The Treatment of Obsessive Compulsive Disorder

Despite the fact that individuals with intellectual disabilities are at an increased risk for psychiatric problems, a fact that has been well documented in scientific literature for decades, many mental health professionals do not properly recognize the co-occurrence of psychiatric disorders and intellectual disorders . Most mental health professionals do not receive training in the diagnosis and treatment of dual diagnosed individuals, and most clinical treatment studies list intellectual disabilities as exclusion criteria. Obsessive Compulsive Disorder (OCD) likewise tends to be under recognized and missed during mental health examinations  and even when it is diagnosed properly, mental health clinicians often do not initiate appropriate, evidence based treatment . Therefore, it is not surprising that little is known about the clinical presentation and treatment of OCD in individuals who have Down Syndrome. We describe a case of OCD in an individual with Down Syndrome in which the diagnosis of OCD was overlooked for four years after first contact with mental health professionals. The treatment of the patient is reviewed, including medication management as well as the challenges in using evidence based psychotherapy.

Case Presentation

Mr. B. is a 21 year old white male with a past medical history significant for a diagnosis of Trisomy 21 which was diagnosed at birth. He presented to our clinic accompanied by his parents with complaints of behavioral concerns effecting him at home as well as at his supported work program. He had become irritable at both work and home, would refuse to go to work, and was using vulgarity while at his place of employment. He would repeat certain vulgarities over and over, and the words did not always seem to be precipitated by a specific person or event, and were often not targeted at any individual. He described this as an intentional ritual done to relieve distress and it did not appear tic-like. He was also noted to have unusual behaviors- specifically he would continuously ask his mother if she was “OK”. She could not simply answer “yes”, but she had to use a very specific phrase when responding to him: any other phrasing would prompt him to become anxious and ask the question again. This would occur multiple times in an hour. He was unable to go to bed unless the kitchen and living room was arranged in a specific way resulting in a diminished sleep schedule. He would experience crying spells when his living space was rearranged. 

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