Download Effectiveness of Fluoxetine on Various Subtypes of Obsessive

Arch Iranian Med 2008; 11 (5): 522 – 525
Original Article
Effectiveness of Fluoxetine on Various Subtypes of
Obsessive-Compulsive Disorder
•
Alireza Farnam MD *, Mohammad-Ali Goreishizadeh MD*,
Sara Farhang MD*
Background: Obsessive-compulsive disorder typically begins early in life and has a chronic
course. Despite the need for long-term treatment, the information about therapeutic effect on
different clinical subtypes is limited.
Methods: Consecutive outpatients with obsessive-compulsive disorder were evaluated for
response to a two-month fluoxetine therapy course by Yale-Brown obsessive -compulsive scale
according to the clinical subtype of the disease.
Results: Of 265 patients, fluoxetine significantly decreased the symptoms in general. The mean
Yale-Brown obsessive- compulsive scale in washers and patients with obsessive thoughts was
significantly decreased after the intervention. The decrease in Yale-Brown obsessive- compulsive
scale in checkers was not statistically significance.
Conclusion: Fluoxetine has sustained efficacy on patients with obsessive-compulsive disorder
and is generally well tolerated. Fluoxetine has greater efficacy on washers and on obsessive
thoughts than checkers.
Archives of Iranian Medicine, Volume 11, Number 5, 2008: 522 – 525.
Keywords: Clinical subtype • fluoxetine • obsessive-compulsive disorder
Introduction
O
bsessive-compulsive disorder (OCD) is
characterized by obsessions and
compulsions that are severe enough to
interfere with daily functioning and cause
significant distress. Such perfectionism brings
difficulty in doing things anyway but their own,
and an excessive devotion to work, as well as
indecisiveness. The obsessive part is series of
mental feelings which interrupts one’s mind in a
repeated way while the compulsive part is a special
repeating behavioral pattern as a response to
obsessive thoughts or a mean to lessen the anxiety.
There are plenty of behavioral subtypes;
washing, checking, and counting are the common
Authors’ affiliation: *Department of Psychiatry, Razi Hospital,
Tabriz University of Medical Sciences, Tabriz, Iran.
•Corresponding author and reprints: Alireza Farnam MD,
Department of Psychiatry, Razi Hospital, Elgoli St., Tabriz, Iran.
Tel: +98-914-311-0910,
E-mail: [email protected]
Accepted for publication: 23 October 2007
ones, but the most common pattern of the
obsessive thought is series of contamination,
sexual and gender identity, and aggressive
obsessions which are subdivided as obsessive
thoughts.1,2 The prevalence of each type of OCD is
different among different communities, but it has
been estimated at 2.3 – 4% life-long.2
OCD obeys a chronic and long trend. It has
been reported that 85% of such patients experience
a long period of illness; 10% of them show a
significant reduction of symptoms while 2 – 5% of
them enjoy a betterment periods with intervals of
at least six months.2,3
There are several etiologic theories for the role
of the serotonin in outbreak of OCD reported by
pharmacologic studies. Nevertheless, the exact
mechanism is not known.3 Apparent etiologic role
of neurotransmitters in OCD has increased the
chance of using selective serotonin reuptake
inhibitors (SSRIs) for treatment of OCD.4–6
Fluoxetine, a well-known SSRI, is being used in a
wide scale which causes a high effectiveness with
522 Archives of Iranian Medicine, Volume 11, Number 5, September 2008
A. Farnam, M. A. Goreishizadeh, S. Farhang
responsiveness were evaluated.
Therapeutic results, before and after the intervention, were analyzed by paired-sample Student’s
t-test, using SPSS (version 13). A “response” was
defined as occurring when patients’ total scores
decreased by 25% or more from its baseline (at
entry) value on the Y-BOCS.10 These rates were
compared between groups by χ2 test.
rational cost, less side effects, and good
tolerability, acknowledged by several studies.1–3
Range of clinical subtypes of the disorder has
brought about different pharmacologic and nonmedicated therapeutic methods (cognitive or
behavior therapy) or combination of them, as well
as electroconvulsive therapy and surgical
treatments.2,3,7 Use of SSRIs, particularly high
doses of fluoxetine (40 – 80 mg/day) is being used
widely.4,6
Researchers have compared the disorder
according to the extent of symptoms (e.g., clinical
subtype) while the difference of the subtypes in
terms of response to treatment and long-term
outcome is challenging.8–10
Comparative treatment studies may allow us to
target treatment to OCD subtypes, allowing us to
offer more specialized treatment intervention for
patients. We conducted this study to determine the
effectiveness of fluoxetine on various subtypes of
OCD.
Results
Patients with obsessive thoughts (n=108) and
washers (n=80) were the most common subtypes in
the study population, followed by checkers (n=63)
and washers and checkers (n=14). Sixty-six
percent of the studied patients were married, 30%
were single, and the remaining 4% were divorced
or widowed.
Gender, literacy, and job of our patients did not
affect the therapeutic outcome of fluoxetine
therapy. Comparison based on the scores of YBOCS before and after fluoxetine therapy yielded
a significant difference in general (P<0.001).
The patients had a mean Y-BOCS of 22.98
before the intervention (i.e., severe form of OCD)
which was decreased to 15.4 two months after the
intervention—a fall of 7.58 in score as the
reduction of symptoms and recovery.
The mean Y-BOCS in washers and patients
with obsessive thoughts was significantly
decreased after the intervention, while the decrease
in checkers was not statistically significance.
Table 1 shows the mean YBOCS before and
after the intervention in the study population.
The response rate was significantly higher in
washers (75%) and patients with obsessive
thoughts (86.4%) compared to checkers (31.7%)
and washer-checkers (7.1%) (P=0.001).
Patients and Methods
Two hundred and sixty-five consecutive
patients (154 women and 111 men) attended Razi
Outpatient Clinic, Tabriz, who met the DSM-IVTR criteria for OCD, were enrolled into this study.
An interview by the same physiatrists was
completed after clinical examination.
Individuals with a history of comorbid
psychotic disorders, drug abuse, or medical illness
were excluded. Yale-Brown obsessive-compulsive
scale (Y-BOCS) was used to determine the
severity of the illness before and two months after
the therapy.
The patients were categorized into four groups
according to their symptoms: 1) obsessive
thoughts; 2) washers; 3) checkers; and 4) checkers
and washers. High-dose fluoxetine (>40 mg/day)
was prescribed for two months. Any possible
effects of age, gender, level of education, marital
status, and occupation on the therapeutic
Discussion
OCD is a multidimensional and heterogeneous
disorder. Diversity of clinical and compulsive
behaviors has brought about different clinical
Table 1. The mean Yale-Brown scores before and after fluoxetine therapy in clinical subtypes of obsessive- compulsive
disorder (OCD).
Y-BOCS† before the
Y-BOCS† after the
P value
OCD subtypes
n
intervention
intervention
Obsessive thoughts
Washers
Checkers
Checkers and washers
Total
108
80
63
14
265
23.53
20.18
24.20
34.00
22.98
16.92
13.05
21.00
32.00
15.40
0.001
0.001
0.141
—
0.001
†
Yale-Brown obsessive- compulsive scale.
Archives of Iranian Medicine, Volume 11, Number 5, September 2008 523
Effect of fluoxetine on subtypes of OCD
subtypes of the disorder. Though there is no
definite agreement on subtypes, therapeutic
response and results for each subtype are
differrent.11 The main goal of the present study was
to examine the probable difference of therapeutic
outcome with fluoxetine on different dimensions of
OCD which are demonstrated as clinical subtypes.
Serotonergic neurotransmitter systems have
been implicated in the etiology of obsessional
symptoms since the 1960's but studies concerning
therapeutic effects on clinical subtypes of OCD are
limited. Some indicate that both behavioral and
medical therapy better affect ritual behaviors than
obsessive thoughts in which response is often slow
and incomplete.12 Well-known therapeutic effects
of fluoxetine on symptoms of OCD2,5,7 were
achieved in our study.
Pathologic checking and washing symptoms are
the most common OCD symptoms13,14 and have
been identified as being rather independent of each
other.12 In a positron emission tomography study,
increased regional blood flow was reported in the
striatum of OCD checkers, and in the anterior
cingulate and orbitofrontal cortex of OCD
washers.15
Symptoms of washers make greater discomfort
for the patient with a desire to get rid of them.
Patients with obsessive thoughts believe in
inaccuracy of their thoughts which lead them to
accept therapy while in checking type patients
have enough reasons for their actions which make
them avoid therapeutic helps. Recent studies have
confirmed differences in the clinical features or
treatment outcome between washers and
checkers.16,17 Such studies support the potential
clinical validity and utility of a washer-checker
subdivision as well as the association between
checker symptoms with obsessive-compulsive
personality. Checking obsessions have been
reported as a predictor for poorer outcome and
associated to an inferior response to exposure and
ritual prevention therapy in most18,19 but not all20
studies. In the current study, fluoxetine particularly
affected obsessive thoughts and symptoms of
washers opposed to checkers and gives added
evidence to an inferior outcome of checking
compulsions.
Such concepts and findings inform and expand
the understanding of meaningful OCD subtypes.
Further study of clinical characteristics such as
long-term treatment response and illness path and
outcome will likely help further delineate
meaningful subtypes. Specific subtypes of OCD
based on treatment response are beginning to be
clarified, and may provide a framework from
which further to conceptualize, combine, and
describe what we understand of the variations in
neurobiology, symptomatology, and treatment
response in OCD.
In conclusion, the current study examined the
effects of fluoxetine therapy on common clinical
subtypes of OCD. The results confirmed the
clinical efficacy of fluoxetine in achieving
response and its better effect on relieving the
obsessive thoughts and symptoms of washers.
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