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Obsessional thought patterns could lead to serious bodily harm: Lankan case studies 

21 Sep 2021

  • Pharmacological and cognitive behaviour therapy/exposure and response prevention therapy recommended
By Ruwan Laknath Jayakody Obsessional thoughts and doubts and associated behaviour of avoidance could lead to serious bodily harm, a study of a series of local case reports suggested. This observation was made by M. Chandradasa (attached to the Kelaniya University’s Medical Faculty), D. Hettiarachchi and S. Wijetunge (attached to the Lady Ridgeway Hospital for Children), and L. Champika and J. Mendis (attached to the National Institute of Mental Health) in “Serious bodily harm related to obsessions from Sri Lanka” which was published in the Psychiatria Danubina 29 (1) in 2017.  Background An obsession is described by F.J. Fish and M. Hamilton in Fish’s Clinical Psychopathology: Signs and Symptoms in Psychiatry, as a thought that persists and dominates an individual’s thinking, despite the individual’s awareness that the thought is either entirely without purpose or has gone beyond the point of relevance or usefulness. Such obsessions occur in the context of many psychiatric disorders including obsessive compulsive disorder (OCD), major depressive disorder (a mood disorder characterised by a persistent feeling of sadness or a lack of interest in outside stimuli), and schizophrenia (a psychosis in which a person cannot tell what is real from what is imagined). At the same time, medication may also induce obsessions in some patients, according to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), “The role of obsessive beliefs in patients with major depressive disorder” by B. Bahceci, E. Bagcioglu, F.H. Celik, S. Polat, A. Koroglu, G. Kandemir, and C. Hocaoglu, and “Obsessive compulsive symptoms in patients with schizophrenia on clozapine (atypical antipsychotic medication) and with OCD: A comparison study” by M. Doyle, A.N. Chorcorain, E. Griffith, T. Trimble, and E. O’Callaghan. OCD has in the DSM-5, been categorised together with a few other related disorders, among which are several disorders which involve direct physical self-harm such as trichotillomania (an obsessive compulsive and related psychiatric disorder where the individual pulls out their hair from various body sites) and excoriation disorder (repeated picking at one’s own skin which results in skin lesions), which are presumably related to OCD. In terms of case reports on patients with OCD presenting with self-injurious behaviour, in India, L. Pandit and V. Vardhan described an older male presenting with late onset OCD and genital self-mutilation in “Late onset OCD presenting as genital self mutilation”, while D. Kruger and K.R. Muller-Vahl’s “Severe self injurious behaviour with teeth extraction in a body with Tourette syndrome (a condition of the nervous system which causes people to have repetitive tics which are sudden twitches, movements, or sounds)” noted cases of Tourette’s disorder with co-morbid OCD presenting with severe self-injurious behaviour, and S. Wilhelm, N.J. Keuthen, T. Deckersbach, I.M. Engelhard, A.E. Forker, L. Baer, R.L. O’Sullivan, and M.A. Janike found in “Self injurious skin picking: Clinical characteristics and comorbidity” that in a set of patients with self-injurious skin picking, 52% were found to be suffering from co-morbid OCD. Identifying the same in Sri Lanka is affected by the low psychiatrist to patient ratio (in 2012, there was approximately one consultant psychiatrist per a population of 500,000 and also because only 1.6% of the total health budget is spent on mental health [per R. Jenkins, J. Mendis, S. Cooray, and M. Cooray’s “Integration of mental health into primary care in Sri Lanka”]). However, Chandradasa et al. described two Sri Lankan patients who presented with significant bodily harm related to their obsessions. First patient  The patient was a 52-year-old male. He was right-handed. He complained of being scared to open a bandage on his right middle finger for a period of two years after sustaining a small abrasion on his finger and bandaging it using a cotton cloth. After a few days, he was concerned with regards to opening the bandage, as he feared that the wound would have worsened and that the finger would be unusable. This thought was repetitive, not pleasurable, resistant, and believed to be his own. He had then gradually trained himself to use the left hand for important activities. He frequently repeated the same Buddhist stanza mentally, 21 times at a stretch. He was of the belief that this mental act would help protect his finger from possible harm. If he could not complete the repetition for 21 times, he would restart from the beginning and do it until he felt right. The patient claimed that at times, he knew that keeping the bandage on the finger and the repetition of the stanza were highly irrational acts. However, despite family members pleading with him to do so, he did not have the will to go ahead and remove the bandage. On the initial mental status examination, the patient appeared to be anxious and distressed. The mood was euthymic (the state of living without mood disturbances) and he had obsessive thoughts and mental rituals. That said, there were no delusional beliefs and the cognitive functions were normal with good insight. He scored in the severe range for obsessive compulsive symptoms as per “The Yale-Brown Obsessive Compulsive Scale (YBOCS). I. Development, use, and reliability” by W.K. Goodman, L.H. Price, S.A. Rasmussen, C. Mazure, R.L. Fleischmann, C.L. Hill, G.R. Heninger, and D.S. Charney. The patient was treated with a tricyclic antidepressant used to treat OCD and at the end of 12 weeks, he was significantly better clinically. Following the improvement of the obsessive symptoms, he had voluntarily removed his bandage on the right middle finger. Since it was found to have an ulceration, he was referred for a plastic surgeon’s opinion, and required inpatient admission for skin grafting. The patient was subsequently referred to an occupational therapist for the functional improvement of the right hand. According to the surgical opinion, further delay in presentation to psychiatric services could have led to far more serious damage to his finger, culminating in possible amputation. Second patient  The patient was an 11-year-old boy. He presented with recurrent thoughts about the looseness of his teeth, stating that he is doubtful whether his teeth are loose or not. These thoughts were recurrent, resistant, and not pleasurable. The boy said that at times, he felt the irrationality of the thoughts and believed that these thoughts were his own. In order to clear his doubt, he would engage in repetitive checking of the fixity of the relevant tooth to the jaw. The boy would pull mainly the lower incisors to check their fixity. If he felt them to be loosely fixed, he would be in significant psychological distress to such a degree that it would even affect his daily activities. If a particular tooth is felt to be loose, he would pull it out completely and he had thus pulled off three teeth in one month. After the third tooth removal, he developed profuse gum bleeding from the site of extraction and needed admission to the emergency dental care unit. The parents subsequently revealed that they had used restraints to stop the boy from removing his own teeth. On the mental status examination, the mood was euthymic and the boy had obsessional doubts, sans however, any delusional beliefs. The YBOCS scores were in the severe range. He was treated with cognitive behaviour therapy (CBT) together with exposure and response prevention (ERP) therapy and an antidepressant. He appeared to be clinically speaking much better at 12 weeks and he had not removed any teeth afterwards. The boy was also referred to the relevant paediatric dental surgeon for follow up care. The first patient had presented with late onset OCD, associated with obsessive thoughts of the catastrophic outcome of his wound. Due to his avoidance-related behaviour, he had kept the bandage on for a long time, which had in turn led to significant tissue damage to the right middle finger and functional impairment due to difficulty in using the dominant right hand. He was commenced on pharmacotherapy, as he declined to come regularly for CBT. The patient’s distress related to the bandage reduced significantly with the improvement of his obsessional symptoms. The adolescent who was the second patient had presented with early onset of OCD. According to “The influence of age at onset and duration of illness on long term outcome in patients with OCD: A report from the International College of Obsessive Compulsive Spectrum Disorders (ICOCS)” by B. Dell’Osso, B. Benatti, M. Buoli, A.C. Altamura, D. Marazziti, E. Hollander, N. Fineberg, D.J. Stein, S. Pallanti, H. Nicolini, M.V. Ameringen, C. Lochner, G. Hranov, O. Karamustafalioglu, L. Hranov, J.M. Menchon, J. Zohar, and the ICOCS group, such is known to be associated with more severe symptoms and poorer prognosis. He had obsessional doubts related to his teeth which caused the loss of three. According to the parents, he has been previously seen by dental and medical doctors who failed to identify the possibility of OCD. The failure of treatment of obsessions may have led to the further loss of teeth and lifelong difficulties in chewing, Chandradasa et al. observed. In severe OCD, as D.S. Baldwin, I.M. Anderson, D.J. Nutt, C. Allgulander, B. Bandelow, J.A.D. Boer, D.M. Christmas, S. Davies, N. Fineberg, N. Lidbetter, A. Malizia, P. McCrone, D. Nabarro, C. O’Neill, J. Scott, N.V.D. Wee, and H.U. Wittchen’s “Evidence based pharmacological treatment of anxiety disorders, post traumatic stress disorder and OCD: A revision of the 2005 guidelines from the British Association for Psychopharmacology” noted, a combination of psychological and pharmacological treatment is warranted in order for better outcomes. In this boy, the reduction of symptom scores was seen after treatment accompanied by the stopping of tooth removal. In conclusion, Chandradasa et al. noted with regard to both patients who presented with bodily harm related to their psychiatric presentations, that injurious behaviour is likely linked to their obsessions, based on the consideration of their history and the findings with regard to their mental state. The researchers therefore expressed hope that this description of the cases would prove useful to clinicians who treat patients with similar presentations. If you feel that you or someone you know may be dealing with mental health issues and/or thoughts of self-harm, the following institutions would assist you. The National Institute of Mental Health: 1926 Sri Lanka Sumithrayo: 0112 682 535 Shanthi Maargam: 0717 639 898 Courage Compassion Commitment (CCC) Foundation: 1333


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