Obsessive Ruminations Embedded In A Mood Disorder

Sharon writes in . . .

My son has just started Seroquel XR for bipolar depression. However, he is suffering with repetitive thoughts, for example he recently was emptying a bag of trash that contained old light bulbs and in carrying it outside he lifted it over an ottoman in his living room, that was 4 days ago and all he can talk about is “what if there was a small piece of glass that somehow went onto the ottoman and even tho he vacuumed the ottoman several times, he still thinks there could be a microscopic piece of glass that could get on his shoe or hand or sofa, or his eye, mouth, what if… He realizes that it is pretty close to absolutely impossible for that to have happened, but the thought just won’t leave his mind and just keeps repeating over and over and over. This happens quite often “the what if” episodes, could involve the conveyor belt at food stores, what if someone ahead of him just bought soap or soap products and then he put is milk carton down in the same spot, and it goes on and on. What kind of medication would address this situation? This has been happening for over 10 years, it wears him down and tears me apart. Nothing I say helps, sometimes I even get angry because it may seem ridiculous to me but it is torture for him. I am not asking you to prescribe or diagnose, but a list of medication that would help so I can present that to his physician. We are in the process of looking for another psychiatrist. My son recently stopped all of his medication, he was on Geodon 80 mg 1 to 2 times a day, PaxilCR 37.5 mg 2 @ bed time, Xanax XR 2 mg, 2 in am and 1mg, 1 in am (5mg), Remeron 15 mg. @ bed, Trazadone 100mg 1 to 1 1/2 @ bedtime and Lamictal 100-150 mg and he was like a zombie and one day he just stopped all meds abruptly, a nightmare ensued and I am trying to get him back on track which is difficult since I need his attention and we need to communicate and he is too preocuppied with these repetitive thoughts. I need some help here and I know it is just an email away. Please help me to help my son. Thank you so much.

Yikes!!!  That was a long introduction to this blarticle, but it was meaty and seemed like it needed to all be there to tell this story.  Really sounds like your son (and you) have been suffering with this for quite some time.  There are many levels to the issues that you present, but I will try to make my answer straight forward and helpful.  As always, I must make some assumptions here.  I will assume that your son’s diagnosis of Bipolar Disorder is correct and that there is no psychosis going on here.  The issue that occupies most of your letter is not related to depression or to mania, however, but to the anxious repetition of fear thoughts . . . the “what ifs” that plague him and at times paralyze him.  What are they?   And more importantly, what can we do to make them go away?

First off, as you describe them, they are not a feature of depression or of Bipolar disorder.  The sort of ruminations that are described above are best thought of as being in the anxiety disorder family.  But, unlike the usual “what ifs” that we all fall prey to at times, these are completely unreasonable and odd and cannot be let go.  The “what ifs” can show up as Generalized Anxiety (“what if I lose my job and I don’t have any money and I lose my house and my wife leaves me to live with her family and I am left alone on the street for ever and ever and ever . . . .”) or as Social Anxiety (“what if I go into that room to do my presentation and I start stumbling over my words and everyone finally realizes what a dork I am and they are going to be talking about me and laughing about this and I will never be able to live this down and my career with be destroyed and I will get sick on my shoes in the middle of the presentation and on and on and on and on”).  The sort of ruminations that you describe above are ODD and STRANGE and are possible in a fantastic sort of way, but . . . not really.  This presentation is much more consistent with a Obsessive-Compulsive spectrum illness, rather than any of the other anxiety disorders and, certainly, lies outside of the standard diagnostic criteria for a mood disorder.  This sort of obsessive rumination can occur by itself or it can be embedded in another psychiatric condition.  I think it is important that the pattern of it be clearly identified and characterized to see if it does meet true Obsessive Compulsive Disorder criteria.  Regardless, the treatment of it will be similar.

The medicines that work to decrease such obsessive ruminations (and true OCD) are the medicines that work to increase serotonin levels . . . the SSRIs. Interestingly, medicines that work on the serotonin system but also on the norepinephrine system (such as Cymbalta and Effexor) do NOT work as effectively for OCD spectrum illness.  Adding an SSRI agent such as Zoloft or Prozac (or the Paxil he was taking) may be helpful for reducing the above ruminative symptoms.  The complication here is that your son is also diagnosed with Bipolar Disorder.  Using medicines like the SSRIs in a patient with Bipolar Disorder runs the risk of inducing manic or hypomanic symptoms.  To reduce that risk, it I strongly urge that he be on a mood stabilizer.  There are so many potential mood stabilizers that I do not want to go into that here (I have multiple blarticles on this in the archives) but he MUST be on one before starting the SSRI.  It is not clear how the presence of the Paxil he was taking impacted on the pattern of symptoms.  While most people do respond to any of the SSRIs, some do better on one than on the other.  Compliance is also key.  Are you sure that he was taking the medication as prescribed?  If he was compliant with the Paxil and he was on that dose for at least three months, it would be reasonable to try another one of the agents in that class.  Important here is the need to take a high enough dose for long enough.  It is common to need very high doses of an SSRI (often over the standard “high dose” that is give for depression) for a long time (at least three months) before you can call a trial a failure.  If he did have an adequate trial of the Paxil and then goes on to fail an adequate trial of another SSRI, then augmenting strategies can be used.  Lithium is a common adjunct to the use of antidepressants to help make them work more effectively.  And again, he must be on adequate mood stabilization for this treatment to be done safely.

There is also plenty of research showing that concomitant implementation of good cognitive-behavioral therapy for OCD improves the outcome of treatment.  It must be very specific CBT with exposure and response prevention in order for it to be adequate treatment for this sort of condition.

My best wishes go out to you and to your son.

–Dan Hartman, MD

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