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Case Study: Caudate Glutamatergic Changes With Paroxetine Persist After Medication Discontinuation in Pediatric OCD

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ABSTRACT

Proton magnetic resonance spectroscopy (1 H-MRS) was used to examine glutamatergic (Glx) abnormalities in the caudate nucleus in pediatric obsessive-compulsive disorder (OCD), associated with severity of illness and response to acute (12 weeks) treatment with paroxetine. In this report, OCD symptoms improved markedly in an 8-year-old girl treated for 14 months with the selective serotonin reuptake inhibitor paroxetine (titrated from 10 to 40 mg/day). Paroxetine dose was then decreased in 10-mg decrements and discontinued without symptom recurrence. Serial 1 H-MRS examinations were acquired before and after 12 weeks of paroxetine treatment (40 mg/day) and 3 months after medication discontinuation. A striking decrease in caudate Glx was observed after 12 weeks of treatment which persisted after medication discontinuation. These data provide further support for a reversible glutamatergically mediated dysfunction of the caudate nucleus in OCD that may serve as a pathophysiological and treatment response marker.

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METHOD

This 8-year-old girl had a normal vaginal delivery at full-term and achieved all developmental milestones. She presented with a 4-month history of OCD manifested by contamination, scrupulosity, religious and moral preoccupation, as well as recurrent, intrusive violent and sexual images coupled with fear of blurting out obscenities. Compulsions included hand-washing, excessive showering and cleaning, hoarding behaviors, and ritualistic rereading and rewriting. These symptoms significantly

RESULTS

The patient experienced a significant reduction in OCD symptoms with paroxetine treatment; her CY-BOCS score had decreased by 17 points, from 27 before treatment to 10 after 8 weeks (30 mg/day) and 12 weeks (40 mg/day) of treatment (Fig. 2). The patient was then maintained on paroxetine 40 mg/day for 14 months, with a CY-BOCS score of 4 recorded.

The treatment team, the patient, and her mother then attempted to discontinue the patient's paroxetine by decreasing the medication by 10 mg every 2

DISCUSSION

Caudate Glx concentration was seen to undergo a striking decrease in relation to paroxetine therapy and OCD symptom remission, and this decrease in Glx was maintained 3 months after medication discontinuation. These results suggest that a reversible glutamatergically mediated striatal dysfunction in pediatric OCD may serve as a pathophysiological and treatment response marker. Although direct clinical application on the basis of a single case study is limited, it illustrates how treatment

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This work was supported in part by the Miriam L. Hamburger Endowed Chair at Children's Hospital of Michigan, Wayne State University, and the State of Michigan Joe F. Young Sr. Psychiatric Research and Training Program, and by grants from the NIMH (MH01372, MH59299) and the National Alliance for Research on Schizophrenia and Depression.

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