are referred to as anticholinergic effects. They are by far the most frequently seen with clomipramine (Anafranil) and occur to a lesser extent with paroxetine (Paxil). Anticholinergic side effects always respond to dose reduction. Chewing sugarless gum or sucking on lemon drops (which stimulates salivation) can also be helpful for dry mouth. Other potential problems specific to clomipramine (Anafranil) are heart conduction abnormalities (patients who are over forty should have an electrocardiogram before starting Anafranil) and a lowering of the seizure threshold.

  Medication Interactions

  The SRIs—in this case clomipramine (Anafranil) much less than the others—have a strong effect on the liver’s metabolism of certain medications. As a result, the SRIs have the potential to dangerously increase the blood levels of many drugs, including antidepressants, anticonvulsants, blood sugar medications, heart medications, pain medications, and allergy medications. Although I have never had a patient who ran into a major problem in this regard, these drug interactions are potentially serious. For the older person on a number of medications, these drug interactions represent the major drawback to the use of an SRI.

  Alcohol

  Can a patient drink while on medications? Psychiatrists tend to take the conservative position that it is better not to consume any alcohol while on any psychiatric medication. It should be pointed out, however, that many patients drink socially while on SRI medications without a problem. There is, in fact, no direct, harmful interaction between alcohol and the SRI drugs. The case is somewhat different with benzodiazepine medications, such as lorazepam (Ativan), clonazepam (Klonopin), and alprazolam (Xanax). Here there is an interaction, and alcohol should be avoided.

  OTHER MEDICATIONS HELPFUL IN THE TREATMENT OF OCD

  Benzodiazepines (BZDs)

  This group of anti-anxiety agents, which includes chlordiazepoxide (Librium), diazepam (Valium), alprazolam (Xanax), lorazapam (Ativan), and clonazepam (Klonopin), is taken by approximately 15 percent of American adults, making them among the most widely prescribed of all medications. Next to the SRIs, these are also the most useful medications in the treatment of OCD. In my practice, approximately one third of my OCD patients take a benzodiazepine, almost always in conjunction with an SRI. The more severe the OCD, the more likely a BZD will be helpful.

  The benzodiazepines are remarkably free of side effects. Oversedation, and in some cases short-term memory loss, are the main problems, and they are seldom severe. The primary concern with the BZDs is that, unlike SRIs, they can be addicting. Even here, however, the danger of addiction must be put in perspective. I remind my patients that addiction is, in essence, a loss of personal freedom. The addict’s choices lessen as she is controlled by the desire to obtain and ingest a substance. Yet the OCD sufferer, too, is enslaved—to obsessions and compulsions—and medications help reverse those. In this sense, BZDs are the opposite of addicting; they help open life up, they are freeing. Of course, these drugs must be properly prescribed. The dose should be kept in a moderate range; and they should not, as a rule, be given to individuals with a history of substance abuse. In my experience, though, OCDers never become addicted to BZDs.

  Benzodiazepine medications are indicated when OCD is accompanied by disabling anxiety symptoms, especially severe phobias and panic attacks (shaking, rapid heartbeat, shortness of breath), which are present in up to a third of OCD sufferers. These symptoms should be aggressively treated because, in addition to the direct suffering they cause, they can provoke a marked worsening of obsessions and compulsions.

&n
bsp; There is a second indication for BZDs in the treatment of OCD: They may be added to SRI medications to increase their therapeutic effect. Several studies, as well as clinical experience, show that clonazepam (Klonopin) is especially useful as an augmenting agent. Unlike most other BZDs, Klonopin appears to have a direct effect on serotonin that is similar to that of the SRIs.

  Additional Augmenting Agents

  In addition to benzodiazepines such as Klonopin, there are several other medications that, when used in conjunction with the SRIs, may increase anti-OCD effect. These augmenting drugs include buspirone (Buspar), trazodone (Desyrel), fenfluramine (Pondamin), and lithium. All have some effects on serotonin. Any one of them, when added to an SRI, can produce a better therapeutic response. The research supporting the use of these, however, consists primarily of uncontrolled studies and case reports. I must admit that I have had limited success with augmenting agents other than benzodiazepines and occasionally buspirone.

  Antidepressants

  Depression frequently accompanies OCD. Approximately 30 percent of OCD sufferers show symptoms of severe depression at the time they are first treated, and 60–70 percent of OCD sufferers—as opposed to 15 percent of the general population—develop severe depression at some time during their lives. When OCDers show symptoms such as loss of energy, appetite, concentration, and interests, the addition of a standard “tricyclic” antidepressant, such as desipramine (Norpramin) or imipramine (Tofranil), to an SRI can be extremely helpful.

  Antidepressants known as monoamine reuptake inhibitors, MAO-Is, are also occasionally used to treat depression in OCD, and sometimes even as primary treatments for OCD. I have not included a discussion of the use of MAO-Is in this chapter, however. Recent research has demonstrated that MAO-Is are less effective in the treatment of OCD than SRIs. Furthermore, the MAO-Is are associated with severe, even life-threatening side effects.

  Neuroleptics

  This powerful group of medications, which includes a number of well-known drugs such as chlorpromazine (Thorazine), haloperidol (Haldol), and risperidone (Risperdal), is used primarily in the treatment of psychotic states. Side effects are a major problem: All neuroleptics can cause tremor and restlessness and can occasionally produce irreversible, abnormal movements of the mouth referred to as tardive dyskinesia. Although these medications have no role in the treatment of classic, uncomplicated OCD, they are extremely helpful in two situations where OCD overlaps with other disorders.

  A significant minority of OCD sufferers, perhaps 5–10 percent, have difficulties sorting out what is real and what is not. They may lack insight into their obsessions, insisting, for instance, that their hands truly are contaminated despite all evidence to the contrary. Or, they may have subtle evidence of psychotic symptoms, such as hearing vague sounds or voices. In these situations, neuroleptic medications may be indicated.

  A second situation in which neuroleptics are helpful is when OCD is accompanied by troublesome tics—involuntary, repetitive movements such as eye blinks and shoulder shrugs. Here, OCD overlaps with the disorder known as Giles de la Tourette’s syndrome, and several controlled studies have proven that very low doses of neuroleptic medications are beneficial.

  Experimental Treatments

  There is encouraging evidence that other forms of therapy may be helpful for OCD as well. The evidence, however, is not yet substantial enough to recommend these treatment for general use. Lorin Koran and co-workers at Stanford have been using intravenous clomipramine (Anafranil) in treatment-resistant OCD with some success. Inositol, a natural sugar, has also been shown to be helpful in OCD in a couple of studies, the most recent reported in the American Journal of Psychiatry in 1996. It is intriguing that a simple and inexpensive foodstuff might help OCD. I will list another treatment here as experimental, yet in doing so I do it a disservice for the data supporting its efficacy as actually quite strong: brain surgery, which can work in the one-in-a-thousand cases of totally disabling, totally treatment-resistant OCD. I have referred one patient for neurosurgery, and she had a successful outcome. (Interestingly, OCD is at this time the only psychiatric problem for which brain surgery is considered a reasonable treatment option—a clear indication of the largely neurobiological nature of this disorder.)

  What to do when medication doesn’t work? This is generally when the OCD sufferer should review medication treatment with his or her physician and come to a decision. Has anything worked at all? If so, that can be prescribed. If not, medication should be stopped—with the caveat that new medications are being developed constantly, and one of them may well work in the future.

  A look at how medications were used in the cases of Raymond, Sherry, Jeff, and Melissa, whose presenting symptoms were described in Chapter 1 and whose behavior therapy was described in the previous chapter, illustrates the way drug therapy can work in the treatment of OCD.

  When Raymond first came to me in the summer of 1993, he was on the verge of a breakdown. Agonizing obsessions of contaminated spills and hours a day of checking compulsions were causing anxiety attacks, deep depression, and finally, an inability to keep up in his work. Raymond welcomed a trial on medications. He was ready for anything that would help.

  Although I prefer not to start two different medications on the first visit, the severity of Raymond’s condition warranted this approach. I prescribed clomipramine (Anafranil), 50 milligrams at bedtime, and over a week increased the dose to 150 milligrams. I also prescribed lorazepam (Ativan) at 1.0 milligrams three times a day, a dose that was quickly increased to 2.0 milligrams. Raymond noted immediate improvement in his anxiety and ability to sleep. Over the next month, he also began to notice a decrease in the power of his obsessions. Unfortunately, Anafranil caused several side effects including dry mouth and constipation, and when he tried to lower its dose, his OCD and depressive symptoms worsened. We replaced Anafranil with fluoxetine (Prozac), which he tolerated well at a dose of 40 milligrams in the morning.

  Raymond continues on Prozac and Ativan to this day. When he cuts down the Prozac, he notices a return of depression and OCD symptoms. When he cuts down the Ativan, which I occasionally encourage him to try, he feels markedly more anxious. The only side effect he notices from his medications is decreased sex drive. We tried adding two different medications, yohimbine (Yocon) and trazodone (Desyrel), to counteract that side effect but have had no luck. Raymond insists it is not a major problem.

  Raymond’s own conclusions about medications? He told me recently: “The Ativan helps a lot, because when I’m relaxed I can let go of obsessions quicker. Prozac works differently. There’s something deep going on with Prozac. It doesn’t make me feel any different in any way that I can put my finger on, but when I stop it the obsessions become much worse.”

  When Sherry came to see me for treatment of her OCD, she was suffering recurring terrifying images of stabbing her husband or driving her car into little children. Sherry was even more anxious than Raymond. Frequent panic attacks—episodes of rapid heartbeat, shortness of breath, and chest pains—could keep her in bed all day long.

  Although Sherry had been on medications before, she had many qualms about restarting them. Wouldn’t they cause addiction? Couldn’t they interfere with her creativity as a painter? And anyway, wasn’t using medications a “cop-out”? Upon learning that there were new and specific anti-OCD drugs, however, she did agree at least to give them a try.

  A combination of Prozac (20 milligrams in the morning) and Klonopin (0.5 milligrams in the morning and 1.0 milligrams at bedtime) worked well for several months. Sherry’s panic attacks vanished and her obsessions seemed less strong and persistent. Higher doses of Prozac caused jitters and vivid nightmares. Even at 20 milligrams interference in sex drive became a problem. This was helped by the addition of a third medication, trazodone (Desyrel) at a dose of 75 milligrams at bedtime. After a year, Sherry’s OCD markedly improved, and she was able to cut down her medications. She is now maintained on Prozac at a dose of 10 alternat
ing with 20 milligrams a day, and Klonopin 0.5 milligram as needed.

  None of the fears Sherry had about medications materialized. When she first started Prozac, she told me, her husband called every hour to check that she “wasn’t out murdering anyone.” Yet neither she nor her husband noted any personality changes. As far as medications interfering with her painting, the opposite occurred. “On the medication,” she said, “I can get my thoughts together and produce better work.” Yet being productive is now no longer such an important issue. For the first time in her life there are moments when her mind is not frantically active, when she can relax and enjoy herself. Reflecting on this change she said one day, “Even if the medication would have ruined my creativity, I’d still take it. It is an incredible gift to live a normal life.”

  Last year Sherry developed TMJ syndrome, a click in her jaw, and her dentist, speculating that Prozac had been causing her to grind her teeth at night, did not hesitate to suggest that she stop the medication. As she related it, she told her dentist: “I’m sorry, I don’t care! You’re not taking that away from me.”

  As for Jeff, his treatment with medications was simpler and less spectacular than that of Raymond or Sherry. He was eager to give medications a try and did well right away on a relatively low dose of sertraline (Zoloft), 100 milligrams a day. After six months in treatment, he was doing very well and he decreased the Zoloft to 50 milligrams. He has since been able to discontinue medication completely.