Catatonia in obsessive-compulsive disorder: etiopathogenesis, differential diagnosis, and clinical management.

OBJECTIVE: We describe the case of a patient who developed an episode of catatonia during the course of her life-long obsessive-compulsive disorder (OCD) and discuss issues related to the etiopathogenesis, differential diagnosis, and therapeutic management of this association. BACKGROUND: Catatonia is conventionally considered a heterogeneous syndrome of motor dysregulation characterized by mutism, immobility, negativism, posturing (catalepsy), stereotypies, and echophenomena. The relationship between OCD and catatonia is still misunderstood and poses significant challenges to the diagnosis and treatment of patients with both conditions. METHOD: Naturalistic follow-up of a single case. RESULTS: A patient with OCD developed catatonia in concert with deteriorating mood, thought, and behavior. This atypical clinical presentation of individuals with OCD and the list of differential diagnosis raised during the patient's clinical assessment are discussed on 3 different levels: symptomatic presentation, comorbidity pattern, and pharmacodynamic mechanisms involved. CONCLUSIONS: The development of a systematic therapeutic plan for patients with OCD and comorbid catatonia includes: the fine-tuning of the antiobsessional treatment; management of comorbid disorders that may engender catatonia; prompt discontinuation, and subsequent slow reintroduction of drugs deemed to trigger toxic reactions or to worsen comorbid disorders and, ultimately, the catatonia; and the implementation of specific anticatatonia measures.

A sociodemographic, phenomenological, and long-term follow-up study of patients with body dysmorphic disorder in Brazil.

OBJECTIVE: The main characteristic of body dysmorphic disorder (BDD) is a preoccupation with an imagined defect in appearance in a normal-appearing person or an excessive preoccupation with appearance in a person with a small physical defect. In this non-controlled study, our objective was to describe the socio-demographic, phenomenological, and long-term outcome features of a Brazilian sample of patients with BDD. METHODS: We performed a chart-review of the 166 patients who attended the Obsessions, Compulsions, and Impulsions Subprogram of the Institute of Psychiatry of the Federal University of Rio de Janeiro, Brazil, during the period between 1998 and 2005. RESULTS: Twenty patients (12%) had clinically significant BDD. This sample was characterized by a predominance of female (n = 11; 55%), single or divorced (n = 18; 90%), and economically unproductive patients (n = 17; 85%). We found an average of 2.5 current imagined defects per patient. The most frequently reported body parts of excessive concern were the overall appearance, size or shape of the face (n = 7; 35%), the skin (n = 6; 30%), the hair (n = 6; 30%), the nose (n = 5; 25%), and the body build and weight (n = 5; 25%). Most individuals exhibited a chronic condition (n = 13; 65%) and kept the same concerns during the course of the disorder (n = 12; 60%). All patients displayed compulsive behaviors, including recurrent mirror checking (n = 14; 70%), camouflaging (n = 13; 65%), reassurance seeking by means of repetitive questioning of others (n = 9; 45%), and excessive use of cosmetics (n = 7; 35%). Two patients reported "do-it-yourself" surgeries. Seven patients had current suicidal ideation (35%). Six patients (30%) showed no insight over their dysmorphic beliefs. Fifteen patients (95%) exhibited psychiatric comorbidities, mostly obsessive-compulsive disorder (OCD) (n = 14, 70%) and major depressive disorder (n = 11; 55%). The majority of patients were treated naturalistically with serotonin reuptake inhibitors (n = 15; 75%), either solo or in association with antipsychotics (n = 10; 50%). Nevertheless, only 5 (25%) responded favorably to treatment during the long-term follow-up (CGI < or = 2). CONCLUSIONS: BDD is a severe disorder that is frequently associated with other psychiatric conditions and responds poorly to treatment in the naturalistic setting. No significant trans-cultural variations were identified in the comparison between Brazilian, North American, and European samples.