Dance-Like Movements in Obsessive Compulsive Disorder.

The presentation of Obsessive Compulsive Disorder (OCD) is sometimes unusual and can mimic other disorders. There are a number of rare and varied manifestations of this disorder, reported in literature. The case reported here, presented with a hitherto unreported symptom; a dance-like compulsion in a case of OCD. This symptom is notable for the influence of cultural environment, on the content of symptom manifestation, in a psychiatric disorder. When one symptom in a disorder presents itself very prominently, the other symptoms, which are less prominent become masked; and need to be elicited by detailed assessment.

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a fairly common condition which is usually easily diagnosed. Sometimes, when the presenting symptom is rare and prominent, the diagnosis becomes difficult. Per our knowledge, this is the first case report of dance-like movements, occurring as a compulsion in OCD.

CASE REPORT

We report herein, a case of a 23-year-old Bodo housewife from Assam, in North-east India, presenting with a 2 years history of abnormal movements. The movements mainly involved the upper limbs, were symmetrical, dance-like and voluntary. Some of the movements resembled the movements seen in the Bagurumba, which is the main folk dance of the Bodos; they were repetitive and complex, flowing from the shoulders to the hands, in the same sequence each time. They occurred episodically throughout the day and were present for about 8 h/day. She could voluntarily control these movements for 10-15 min at a time; doing so made her anxious and the movements would begin again. There was an obsessive urge to perform these movements all through the day, and resistance to control the urge, which failed. These movements did not resemble any known movement disorder.

On detailed assessment, she was also found to have obsessions of contamination with repetitive washing compulsions; obsessive doubts with checking compulsions, and counting compulsions. Her furniture, vessels and clothes had to be arranged in a particular manner, which, when disturbed, greatly upset her.

There was no history suggestive of psychosis, organicity, substance use or any other medical condition, which could account for these symptoms.

During the course of illness, she was extensively investigated and was seen by two neurologists. All investigations, including electroencephalogram, magnetic resonance imaging of the brain and metabolic parameters were normal.

She was drug-naïve and had not received any medical treatment till she was first seen by us, 2 years after the onset of the illness. The psychological assessment was done. On the Yale-Brown Obsessive-Compulsive scale, her score was 34. A diagnosis of OCD with good insight (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]) was made.

Currently, the patient is on fluvoxamine 300 mg/day and cognitive behavior therapy.

DISCUSSION

The obsessive-compulsive disorder commonly presents with themes of contamination, doubts, urges, images, fear of harming others, and not uncommonly, religious and sexual thoughts. Excessive washing, checking, counting, demanding reassurance and orderliness, are some of the common symptoms this disorder.

Unusual and rare presentations of OCD have been reported. Some of these are obsessions of sexual orientation,[1] obsessions of vowels;[2] rapid illegibly hand writing,[3] sexual compulsivity,[4] and eve teasing,[5] as manifestations of compulsions.

At first sight, Conversion Disorder (Functional Neurological Symptom Disorder): DSM-5, was considered, mainly because the abnormal movements did not appear like any of the described movement disorders, and the patient presented with these movements as the chief presenting complaint. This possibility was ruled out, and these turned out to be compulsive movements, as, on detailed evaluation, the other less troublesome obsessions and compulsions came to the fore.

Many medical and neurological diseases are associated with obsessions and compulsions. For example there are seen in epilepsy, brain tumors, cerebrovascular diseases, Parkinson's disease, acute intermittent porphyria, hypoparathyroidism, Gilles de la Tourette syndrome, Wilson's disease, manganese intoxication, clozapine and risperidone use, fronto-temporal dementia, to name some of them.[6]

Late age of onset of OCD (after the age of 40 years) should raise suspicion of the underlining medical cause.[7]

In recent years, an organic cause is rarely overlooked. A few decades back, cases diagnosed with conversion disorder, on long-term follow-up, had a frequent change of diagnosis to one with an organic etiology. By the turn of the century, missing an organic condition became very infrequent. A change in diagnosis from conversion disorder to an organic one fell from 29% to 4%.[8]

In many cases of OCD, when one symptom is unusual or rare and is very prominent, the diagnosis of OCD, though the other obsessions and compulsions are present, is masked by the presence of the prominent and rare symptom. This seems to have happened in this case. There are quite a few reported cases, where the diagnosis of OCD was initially masked by such rare and prominent symptoms.

Cultural factors have a great role in the manifestation of symptoms. In schizophrenia, cultural factors play a role in the content of delusions and hallucinations. So also, in a number of other psychiatric disorders, the same psychiatric condition, manifests differently; the symptomatology being influenced by the sociocultural environment of the patient; dissociative disorders and conversion disorders being common examples.

This patient was from the Bodo community in Assam, a North-eastern state of India, which has a distinct sociocultural background. The Bagurumba Bodo dance is the folk dance of the Bodos. The abnormal movements seen in this patient had a striking resemblance to some of the movements seen in this folk dance. This is perhaps, the first case report, of dance, as a cultural factor, influencing the manifestation of a compulsion in OCD.

In this case, as there was one presenting symptom, a prominent compulsion, the other obsessions, and compulsions present, of less severity, were elicited after probing. Furthermore, a co-morbid condition had to be considered and ruled out. In this case, the condition that was ruled out was conversion disorder.

This case of OCD highlights three points: Cultural influence on symptomatology; a very prominent symptom masking other less prominent symptoms; a rare, unreported presentation.