Case Studies Offer OCD Insights

by Denis Storey
April 16, 2024 at 1:25 PM UTC

The Primary Care Companion for CNS Disorders has published several case studies that explore various aspects of OCD.

Clinical relevance: The Primary Care Companion for CNS Disorders has published several case studies that explore various aspects of OCD.

  • One study looks at postictal behavioral changes in epilepsy that can include obsessive-compulsive phenomena, highlighting the importance of recognizing and treating these manifestations.
  • Another case report discusses late-onset OCD with somatic obsessions and the diagnostic challenges it can present.
  • Finally, a third paper reports on shared or induced OCD, such as olfactory reference syndrome (ORS), in a case involving two sisters.

Obsessive-compulsive disorder (OCD) is defined by persistent intrusive thoughts and repetitive behaviors, can seriously hamper a patient’s quality of life. And they affect anywhere between 1 percent and 1.5 percent of the population.

The Primary Care Companion for CNS Disorders recently published a trio of case studies that explore the different aspects of OCD and how it can interfere with patients’ lives. Here are summaries as well as links to these studies for further review.

Researchers Identify Obsessive-Compulsive Phenomena as Postictal Behavioral Change

Recognizing postictal behavioral changes (PBCs) remains vital for medical professionals trying to diagnose and treat both epilepsy and associated psychiatric morbidity. Common PBCs can include aggression, psychosis, confusion, and mood alterations.

In temporal lobe epilepsy, obsessive-compulsive phenomenon (OCP) normally manifests during the interictal phase. But it rarely crops up as a postictal manifestation.

This report examines the case of a 23-year-old man with focal epilepsy who exhibited obsessive-compulsive PBCs after multiple seizures. Symptoms included the patient muttering and smiling to himself, constant hand and face washing, low mood, anxiety, and restlessness.

Despite being well-adjusted premorbidly, the patient displayed these behaviors for four years. Seizure symptoms included abdominal heaviness, eyeball rolling, tonic-clonic movements, frothing, tongue biting, and urinary incontinence. A postictal phase soon followed, characterized by drowsiness and obsessive-compulsive behaviors such as repetitive cleaning.

The patient’s Yale-Brown Obsessive-Compulsive Scale scores fell significantly from 31 to zero between 24 hours and the fifth day postictal. Electroencephalography revealed bilateral temporal intermittent rhythmic delta activity (TIRDA), more pronounced on the right side, while neuroimaging didn’t reveal anything out of the ordinary. Carbamazepine treatment resulted in seizure relief throughout a one-month follow-up.

This case highlights the destructive power of PBCs on an epilepsy patient’s quality of life and the scarcity of obsessive-compulsive PBCs, as opposed to the more common incidence of anxiety disorders.

Further research into the association between obsessive-compulsive PBC patterns and seizure discharges could offer insights into behavioral changes in epilepsy and other psychiatric disorders. Neurobiological models like the striate-thalamic-orbitofrontal connectome and kindling might explain these phenomena but need more data about the context of obsessive-compulsive PBCs.

Is Late-Onset OCD with Somatic Obsessions an Overlooked Phenotypic Subtype?

Late-onset OCD often drives psychiatric professionals to dig deeper for secondary origins, even though so many cases can appear idiopathic. Some patients exhibit somatic obsessions, which present diagnostic challenges because of the frequent crossover with hypochondriasis.

This second case describes a 73-year-old man with religious obsessions that degenerated into mystical delusions. Eventually, those manifested into somatic obsessions of choking or dying. Rhinorrhea triggered these compulsions, which spawned extensive rituals and avoidance behaviors. Treatments with sertraline, mirtazapine, aripiprazole, and other medications proved effective.

Late-onset OCD typically follows extended subclinical phases and stressful events. Differential diagnosis between OCD and hypochondriasis can be complex since they both involve high anxiety, catastrophic thoughts, and repetitive behaviors.

But, somatic obsessions in OCD are ego-dystonic, which stand in stark contrast to hypochondriasis and its ego-syntonic beliefs. And ritualized neutralizing strategies and the presence of non-somatic obsessions helps caregivers diagnose OCD.

Poor insight can obscure this distinction, as observed in cases with reduced ego-dystonia.

Somatic obsessions might represent a distinct OCD phenotype influenced by both neurobiological and environmental factors – just like hypochondriasis. But the authors urge further research to clarify this relationship.

Shared or Induced Olfactory Reference Syndrome

There’s little documentation on shared or induced obsessive-compulsive disorder (OCD) compared to shared or induced delusional disorder.

Olfactory reference syndrome (ORS) remains a lesser-known condition distinguished by an intense fixation on body odor, leading to distress and impaired functioning. Many experts consider ORS an unconventional subtype of OCD, classifying it under “other specified obsessive-compulsive disorders” in the DSM-5.

In this third and final case, the authors discuss a pair of sisters with induced ORS – likely triggered by one of the sibling’s use of homeopathic COVID-19 prevention treatments.

The elder sister reported a persistent unpleasant sweat odor despite extensive hygiene measures, accompanied by a fear of repulsing others. She also admitted to an aversion to cooked food smells, especially from outside sources.

Clinical evaluation ruled out epilepsy, and psychiatric assessment revealed no prior obsessive behaviors or psychiatric history. Remarkably, the younger sister exhibited similar symptoms, possibly indicating shared or induced ORS.

Treatment involved oral sertraline for the elder sister, leading to significant symptom improvement after two months. The younger sister, who started taking oral fluoxetine, also saw the resolution of most symptoms within the same timeframe. The caregivers couldn’t separate the sisters, but it didn’t seem to hamper the treatment outcomes.

This case sheds light on a rare occurrence of shared ORS, which could have been influenced by genetic and environmental factors. It also underscores the effectiveness of selective serotonin reuptake inhibitors (SSRIs) in ORS treatment, suggesting a potential overlap between ORS and the obsessive-compulsive spectrum. Overall, this report highlights the challenges and successful management of shared ORS in two sisters.

Further Reading

Weekly Mind Reader: Treating OCD and Compulsive Sexual Behavior

How Brain Chemical Imbalances May Contribute to OCD

Obsessive-Compulsive Disorder Following COVID-19 Infection

Clinical and Practical Psychopharmacology

Antipsychotic Medication Continuation vs Taper and Discontinuation in Patients With Schizophrenia and Other Nonaffective Psychotic Disorders

Dr Andrade discusses two studies that examined the outcomes of gradual, individualized antipsychotic dose reduction and discontinuation in patients with psychosis.

Chittaranjan Andrade

Letter to the Editor

Geriatric Depression: What Clinicians Need to Know

The authors discuss what clinicians should be aware of when caring for elderly patients with depression.

Ahmed Naguy and others