Shared or induced obsessive compulsive disorder: Is it a reality?

Abstract

Background:

Shared or induced obsessive compulsive disorder (OCD) is not yet a distinct diagnosis in classification of psychiatric disorders. In fact, though recognized as a diagnostic category, shared or induced psychotic disorders are rare and most of the literature is based on the case reports.

Materials and Methods:

We are reporting three case studies manifested with shared or induced OCD (cases with obsessive symptoms that were shared from the primary case in their family).

Results:

All the cases were treated considering shared or induced OCD as psychopathology. Response to treatment modalities in first and second case and poor response to treatment in third case is suggestive of shared or induced OCD as a distinct entity. It is different from shared psychosis in many ways.

Conclusion:

Shared or induced OCD is a distinct diagnosis. Greater awareness about this entity among mental health professionals is needed.

INTRODUCTION

Folie à deux, a phenomenon of a shared psychotic disorder has been known for years, but it still remains an elusive entity. It is uncommon, although some authors believe it to be more frequent than usually thought, especially when the patient is seen together with family members.[1,2] This syndrome includes the “primary” individual, who first develops psychotic symptoms and one or more “secondary” individuals, in whom the symptoms are induced that is the delusions of a primary patient are adopted by the partner(s).[3] The relationship between the psychopathology exhibited by the dominant partner and that shown by the submissive one remains unclear. The essential theme is often persecutory or grandiose. The delusions are first manifested in the dominant personality, who in turn influences the weaker personalities and suggestible and less intelligent people. It is identified more frequently in women[4,5] reflecting the traditional submissive role of females in the family. The involved cases have an unusually close relationship and are isolated from others by language, culture, or geography; most of the reported relationships have been within the nuclear family.[6]

Shared obsessive compulsive disorder (OCD) is a relatively new concept and only few case reports of shared OCD[7,8] are available which suggest that this phenomenon represents the continuum between obsessions and delusions. In a study by done Mergui et al. it is suggested that shared OCD may represent a different diagnostic entity.[9] This disorder includes induction of an obsessive and compulsive symptoms of a dominant person in the submissive one who is in close relation with the dominant person (a primary case). We present three cases of induced OCD; all manifested in women and primarily advised separation as a treatment modality.

CASE 1

The first case was a 27 year old married woman from a rural area, seen in a psychiatry out-patient department (OPD) with the complaints of preoccupation with contamination and cleanliness, apprehension about lizards falling in food and washing hands and utensils repeatedly since 3 years.

She was living in a joint family which consisted of her husband, father-in-law and mother-in-law. Her mother-in-law was a dominating person. Patient's husband was a submissive type of person generally obeying his mother.

As per the observation and history given by her relatives, the mother-in-law was suffering from OCD with predominant obsessions of contamination since 7 years. She had no insight into her illness and was not willing for treatment. Patient could not adjust well with her mother-in-law for the initial 2 years after her marriage. The mother-in-law would satisfy her own obsessions by compelling the patient to wash the house, utensils and clothes repeatedly. The patient would be repeatedly scolded by her mother-in-law for mistakes in the household chores regarding cleanliness. The patient tried her best to follow her instructions with lot of mental resistance for 2 years.

Since 3 years the patient started doubting her own work. She used to get repeated thoughts of contamination, which made her perform the cleaning activities frequently to reduce her anxiety. Over 1 year the patient's compulsive activities increased to such an extent that she started spending more than 5-6 h in a day washing utensils and clothes while the mother-in-law would spend most of her day time in cleaning the house. She used to experience the obsessions for about 5-6 h daily. She had serious distress and disruption in her daily functioning due to the obsessions and compulsions. She tried to resist the obsessions and compulsions but had little control over it. The Yale-Brown obsessive compulsive scale (Y-BOCS) was used to measure the severity of her symptoms.[8] Her total Y-BOCS score was 28.

She had no other psychiatric comorbidities. She was not suffering from any significant medical or surgical illness. There was no past history of any significant psychiatric problem. Family history was not significant.

She was the eldest among three siblings. Her parents were educated and supportive of her and her sisters. The patient was educated up to higher secondary. Her performance in school was average. Her adolescence was without any significant psychological problems. She had been married since 5 years. Her pre-morbid personality assessment revealed her as quiet, submissive, suggestible and cooperative.

On mental status examination, her mood was anxious with appropriate affect and thought evaluation revealed obsessions of contamination and ideas of helplessness due to the obsessions. She had insight into her illness.

Patient was treated with tablet escitalopram 10 mg OD and tablet clonazepam 0.5 mg OD. The dose of Escitalopram was increased to 20 mg/day after 15 days. Clonazepam was reduced and then subsequently tapered off. Patient was assessed every 2 weeks. She did not report any significant improvement for 3 months. We advised separation of the patient from her mother-in-law by considering this illness as an induced OCD without any further change in medications. After 1 month of separation, patient's obsessions and compulsions were reduced by around 60%. Escitalopram 20 mg/day was continued over this duration. She was not willing for any psychotherapy and hence this could not be undertaken. Medications were tapered and stopped over the next 6 months. During this period, she continued to stay separated from her mother-in-law. She was further assessed every month for next 6 months. The residual obsessions improved completely over 3 months. She has no obsessions and compulsions since last 3 months.

CASE 2

The second case is about a 20-year-old female patient from urban area seen in psychiatry OPD with the complaints of excessive preoccupation with cleanliness and repeated hand washing since 1 year.

The patient was apparently alright 1 year back. She belonged to a nuclear family including her parents. Her father reported that she was excessively attached to her mother. Patient's mother was suffering from OCD, moderate to severe in degree, since 10 years and was under treatment from same hospital. She had predominant obsessions of contamination. Her response to treatment was not good. She was not a dominating figure.

The patient was excessively close to her mother. She used to help her mother in household activities and would also take care that adequate cleanliness is maintained so that her mother is not distressed. In her attempts to help her mother, she was excessively involved in compulsive rituals.

Since last 1 year the patient herself started doubting her work. She would perform the cleaning activities repeatedly to reduce her own distress. She used to spend 2-3 h a day to clean the house leading to disruption in her daily activities. She would try to resist the obsessions and compulsions but had little control over it. Her total Y-BOCS score was 18.

Patient had no other psychiatric co-morbidities. She was not suffering from any medical or surgical illness and her past history was not significant.

Patient was studying in the 2^nd year of her undergraduate training in engineering. Her pre-morbid personality assessment showed that she was anxious, submissive, social and cooperative.

On mental status examination her mood was anxious with appropriate affect and thought evaluation revealed obsessions of contamination. She had insight into her illness.

We advised separation of the patient from her mother by considering the probability of induced OCD. Patient's father cooperated for the same. We suggested the patient to stay at the college hostel for 6 months. She was allowed to talk to her parents on phone. She insisted on spending the Sundays with parents. We allowed that in the 2^nd month of separation. The patient had significant distress for the 1^st month. She was anxious about her mother's health. At the end of the 2^nd month of separation patient showed 30-40% reduction in her symptoms. Her Y-BOCS score was 12. We continued the separation for next 4 months with monthly follow-up. At the end of 6 months, the patient had significant improvement. Patient decided to stay in hostel for her further education and to stay with her parents on weekends.

CASE 3

A 50-year-old female patient from rural area was seen in psychiatry OPD with the complaints of repeated checking of doors, gas knobs and electrical switches, excessive involvement in cleanliness such as cleaning floors, utensils and bathing idols of God. This started 5 years back and had increased over last 2-3 years.

The patient was staying with her husband, two children and mother-in-law. Patient's mother-in-law was 70 years old. She was under treatment for OCD since last 40 years with poor response to treatment. She was debilitated and bed-ridden since last 5 years due to complications of osteoarthritis. It was not possible for her to perform her compulsive activities due to arthritis, which in turn would result in increase in her distress. Hence she started forcing the patient to perform the compulsive rituals for her. The patient was submissive. The patient could not refuse her dominating mother-in-law for performing cleaning activities. For the initial few years the patient started performing compulsions with a lot of resistance. Gradually her resistance reduced and since 2-3 years she started doubting her own work.

She started spending 5-6 h a day in doubting her work and performing compulsive rituals. She had significant distress and interference in her life due to obsessions and compulsions. She tried to resist the obsessions and compulsions but had little control over it. Her total Y-BOCS score was 30.

Patient was started on tablet sertraline 100 mg/day and the dose was increased to 200 mg/day on follow-up. The patient was also treated with tablet clonazepam 0.5 mg/day for first 4 weeks.

We advised separation from her mother-in-law considering her illness as shared OCD. The patient and her family members were not willing for separation in view of the mother-in-law's medical condition. There is no other caretaker for mother-in-law apart from the patient. Pharmacotherapy reduced patient's restlessness, but there was no significant improvement in her obsessive compulsive symptoms even after 6 months of treatment.

DISCUSSION

Though shared or induced psychotic disorders are well-known entities in psychiatry, induced OCD or shared OCD is not yet commonly recognized.

The above three case studies revealed some facts which are worth considering. In shared or induced psychotic disorder the two concerned persons are closely associated for a long time and live together in social isolation. The primary case is usually the dominating person while the secondary case is usually the more suggestible person. Almost all cases involve members of a single family. The most common relationships are sister-sister, husband-wife and mother-child.[10]

The first and third case-study showed that the primary case was dominating and the secondary case was submissive while the second case-study showed that the primary case was not influential and over-involvement of secondary case to primary case could be associated with sharing of obsessions and compulsions.

The above case studies showed that such cases involve members of a single family. The common relationships are mother-daughter and mother-in-law and daughter-in-law. Mother-in-law and daughter-in-law relationship could be specific to the Indian scenario due to cultural factors. In rural India, mother-in-law is expected and accepted as a dominating person and daughter-in-law is expected and accepted as a submissive person. It is considered a “good” relationship if the daughter-in-law listens to the mother-in-law without questioning. If the daughter-in-law is suggestible she accepts all the commands of the mother-in-law without any active resistance. In the first and third case studies daughters-in-law was submissive. They started helping their mothers-in-laws in carrying out their compulsions with a lot of resistance but over a time their resistance decreased and they started doubting their own work. In second case-study the daughter was excessively attached to her mother. This is a common scenario in a nuclear family in India. Finding the mother distressed about cleanliness, the daughter started feeling helpless and out of guilt of not being able to help out the mother she started helping the mother in carrying out her compulsions.

Mergui et al. in their study have reported a case of induced obsessive-compulsive disorder in a married couple. Wife developed obsessive compulsive symptoms 6 months after the deterioration of the husband's OCD.[9] Grover and Gupta reported shared OCD among sisters.[7] Stengler-Wenzke et al. have reported that family members attempt to cope with patients with OCD by assisting in rituals, opposing the symptoms and supporting patients in dealing with the illness.[11]

Unconscious identification with the aggressor can be a psychological explanation for this disorder in the first and third case study. It is an unconscious process in which a person adopts the perspective or behavior patterns of a captor or abuser.[12] A dominating person with OCD living with a submissive person, induction of obsessive compulsive symptoms in the dependent person and improvement after separation from the dominating person hints toward the diagnosis of an induced OCD.

Unlike shared or induced psychotic disorder, the families mentioned in all three case studies were not truly socially isolated. In the first and third case studies patients belonged to joint family structure and in the second case-study patient belonged to a nuclear family.

Management of these cases is different from managing the usual cases of OCD. The treatment of the primary case is of paramount importance. Mergui et al. reported resolution of symptoms in secondary case without medication in parallel with the resolution of primary case with OCD.[9]

The management becomes difficult when the primary case is not willing for treatment, as seen in the first case. The management is also difficult if the primary case has poor response to the treatment as shown in second and third cases. Separation of secondary case from the primary one with or without pharmacotherapy could be another approach in the management of OCD in the secondary case in such circumstances. The first case study showed the importance of separation of secondary case from primary case along with pharmacotherapy. The second case study showed the importance of separation of secondary case from primary case without pharmacotherapy in mild to moderate cases of shared or induced OCD. In the third case study, it is important to note that there was no significant improvement with the pharmacotherapy alone.

CONCLUSIONS

A shared OCD is distinct from shared psychosis. It is seen among closely related members of the family. The primary case is usually a dominating person while the secondary case is a submissive one. Excessive attachment can be related to such sharing of symptoms. Cultural factors can affect the association between primary and secondary cases. Close association, excessive attachment, guilt and identification with the aggressor could be related to the shared OCD. Though treatment of primary case is of paramount importance, secondary case requires independent interventions if the primary case is not willing for, or having a poor response to treatment.

IMPLICATION

Awareness of this clinical entity will help mental health professionals to identify cases of shared OCD. Unnecessary use of anti-obsessional agents can be avoided in this condition as separation is the primary treatment modality.