Written in stone: a clinical case of compulsive note taking

Dear Editor

We report the clinical case of a 49 year-old housewife with OCD who, 8 years ago, developed compulsions for taking notes in a notepad of almost every phrase, car plates, random words or numbers that she would place her eyes on, including the ones found in plastic bags and clothing. She started to walk on the streets staring at the floor to avoid seeing new words or numbers she would feel urged and compelled to write down. The patient would even take notes of the serial number of every bill handled during the day. Despite having the clear insight that this was unnecessary, she argued that could not resist keeping doing it because of the putative need to access this information later. The patient even started to request the help from other family members to help with this task.

Such symptoms started after a quarrel about a foster daughter under her guard, adopted from a sibling who refused to be responsible for the newborn 15 years ago. The patient was always very concerned that the “real” mother could show up anytime and take the child away from her, thus never telling her daughter that she was adopted. Nevertheless, as the biological mother of her daughter came back to her home town after leaving for more than a decade, she was finally confronted by her daughter regarding the adoption. The patient was afraid to lose the child to the original biological mother. After clarifying the adoption process, her daughter apparently understood the whole situation and kept in good terms with the foster mother, and avoiding any contact with the biological mother. It is intriguing that her symptoms could be psychodynamically linked to the challenge she was facing. She was keeping record of every note , even useless information, as if she wanted to make sure that the agreement settled several years ago would be actually irreversible and “written in stone”.

This patient improved dramatically with paroxetine (40 mg/day), ceasing most note taking. She presented a noticeable and maintained response to treatment, especially 1 month after the beginning of drug therapy. Most obsessions concerning taking notes stopped progressively and a general relief feeling was mentioned at the follow-up. Drug therapy with paroxetine was maintained all these years. We have tried to increase dosage to a maximum limit but there was no additional effect. However, the patient could not stop to record the time she went to bed, at the end of the day. Nowadays, she persists complaining that this is the only ritual she was not able to quit.

Besides that, she started complaining of memory failure, especially short term memory events, in daily events of routine house management. A neurologic evaluation was performed by assistant clinicians that excluded organic causes. They linked the finding as a probable OCD associated memory impairment, often reported in chronic patients¹. There is a current investment in therapy for this patient, in order to improve remaining symptoms.

Movement disorders such as disturbances of fine motor coordination are a frequent phenomenon in patients with obsessive-compulsive disorder (OCD), suggesting involvement of basal ganglia circuitry^2-5.

There are few studies on such underrepresented form of OCD (note taking) and a few authors studied the kinematic analysis of handwriting movements in patients with obsessive-compulsive disorder^2-5. OCD patients usually write and draw slower and less automatically than do control patients, with lower peak velocity while writing and sometimes presenting with micrographia, without lateralization asymmetry³. Handwriting symptoms are usually more accentuated in early-onset OCD. Handwriting disturbances are also associated with worse therapeutic responses⁵. Nevertheless, such symptoms may improve with serotonin-enhancing therapy, similarly to the present case⁴.

Additional case descriptions would be welcome to compile data about how common may be such clinical variety of OCD.

References

• ¹
  Weber F, Hauke W, Jahn I, Stengler K, Himmerich H, Zaudig M, et al. Does “thinking about thinking” interfere with memory? An experimental memory study in obsessive-compulsive disorder. J Anxiety Disord. 2014;28(7):679-86.
• ²
  Stein DJ. Handwriting and obsessive-compulsive disorder. Lancet. 2001;358(9281):524-5.
• ³
  Mavrogiorgou P, Mergl R, Tigges P, El Husseini J, Schröter A, Juckel G, et al. Kinematic analysis of handwriting movements in patients with obsessive-compulsive disorder. J Neurol Neurosurg Psychiatry. 2001;70(5):605-12.
• ⁴
  Mergl R, Mavrogiorgou P, Juckel G, Zaudig M, Hegerl U. Effects of sertraline on kinematic aspects of hand movements in patients with obsessive-compulsive disorder. Psychopharmacology (Berl). 2004;171(2):179-85.
• ⁵
  Mergl R, Mavrogiorgou P, Juckel G, Zaudig M, Hegerl U. Can a subgroup of OCD patients with motor abnormalities and poor therapeutic response be identified? Psychopharmacology (Berl). 2005;179(4):826-37.

Publication Dates

• Publication in this collection
  2014

History

• Received
  22 Aug 2014
• Accepted
  15 Sept 2014