MJP Online Early MJP-01-11-14

CASE REPORT

Auditory in an Obsessive Compulsive Disorder Adolescent

Khadijah HAA1,2, Seed HF1, Lee VY1, Wan Salwina WI1

1Department of , UKM Medical Centre, Kuala Lumpur, Malaysia 2Universiti Sains Islam Malaysia, Malaysia

Abstract

Although comorbidity of obsessive compulsive disorder (OCD) with is well-established, the occurrence of psychotic symptoms especially with OCD still requires further studies. We report a case of a child with OCD who experienced auditory hallucination with the recurrence of his OCD symptoms and the management involved. We discussed the possible differentials when auditory hallucinations occur in the context of OCD.

Keywords: Obsessive Compulsive Disorder, Auditory Hallucination, , Schizophrenia

Introduction Case study

Obsessive compulsive disorder (OCD) is a Mr A was first diagnosed to have OCD at complex and distressing disorder. It has a the age of nine years old, during which he lifetime prevalence of 2.3% and about a presented with obsessions of contamination quarter of males with OCD developed and doubts, and compulsion of washing and before age of ten1. OCD or OC symptoms in checking. The episode was triggered after he psychotic disorders like Schizophrenia has was bullied by his schoolmates to pick up been well established, with a prevalence rate stool with his bare hands. He had repeated as high as 15%2. Interestingly, psychotic thoughts of ‘things being dirty’ resulting in features such as hallucinations are also being repeated washing of his hands and feet. He reported to occur in patients with OCD3, but avoided touching and being touched for with poorer understanding. of contamination. There was also repetitive checking behaviour such as checking the car This case study describes a child who was locks. The symptoms distressed him and his diagnosed with OCD and later developed family members. There was also impairment auditory hallucinations when his OCD in his academic and social functioning. symptoms recurred.

MJP Online Early MJP-01-11-14

He was treated with which was treatment of medication and psychological gradually titrated to 10mg daily. He was also intervention were started. taught relaxation and breathing technique, was restarted and a low dose of and exposure and response prevention added. Cognitive Behaviour . He responded well to treatment and Therapy was introduced to help him with the medication was stopped after two years of obsessional thoughts as well as the cognitive complete remission. errors. He was also taught stress management and efficient coping skills. A Two years after stopping the medication, he family session was also conducted. had a relapse. The episode was triggered by a break up with his girlfriend. At the same He improved with treatment but took time, he was also very stressful with his relatively longer time to respond. The OCD academic work. The clinical presentation symptoms and auditory hallucination was different compared to the first episode. disappeared after starting treatment. During the initial period, he had obsessions Psychological intervention focused on stress of contamination and compulsion of management and coping skills as he washing, but were later replaced with struggled to manage his stressors which obsessional thoughts and images of self were mainly academic and relationship aggression and aggression towards others. issues. He had images of hurting himself and his ex-girlfriend. He also had auditory Discussion hallucination which was second person and commanding in nature. The voices were OCD was once grouped under congruent with his obsessional theme of disorders but the new DSM 5 recognizes it aggression .The symptoms distressed him to as a group on its own; “Obsessive- the extent of affecting his academic Compulsive and Related Disorders” and it performance. There were no depressive can be diagnosed with a specifier of absent symptoms and other psychotic symptoms. or delusional beliefs, thereby still retaining the patient in OCD rather than a psychotic There was strong family history of mental disorder4. Hallucinations in OCD had been illness. His paternal grandaunt and maternal reported3 but require further research. uncle had history of untreated mental illness. His eldest sister was a perfectionist and had Differentiating one’s own thoughts and true history of during adolescent auditory hallucination can be challenging period. Both parents had obsessional traits. especially in children or adolescent. They were perfectionist, highly ambitious, is one possible and had high expectations in academic explanation for ‘ voices’ in an achievements of the children. They were adolescent who was distressed with the also particular about cleanliness and OCD symptoms. However, this patient was tidiness. The obsessional traits were able to delineate the perceptual disturbance reflected in their parenting and modeled by he had, as opposed to his own thoughts. the children. He also had poor coping and Although there was no external to poor stress management. the hallucination, there was internal stimulus, where he had images of aggression MRI was done to rule out organicity, which along with the voices. According to Vera showed no abnormality. Combined et.al.5,children with OCD often had inner MJP Online Early MJP-01-11-14 voice ordering ritualization. Furthermore, schizophrenia or have a wax and wane the perceptual disturbance accompanied the psychotic symptoms with his OCD is obsessions, and not compulsion as described something that remains unanswered at the by Miguel6 in his discussion of “sensory present time. phenomena”, where sensations or urges may precede or accompany repetitive behaviours References in OCD patients. In this case, the voices he heard were homicidal and suicidal in nature 1. Ruscio AM, Stein DJ, Chiu WT, thus prompting immediate intervention of Kessler RC. The Epidemiology of antipsychotic that was beneficial for him. Obsessive-Compulsive Disorder in the National Comorbidity Survey Fontenelle3 shared a case of a patient with a Replication. Mol Psychiatry. diagnosis of Schizophrenia and 2010;15(1): 53–63. retrospectively found out to have obsessive doi:10.1038/mp.2008.94. compulsive disorder during adolescent with auditory hallucinations and treatment was 2. Berman I, Kalinowski A, Berman changed accordingly. OCD has been SM, Lengua J, Green AI. Obsessive suggested as prodromal symptoms in and compulsive symptoms in chronic schizophrenia7. Similarly, OCD and schizophrenia. Compr Psychiatry. schizophrenia commonly co-occur. Studies 1995; 36(1):6-10. also show that Schizophrenia patient with OCD who respond poorly to antipsychotic 3. Fontenelle LF, Lopes AP, Borges may benefit from adjunctive treatment of MC, Pacheco PG, Nascimento AL, anti-OCD8,9. Versiani M. Auditory, Visual, Tactile, Olfactory, and Bodily Schizophrenia and OCD possibly lies in a Hallucinations in Patients with continuum where they could have Obsessive-Compulsive Disorder. overlapping psychotic symptoms like CNS Spectr. 2008;13(2):125-130. hallucinations. One useful differentiating factor is the impaired reality testing that 4. American Psychiatric Association. occurs in Schizophrenia as compared to Desk Reference to the Diagnostic those with OCD. As Insel and Akiskal Criteria From DSM 5. United States: postulated, a neurotic obsession shift to American Psychiatric Publishing; psychosis when insight is impaired10. In this 2013. 129-130 p. case, his reality testing remains intact. A review by Bottas et al7 suggests OCD and 5. Vera L, Vera LP. Trouble schizophrenia to share some similarities in obsessionnel-compulsif chez l'enfant terms of neurotransmitters, neuroanatomy et l'adolescent. AnnalesMédico- and neurocircuitary. However, these Psychologiques. 2010;168:163–169. findings are still inconclusive and still require further research. 6. Miguel EC, do Rosário-Campos MC, Prado HS, et al. Sensory phenomena As a clinician, being aware of the possibility in obsessive-compulsive disorder and of psychotic symptoms in OCD would help Tourette’s disorder. J Clin the clinician to manage the patient better. Psychiatry. 2000;61:150-156. Whether the patient would develop MJP Online Early MJP-01-11-14

7. Bottas A, Cooke RG, Richter MA. (Edgmont). 2006; 3(9): 34–41. Comorbidity and pathophysiology of obsessive–compulsive disorder in 9. Boileau B. A review of obsessive- schizophrenia: Is there evidence for a compulsive disorder in children and schizo-obsessive subtype of adolescents. Dialogues in clinical schizophrenia? Journal of Psychiatry neuroscience. 2011; 13(4): 401. and Neuroscience. 2005; 30(3):187 10. Insel TR, Akiskal HS. Obsessive- 8. Hwang MY, Yum SY, Losonczy compulsive disorder with psychotic MF, Mitchell G, Kwon JS. features: a phenomenologic analysis. Schizophrenia with obsessive Am J Psychiatry 1986; 143:1527- compulsive features. Psychiatry 1533.

Corresponding Author Dr. Khadijah Hasanah Abang Abdullah Department of Psychiatry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakob Latiff, Bandar Tun Razak, 56000 Cheras, Kuala Lumpur, Malaysia Tel: +603-91456149 Fax: +603-91737841

Email: [email protected]