Early Onset Obsessive Compulsive Disorder with Obsessive Slowness: A Case Report and Demonstration of Management
Mr. M, a 15-year-old boy from middle socioeconomic status, Hindu, nuclear family, student of eighth class, without any past medical and psychiatric illness, with anankastic traits in parents as rigidity and stubbornness, and with slow to warm premorbid temperament; presented with 3 year history of insidious onset and progressively deteriorating course of symptoms characterized by repeated doubts (regarding locking and unlocking the door knobs, turning switches on and off), repeated fears (something bad would happen with him if somebody would touch him while performing almost all routine activities), magical thinking (roof falling on him if he would not stand properly from toilet seat), mental compulsion (counting) with progressive slowness in self-care behavior (brushing, bathing, changing clothes, walking, and eating), and avoidance of routine activities with academic decline. For 6 months prior to reporting to a tertiary level referral hospital in India, the patient started having anxious and low mood, loss of interest in all pleasurable activities, and stopped going to the school. He would remain confined to bed, would not speak and communicate mostly by gestures. He would spend 2-3 h in finishing his one meal, and similar time in bathing, changing clothes, etc., The mental status examination revealed obsessive slowness, obsessive doubts and fears, magical thinking, yielding, and mental compulsions. Yale-Brown Obsessive Compulsive Scale (YBOCS) score was 40 at the time of initial assessment. He was diagnosed as a case of OCD with slowness following International Classification of Diseases and Related Health Problems (ICD-10).[] It was planned to manage him as inpatient with combined pharmacological and behavioral treatment. His relevant and routine investigations were within normal limits. He was started on fluoxetine 20 mg/day. After detailed behavior analysis, it was found that he had slowness and repetition in all routine activities with score of 9-10 for distress on a scale of 1-10. He would remain in bed throughout the day and would do all routine activities only on being coaxed by parents. Prompting, pacing, and shaping of routine activities were carried out daily. Exposure and response prevention sessions were conducted on alternate days. Also, fluoxetine was slowly titrated to 60 mg/day and was well tolerated by him. Initially, it was difficult to get him involved in the treatment as he would take several minutes while coming to interview room, starting conversation, and following instructions. It was decided to make individual sessions longer because the slowness and resistance made it difficult to achieve the individual session goals. The duration of sessions was increased to 90-120 min instead of usual 45-50 min. Also, psychoeducation for the family members was started. Initially, the parents had difficulty in accepting the fact that their son's problems were because of a psychiatric illness as they believed that M's problems were due to maladaptive behavior and he did it on purpose to annoy them. However, later on with psychoeducation, his mother understood the nature of his illness. She agreed to be cotherapist and her increased involvement and dedication made the therapy more intense and helped the team to achieve more and more cooperation from the patient. The two major hurdles in managing the case were difficulty in establishing rapport with the patient and retaining him in the therapy. After beginning of the combined therapy, he started showing improvement in almost all the problem areas (as tabulated below) and after 3 months, YBOCS score reduced to 25 with improvement in the time spent in getting out of bed, brushing, going to toilet, answering to questions, changing clothes, and eating. Post discharge from the hospital, he came regularly for follow-ups and his mother continued to be a cotherapist and would practice therapy at home. He maintained the improvement post 3 months of discharge [].