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Case Study: Ronald, a 59 Year-Old Male with Obsessive Compulsive Disorder

By addressing the microbiome issues, vitamin levels and supporting depressive symptoms, OCD symptoms can be more effectively addressed.

Initial Presentation

Ronald was a 59-year-old male with a long history of debilitating obsessive-compulsive disorder (OCD). He would obsess about cleanliness and often washed his hands 20, 30 or more times throughout the day. He also had problems getting to work, returning to check that the front door of his home was locked multiple times. The symptoms were destroying his self esteem, damaging his relationships and left him feeling irritable, exhausted and hopeless.

While numerous medications and counseling strategies had been explored, the symptoms were virtually non-responsive to standard treatments. The medications also led to intolerable side effects, flattening his affect and reducing his energy levels. Due to numerous treatment failures, he had been referred to our clinic for a more integrative treatment approach.

Initial Relevant labs

  • Urinary organic acid testing (OAT)
    • Numerous elevated markers indicating dysbiosis
    • HPHPA was elevated indicating the presence of Clostridium in the gut
  • Kryptopyrrole levels were within normal limits
  • 25-hydroxy vitamin D was low at 13 ng/ml

Initial Treatment

  • Vitamin D, 5000 iu
  • Probiotic and herbal antimicrobial to target Clostridium and decrease HPHPA
  • High EPA Omega-3 fish oil, two grams daily
  • Lithium Orotate, 5 mg daily
  • Rhodiola, 1 cap twice daily

Explanation

Vitamin D is necessary for serotonin production in the brain (DeLuca 2013). Evidence is also suggestive that levels may be lower in patients with OCD, and that symptoms may be worse in those patients with more significant vitamin D deficiencies (di Michele 2018, Soyak 2022).

While the data on omega-3 fatty acid supplementation for treatment of OCD is insufficient to draw direct conclusions, due to Ronald’s many overlapping depressive symptoms, a high EPA-containing fish oil was included in the initial treatment. As a treatment, EPA has been shown to provide benefits for reducing depressive symptoms (Kelaiditis 2023).

HPHPA or 3-(3-hydroxyphenyl)-3-hydroxypropionic acid is a metabolite from clostridia bacteria that can indicate overgrowth of clostridia species in the gastrointestinal tract. The metabolite appears to be neurotoxic, interfering with neurotransmitter function in the brain, contributing to schizophrenia, autism and other forms of mental illness (Shaw 2010). When present, the simplest initial treatment is high-dose probiotics, herbal antimicrobials or both. In Ronald’s case, due to the duration of his symptoms, a combination of probiotics and herbal antimicrobials were prescribed.

Low-dose lithium has also been proposed as a potential support for OCD that targets numerous underlying mechanisms, including inflammation, oxidative stress and dysregulated glutamate neurotransmitter signaling (Vallée 2021). In addition, low-dose lithium can be helpful for irritability, a symptom which Ronald initially also struggled to control.

Rhodiola rosea or rhodiola, is an herb from arctic regions around the world with a long history of use to improve stress resiliency. In the mental health literature, rhodiola has been shown to be helpful for treating depression and anxiety disorders (Sarris 2018).

Follow-up Presentation

At the two month follow-up, Ronald started to notice some improvements in his compulsions. While he still had them, at times it was easier to overcome the desire to follow through. He was encouraged by the progress, especially since previous standard treatments were of very little help for his symptoms. Based on his progress, follow-up testing was ordered.

Follow-up Testing

  • Upon repeat urinary organic acid testing:
    • HPHPA levels were within normal limits
    • Some dysbiosis markers were still elevated suggesting yeast overgrowth

Follow-up Treatment

  • Stop herbal antimicrobial
  • Add Saccharomyces boulardii 
  • Reduce overall sugar intake

Explanation for Follow-up Treatment

The herbal antimicrobial and probiotic had been effective for clearing the clostridia bacteria in the gut as evidenced by the reduced HPHPA levels. Due to indications of potential yeast from the organic acids test, Saccharomyces boulardii, a yeast-based probiotic was added. As Ronald liked to indulge in sweets, reducing sugar consumption was also recommended to discourage yeast overgrowth.

Additional Follow-up

At the six-month mark, Ronald’s symptoms had continued to improve. While the compulsions were not gone, they were more manageable and not as disruptive to his daily routine. He was doing better at work and his family life had noticeably improved. Ronald’s mood had also stabilized as his own outlook about the future had become more positive with treatment.

Case Summary

OCD can be a challenging condition to treat, as symptoms are often recalcitrant to standard medication-based treatments. By assessing for and treating the underlying factors that disrupt normal brain function, OCD symptoms can be more effectively addressed. For Ronald, disruption in the normal gut flora by both clostridia species and yeast were likely disrupting normal neurotransmitter function and increasing inflammation throughout the body. By addressing the gut flora issues, low vitamin D levels and supporting his depressive symptoms with additional treatments, Ronald’s symptoms improved and his ability to function in daily life was restored.

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References

DeLuca GC, Kimball SM, Kolasinski J, Ramagopalan SV, Ebers GC. Review: the role of vitamin D in nervous system health and disease. Neuropathol Appl Neurobiol. 2013;39(5):458-484. doi:10.1111/nan.12020

Kelaiditis CF, Gibson EL, Dyall SC. Effects of long-chain omega-3 polyunsaturated fatty acids on reducing anxiety and/or depression in adults; A systematic review and meta-analysis of randomised controlled trials. Prostaglandins Leukot Essent Fatty Acids. 2023;192:102572. doi:10.1016/j.plefa.2023.102572

di Michele F. Vitamin D supplementation in obsessive-compulsive disorder. Psychiatry Res. 2018;270:1174. doi:10.1016/j.psychres.2018.06.059

Sarris J. Herbal medicines in the treatment of psychiatric disorders: 10-year updated review. Phytother Res. 2018;32(7):1147-1162. doi:10.1002/ptr.6055

Soyak HM, Karakükcü Ç. Investıgation of vitamin D levels in obsessive-compulsive disorder. Indian J Psychiatry. 2022;64(4):349-353. doi:10.4103/indianjpsychiatry.indianjpsychiatry_26_22

Shaw W. Increased urinary excretion of a 3-(3-hydroxyphenyl)-3-hydroxypropionic acid (HPHPA), an abnormal phenylalanine metabolite of Clostridia spp. in the gastrointestinal tract, in urine samples from patients with autism and schizophrenia. Nutr Neurosci. 2010;13(3):135-143. doi:10.1179/147683010X12611460763968

Vallée A, Vallée JN, Lecarpentier Y. Lithium: a potential therapeutic strategy in obsessive-compulsive disorder by targeting the canonical WNT/β pathway. Transl Psychiatry. 2021;11(1):204. Published 2021 Apr 7. doi:10.1038/s41398-021-01329-3