What treatment options are available for a patient with obsessive-compulsive disorder (OCD), skin picking, weight loss, and attention deficit hyperactivity disorder (ADHD) symptoms, who is currently taking atomoxetine (Strattera), buspar (buspirone), and Prozac (fluoxetine)?

Treatment Optimization for Complex OCD with ADHD and Skin Picking

Immediate Assessment and Medication Review

First, critically evaluate whether the current Prozac (fluoxetine) dose is optimized, as higher SSRI doses are required for OCD than depression, and consider that fluoxetine itself may paradoxically be causing or worsening the skin picking. 1

Critical Medication Concerns

• Fluoxetine can paradoxically induce skin picking and compulsive behaviors, particularly in younger patients, which may be contributing to rather than treating the excoriation disorder 2
• Weight loss is a known adverse effect of fluoxetine, occurring in 1.4% of patients in clinical trials, with anorexia (decreased appetite) reported in 11% of patients versus 2% on placebo 3
• Atomoxetine can also cause decreased appetite and weight loss, and paradoxically may either improve OR worsen skin picking depending on the individual 4, 5, 6

Treatment Algorithm

Step 1: Optimize Current SSRI Therapy

• Ensure fluoxetine is at maximum recommended dose for OCD (typically 60-80 mg/day, higher than depression dosing) and has been trialed for 8-12 weeks at this dose 1
• Monitor for early response by week 2-4, as this predicts 12-week outcome 1
• If weight loss is problematic and skin picking worsened after fluoxetine initiation, strongly consider switching to a different SSRI with less appetite suppression effect 1, 3

Step 2: Address Skin Picking Specifically

Skin picking (excoriation disorder) is classified as an obsessive-compulsive related disorder and typically responds to the same treatments as OCD 1

• Add or intensify CBT with Exposure and Response Prevention (ERP) specifically targeting skin picking behaviors, as CBT has a number needed to treat of 3 versus 5 for SSRIs 1
• If fluoxetine was started recently and skin picking emerged or worsened afterward, this is a red flag for fluoxetine-induced skin picking and warrants switching SSRIs 2
• Atomoxetine has mixed evidence: one case report showed improvement in skin picking with ADHD 5, but another showed atomoxetine-induced skin picking 6

Step 3: Augmentation for Treatment-Resistant OCD

If adequate SSRI trial (8-12 weeks at maximum dose) shows inadequate response 1:

First-line augmentation options in order of evidence strength:

1. Augment with CBT/ERP if not already implemented - this is superior to antipsychotic augmentation 1

2. N-acetylcysteine augmentation - has the largest evidence base among glutamatergic agents, with 3 out of 5 RCTs showing superiority to placebo 1

3. Memantine augmentation - can be considered as several trials demonstrate efficacy in SSRI-resistant OCD 1, 7

4. Atypical antipsychotic augmentation (risperidone or aripiprazole) - evidence-based but major concern for weight gain, which is problematic given current weight loss 1

   • Only one-third of SSRI-resistant patients show meaningful response 1
   • Requires ongoing monitoring for metabolic dysregulation 1

5. Switch to clomipramine - equivalent efficacy to SSRIs but better tolerability profile with SSRIs makes them first-line 1

Step 4: Address Weight Loss and Appetite

• Monitor weight change closely during therapy 3
• Consider switching from fluoxetine to an SSRI with less appetite suppression if weight loss is clinically significant 1, 3
• Evaluate if atomoxetine dose can be optimized or reduced if contributing to appetite suppression 4
• Rule out medical causes of weight loss unrelated to medications 3

Specific Recommendation for This Patient

Given the complex presentation with weight loss, I recommend:

1. Verify fluoxetine is at 60-80 mg/day for adequate OCD treatment (not just depression dosing) 1

2. Immediately initiate or intensify CBT with ERP for both OCD and skin picking, as this has superior efficacy to medication alone 1

3. If skin picking emerged or worsened after fluoxetine initiation, switch to a different SSRI (such as sertraline or fluvoxamine) as fluoxetine may be paradoxically causing the behavior 2

4. If adequate SSRI trial fails after 8-12 weeks, add N-acetylcysteine augmentation as first-line pharmacological augmentation given its evidence base and favorable side effect profile 1

5. Avoid antipsychotic augmentation initially due to weight gain risk in a patient already losing weight 1

6. Continue atomoxetine for ADHD unless clearly temporally associated with skin picking onset 5, 6

Critical Pitfalls to Avoid

• Do not assume current SSRI dose is adequate - OCD requires higher doses than depression (fluoxetine 60-80 mg vs 20-40 mg) 1
• Do not add antipsychotics as first augmentation when weight loss is present - choose N-acetylcysteine or memantine instead 1
• Do not overlook that fluoxetine itself may be causing skin picking - temporal relationship is key 2
• Do not neglect CBT/ERP - it has better efficacy than medication and should be prioritized 1
• Do not wait beyond 8-12 weeks to declare SSRI trial adequate or inadequate, though early response by 2-4 weeks is predictive 1