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<p class="ltrs-br-ltr-br-title"><span class="bold">Compulsive Joint Clicking on the Obsessive-Compulsive Spectrum: A Case Report</span></p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold">To the Editor:</span> Compulsive motor acts are often a challenge in clinical practice. Tics and habit spasm per se are considered neurologic disorders, whereas skin picking and onychophagia are viewed primarily as impulsive neurotic behaviors associated with emotional immaturity. However, both types of behaviors are well known to be associated with obsessive-compulsive disorder (OCD). We add compulsive joint clicking to this spectrum.<span class="htm-cite"><a href="#ref1">1</a></span></p>
<p class="ltrs-br-ltr-br-body-text"> </p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Case report.</span> Ms A, a single woman in her early 20s, presented with severe obsessions and compulsions complicated by depressive symptoms a year after graduation from university. Her obsessions and compulsions were related to checking, searching for symmetry in her environment, and avoidance of anything that men use, wear, or even touch, which was a cause of frequent quarrels with her brothers and father. The latter was precipitated by her witnessing her mother sexually harassed on a public bus in Cairo. She had a past history of trichotillomania and current compulsive onychophagia (biting of fingernails and toenails) of mild severity, compulsive skin picking that led to facial disfigurement, and compulsive joint clicking (mostly the ankle and fingers).</p>
<p class="ltrs-br-ltr-br-body-text">She suffered from OCD (<span class="italic">DSM-IV-TR</span> criteria) dominated by religious ruminations and blasphemous ideation in childhood and went through a phase of hoarding empty boxes.</p>
<p class="ltrs-br-ltr-br-body-text">Behavioral analysis revealed that onychophagia was mostly a response to stressful situations whereas compulsive skin picking was triggered by presence of wounds or furuncles. She complained of being unable to prevent herself from repetitive clicking of her ankle, joints, and fingers. The clicking sometimes lasted for several minutes and was observed to be slow, voluntary, compulsive, and repetitive and triggered by a strange uncomfortable joint feeling that subsided only after the joint was exhausted by repeated clicking. We referred to the latter as “compulsive joint clicking,” and an orthopedic consultation ruled out organic factors.</p>
<p class="ltrs-br-ltr-br-body-text">She was successfully treated using combined cognitive-behavioral therapy (CBT) and pharmacotherapy (clomipramine 150 mg, sertraline 50 mg), which led to improvement in depressive symptoms first. Her avoidance of male belongings as well as her searching for symmetry and checking improved at a later date, but compulsive skin picking and compulsive joint clicking responded only to the addition of pimozide 2 mg daily 3 months after the start of CBT and initial pharmacotherapy. The compulsive onychophagia did not change.</p>
<p class="ltrs-br-ltr-br-body-text">Her condition remained stable for 4 years. She asked for withdrawal of medication before getting married, which was done during 3 months. She continued to be well a year later.</p>
<p class="ltrs-br-ltr-br-body-text"> </p>
<p class="ltrs-br-ltr-br-body-text">The behavior of the patient was in response to strange uncomfortable joint feeling. She attributed her compulsive behavior to wanting to get rid of this sensation. This case demonstrates the presence of several obsessive-compulsive spectrum behaviors related to skin and appendages such as trichotillomania, onychophagia, and compulsive skin picking. The compulsive joint clicking was different in being slow, voluntary, and repetitive. It is similar to complex motor tics that are defined as intentional movements made in an attempt to diminish uncomfortable sensations.<span class="htm-cite"><a href="#ref2">2</a></span> Treatment of OCD with double therapy did not influence the behavior, and it was only after the addition of pimozide that the patient noticed marked improvement.</p>
<p class="ltrs-br-ltr-br-body-text">We may formulate a spectrum from compulsive motor acts (compulsive but voluntary or intentional to get relief from anxiety or discomfort) to motor tics (impulsive and involuntary and purposeless). Compulsive joint clicking is situated toward the motor tics end of that spectrum.</p>
<p class="ltrs-br-ltr-br-references-head"><span class="smallcaps">References</span></p>
<p class="references-references-text-1-9"><a name="ref1"></a>1. World Health Organization. <span class="italic">ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines</span>. Geneva, Switzerland: WHO; 1992.</p>
<p class="references-references-text-1-9"><a name="ref2"></a>2. Karp BI, Hallett M. Extracorporeal ‘phantom’ tics in Tourette’s syndrome. <span class="italic">Neurology</span>. 1996;46(1):38–40. <span class="pubmed-crossref"><a href="
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8559416&dopt=Abstract">PubMed</a> <a href="
http://dx.doi.org/10.1212/WNL.46.1.38">doi:10.1212/WNL.46.1.38</a></span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Wa-il Abouhendy, MD</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Sudad S. M. Jawad, MD, FRCPI, FRCPsych</span></p>
<p class="ltrs-br-ltr-br-author"><a href="
mailto:sudad.jawad@btinternet.com">
sudad.jawad@btinternet.com</a></p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Author affiliations:</span> Department of Psychiatry, Zigazeg Medical School, Cairo, Egypt (Dr Abouhendy); and Cardiff and Vale University Health Board, Cardiff, Wales, United Kingdom (Dr Jawad). </p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Potential conflicts of interest:</span> None reported<span class="semibold">.</span></p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Funding/support: </span>None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Published online:</span> July 4, 2013.</p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">Prim Care Companion CNS Disord 2013;15(4):</span><span class="doi">doi:10.4088/PCC.13l01513</span></p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">© Copyright 2013 Physicians Postgraduate Press, Inc.</span></p>
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