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Primary Psychiatry. 2010;17(7):35-36
Dr. Aggarwal is senior resident in the Department of Psychiatry at Indira Gandhi Medical College in Shimla, Himachal Pradesh, India. Dr. Jain is senior resident in the Department of Psychiatry at IDr RML Hospital in New Delhi, India. Dr. Khandelwal is resident in the Department of Psychiatry at Maulana Azad Medical College in New Delhi.
Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.
Please direct all correspondence to: Ashish Aggarwal, MD, Department of Psychiatry, Indira Gandhi Medical College, Senior Resident IGMC Shimla Himachal Pradesh 171001 India; Tel: +91 0 9218832616; Fax: 91-177-2658339; E-mail: drashish1980@gmail.com.
Focus Points
• Obsessive-compulsive disorder (OCD) is a common anxiety disorder associated with significant disability.
• Patients with OCD might have poor insight and may not come for treatment for long periods of time.
• Pathologic doubts are common in OCD and can be so disabling that patients may even develop physical complications.
Abstract
This report describes an unusual presentation of obsessive-compulsive disorder with predominant pathologic doubts in which the patient did not remove her slippers for years to the extent of excoriation of skin and development of varicose veins necessitating surgical management.
Introduction
Obsessive-compulsive disorder (OCD), previously considered a relatively rare disorder, is quite common and has a lifetime prevalence rate of 2.5%.1 There are different types of obsessions and compulsions. Pathologic doubts in various forms have been reported to be common obsessions in patients with OCD, occurring in ~42% of cases.2 People with OCD have been hypothesized to be more affected by possibility-based information leading to higher levels of doubt.3 Although a variety of pathologic doubts have been reported, report of pathologic doubt that something would prick the patient’s feet leading to not removing slippers for years together and development of bilateral varicose veins has not been reported to the best of the authors’ knowledge. This is a case report of a woman with OCD presenting with swelling both legs with varicosities resulting from compulsive wearing of slippers to avoid anxiety associated with pathologic doubts.
Case Report
A 62-year-old, postgraduate Hindu woman, of middle socioeconomic status, was referred from surgery outpatient department (OPD) to the authors’ psychiatry OPD as the patient was not removing her slippers and not cooperating for examination for suspected varicose veins. Detailed evaluation from the patient and her family members revealed that since the last 30 years, the patient would have doubts that her hands were not clean and would repeatedly wash them. She was excessively concerned regarding cleanliness and would not allow any family member to enter her house without washing hands and removing shoes. The family members thought it to be culturally appropriate and did not seek any consultation for the same. However, this led to frequent altercations between family members and the patient’s household chores would suffer because of these. Over the last 5 years, the family members noticed increasing swelling of the bilateral lower limbs.
On exploration, it was found that the patient had developed obsessional doubt that something like a pebble or a thorn might prick her. As a result, she would not remove her slippers. The patient recognized these doubts to be of her own creation, but would on few occasions only recognize that these were senseless. As a result of these doubts, she started wearing slippers around the clock. She would sleep keeping her feet hanging from the side of the bed or sofa and would often sleep in the sitting posture. The family members reported that the patient did not remove her slippers even while taking baths or doing other activities. She even stopped visiting temples for the fear of removing her slippers.
There was no other significant past, personal, or family history. She was well adjusted premorbidly. Family members tried to contact doctors but the patient would not go for treatment, saying she was not ill and did not require any medical help. Faith healing was tried but to no help. She had developed marked swelling in the feet which resulted in excoriation of skin and dilatation of superficial veins along with development of varicose veins (Figure). She developed oozing of blood from theses veins.
Mental status examination revealed an obese female, with depressed affect and pathologic doubts. However, she did not report these doubts to be unreasonable. She insisted on not removing her slippers. Her Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score at this time was 32. A diagnosis of OCD with poor insight was made in accordance with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision4 criteria. The patient was started on fluoxetine 20 mg/day increased to 60 mg/day over a period of 10 days. She initially refused medications and hence had to be given liquid fluoxetine after taking consent from the family members. Simultaneously, surgical management was started. The patient started showing improvement in ~2 months time and now participated in behavior therapy as well. She started to recognize these thoughts as unreasonable and would now take medications. After ~3 months of therapy (pharmacologic as well as non pharmacologic), the patient started removing her slippers and would cooperate from surgical examination and intervention for varicose veins.
She was still maintaining improvement after 8 months of treatment, with a Y-BOCS score of 11. She has now started taking less time in daily chores, sleeps comfortably in bed, and started going to temples.
Discussion
OCD is one anxiety disorder that is a potentially disabling condition that can persist throughout life. Those who suffer from OCD get trapped into a pattern of repetitive thoughts and behaviors, which they know are senseless or exaggerated. Regardless, this knowledge remains insufficient to stop them obsessing or carrying out the rituals. Additionally, as noted in the DSM-IV,5 some patients may not recognize the unreasonabilty of these thoughts. This patient fulfills the diagnostic criteria of OCD with poor insight according to DSM-IV criteria, as she considered her thoughts and behavior as absurd and tried to resist them in the initial phase of the disorder. However, later she had poor insight and there was minimal or no resistance. This is not an uncommon feature seen in the course of OCD. In this case, the patient was trapped in a pattern of doubts which led her not to remove her slippers.
Her behavior cannot be considered as features of psychotic disorder as the it was performed by her to relieve her anxiety which arose as a result of obsessive pathological doubts and she had full insight into his behavior and tried to resist them in the initial course of illness. Development of poor insight and minimal resistance to obsessions at a later stage may be the natural progression of the disorder.
It has been reported that OCD patients frequently visit non-psychiatric clinical specialists such as general practitioners, dermatologists, cosmetic surgeons, oncologists, neurologists, obstetricians, and dentists, among others, for various complications or for conditions associated with OCD.6 A case presenting to a general surgeon with varicose veins has not been reported to the best of the authors’ knowledge.
Conclusion
OCD may present with severe pathologic doubts leading to development of varicose veins. Appropriate management of such cases is warranted. There is a dire need to sensitize the public regarding OCD and also to sensitize physicians and surgeons regarding the possibilities of rare complications of this disabling disorder. PP
References
1. Regier DA, Boyd JH, Burke JD Jr, et al. One month prevalence of mental disorders in the United States based on five epidemiologic catchment area sites. Arch Gen Psychiatry. 1988;45(11):977-986.
2. Rasmussen SA, Eiser JL. The epidemiology and differential diagnosis of obsessive compulsive disorder. J Clin Psychiatry. 1992;53(suppl):4-10.
3. Aardema F, O’Connor KP, Pélissier MC, Lavoie ME. The quantification of doubt in obsessive-compulsive disorder. Int J Cogn Ther, 2009;2(2):188-205.
4. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.
5. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.
6. Heyman I, Mataix-Cols D, Fineberg NA. Obsessive-compulsive disorder. BMJ. 2006;333(7565):424-429.
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