Year : 2017 | Volume
: 6 | Issue : 4 | Page : 233--236
A compulsion to throw away prescribed tablets in a case of childhood obsessive-compulsive disorder with attention deficit hyperkinetic disorder
Suhas Chandran, M Kishor, T Navya Spurthi, TS S Rao, Rajesh Raman
Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore, Karnataka, India
Dr. Suhas Chandran
Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mahathma Gandhi Road, Mysore - 570 004, Karnataka
Obsessive-compulsive disorder (OCD) is one of the most complex and disabling disorders presenting to a hospital setting. Its symptomatology can mimic other psychiatric disorders, especially in children, making it confusing for the treatment team. It is often associated with comorbidities such as tics, depression, and attention deficit hyperactivity disorder (ADHD). We hereby report an instance of ADHD-OCD co-occurrence in a 16-year-old boy, who presented with a 9-year history of restlessness, obsessions of contamination, symmetry, causing harm to others, setting fire, magical thoughts, with compulsions of washing, checking, ordering and arranging, counting and repeating, swallowing stones, mental rituals, and self-mutilating behavior. Independent of these repetitive rituals, there were multiple instances throughout his schooling where he would be in disciplinary trouble due to his hyperactivity, disorganization, and inattentiveness. The resulting distress from all the above symptomatology had led to two suicidal attempts. His presentation to us was the index presentation to a psychiatric setting, and following initiation of treatment, he developed a compulsion to throw away his prescribed tablets. The interesting aspects of the phenomenology and management will be discussed.
|How to cite this article:|
Chandran S, Kishor M, Spurthi T N, S Rao T S, Raman R. A compulsion to throw away prescribed tablets in a case of childhood obsessive-compulsive disorder with attention deficit hyperkinetic disorder.Int J Health Allied Sci 2017;6:233-236
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Chandran S, Kishor M, Spurthi T N, S Rao T S, Raman R. A compulsion to throw away prescribed tablets in a case of childhood obsessive-compulsive disorder with attention deficit hyperkinetic disorder. Int J Health Allied Sci [serial online] 2017 [cited 2020 Feb 17 ];6:233-236
Available from: http://www.ijhas.in/text.asp?2017/6/4/233/220521
Obsessive-compulsive disorder (OCD) in children is one of the most complex and disabling disorders presenting to a hospital setting. Its symptomatology can mimic other psychiatric disorders and often goes unrecognized. It is often associated with comorbidities such as Tic disorders and attention deficit hyperactivity disorder (ADHD). The prevalence of OCD in children is 1%–3%. ADHD occurs in approximately 5% of the population. In three Indian studies, rates of comorbid ADHD ranged from 3% to 18%. Comorbid ADHD and Tic disorders are considered by some to be a developmental marker of OCD. An important issue in assessing comorbidity is the fact that nonresponse to treatment often involves the presence of comorbid conditions. Nonresponsive patients are more likely to meet criteria for comorbid axis I or axis II disorders. Particularly, conditions such as Bipolar disorder and ADHD are common in treatment-resistant patients
Compulsivity and impulsivity are defined as follows, the former as the feeling of being forced to perform certain actions to relieve stress or anxiety, and the latter as the proneness to act without adequate forethought. At first glance, they may be considered as two opposite behavioral features, but actually seem to be closely related in certain clinical entities. Due to the fact that both of the conditions may present with symptoms of inattention, differentiating between primary attentive symptoms like in ADHD and attentive symptoms secondary to anxiety disorders like OCD is of crucial relevance for prognosis and treatment. Family studies suggest that OCD and ADHD may cosegregate in families and the evidence that they frequently comorbid with Tic disorders suggests that these three disorders may be etiologically related. From this viewpoint, the frequent comorbidity between OCD and ADHD probably suggests an overlap in their neurobiological underpinnings.
A 16-year-old boy presented to our OPD with episodes of irritability and poor scholastic performance. The previous medical history was unremarkable with no family history of psychiatric or neurological disorders. At the time of presentation, he had dropped out of school after failing his tenth-grade examination. Despite having scored above 70% in 5 of the 6 subjects, he had scored only a mere 25% in mathematics. This had led to strained relations with his parents. Initial explanations by the patient that he was “unable to concentrate” cut no ice with his family. It was only when the child communicated to his mother about a set of repeated distressing images that his parents decided to seek help for him.
Following a detailed assessment, it was evident that the patient had a long-standing difficulty of functioning at school because of inattention, hyperactivity, impulsivity, obsessions, and compulsions. He was easily distracted and had poor concentration, because of which he was forgetful in daily activities and poor at the organization. He would often lose things needed for curricular activities such as toys, pencils, and books. He would talk excessively and would find it difficult to sustain his attention and listen completely to instructions provided by his parents and teachers. He was restless and would find it difficult to stay put even while doing things that he enjoyed like never being able to sit and watch a film or cartoon through to its conclusion. The patient's father remembered that he was a lot like this when he was a child, and therefore was not particularly worried up until now.
The patient himself describes the above sets of behaviors to be “confusing” and felt alienated in the presence of other children who were “lucky” not to have similar problems. He felt a “silly desire” to do certain acts even though he does not like doing them, like how he would feel “pushed” to blurt out answers and sometimes noises even before the questions have been completed, getting up from his seat when he was expected not to and disrupting the class.
Most of his difficulties with daily functioning appeared to be an outcome of his OCD. He experienced intrusive and repetitive gory images of people soaked in blood, the flashing lights of the ambulance, snakes slithering over the walls and that of chunks of money dropping down from the ceiling, the incessant nature of which interfered with his ability to study. He would experience palpitations, tremors, and fearfulness in response to them and stated that they were in total contrast to his innate “peaceful nature.” He recognized these as irrational but felt “powerless” in stopping them. Techniques to counter them like chanting hymns did not provide any tangible relief. Other repetitive behaviors included putting on switches repeatedly, checking locks, whether school books have been placed correctly in the bag and if the gas cylinder was leaking. He would spend overall 8–10 h in these thoughts and acts.
Although initially just perceived as a fondness for neatness, the patient slowly began to realize that this had grown into a compulsory requirement for exactness in the arrangement of objects around him, including the shaping of numbers and letters and the slightest misalignment causing distress to the patient. He would re-read sentences and words, erasing and re-writing, counting them in sets of four as it “just didn't feel right otherwise.” This was the core problem that lead to his arithmetic difficulties throughout schooling.
He would prefer to wear the same pair of uniforms to school day in and day out, despite them being worn out. While returning home from school, he would feel an intense urge to ask for a lift home from a passer-by, he believed that not doing so would bring on some harm on himself and his family and this was his way of stabilizing the continuum. These urges soon became rampant; he would act on the urges to swallow stones. He says an irregular crooked contour of the stones would give him these unwanted thoughts.
He had “senseless” and recurrent thoughts such as, “Why do doors open and close?,” “What will happen if water falls on TV screens, what will happen if deodorants are sprayed over these screens?” He felt compelled to repeatedly hit a door with his hands, sometimes banging his head onto the wall, biting the dining table. He would scratch his nasal bridge and feel like squeezing his nostrils, notice his chest, and fall prey to the urge to hyperventilate. The relief, however, would only be transient despite these acts.
His social functioning too suffered, and the course was further complicated with the development of vocal tics. If he came across dogs, cats, or birds, he would feel like reproducing the bark, purr, or chirping noises. The sounds of people coughing and sneezing would compel him to produce the same noises repeatedly. He recognizes these utterances to be purposeless and tries his best to resist them, but is unsuccessful at these attempts on most occasions. He invariably takes a longer route home, as in and around the shortest path home is situated a mortuary. The sight of which compels him to go inside, search for corpses, to take the skull, and burn the same over a funeral pyre.
Over the past 5 years, he had sadness and tearfulness almost every day, poor sleep, and feelings of not wanting to be alive with two suicide attempts in the past. The patient has no history of conduct disorder behavior or mania. There was no history of recurrent streptococcal infections before the onset of the obsessions and compulsions. There was no history of coprolalia. No history of complex motor tics. The child was developmentally normal. Physical examination was unremarkable. Screening for organicity was negative, and a CT scan of brain revealed no abnormality. Learning disability was ruled out.
With psychometric rating scales, he scored in the severe-extreme range on the CY-BOCS for obsessive-compulsive symptoms, a significant level of depression indicated by the score of 44/60 on the Centre for Epidemiological Studies Depression Scale for Children.
We made a diagnosis of OCD with depression, and he was started on 50 mg of Sertraline which was subsequently hiked to 100 mg. In addition, 0.5 mg of clonazepam was added to control the anxiety symptoms as well as 0.5 mg of risperidone for the distressing vocal tics. Psychoeducation was given to the parents and child to alleviate their distress and reduce critical/hostile comments by the family
Over subsequent follow-ups, it was noticed that the patient had poor compliance to the medications, he had developed a compulsion to throw away the tablets. The patient was taught the JPMR-relaxation technique to help alleviate his anxiety, and he was started on a once weekly depot formulation of tan Penfluridol 20 mg to help with his symptomatology until he became amenable to swallow tablets on a daily basis. Using his childhood ambition of becoming an IAS officer as reinforcement for compliance and follow-up, the compulsion to throw away medications was overcome.
This patient had coexisting late-onset, long-standing ADHD symptoms, and severe pediatric-onset OCD. It does appear that both ADHD and OCD contributed to his difficulty in mastering the tasks of the school-age period, including academic and social-emotional development. Studies have reported that approximately a third of children with OCD will also meet diagnostic criteria for an externalizing disorder
This case represents the complexity in the evaluation and treatment of comorbid disorders and the challenges of disentangling the ''primary'' and “secondary” disorders, when both sets of symptoms appear to have emerged at approximately the same time.
Differentiating between them is of crucial relevance for prognosis and treatment. This can be achieved by delineating:
Compulsivity and impulsivityBy exploring as to what will happen if the patient tries to exert control over his distressing urges or thoughts.
ADHD is an externalizing disorder characterized predominantly by inattention, behavioral impulsivity, and hyperactivity. OCD is an internalizing disorder characterized predominantly by obsessions and compulsions, and is associated with harm avoidance and restrained behavior. While considering the comorbidity between ADHD and OCD, it is important to address the concept of impulsivity and compulsivity.
Compulsivity refers to thoughts and behaviors that are repetitive and performed in a stereotyped or habitual fashion. They are often purposeless acts performed based on certain self-formed rules like in OCD. In contrast, impulsivity is premature, poorly thought out actions without foresight. They are unplanned reactions to internal or external stimuli without regard to the negative consequences of these reactions due to an inability to delay aversion as seen in ADHD. At the level of neurotransmitters, compulsivity is mediated by serotonin, whereas impulsivity is mainly regulated by dopamine. In contrast to the prominent impulsiveness phenotype associated with ADHD, OCD is associated with generally inhibited temperament typified by behavioral restraint, withdrawal, and avoidance of novel stimuli.,
Patients with a predominantly inattentive subtype of ADHD do not always have a complete overview of tasks and often use coping strategies such as use of extra control to manage the confusion and disorganization. This exertion of extra control resembles the perfectionist coping style seen in OCD. Hence, one way of differentiating between the two conditions in such a scenario would be to ask the patient what will happen if control cannot be performed. If irritation arises, it is more likely to be ADHD; if there is anxiety or panic, OCD should be considered first.
With respect to neurobiology and neuronal network abnormalities, an abnormal pattern of brain activity along the frontostriatal networks is reported both in ADHD and OCD. OCD is associated with abnormally increased activity (hypermetabolism) in frontal and striatal regions such as the orbitofrontal cortex, the basal ganglia, and thalamus with increased frontostriatal functional connectivity. Whereas, in ADHD, there is decreased activity (hypometabolism) in similar prefrontal and striatal brain regions with decreased frontostriatal functional connectivity.
OCD is highly comorbid with many psychiatric disorders, including other anxiety, and Tic disorders. However, its co-occurrence with ADHD, another common childhood-onset neurodevelopmental disorder remains less well understood. Both are often missed or underdiagnosed, particularly during latency and early adolescence. An important issue in assessing comorbidity is the fact that nonresponse to treatment often involves the presence of comorbid conditions.
The frequent comorbidity between OCD, ADHD, and Tic disorders suggests an overlap in their neurobiological underpinnings. The next decade of research on OCD and related disorders like ADHD will continue to build on advances in neuroimaging and genetics will provide a better definition of the dysfunction implicated in the pathophysiology of OCD., Elucidating the relationship between these disorders will aid in appropriate diagnosis and treatment of these childhood-onset disorders, and advance our understanding of their etiologies. This process will improve the definition of different neurodysfunctional treatment targets. Thus, the treatment of OCD and its comorbidities will become more neurodysfunctional guided.
We would like to thank JSS Hospital, Mysore, Karnataka, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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