Obsessive and/or compulsive behaviors occur frequently as a complication of Huntington's disease and often worsen as the disease progresses [Beglinger LJ 2007]. Obsessions are repetative thoughts or ideas which "get stuck" and compulsions are the actions associated with obsessive thoughts. As an example, the thought of absolute need for cleanliness or worry about germs can be followed by the action of hand washing.

Cognitive inflexibility is a medical description of what is happening in the brain that causes difficulty with switching from one thought or action to another.  Common examples include:

  • Difficulty changing a schedule or routine
  • Difficulty letting go of anger
  • Thinking, talking, worrying about the same thing over and over
  • Ongoing worry about a threat or a pain

Occuring more often in later disease:

  • Inappropriate verbal outbursts
  • Smoking
  • Toileting
  • Hypersexuality
  • Religious or political zealotry

These behaviors rarely occur in isolation and are associated with anxiety, depression, agitation and can occasional be associated with delusional thoughts.

Management Strategies for Obsessive Compulsive Behaviors include behavioral and pharmacologic approaches:

"Do" behavioral strategies include modifying the environment by simplifying life:

  • Regular schedules/routines. If change is necessary give advance warning
  • Allow more time for accomplishing activities
  • Identify triggers of overstimulation like noise, too rapid requests/demands
  • Distract
  • Non judgemental response
  • Give time to cool down

Don't behavioral strategies:

  • Don't try to rationalize or convince
  • Don't respond with anger

First line treatments are SSRI antidepressant drugs, several of which have been FDA approved for obsessive compulsive symptoms. These include fluoxetine (Prozac®), paroxetine (Paxil®), sertraline (Zoloft®), and fluvoxamine (Luvox®). The NSRI antidepressant drug venlafaxine (Effexor®) has been approved for severe anxiety and is also used for obsessive compulsive symptoms. Duloxetine (Cymbalta®) is a good alterntative NSRI. Often higher doses of these drugs are needed than those used for depression. Clomipramine (Anafranil®) that has combined SSRI and tricyclic that can be used in more severe presentation, but is not used first due to greater side effects than SSRI or NSRI drugs.  Mirtazepine (Remeron®) is an atyptical antidepressant that is FDA approved for obsessive compulsive disorders.

Antipsychotic are not the drugs of choice for obsessive compulsive sypmptoms, but are often added if this symptom causes agitation.

Treatment Algorithm for Obsessive Compulsive Behavior in Huntington's disease [Anderson K 2011] can be downloaded from this article for your physician, detailing expert preference drug management of this symptom in HD.

References

Beglinger LJ, Langbehn DR, Duff K, Stierman L, Black DW, Nehl C, Anderson K, Penziner E, Paulsen JS; Huntington Study Group Investigators. Probability of obsessive and compulsive symptoms in Huntington's disease. Biol Psychiatry. 2007 Feb 1;61(3):415-8. Epub 2006 Jul 12. PubMed abstract

Anderson K, 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