Descriptive Psychopathology: The Signs and Symptoms of ...

301 Chapter 12: Obsessive–compulsive behaviorsHe was re-hospitalized four months later, now age 18 years, again forcatatonia and an exacerbation of repetitive behaviors including repeatedlygetting in and out of bed, repeatedly putting his sunglasses on and off andthen on a precise spot on the table, signing his name and repeatedly retracinghis signature, and walking in circles. He refused being touched, describing theexperience as a shock or tingling. He rubbed his head repeatedly. His movementswere slow and stiff, and his ritual counting and re-arranging of objectsresulted in his taking hours to dress, wash, and eat. He exhibited echolalia.He said he was “depressed” and exhibited minimal emotional expression. Hedenied hallucinations and had no delusions. A lorazepam challenged had noeffect on his symptoms. The family refused further ECT which they said madehim cognitively worse without sustained improvement. Low-dose antidepressantsand antipsychotics were continued in his outpatient management. 59Because of previous strep throat infections and associated mild choreiformmovements, an evaluation was undertaken for PANDAS. A lumber puncturebefore admission revealed elevated IgG protein, strep O titer was 1:1000 andASO titer was 249, both high. A PET study showed reduced bilateral temporallobe metabolism. He had a low red cell count (4.2) and a low hematocrit(37.9). Repeat titers showed a high ASA titer of 270. He was begun on acombination of amoxicillin and clavulanate which led to substantial but notfull relief, permitting him to return to school.Eating disordersEating disorders are given a separate category in classifications based on a sharedproblem with eating or body weight that dominates the clinical picture. Thisdetermining factor, however, delineates a heterogeneous patient group. Anorexianervosa best fits within the OCD spectrum, although some patients have a delusionaldisorder. Bulimia nervosa is commonly associated with manic-depression.Anorexia nervosaWilliam Gull offered the first clear presentation of patients with anorexia nervosain 1868. In an 1874 address to London’s Clinical Society he described two patientsand presented woodcuts of their features during the illness and after recovery.His note about one follows. 60Miss B., aet. 18, was brought to me Oct. 8, 1868, as a case of latent tubercle ... The extremeemaciated look ...much greater indeed than occurs for the most part in tubercular cases wherepatients are still going about, impressed me at once with the probability that I should findno visceral disease. Pulse 50, Resp.16. Physical examination of the chest and abdomen discoverednothing abnormal. All the viscera were apparently healthy. Notwithstanding the great