Behavioural therapy in persons with intellectual disability and OCD: An effective augmentation strategy

To the Editor

Obsessive-compulsive disorder (OCD) is a common and disabling psychiatric disorder. Recent evidence (Davis et al., 2008) suggests that OCD occurs more frequently in individuals with intellectual disability (ID) than in the general population. Treatment of a patient with OCD and ID is a clinical challenge. Non-pharmacological options as an augmentation strategy have not been explored and there is only a single report (Maikandaan et al., 2009) on the use of behavioural therapy (BT) in such patients. We report a case of ID with OCD, who responded to BT.

An 18-year-old male was brought by his parents to the specialty OCD clinic of the National Institute of Mental Health and Neuro Sciences (NIMHANS) with the chief complaints of fear of contamination, compulsive hand washing, symmetry-related obsessions, arranging compulsions and frequent anger outbursts, noticed over the last 3 years. Early developmental history revealed a delay in gross and fine motor and adaptive milestones and slowness in acquiring scholastic skills. Structured assessments were conducted at baseline using the Mini-International Neuropsychiatric Interview (Sheehan et al., 1998), Wechsler Adult Intelligence Scale – Performance Scale (Indian adaptation) (Swami, 1974), Yale–Brown Obsessive Compulsive Scale (YBOCS) (Goodman et al., 1989) and a semi-structured clinical interview. He was diagnosed with OCD and mild ID (intelligence quotient of 52). His baseline YBOCS score was 28. Treatment with fluoxetine 80 mg and clomipramine 100 mg was initiated.

At the 12 weeks’ follow-up he showed improvement (YBOCS score = 23). However, both the patient and his family were significantly distressed by the persisting symptoms. Hence, he was admitted to the hospital for BT. A total of 20 sessions were conducted over the admission period of 4 weeks. Following the initial assessment, exposure and response prevention (ERP) was conducted using differential positive reinforcement and performance-feedback procedures. In view of his low intellectual status, a reward system was decided upon as being the most effective strategy. The concept of token economy was explained to the patient. He was given graded tasks, the completion of which would earn him a star. Initial tasks were to refrain from performing compulsions. Subsequently, the patient was exposed to avoided objects/situations that otherwise increased his compulsions. At the end of the week all the stars would be summed up to give privileges that were of the patient’s choosing. A similar approach was used for controlling his anger outbursts. In addition, his mother was trained to be the co-therapist for continuing therapy outside the hospital.

Psychosocial issues were predominantly in the area of inconsistent parenting and expressed emotions in the form of critical comments. These were taken up in the session with his parents and a reduction in the same served as positive reinforcement to the patient and by itself may also have contributed to a therapeutic environment. He showed significant improvement with a YBOCS score of 11 at the time of discharge. He has been able to maintain his gains, as evidenced by follow-up over 1 year, during which time he remained compliant with medications (YBOCS = 12).

It is possible that some of the treatment gains in this patient can be attributed to the longer duration of medication treatment. However, medication-related treatment gains mostly occur within the first 12 weeks (Kellner, 2010). Considering that BT was initiated in this patient after 12 weeks of medication, BT is likely to have produced the major therapeutic gains.

Psychotherapy, by its very concept, means that it should be tailored to suit the patient’s profile so that it may be beneficial. Patients with ID and OCD are significantly distressed by their symptoms: it affects their quality of life as well as that of their caregivers. This underlines the importance of a holistic approach, limited as it may be for this population with intellectual deficits. The current case highlights the importance of ERP using differential reinforcement procedures as an augmentation strategy in patients with OCD and mild ID.