Case presentation:
A 36 years old female was brought to a psychiatric inpatient unit by her
children with complaints of slowness in activities, withdrawn behavior,
slow speaking, and blank staring for the past 7-8 months. She has a
history of separation from her husband, is unemployed for 2 years, and
has a known psychiatric illness of 13 years, episodic in nature with
incomplete remission in between. Her activities of daily living
including, the ability to work, look after her children, caring for
herself were completely compromised. She scored 24 with BFCRS, with
immobility, mutism, staring, posturing, grimacing, negativism,
withdrawal, and ambitendency. Citing the severity of her condition and
inability to consume food, she was started on ECT with a threshold of 60
MC and an average seizure duration of 25-50 secs. After 3 ECT sessions,
her BFCRS score dropped to 4 within a span of 1 week. She then only had
negativism, mutism, and immobility. Her condition improved further
during the coming days.
She, however, reported that she was not talking as she talks before the
episode of catatonia, had recurrent negative thoughts, and had a strong
urge to utter obscene words. She was afraid to open her mouth and speak
at all. Her behavior was observed to be of obsessive nature. She spent
several hours obsessing over her thoughts, moderate distress,
impairment, and control of her obsession scoring 12 on the obsession
scale. Out of compulsion for the same, she decided to stop speaking
altogether, avoided social gatherings out of fear, dragged her leg, and
tapped her fingers in view of controlling it.
Following a complete recovery from her catatonic state, she expressed
extreme regret, depressed mood, guilt, and worthlessness. She was
eventually treated for a brief episode of depression. She confided that
her urge of blurting obscene language and recurrent negative thoughts
began every time before the episode of catatonia and had experienced 3
such episodes in the past 13 years, with each episode of depression
following her OCD. Every time she improved with ECT and was maintained
on SSRI. She stopped the medications after a few months following
improvement. After more elaborate and repeated case histories, it was
found that her previous depressive symptoms used to be for 6-8 months
with OCD symptoms of 1-4 weeks. This time it was reversed with
depression of 2 weeks and OCD of 7 weeks. Considering her poor drug
compliance, distress and self-guilt, and lack of knowledge about her
condition, she was also started on ERP. The first few days proved to be
the most challenging for both the patient and the clinical psychologist,
as her compulsive thoughts forced her to stop speaking out of fear with
the psychologist. With adjunctive Clonazepam, she was educated about OCD
and ERP principles. And maintained on ERP. On subsequent follow-ups, the
patient seemed to be doing well and was eager to begin working again.