There are no reports of a child taking a selective serotonin reuptake inhibitor and an atypical anti-psychotic being successfully tapered from these medications after completion of cognitive-behavioral therapy (CBT) for obsessive-compulsive disorder. With this in mind, we report the case of an 8.5-year-old male who was taking risperidone 0.5 mg bid, sertraline 100 mg, and atomoxetine 25 mg at presentation. After a successful course of CBT, we describe how medications were systematically withdrawn. Implications of this case on practice parameters (e.g., CBT may be an effective augmenting agent for those non-responsive to initial pharmacological treatments) are highlighted.
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"Ideally, both antipsychotics and benzodiazepines would serve a short-term role in the treatment of OCD until the benefits of CBT and SSRIs can take hold. There is some evidence that treatment gains made through CBT while patients are on antipsychotics still hold after the antipsychotic has been tapered off (Goldstein et al., 2009). On the contrary, there are concerns that patients receiving both CBT and benzodiazepines for anxiety disorders experience a loss of efficacy after the benzodiazepine treatment is discontinued (Otto, Bruce & Deckersbach, 2005; Westra, Stewart & Conrad, 2002). "
[Show abstract][Hide abstract] ABSTRACT: The initial treatment of obsessive-compulsive disorder (OCD) has generally been limited to serotonergic agents, cognitive-behavioral therapy (CBT), or a combination of the two. These findings were supported by the POTS study for OCD in children and adolescents. However, treatment with serotonergic agents or CBT can take several weeks before benefit is seen; severe cases of OCD may require more immediate treatment.
The authors present a case of severe OCD in an adolescent that required immediate treatment due to her critical medical condition. The patient's symptoms included not eating or taking medications or fluids by mouth due to fears of contamination. A medical hospitalization was previously required due to dehydration. As treatment with an SSRI would not have quick enough onset and the patient was initially resistant to participating in CBT, the patient was psychiatrically hospitalized and first started on liquid risperidone. After several doses of risperidone, the patient was able to participate in CBT and start sertraline.
The authors discuss the differential diagnosis of such a patient, including the continuum of OCD symptoms and psychotic symptoms. The authors discuss the different treatment options, including the utilization of inpatient psychiatric hospitalization. The authors discuss the potential risks and benefits of using atypical antipsychotics in lieu of benzodiazepines for the initial treatment of severe adolescent OCD. The authors also discuss other current treatment recommendations and rationale for the treatment that was pursued.
This patient received benefit of her symptoms relatively quickly with psychiatric hospitalization and an atypical antipsychotic. The diagnosis of a psychotic disorder should be considered. These treatment options must be weighed against the risks of atypical antipsychotics, including extrapyramidal symptoms, weight gain, and metabolic syndrome; benzodiazepines also have their risks and benefits. Additionally, the cost of time and finances of inpatient hospitalization must be considered. More research is needed regarding the short- and long-term efficacy and safety of antipsychotics in the treatment of OCD in the child and adolescent population.