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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 38  |  Issue : 3  |  Page : 304-306

Clinical description of rare phenomenology of obsessive–Compulsive disorder


Department of Psychiatry, All India Institute of Medical Sciences, Patna, Bihar, India

Date of Submission01-Jul-2020
Date of Decision21-Oct-2020
Date of Acceptance08-Dec-2020
Date of Web Publication20-Jul-2021

Correspondence Address:
Dr. Sambhu Prasad
Department of Psychiatry, All India Institute of Medical Sciences, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_173_20

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  Abstract 


Obsessive–compulsive disorder (OCD) is marked by intrusive thoughts, images, and impulses which are recurrent in nature, disturbing, and senseless. Typical anxiety provoking and distressing themes of the disorder include various forms such as repeated unwanted ideas, repeated urge of hurting to self, fear of contamination, aggressive impulses, sexual thoughts, guilt, and repetitive behaviors to relieve that anxiety in the form of repetitive cleaning, checking, arranging, etc., Here, we tried to describe a phenotypically different and rare form of OCD through a case of a 51-year old lady who had an obsessional fear of her own shadow.

Keywords: Images, obsessive–compulsive disorder, phenomenology, shadows


How to cite this article:
Prasad S, Manna C. Clinical description of rare phenomenology of obsessive–Compulsive disorder. Indian J Soc Psychiatry 2022;38:304-6

How to cite this URL:
Prasad S, Manna C. Clinical description of rare phenomenology of obsessive–Compulsive disorder. Indian J Soc Psychiatry [serial online] 2022 [cited 2022 Oct 3];38:304-6. Available from: https://www.indjsp.org/text.asp?2022/38/3/304/321881




  Introduction Top


Obsessive–compulsive disorder (OCD) is a common psychiatric disorder with a lifetime prevalence of 1%–3%.[1] It is characterized by obsessions (e.g., uncontrollable thoughts) and compulsions (e.g., repetitive behaviors) or both to reduce the fear, anxieties, and worries caused by obsessions. Although some symptoms are more common in OCD such as doubts of contamination and frequent washing, need for symmetrical arrangement of objects, fear of germs, major illness, etc., while in some cases, symptoms are quite idiosyncratic and often go undetected by the inexperienced hands. These atypical ones may include difficulty in hearing (dysacusis),[2] persistent vomiting,[3] and amnesia.[4] In this presentation, we will try to bring up another phenotypically odd symptom of OCD which we encountered in a female who had repetitive thoughts of visualization of shadows of oneself including the surrounding.


  Case Report Top


A 51-year-old post menopausal married female, 12th pass, a housewife from urban background, presented with repetitive images of her own shadow into mind She had the illness for last 3 years characterized by insidious in onset with continuous and deteriorating course. She was apparently well 3 years back when she started visualizing her own shadow into her mind. Initially, she claims that her shadow would give her a sense of existence and did not bother her most. Over months, she would remain preoccupied with the repetitive images of the shadows. Gradually, over the next 1.5 years, she would complain that these shadows would come into her mind more excessively which became hard to control. These shadows would be clear, vivid, and reflecting her whole body. In the beginning, she ignored these thoughts thinking they were irrelevant. However, as time passed, these shadows would come into her mind more frequently even during the night which disturbed her sleep. She started expressing that the thoughts were irrational, but the fact that she could not resist it started to bother her. She also started to have thoughts of visualization of even other person's shadow in her mind who she came across. She reported that whenever these thoughts came to her mind, she would close her eyes to remove those from her mind. However, over time, they came more repeatedly and excessively. Following the next 6 months, she started to have thoughts of seeing shadows of any living or nonliving objects which she come across in her daily routine into her mind. She tried to avoid lights and preferred dark places; otherwise, she would have excessive anxieties, worries, and sense of restlessness. She would remain upset and helpless and used to claim that she might go “mad” if such things continue. She would have difficulty in sleeping and would struggle in her daily routine functioning. For her, the diagnosis of OCD was established by meeting ICD-10 criteria. On further evaluation, she did not have any complaints or history of checking, contamination, and the inappropriate image in her mind. She did not have any history suggestive of depression, mania, psychotic symptoms, or any other psychiatric illness in this episode or in the past (even OCD). Her family members did not have a similar illness. She denied any history of violence, trauma, or abuse including sexual. She did not have any comorbid medical illness or such illness in the past. She denied intake of any psychotropic in the past and claimed that it was the first contact with the mental health professional.

On assessment, she appeared to be well groomed but expressed distress during the interview. Her higher mental function was unremarkable except her obsession with the visualization of shadows in thought content. Her mini-mental status examination score was normal. The temperature was 37.5°C, blood pressure was 116/70 mmHg, pulse was 94 beats/minute, and respiratory rate was 15/min. The systemic examinations were unremarkable including the nervous system. The various laboratory parameters show hemoglobin of 13.5 g/dL; white blood cell count of 7430/μL; platelet count of 176,000/μL; and erythrocyte sedimentation rate of 7 mm/h. Other investigations such as serum Vitamin B1, Vitamin B12, Vitamin D, calcium, and thyroid profile; noncontrast computed tomography; magnetic resonance imaging (plain and contrast) of the head; and electroencephalogram did not show any abnormality. She had gone for ophthalmology consultation to sort out any vision-related issues which was also unremarkable. She did not show any other obsessions as it was screened with the symptom checklist.[5] Yale–Brown Obsessive–Compulsive Scale was applied to rate the severity and she scored 30 (severe range).[5]


  Discussion Top


The phenomenology of OCD has become so common nowadays and the intellectual environment has influenced the history of diagnosis of OCD. The clinicians encounter its vivid symptoms but may sometimes overlook the atypical ones. The symptoms may have features of generalized anxiety disorder, eating disorder, impulse control disorders, and hypochondriasis and sometimes have co-occurrences with other psychiatric illness such as bipolar and schizophrenic illness.[6],[7],[8],[9],[10] Many such patients have difficulty in expression, often remain confused, and have fear of losing control, thus making the diagnosis more difficult. The present case report showed that the patient has atypical symptoms of visualizing her own shadow including the surrounding which appears to be quite rare till date and unique within itself. The origin of visualization of shadows would be explained on the basis of intrusive images in OCD, panic attacks, eating disorders, depression, phobia, and other anxiety disorders. The memories related to unusual experiences to self and surrounding and excessive degree of self-consciousness are generally associated with such disorders. Although not all the patients experience adverse events in the past for their genesis, some would experience such images that are partly or entirely due to their imagination.[11] In our case, we had done extensive assessment including various imaging procedures to rule out any evidence of organic causes including ophthalmology consultation. Considering the present case with a diagnosis of OCD with no past evidence of any treatment history and also the effectiveness of selective serotonine reuptake inhibitor with behavior therapy in atypical cases,[12] we started with fluoxetine 20 mg/day (gradually build up up to 60 mg/day) and exposure and response prevention (ERP) sessions. She was exposed to her obsession (shadows) and encouraged to feel the anxiety and asked to refrain from engaging in the closure of eyes and avoidance of light to reduce the fear. The treatment continued extensively with a weekly session of ERP for the next 2 months. The patient showed an improvement in her symptoms which was rated with Yale–Brown Obsessive–Compulsive Scale on subsequent intervals. In conclusion, our care has encountered a rare phenomenology of OCD with atypical obsessional fear of visualization of images with compulsive behavior modifications. Thus, awareness, clinical skill, and depth of experience require for appropriate diagnosis and timely management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Grant JE. Clinical practice: Obsessive-compulsive disorder. N Engl J Med 2014;371:646-53.  Back to cited text no. 1
    
2.
Singh I, Rana AK, Singh MK, Tripathi RK. An atypical presentation of obsessive compulsive disorder with difficulty in hearing. Indian J Psychol Med 2009;31:96-7.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Kirkcaldy RD, Kim TJ, Carney CP. A somatoform variant of obsessive-compulsive disorder: A case report of OCD presenting with persistent vomiting. Prim Care Companion J Clin Psychiatry 2004;6:195-8.  Back to cited text no. 3
    
4.
Thomasantérion C, Cadet L, Dirson S, Laurent B. Amnesic presentations of the compulsive obsessional confusions (about 3 patients appearing in a consultation of memory). Encephale 2002;28:154-9.  Back to cited text no. 4
    
5.
Goodman WK, Price LH, Rasmussen SA. The yale-brown obsessive compulsive scale. Arch Gen Psychiatry 1989;46:1006-11.  Back to cited text no. 5
    
6.
Rasmussen SA, Eisen JL. The epidemiology and differential diagnosis of obsessive compulsive disorder. J Clin Psychiatry 1992;53 Suppl: 4-10.  Back to cited text no. 6
    
7.
Altman SE, Shankman SA. What is the association between obsessive-compulsive disorder and eating disorders? Clin Psychol Rev 2009;29:638-46.  Back to cited text no. 7
    
8.
Fallon BA, Qureshi AI, Laje G, Klein B. Hypochondriasis and its relationship to obsessive-compulsive disorder. Psychiatr Clin North Am 2000;23:605-16.  Back to cited text no. 8
    
9.
Ferrão YA, Miguel E, Stein DJ. Tourette's syndrome, trichotillomania, and obsessive-compulsive disorder: How closely are they related? Psychiatry Res 2009;170:32-42.  Back to cited text no. 9
    
10.
Chandan N, Parmar A, Deb KS. A rare care of Obsessive-compulsive disorder co morbid with bipolar affective disorder.Indian J Psychol Med 2017;6:794-6.  Back to cited text no. 10
    
11.
Çili S, Stopa L. Intrusive mental imagery in psychological disorders: Is the self the key to understanding maintenance? Front Psychiatry 2015;6:103.  Back to cited text no. 11
    
12.
Miyauchi R, Tokuda Y.A rare case of obsessive- compulsive disorder withsymptoms of unexplained somatic and memory problem. Gen Med 2015;16:33-6.  Back to cited text no. 12
    




 

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