Compulsion or chronobiology? A case of severe obsessive-compulsive disorder treated with cognitive-behavioral therapy augmented with chronotherapy

Objectives: Individuals with treatment-resistant obsessive compulsive disorder (OCD) have elevated rates of delayed sleep phase. This report describes a patient with severe OCD who had failed prior trials of pharmacotherapy and psychotherapy, and whose symptoms were associated with delayed bedtimes and delays in the time she initiated her nighttime compulsions. Methods: Case report. Results: A 54 year-old woman with OCD kept sleep/symptom logs as an adjunct to traditional cognitive-behavioral therapy for OCD. At presentation, she reported habitual bedtime = 06:00, wake time = 13:00, sleep latency ≤ 5 min, and total sleep time = 6.5-7.5 h. Later time of initiating her compulsions was associated with longer time performing the compulsions (r = 0.86, p < 0.001). Cognitive-behavioral therapy with adjunctive chronotherapy was associated with substantial improvement. Conclusions: OCD patients with nighttime compulsions may receive light exposure that results in delayed sleep times/circadian phase. Chronotherapy may enhance outcomes for refractory OCD patients, particularly those who perform compulsions at night.