Case 1: Contamination Fears and Washing
K.W., age 8, was brought to the NIMH by his parents after 2 years of excessive hand washing. He would spend 4 hours or more per day washing and rewashing his hands, which caused him to be late to school and to stay up late at night. K.W.’s hands were chapped and bleeding from the washing, and he would not allow any lotion to be put on his hands for fear of “contamination.” He walked around with his hands up in the air in a “surgeon’s position” for fear of contacting anything dirty. He was no longer able to touch doorknobs, flush toilets, touch anyone else, or play with his dog or in any contact sports. K.W. responded to clomipramine (at 3 mg/day) but not to desipramine during the NIMH double-blind study with a dramatic decrease (85%) in his washing and avoidance rituals. He was maintained on clomipramine for VA years and spent only 20 minutes per day washing his hands. Although traces of the rituals remained, they did not interfere in his life (e.g., he could play with his dog). When the patient’s clomipramine was blindly substituted with desipramine, he relapsed within 3 weeks and was returned to his maintenance clomipramine dose.
Case 2: Repetition
J.R., age 17, would retrace his steps from the car into the house in a very elaborate and specific manner (two steps forward, look to the sky, three steps backward, glance to the left and think a good thought). It took 20 minutes to go a distance that normally should have taken seconds. His complex rituals made him the object of neighborhood curiosity. If interrupted or prevented from completing his elaborate walking ritual, he became enraged and inconsolable. J.R. had a good response (70%) to clomipramine but not desipramine during the NIMH double-blind study. He completely stopped his repeating rituals. He acknowledged that the impulse to perform the rituals remained but that he was able to resist it without much effort. J.R. was maintained on clomipramine (at 3 mg/kg/ day) and developed tachycardia and orthostatic hypotension without any electrocardiogram changes. When his dose was dropped (to 2 mg/ kg/day) and 1,000 mg/day of L-tryptophan was added to augment the clomipramine the tachycardia resolved, but he was unable to maintain his clinical response. J.R. was switched to fluoxetine, 60 mg/day, and had an excellent response without side effects.
Case 3: Checking
L.S., age 16, had checking rituals as her predominant symptom. Approximately 1 year before presentation, she rather suddenly began to spend an hour at night checking whether the doors and windows were locked and all electrical plugs were pulled out. She could not trust her parents’ efforts. Her elaborate pattern of checking the house included many repetitions until she felt “it had been done right.” When her symptoms increased and she began to wake her parents up at 3 A.M. to recheck the house, help was sought. L.S. showed a dramatic response to clomipramine at 3 mg/kg/day with minimal side effects (dry mouth, mild tiredness). After 1 year of maintenance, she was tapered off the clomipramine to assess whether it was necessary, and her symptoms returned 3 weeks after discontinuing the medication. L.S. resumed her previous dose of clomipramine, and she regained her clinical response within 3 weeks.
Case 4: Touching
Touching rituals are slightly less common than those of washing and checking. D.D., age 13, felt incapacitated by a need to touch the corners of chairs, refrigerators, doors, and walls. She developed callouses on her hands from touching the walls so many times. She felt compelled to touch them “just the right way” for as long as 2 hours per day. If the ritual was interrupted, she had to start all over again. This behavior was extremely distressing to her, yet she was unable to stop. D.D. had a moderate response (50% reduction in time spent in rituals) to clomipramine at 3 mg/ kg/day but not to desipramine in the NIMH double-blind comparison. D.D. felt moderately troubled by the side effects of excessive sweating and daytime tiredness, and she elected not to continue clomipramine maintenance. Currently, the family reports that she is “doing well,” but she has not been seen for reevaluation.
Case 5: Arranging
S.E., age 11, was brought for evaluation for needing to “have everything in her room just so.” She would spend about 3 hours every day straightening every item in each drawer in her bedroom and every article of clothing in her closet. The rituals increased in time and became so subjectively incapacitating that she refused to go into her room anymore and had to sleep on the floor outside her room to make sure that no one went in to mess anything up. S.E. had a favorable response to clomipramine (75% reduction in time spent in rituals) during the NIMH study. Clomipramine (Anafranil) maintenance at 3 mg/kg/day was adequate for continuing the response; however, with an increase of medication to 3.5 mg/kg/day and the addition of behavior therapy, her rituals were decreased 95% to about 5 minutes per day of “making things right.”
Case 6: Hoarding
B.W., age 6, had to pick up anything that he might walk over. He began to bring home old pieces of paper, rocks, twigs, and trash that he found on the way home from school. The problem progressed until he was late to school because of having to pick everything up, and he would not allow anything that he had collected to be thrown away. He would go through the house trash and save old coffee envelopes, empty toothpaste tubes, ads, and newspapers. The problem progressed to such a point that his room was full of trash, and his parents felt that it was a health hazard. Whenever they tried to clean his room, B.W. would become agitated and have to be restrained. B.W. had an excellent response to clomipramine (3 mg/kg/day) but was unable to tolerate desipramine, which caused agitation. Unfortunately, B.W.’s coexisting severe ADHD was unchanged by the clomipramine and remained a continuous problem. When fluoxetine was substituted, he experienced agitation and was unable to tolerate the medication for this reason. During a trial of methylphenidate, the patient developed tics, and the medication was discontinued. Trials of imi-pramine, desipramine, and clonidine to target the ADHD symptoms were unsuccessful. Other psychopharmacologic interventions are being considered.
Case 7: Scrupulosity
W.S., age 17, prayed about 4 hours per day. Although he came from a very religious family, they became quite concerned about what they perceived as excessive prayer. W.S. would ruminate over past deeds for hours, tortuously reviewing them and wondering if he had done something wrong. He began to go to confession three times per day seeking forgiveness for imagined misdeeds and would repeatedly ask his parents if he had done anything wrong and if he were going to hell. Although W.S. experienced a decrease in symptoms while receiving clomipramine, he chose not to continue on the medication because he was not distressed enough by his praying to want it treated.
Case 8: Somatic Preoccupation
A recent presentation of obsessive-compulsive disorder is the preoccupying fear that one might have AIDS. K.T., age 17, believed that she had contracted AIDS from having touched a sterile, packaged syringe on the ground at a carnival. This conviction that she had AIDS later transformed into fearing that she had herpes and rabies. K.T.’s obsessions about AIDS disappeared while she was receiving clomipramine maintenance over a period of 6 months. When the medication was discontinued, her symptoms did not return. She has been symptom-free for 2 years now.
Selections from the book: “Current treatments of obsessive-compulsive disorder”, 2001