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Refractory obsessive–compulsive disorder complicated by alcohol withdrawal seizures in a female

S342 neurologist initially. Her electroencephalography and magnetic resonance imaging brain were normal. She was diagnosed with a case of Seizure Disorder and started on antiepileptic drugs. She was referred for psychiatric evaluation in view of past history of OCD. The patient disclosed a history of surreptitiously consuming increasing amounts of alcohol over the past 5 years. She apparently felt a temporary reduction in her anxiety with alcohol and had a better sleep. She had gradually increased the amounts consumed daily due to reduced effects with previously consumed amounts. Her intake further increased after she felt that medications were not helping her and she perceived that there was no cure to her illness. She had temporarily felt tremors and excessive sweating when she did not consume alcohol and improvement in these symptoms after consuming alcohol. She was unable to abstain from alcohol due to strong urge even though it caused marked impairment in her social relations with family members. The patient was reassured and was given a dual diagnosis of OCD with alcohol dependence syndrome. Antiepileptic drugs were gradually tapered off and stopped. Fluoxetine 80 mg/day was reinstituted along with tablet clomipramine 75 mg/day, tablet acamprosate as an anticraving agent and cognitive behavior therapy and family therapy. She persisted to have distressing OCD. Her treatment was then optimized with the addition of aripiprazole 15 mg, with which she reported gradual reduction in her symptoms. She had achieved abstinence from alcohol during this period, and her interpersonal relations had improved. In her subsequent follow-ups, she was in remission and was abstinent from alcohol.

neurologist initially. Her electroencephalography and magnetic resonance imaging brain were normal. She was diagnosed with a case of Seizure Disorder and started on antiepileptic drugs. She was referred for psychiatric evaluation in view of past history of OCD. The patient disclosed a history of surreptitiously consuming increasing amounts of alcohol over the past 5 years. She apparently felt a temporary reduction in her anxiety with alcohol and had a better sleep. She had gradually increased the amounts consumed daily due to reduced effects with previously consumed amounts. Her intake further increased after she felt that medications were not helping her and she perceived that there was no cure to her illness. She had temporarily felt tremors and excessive sweating when she did not consume alcohol and improvement in these symptoms after consuming alcohol. She was unable to abstain from alcohol due to strong urge even though it caused marked impairment in her social relations with family members. The patient was reassured and was given a dual diagnosis of OCD with alcohol dependence syndrome. Antiepileptic drugs were gradually tapered off and stopped. Fluoxetine 80 mg/day was reinstituted along with tablet clomipramine 75 mg/day, tablet acamprosate as an anticraving agent and cognitive behavior therapy and family therapy. She persisted to have distressing OCD. Her treatment was then optimized with the addition of aripiprazole 15 mg, with which she reported gradual reduction in her symptoms. She had achieved abstinence from alcohol during this period, and her interpersonal relations had improved. In her subsequent follow-ups, she was in remission and was abstinent from alcohol.
The index case presented various challenges for the treating team because: alcohol is considered a taboo for a female in her social and cultural background; high expressed emotions, criticism, and hostility of family members; social isolation by family members; non-adherence to OCD treatment due to alcohol use and alcohol withdrawal seizures erroneously diagnosed as seizure disorder. She was managed with concurrent targeting of her OCD and alcohol dependence syndrome, along with cognitive-behavioral therapy and family therapy to address high expressed emotions and include family members in the treatment. Drug nonresponse was tackled by augmentation with aripiprazole, with which she achieved remission. Thus, it D rug-resistant obsessive-compulsive disorder (OCD) has been defined as less than 25% reduction in yale brown obsessive compulsive scale (YBOCS) to at least two sequential selective serotonin reuptake inhibitor and clomipramine given for a trial duration of 12 weeks. [1] Furthermore, the course of illness is likely to be complicated by comorbid psychiatric disorders. Up to a quarter of patients who seek treatment for OCD suffer from substance use disorder (SUD), and majority have alcohol use disorders. Patients with SUD comorbid with OCD present with more severe OCD symptoms, poorer insight regarding OCD, poorer quality of life, and greater impairment in overall psychosocial functioning than participants without SUD. [2] Self-medication hypothesis of substance use in OCD states that although ineffective some patients may use alcohol as a way of coping with the anxiety associated with their symptoms. [3] Rates of alcohol use in Indian women have been reported to be low depending on the region of country studied, social, cultural, and religious factors. [4,5] Here, we present the case of a young woman who started using alcohol as self-medication for her OCD and rapidly developed alcohol dependence syndrome.
A 39-year-old female, homemaker was first brought to the psychiatry outpatient department in 2017. She had a 4-year history of repeated obsessions of household things being dirty cleaning and washing them during major part of her daily routine. For the past 1 year, she had decline in social interaction with irritability toward family members. Her general physical and systemic examination was normal.
Relevant laboratory investigations were normal. Mental status examination revealed anxious affect with disturbed sleep and appetite. Her YBOCS score was 28/40, suggestive of severe illness. With a diagnosis of OCD, she was started on fluoxetine, built up to 80 mg/day, psychoeducation and exposure and response prevention, but had suboptimal response to treatment. In view of poor response, she was switched to clomipramine 225 mg, but she continued to experience significant distress and dysfunction due to her symptoms over the next 4 months. She was lost to follow-up thereafter. After a gap of 3 years, she presented with a history of 02 episodes of seizures. She had features of autonomic hyperactivity in the form of tachycardia, tremors, and profuse sweating. She was evaluated by

Refractory obsessive-compulsive disorder complicated by alcohol withdrawal seizures in a female
can be concluded that SUD can complicate the clinical picture of OCD with implications on treatment and outcome. Active addressal of both psychiatric comorbidities simultaneously is recommended for better outcome.

Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

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Conflicts of interest
There are no conflicts of interest.