A 28-Year-Old Man with Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, and Dissociative Identity Disorder Responding to Aripiprazole Augmentation of Clomipramine Combined with Psychoeducation and Exposure and Response Prevention

Background

Obsessive-compulsive disorder (OCD) is a common mental illness that features obsessive thoughts and repetitive behaviors or psychological rituals. Patients often feel compelled to follow rigid patterns to alleviate anxiety and discomfort to the point of impairing social and occupational functionality. Severe cases can have self-harm or suicidality. Studies have shown that OCD has a lifetime prevalence of 2–3%, which, along with its high disability rate, has created a significant burden on society. Research also found strong correlations among OCD, post-traumatic stress disorder (PTSD), and dissociative identity disorder (DID) [1–3].

Treatment using medication, psychotherapy, or neuromodulation have shown some efficacy in OCD and PTSD [4,5]. Exposure and response prevention (ERP) is one of the effective psychotherapies for OCD [6]. At present, pharmacotherapy combined with adjunct psychotherapy remains the primary treatment for OCD and PTSD.

The combination of clomipramine and antipsychotics can be effective in treatment of refractory OCD [6] and dissociative identity disorder (DID) [7]; other antidepressants used together with antipsychotics were also used as a treatment option for refractory PTSD [8].

This report is of a 28-year-old man with comorbidity of OCD, PTSD, and DID responding to aripiprazole augmentation of clomipramine combined with psychoeducation and ERP.

Case Report

The patient was a 28-year-old man with a doctoral-level education. He presented to our clinic with depression, obsessive thoughts, behavioral impulsivity, and suicidal thoughts/ behavior that had lasted for about 4 years. He had 4 previous psychiatric hospitalizations and had tried different psychotropics. One admission was after a psychotic and dissociative episode during his overseas PhD study time. He said he had problems with his supervisor, made threats to harm this person, and wandered off. He was found unresponsive in the wilderness and was subsequently admitted to a local mental hospital. He was administered risperidone, citalopram, escitalopram, and olanzapine but showed minimal improvement per his own account.

There was no family history of mental illness, although he was raised in a strict family with high academic expectations on him. During childhood, he was known to be stubborn and oppositional, with low tolerance to criticism. He also demonstrated obsessive thoughts and compulsive behaviors. Specifically, he insisted on wearing only 1 sock while sleeping and would become extremely uncomfortable and upset when the sock was removed. He also needed to walk in a straight line when crossing the street and would start over by walking backward if the line could not be maintained straight enough to his satisfaction. These compulsions apparently affected his daily routines at the time. The OCD symptoms continued and peaked in his college and postgraduate years.

In 2013, his parents started noticing repetitive self-talking – “I’m a good guy, I didn’t do anything bad” – referring to some overwhelmingly obsessive thoughts of proving that he never had sex with prostitutes while studying abroad. After no response to some traditional Chinese medicine, he was prescribed clomipramine and lithium carbonate, which led to some symptom relief. He was able to return to school and manage his doctoral dissertation defense. However, he continued to feel anxious and irritable, which easily escalated to anger and even combative spells, especially towards his supervisor.

After returning to China, he continued to have overwhelming anxiety with occasional suicidal thoughts. He had frequent panic attacks, waking up in the middle of the night screaming loudly. Noticeably, he complained about inability to let go of his past negative experience with his PhD supervisor. Each time the name of this supervisor was mentioned, he became wildly angry and started making threats to harm him, even if he was thousands of miles away. He would even write emails insulting his supervisor when his emotions were out of control. These led to 2 psychiatric inpatient treatments that included pharmacotherapies with lithium carbonate, sodium valproate, and paroxetine. Unfortunately, his mental condition continued to fluctuate after hospital discharge. In June 2020, he had another dissociative episode. Reportedly, in the middle of a classroom teaching, he suddenly ran off without a reason. He was found the next day on a hillside about 5 kilometers away from the school and was sent to a local emergency room. He started outpatient treatment with us a few days after this episode. A thorough psychiatric evaluation showed that he met the diagnostic criteria for: (1) obsessive-compulsive disorder (OCD), (2) post-traumatic stress disorder (PTSD), and (3) dissociative identity disorder (DID) per Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10). Considering the lack of efficacy of previous medications, we started him on clomipramine and sodium valproate. The doses were titrated to clomipramine 200 mg per day and sodium valproate 1000 mg per day in 2 weeks. Psychoeducation and exposure and response prevention (ERP) were also provided. With such treatment, he showed gradual partial improvement within 2 months. He subjectively felt less anxious but continued to experience emotional arousal whenever the name of his PhD supervisor was mentioned. He attributed this to memories of being yelled at and feeling humiliated by his supervisor and expressed inability to forgive him for the harm the supervisor had caused him. Later, aripiprazole 10 mg in the morning was added to the regimen and clomipramine was increased to 300 mg/day. One month later, the patient became emotionally stable. His anxiety significantly improved and his obsessive thoughts faded away. He was no longer upset when talking about his supervisor. At 6-month follow-up, the patient met the criteria for clinical remission. One year later, his aripiprazole was decreased to 5 mg every morning and clomipramine to 25 mg every evening, and sodium valproate was tapered off. He remained calm and collected, reported working well and having a normal life.

Discussion

This case report provides a detailed account of a young male patient’s experience with co-morbid OCD, PTSD, and DID. The symptoms started in childhood but unfortunately were never treated until college years due to stigma and lack of child and adolescent mental health resources in China. Although he started seeking professional help in adulthood, due to the severity and complexity of his psychopathology, and treatment settings in different cultures, a clear treatment plan was difficult to formulate. When he first established care with us, his knowledge about and insight into his mental condition were apparently limited and not proportionate to his education level. After a careful review of his past and current symptoms, medical history, and treatment history, we decided to administer a combination of clomipramine and aripiprazole as main pharmacotherapy, in addition to psychoeducation and ERP. Psychotherapies were 90-minute weekly sessions gradually phased out to biweekly and monthly. We focused on helping him understand his psychopathology, encouraging openness and acceptance of his mental health struggles, and de-stigmatizing psychiatric illnesses and treatments. While the medications functioned neurobiologically to make him less agitated or distressed, he started to understand that his obsessions could lead to extreme, compulsive behaviors that disrupted his overall quality of life. ERP provided him with new coping skills for psychic pain when a trigger, in his case recalling the traumatic interactions with his supervisor, escalated into emotional turmoil.

Although the patient met criteria for 3 psychiatric disorders, we believed his obsessive-compulsive, impulsive, and egocentric personality traits that manifested during his childhood played a significant role in the course of all 3 psychiatric conditions. His over-sensitivity to criticism, in the context of high academic expectations from his parents, also contributed greatly to the onset and progression of his other mental conditions. This was highlighted by his impulsive behaviors of yelling and making threats to his PhD supervisor who criticized him, which later developed into PTSD. Although he had bizarre and disorganized runaway episodes, he did not report any history of delusions or hallucinations. Instead of psychosis, those were most likely dissociative episodes from severely disturbing emotional misfires in the context of long-term obsessive thoughts, compulsive behaviors, and pursuit of perfection.

Contrary to his previous treatments, which mainly focused on acute stabilization of mood and psychosis, our pharmacotherapy approach focused on OCD and PTSD. Serotonin reuptake inhibitors (SRI) and clomipramine are the only FDA-approved drugs for OCD treatment [9]. Clomipramine has been found to have more adverse effects but is more effective in changing OCD symptoms [10] due to its capacity for 5-HT transmission [11]. Most relevantly, it also showed efficacy in treatment of DID and PTSD [7,12]. Furthermore, for PTSD patients who do not respond to SRI, antipsychotics can be used as augmentative treatment [8]. We did not include SRI in this patient’s treatment regimen because combining clomipramine with SRI can result in a triad of 5-hydroxytryptamine syndrome with altered mental status, myoclonus, and autonomic hyperfunction [10]. Aripiprazole was chosen based on its clear adjunctive effect on the treatment of both refractory OCD and PTSD [13–15]. Moreover, although there is no clear clinical treatment recommendation for DID, case reports have shown that clomipramine and aripiprazole can each be effective [7,16]. After 6 months of treatment, the patient’s symptoms subsided, and he successfully attained clinical remission.

Conclusions

This case highlights the progressive course of coexisting OCD, PTSD, and DID and its debilitating nature. While the combination of TCA medicine clomipramine and partial dopamine agonist antipsychotic aripiprazole with ERP proved effective in this instance, randomized controlled clinical trials and longitudinal studies are still needed in the future to support this treatment approach.