Rapid, illegible handwriting as a symptom of obsessive-compulsive disorder.

This is a case report of a 13 year male child who had co-morbid OCD and trichotillomania. On evaluation, he had rapid, illegible handwriting as a symptom of OCD, which has hitherto not been reported.

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a pleomorphic illness with preoccupation with order, dirt, religion and sex as common themes for obsessions and counting, cleaning, checking and washing as common themes for compulsions.[1] Unusual themes have also been described; musical obsessions[2] and starvation compulsions,[3] are just two examples. We describe, for perhaps the 1st time in literature, rapid, illegible handwriting as a hidden compulsion that resulted in poor academic grades in an adolescent with OCD.

CASE REPORT

The present case report is about a 13-year-old boy with a 5-year history of OCD and comorbid trichotillomania presented for evaluation of poor response to medications (fluoxetine 60 mg/day and clomipramine 75 mg/day, separately and together) to which he had been adequately compliant during the past 5 years. His chief OCD symptoms comprised touching objects, repeating questions and sentences and insisting that his family members answer questions or repeat sentences; these occupied 3-4 h every day and he would throw tantrums if his compulsive needs and behaviors were thwarted. His trichotillomania symptoms included hair pulling from legs, nose, eyebrows and scalp, associated with right temporal and left occipital alopecia areata.

A functional assessment revealed that although he was considered clever in school, his grades were always poor. On probing, it emerged that he had an obsessive fear of being unable to complete his test papers within the allotted time and so experienced a compulsive urge to write fast. Whereas he was always the first to complete his answer paper in examinations, his handwriting was so poor as to be almost completely illegible; and so he always obtained poor marks. Compulsively rapid handwriting soon generalized from examination settings to all settings.

He was treated with a combination of fluvoxamine (final dose, 300 mg/day) and clomipramine (final dose, 75 mg/day). He was also started on cognitive behavior therapy (CBT) with his mother inducted as a co-therapist in order to continue sessions at home. He was initially asked to write to dictation, first one word at a time, then two words at a time and afterwards short phrases. When he achieved legibility with this program, he was asked to copy paragraphs where only one line was shown at a time. He was then graduated to writing short notes without time restriction. Finally, mock tests with time limits were conducted and he was asked to deliberately omit his answer to the last question even if he had time to spare. Whereas his writing worsened in these tests, it remained legible. CBT is currently being continued with a half-hour office session every week and with mock tests at home, daily.

Along with improvement in his handwriting, his other symptoms also attenuated. His Children's Yale-Brown Obsessive Compulsive Scale scores dropped from 33 to 18 and his trichotillomania all but disappeared. These benefits developed across 4 months of medical and behavioral intervention.

DISCUSSION

Scholastic impairment is well-known in children and adolescents who are diagnosed with psychiatric conditions. In our patient, however, what superficially appeared to be illness-related scholastic impairment was actually symptom-related dysfunction in a performance parameter. Once the symptom (rapid, illegible handwriting) was corrected through CBT, his grades began to recover.

The clinical picture in our patient had been dominated by other OCD symptoms and by trichotillomania, which is why his obsessive fear of not completing his written tasks had been missed by his earlier psychiatrists. There are therefore two messages in our report; one is that rapid, illegible handwriting may occur as a compulsion and the other is that unusual expressions of psychopathology may underlie visible impairments.