Obsessive compulsive behaviors, or perseveration, can occur in HD before motor symptoms and at all stages of disease after motor diagnosis. Though there are behavior similarities to obsessive compulsive disorder (OCD), it varies in HD in that the individual is not aware that the behavior is inappropriate. Obsessive compulsive behaviors can present as mental rigidity, or wanting things to be done in definite ways or at definite times, thoughts or actions that "get stuck" and go round and round, or being upset when routines change, or asking the same question over and over.

Obsessive compulsive behaviors tend to increase with disease duration. This symptom is not unique to HD, it also occurs in other diseases of impaired cognition and neuropsychiatric disease.

Obsessive compulsive behaviors are highly distressing and cause much anxiety for the individual with HD and carers. If not recognized and treated early the more severe entrenched behaviors can lead to agitation and aggression.

Clinical Practice Guidelines for Obsessive Compulsive and Perseverative Behaviors in HD Note that this author has changed some of the wording that appears in the journal article for purposes of making it more user friendly. If you wish to share with your medical provider, it would be best to copy the journal link [Anderson KE 2011] for the doctor's review.

General Recommendations

  1. Identify and treat other symptoms of HD or other medical conditions that can contribute to distress of obsessive compulsive behaviors
  2. Identify and modify external factors that can increase distress

Behavior Recommendations

  1. Only in early stage of disease, there is option to offer psychological behavioral therapy (if available and if this is patient preference). In this situation the individual with HD must have some awareness of the behavior 

Drug Recommendations (highly dependent on other symptoms that are present)

  1. First choice drug is an SSRI (like sertraline (Zoloft®) or citalopram (Celexa®)) whether it occurs as a single symptom or occurs with depression and anxiety (because this type of drug treats all three of these symptoms)
  2. Warning should be given that anxiety may worsen briefly after starting an SSRI. (Best to start with a low dose). If worsening of anxiety occurs when starting an SSRI, adding a benzodiazepine short term may be helpful
  3. If the initial SSRI is not helpful or gives unacceptable side effects, alternative SSRI drugs (a different SSRI, or an NSRI (like venlafaxine (Effexor®)) may be used
  4. Treatment of obsessive compulsive symptoms often requires SSRI dosage in higher range than used for anxiety and depression
  5. Clomipramine (Anafranil®) is a drug option for lack of satisfactory response or intolerance to high dose SSRI. Because clomipramine has SSRI activity, it should not be used in combination with an SSRI
  6. An antipsychotic can be added to control agitation that may be associated with severe obsessive compulsive behaviors
  7. A benzodiazepine drug can be used short term for the treatment of agitation associated with severe obsessive compulsive behaviors, but long term use is discouraged in ambulatory persons unless all other options have failed

Author's take home points

Obsessive compulsive behavior is most often only partially treatable. The goal of treatment is to decrease the severity, frequency and distress caused by this symptom, not to make it go away. Treatment of this symptom complication will decrease the burden of HD. The management of obsessive compulsive behaviors in HD is similar to that in treating the symptom in other diseases of dementia and when obsessive compulsive disorder occurs in the general population.

References

Anderson KE, Craufurd D, Edmondson MC, Goodman N, Groves M, van Duijn E, van Kammen DP, Goodman L. An International Survey-based Algorithm for the Pharmacologic Treatment of Obsessive-Compulsive Behaviors in Huntington's Disease. PLoS Curr. 2011 Sep 20;3:RRN1261. PubMed abstract