Relationship between Obsessive Compulsive Disorder, Stroke-related Metabolic Disorders, and Ischemic Stroke

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Published on 6/14/2021

Are your obsessions leading you to stroke?

As the second leading cause of death worldwide, accounting for approximately 11% of total deaths, as well as the third leading cause of disability, medical researchers have for a long time been interested in understanding strokes and the factors that increase the risk of its occurrence. Strokes can be either ischemic or hemorrhagic; an ischemic stroke will happen when a blood clot or build-up of plaque blocking the blood supply to the brain, and a hemorrhagic stroke takes place when a blood vessel bursts in the brain. Commonly known risk factors for stroke are typically listed as high blood pressure, diabetes, high cholesterol, and obesity, with doctors regularly recommending tobacco smoking cessation, weight loss, and physical exercise as a means to avoid stroke-related risk factors.

However, there is now evidence that people who have repeated distressing thoughts may be at a greater risk. A study in Taiwan with 56128 participants over nine years found that people with obsessive-compulsive disorder ("OCD") were nearly three (3) times more likely to suffer a stroke compared to persons without the condition. OCD is a chronic mental disorder that exists on the obsessive-compulsive spectrum. Persons with the condition have recurrent obsessive thoughts (called obsessions). The disorder often manifests itself in perfectionism, fear of contamination, need for symmetry or even sexual fixation. These thoughts often trigger intensely distressing feelings and causes the individual to engage in distressing repetitive behaviors (called compulsions) such as excessive cleaning and ordering or scratching. According to the World Health Organizations, OCD is one of the ten most disabling conditions worldwide. It occurs in approximately two per cent of the population.

The research in Taiwan found that the persons with OCD studied were 45% more likely to have one or more metabolic or cardiovascular health complication compared with the non-OCD controls. The study published on 27 May 2021 Stroke journal, reported that there is an established association between OCD and stroke-related metabolic disorders, including obesity, hypertension, and diabetes, especially in middle-aged and older patients. It also noted that previous studies have already found that patients with OCD are more likely than the general population to develop hypertension, type 2 diabetes, and dyslipidemia later in life, presenting at rates of 12%, 6%, and 11%, respectively. However, the alarming result was that independent of these stroke-related comorbidities, patients with OCD were still three times more likely to have an ischemic stroke compared to non-OCD controls.

Does this mean people are worrying themselves into stroke?

Several pathomechanisms have been proposed to explain the temporal association between OCD and ischemic stroke. Firstly, there are several psychiatric comorbidities that are present in OCD patients that are associated with stroke risk. These include schizophrenia, bipolar disorder, and major depressive disorder, which present at 10%, 9-35%, and up to 50%, respectively. Due to both hereditary and environmental factors, comorbidities of severe mental health disorders further increase the likelihood of stroke-related risk factors, including obesity, smoking, and metabolic disorders. So it could be other mental health diagnoses playing a role.

Also, research evidence suggests that OCD is a systemic inflammatory disease. This presents another possible pathomechanism for the association between OCD and ischemic stroke because systemic inflammation, including elevated levels of CRP (C-reactive protein) and IL (interleukin)-6, increases the risk of cerebrocardiovascular events later in life. CRP is something that doctors test when they are concerned that a patient is at high risk of a heart attack. Research has found that patients with OCD have higher levels of CRP than controls and that low levels of CRP are associated with reduced risk of stroke and coronary heart disease. However, there is still an issue with working out whether OCD causes systemic inflammatory disease or whether the reverse is true.

For persons with OCD wondering what might be the best approach to reduce stroke risk, it appears that management with medications is a very uncertain path. A controversial aspect of the research between OCD and stroke is the effect of serotonin reuptake inhibitors (SSRIs) on the risk of metabolic, cardiovascular, and cerebrocardiovascular complications and events, including ischemic stroke. While some persons may be taking well-known SSRIs such as Clomipramine for relief from OCD symptoms, it is unclear its impact on stroke. Serotonin reuptake inhibitors are a type of antidepressant used to treat depression, particularly in more severe cases. Some believe that taking SSRIs at higher doses for a longer duration can lower the risk of metabolic and also cardiovascular complications, including stroke. However, others studies have found the opposite, namely, an increase in cerebreocardiovascular incidents with such use.

In short, there is a very real link between OCD and stroke. The findings of Chen's recent study in Taiwan call for several actions at a public and private level. Firstly, it means that more research needs to be done on the relationship between OCD and ischemic stroke, as well as stroke-related metabolic disorders. As for the responsibilities of the medical field, physicians and other health professionals need to take several steps to better serve their OCD patients. Firstly, GPs should ensure close monitoring of OCD patients for cerebrovascular disease and other risks so that incidences of strokes can be reduced where possible. Additionally, it is the responsibility of clinicians and medical professionals to educate OCD patients and their caretakers on these potential outcomes and advise them on preventative and mitigating steps to be taken. Lastly, while research is being done and new developments are being presented, medical professionals must keep abreast keenly with this information to effectively care for their patients.

For the individual with OCD, this research may be a call to engage in non-medication-based condition management such as cognitive behavioral therapy as soon as possible.

References

Chen, M., Tsai, S., Su, T, Li, C, Lin, W., Chen, T., Pan, T., Bai, Y. (2021). Increased Risk of Stroke in Patients with Obsessive-Compulsive Disorder: A Nationwide Longitudinal Study. American Stroke Association.

Isomura, K., Brander, G., Chang, Z., Kuja-Halkola, R., Rück, C., Hellner, C., Lichtenstein, P., Larsson, H., Mataix-Cols, D., and Fernández de la Cruz, L. (2018). Metabolic and cardiovascular complications in obsessive-compulsive disorder: a total population, sibling comparison study with long-term follow-up. Biol Psychiatry, 84, 324–331. doi: 10.1016/j.biopsych.2017.12.003

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