Treatment of Obsessive-Compulsive Disorder in a Mentally Challenged Adult

Abstract

Sir: Obsessive-compulsive disorder (OCD) as a comorbidity was earlier considered to be very unusual among mentally retarded individuals.1,2 However, current literature review reveals that OCD does occur at rates at least proportional to the general population but often remains undetected and untreated among individuals with developmental disabilities.3 Herein, we describe the case of a patient with mild mental retardation and OCD, who responded to behavioral therapy. Case report. Ms. A, an 18-year-old woman, presented to our hospital in November 2007 with an insidious onset, 6-month duration of illness characterized by repetitive acts such as cleaning; ritualized bathing, urination, and defecation; excessive need for symmetry in daily activities; and avoidance of morning duties. Nonperformance of proxy compulsions would make the patient aggressive. A structured assessment was conducted at baseline and at subsequent follow-ups. The Mini-International Neuropsychiatric Interview,4 Wechsler Adult Intelligence Scale-Performance Scale (Indian adaptation),5 Yale-Brown Obsessive Compulsive Scale Symptom Checklist,6,7 and a semi-structured clinical interview revealed that she had OCD, an intelligence quotient of 58 (mild mental retardation), contamination obsessions, and cleaning/washing compulsions. The details of the assessments are given in Table 1. Table 1 Assessment Scores of a Mentally Challenged Woman With OCD Treated With Escitalopram and Behavioral Therapy She was started on treatment with escitalopram 10 mg/day, which was increased to 20 mg over a period of 2 weeks. Differential positive reinforcement and performance-feedback procedures were initiated after family members were psychoeducated. By using differential positive reinforcement, exposure and response prevention was conducted. Initially, the patient received 20 sessions of inpatient behavior therapy on a daily basis and, later, 7 sessions on an outpatient basis. Follow-up assessment at week 12 (see Table 1) revealed that Ms. A was mildly ill on the OCD severity rating scale and on the Clinical Global Impressions-Severity of Illness scale. The patient's parents also reported 90% improvement in her symptoms. This patient with mild mental retardation and OCD responded to escitalopram and behavior therapy. The improvements attained at week 4 included a 33% decrease (based on a clinical significance formula11) in severity of symptoms; clinically significant reduction in proxy compulsions; and a 50% overall improvement of symptoms, which was reported by the patient's parents and was visible on the Clinical Global Impressions-Improvement scale. Another important issue that requires attention is the substantial decrease in OCD symptom severity and proxy compulsions, which occurred within the first 2 weeks of treatment. This improvement at week 4 (within the initial few weeks) would be attributed primarily to behavior therapy and not to serotonin reuptake inhibitor (SRI) medication, as it is well known that an SRI would take at least 8 weeks to demonstrate its benefits. This case report assumes importance in the light of the paucity of studies reporting effectiveness of differential reinforcement procedures in causing clinically significant reduction in obsessional rituals in individuals with mental retardation. Physicians should keep in mind the effectiveness of differential reinforcement procedures in mildly mentally retarded patients who have OCD. C. J. Maikandaan, M.B.B.S. Nitin Anand, M.A., M.Phil. Suresh Bada Math, M.D., D.N.B., P.G.D.M.L.E. Y. C. Janardhan Reddy, D.P.M., M.D. National Institute of Mental Health and Neuro Sciences, Bangalore, India