|Year : 2018 | Volume
| Issue : 1 | Page : 51-54
Unusual manifestations of obsessive-compulsive disorder
Jalpa Prajesh Bhuta
Department of Psychiatry, Global Hospitals, Mumbai, Maharashtra, India
|Date of Web Publication||8-May-2018|
Jalpa Prajesh Bhuta
211E, 103, Dinesh Mahal, Dr. Ambedkar Road, Matunga East, Mumbai - 400 019, Maharashtra
Source of Support: None, Conflict of Interest: None
There is limited literature on the atypical or the unusual manifestations of obsessive-compulsive disorder. In this case series, three cases are presented, with special emphasis on the atypicality of their clinical presentation. Each case is unique and attempts to give a different perspective on the dilemmas faced by the treating psychiatrist. Many times, such cases are mistakenly diagnosed with psychosis, and they get wrongly treated for months to years, leading to immense suffering, and chronicity of the illness. Often, such cases may go to different other specialties and end up with mismanagement, with no alleviation of the patient's complaints. With increased awareness, the clinician will be better armed to persist along different lines of inquiry, and get adequate information, to reach the accurate diagnosis. This case series aims to give some such examples of not-so-common symptoms which may prove useful in our regular practice.
Keywords: Atypical, obsessive-compulsive disorder, symptoms, unusual manifestation
|How to cite this article:|
Bhuta JP. Unusual manifestations of obsessive-compulsive disorder. Ann Indian Psychiatry 2018;2:51-4
| Introduction|| |
We are familiar with the common symptomatology and clinical manifestations of obsessive-compulsive disorder (OCD). They mainly comprise intrusive thoughts, rituals, preoccupations, and compulsions. The most commonly reported obsessions for children and adolescents are concerns about bodily wastes, dirt, germs, fears of something terrible happening to self or loved one, concern for symmetry, order, excessive praying, lucky and unlucky numbers, etc., Furthermore, forbidden sexual thoughts, images, impulses or intrusive sounds, music are commonly reported.,
The most common compulsions in this population are frequent hand washing, bathing, brushing, repeating rituals, checking doors and locks often. Furthermore, touching, arranging, counting, hoarding, spitting etc., are commonly seen.
In adults, mainly the obsessions are about contamination, pathological doubt, somatic, need for symmetry, aggressive, sexual, etc., The common compulsions in adults are washing, checking, counting, need to ask/confess, hoarding, etc. Sometimes, the above symptomatology may be varied or may manifest in an unusual manner, which may be confusing for the treating physician. We may also need to look into the context, cultural beliefs, associated stressors and the uniqueness of the presentation along with the individual response to our treatment. There is presently limited literature for the same.
In an attempt to display some variability in the patient manifestation of the above symptoms and to keep them in mind in our day-to-day practice, I have outlined the following case series of some different and not-so-common presentations of OCD in different age populations.
A 34-year-old female divorcee not employed from 2 years, from an ultra-conservative Brahmin family background was brought by her brother with chief complaints of being lazy, not doing housework and visiting many doctors from 2 to 3 years. The patient was attractive but slightly disheveled, appeared of a warm disposition, kept on giggling and talked about passing urine in her underwear. Her brother revealed that her marriage had been broken as she refused to consummate the marriage for 1 year, stopped looking after the house and would talk back to her mother-in-law. She had been taken to 2 psychiatrists and had been diagnosed with Schizophrenia and started on antipsychotic medications. She had not shown much improvement. Her in-laws called her “mad” and obtained the divorce. As she came back to her parents home, she started having conflicts with her father and paternal aunt over trivial issues of not finishing work on schedule, not keeping the kitchen clean or having a routine, etc., She was also fired from her office.
On detailed inquiry, she described her main complaint of soiling her underwear frequently. She had been to various Gynaecologists and Urologists and undergone various investigations which were normal. It became apparent that she had a constant fear/doubt that she had passed a few drops of urine and would keep having the urge of checking and changing her underwear. In spite of seeing the clean underwear, she would still doubt that there were some urine drops. She was unable to accept that she was dry and would be in perpetual discomfort and worry.
During the sexual relationship of her marriage, it emerged that she was fearful about having sex and moreover was acutely conscious about passing urine at the same time. This made her avoid the sexual relationship. Due to her husband's taunts and disapproval, she was unable to communicate about her feelings. She started feeling worthless and helpless and was embarrassed to talk about her problems to anyone. Later, she stopped taking an interest in her appearance and became sloppy where housework was concerned. She had lost her mother a few years ago and had no sisters or friends to confide to. She also had a deteriorating office work performance and had left one job, and was fired from the other, due to the lack of concentration at work and not reaching office on time. After coming to her father's home, there would be a daily criticism of her behavior. Her conservative and orthodox Brahmin family members followed a strict routine of prayers, work and cleanliness, and meticulousness. Paradoxically, she was untidy and careless and unable to wake at 5 am for the routine.
As the symptoms were elucidated, the problem became clear over subsequent interviews and all her previous antipsychotic drugs were stopped. She was diagnosed with obsessive-compulsive disorder, her obsession being repetitive doubts of soiling her underwear and her compulsions being checking and changing her undergarments. She was started on tablet escitalopram 10 mg with a low dose of oral aripiprazole (2.5 mg) added as a precaution to watch and guard against any potential emergence of underlying psychosis. The patient started responding well. It also became apparent that her occasional giggling although inappropriate was due to her sense of acute embarrassment at the nature of doubts. Her medication was increased to 15 mg escitalopram, and later on aripiprazole was stopped. She continued to do well and resumed work.
However, there were strongly expressed emotions by her father at home due to which the family were not completely satisfied. Family therapy was commenced and the negativism and hostility were addressed. The dysfunctional ideas of perfectionism were discussed and the ideas of having a laid-back attitude and approach toward life being acceptable were discussed with great difficulty! A possible routine was negotiated and acceptance of differences in personalities was encouraged. The patient continued to do well. She became less worried about the doubts of her passing urine, would check less and completely stopped changing her underwear. She started to enjoy housework and began to exercise. Sexual education was done, and her strong fears about sex were discussed over three sessions. Two years later, patient had her second marriage, which has been consummated. She is living a normal life and continues on selective serotonin re-uptake inhibitors.
A 8-year-old male child a known case of sickle-cell disease (from 2 years), had developed sudden onset insomnia, severe restlessness, and ideas that people were talking about him, laughing at him with fearfulness of seeing ghosts from 20 days. The patient was admitted in a tertiary cancer hospital for management. For the control of symptoms, a low dose of olanzapine (2.5 mg) and quetiapine (12.5 mg) was started on consultation and investigations were done to rule out organic causes. PANDAS were ruled out by the pediatric neurologist. Anti-basal ganglia test was negative. Autoimmune workup was negative. Serum ceruloplasmin levels were marginally low, but Wilson's disease was ruled out. Ophthalmological examination was normal. Thyroid-stimulating hormone was marginally high, but the pediatric endocrinologist opined that active management was not required. Electroencephalography, magnetic resonance imaging (MRI), and magnetic resonance angiography were all normal. The patient was examined in detail by most specialties, but no significant finding or any organic cause was detected.
During the first assessment in child guidance clinic (CGC), the father described no change with the given medications. The patient was very restless, walking about the room, looked fearful, and reported that in the CGC people were looking and laughing at him. He also said that a ghost would come at night and prevent him from eating his meals. He had started eating mud, and would occasionally smile to self, as per the father.
The patient was unable to articulate his thoughts and feelings despite repeated questioning. He gave the same repetitive answers. Moreover, his IQ clinically appeared borderline to low, and more information could not be obtained. Father described normal delivery and milestones; although he was not academically very bright. There was no history of head trauma or loss of consciousness or any family history of mental illness.
A provisional diagnosis of early onset psychosis with sickle cell disease was considered. Doses were increased to tablet olanzapine 10 mg and a month later to 15 mg with a regular follow-up. As there was no further improvement, tablet risperidone was added and doses gradually titrated up to 4 mg. Patient started putting on weight and started complaining of knee joint pains. Tablet aripiprazole and haloperidol were also tried with no improvement. Due to his medical comorbidity and age factor, clozapine was not tried. Mood stabilizer valproate was introduced and titrated with the patient now being on a combination of valproate 750 mg, olanzapine 15 mg and risperidone 4 mg/day. The persecutory and referential symptoms still persisted. His confidence started going down. He had started school but was unable to maintain attention. He always appeared highly distressed. Fluoxetine was introduced, but it caused behavioral activation and hence was stopped. A trial with benzodiazepines for restlessness was given, but it did not show improvement. Valproate was substituted with oxcarbazepine, but there was no significant change.
Despite being on 2 years follow-up, patient was more or less the same. He then started expressing suicidal ideas and urges and described thoughts of jumping in front of the train and hanging. He would cry and talk about the boys at school making fun of him and laughing at him. He started to repeatedly ask his parents whether they were doing so and constantly sought his father's reassurance. Due to repetitive nature of his behavior, and frequently seeking reassurance which was mentioned for the first time now, the possibility of obsessive thoughts and compulsions was considered. Patient was started on tablet clomipramine, and antipsychotic medications were decreased. Mood stabilizer was stopped and patient was closely monitored with weekly follow-up. There was an initial 30% improvement reported. Tablet clomipramine was steadily increased to 100 mg and low lose tablet fluoxetine was re-introduced. Patient showed significant improvement. Antipsychotic medications were reduced to just 0.5 mg of risperidone and a low-dose beta-blocker propranolol 30 mg in divided doses was added for restlessness. At present, father reports 90% improvement with the patient not asking questions or seeking reassurance. He interacts with his friends and is studying better and has a smile on his face when he comes for a follow-up.
A 70-year-old Maharashtrian widowed female, living with her son and daughter-in-law in a one bedroom house was referred by a colorectal surgeon for complaints of visiting the toilet 4 times a day and spending 3–4 h each time in the toilet (total 12–16 h a day in the toilet). She also expressed a sense of incomplete evacuation of stools while trying to pass them and would repeatedly try to push them out by applying pressure. She was unable to relax or feel at ease when out of the toilet and was completely housebound for 4 years due to the fear of not finding a toilet outside the house. She was continuously preoccupied with the same thoughts and also could not talk on any other topic besides her stools. There was frequent friction with her daughter in law as the other family members would find their single toilet constantly occupied. There was social isolation, lack of enjoyment, feeling anxious, worried, thinking that life is not worth living, and constant tearfulness and helplessness due to the same.
Patient had been to several gastroenterologists and gastrointestinal surgeons and undergone several tests and procedures. She also was of opinion that surgery would fix the problem. Anal manometry showed some dyssynergia in the rectum. Her colonoscopy was normal. In MRI defaecogram, there was a rectocele and mucosal prolapse, indicative of Obstructive Defaecation Syndrome. According to the colorectal surgeon, she was probably fixated on bowels and stools (anal fixation). Her tendency to repeatedly bear down while trying to open her bowels from so many years could have led to the occurrence of the rectocele and mucosal prolapse. Surgery in her case would have a poor success rate with a risk for relapse until she had more psychological insight and awareness.
The patient had no complaints of hand washing, checking, cleaning, magical thinking, praying, etc., The thoughts of having a sensation to pass stools, repeatedly thinking of incomplete evacuation, being preoccupied by the same, and constantly applying pressure to pass the stools were considered to be on an obsessive compulsive spectrum. She was diagnosed with obsessive compulsive disorder with secondary major depressive disorder and comorbid with Obstructive Defaecation Syndrome. The medical and psychiatric conditions were in all probability interlinked due to the cause–effect cycle.
She was started on tablet escitalopram 10 mg and regularly monitored. After 6 weeks, she perceived no difference, although her relatives said that she was visiting the toilet 2–3 times a day and spending only 45 min at a time. She was also going out of her home to meet her daughter and interacting more with her grandchildren. She was more careful about her appearance and smiled more often. Her daughter in law was relieved as they finally got to use the toilet. Tablet escitalopram 15 mg was continued and after 1 year when she remained 70% better but still insisted on surgery, she underwent the Starr Procedure (minimally invasive new surgical procedure of stapled tansnasal rectal resection done for Obstructive Defecation Syndrome). She has remained well on medications since.
| Discussion|| |
In all the above three cases, there was partial or no insight to the problems. All three patients could not describe these thoughts coming from their own mind. However, the thoughts were intrusive, repetitive, and constant and caused acute distress to the patients. The compulsions were also varied where the child had the frequent need to tell his father about the laughing and teasing, later progressing to seeking reassurance, in turn stressing the father out. The first female was too embarrassed to disclose her constant doubt of having passed drops of urine and in turn internalized her distress into depression and helplessness. Her compulsion which was not apparent to her family members of checking her underwear also manifested as having gone to several gynecologists to determine her problem. To compound that, it affected her marital and sexual life to a huge extent.
The elderly female had the obsession of doubt of incomplete sense of stool evacuation. It led her to the compulsion of trying to push her stools for hours at a stretch, leading to the rectocele and mucosal prolapse. It is known that patients with pelvic floor dyssynergias have anxiety, depression, and obsessive neurotic traits. She kept searching for a cure by obtaining various tests, and seeking surgery. It had become a vicious cycle.
In the second case, the patient's lack of ability to express himself and a low IQ makes it more challenging. Furthermore, it is probable that he had developmentally normal fears and imagination of seeing ghosts at the age of 8 years which further added to the confusion of the diagnosis as psychosis. There was also a simultaneous occurrence of pica in the form of eating mud at the same time. It could therefore be like a schizo-obsessive disorder or Psychosis with obsessive symptoms. However, the almost total nonresponse to all the tried antipsychotics and the almost complete improvement with clomipramine builds up the argument for OCD. Moreover, we know that there is substantial evidence of dysfunction in the cortical striatal-thalamic network among patients with obsessive compulsive disorder and Schizophrenia. This dysfunctional network overlap, in a subgroup of patients, may account for some of the obsessions, in severe form, to be associated with lack of insight.
In all the three cases, only the positive histories have been elaborated to avoid repetition. Other differential diagnoses, i.e., delusional disorder, hypochondriasis, body dysmorphic disorder, phobias, other OCD spectrum disorders etc., have been ruled out. Family histories were negative, though for the first case, due to her family's beliefs and perfectionistic traits, she might be more prone for developing obsessive compulsive personality traits (in this case, the disorganized type, as per Freudian theory) or neuroses.
As per a few case reports and scanty literature available, it is essential to be aware of unusual manifestations of OCD.,,, It is often observed that all the necessary information may not be available in the first interview itself. Frequently, after several interviews over a period of time, the patient may reveal about their problem. It is important to be vigilant, and keep reviewing the diagnosis, especially if there is poor response to initial diagnosis and management. Otherwise, it leads to further deterioration and losing time in effectively helping and treating the patients.
Furthermore, a good liaison with other specialties is necessary as the patients with atypical symptoms frequently present to other specialty doctors with unnecessary investigations and procedures including surgeries etc., being done. It is essential to create awareness among the medical fraternity for the same.
| Conclusion|| |
As our society and its ailments evolve, we need to evolve as treating clinicians. Our awareness of various possibilities makes us more astute and efficient. Furthermore, we need to report our observed unusual symptoms regularly and compile them so as to increase our knowledge base and awareness.
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Conflicts of interest
There are no conflicts of interest.
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