P a u lo C a r a m e l/ i, M a u r o A r a n h a d e L im a , E m m a n u e l S t ip , L u iz A lb e r t o B a c h e s c h i
N eurological exam ination in obsessive-com pulsive disorder
Departments
of Neurology and Psychiatry, University of Siio Paulo School of Medicine,
Siio Paulo, Brazil
Department
of Psychiatry, University of Montreal-
Montreal
(PQ), Canada
R e c e n t s tu d ie s s u g g e s t th e o c c u rre n c e o f a n e u ro lo g ic a l d y s fu n c tio n in O b s e s s iv e -C o m p u ls iv e D is o rd e r (O C D ). T h e p u rp o s e o f th e p re s e n t s tu d y w a s to v e rify th e c lin ic a l v a lu e o f a n e u ro lo g ic a l e v a lu a tio n in p a tie n ts w ith th e d is e a s e . W e s u b m itte d 1 5 p a tie n ts w ith O C D (fiv e o f w h o m w e re u n d e r c lo m ip ra m in e ) a n d 1 5 c o n tro ls in a d e ta ile d n e u ro lo g ic a l e x a m in a tio n , in c lu d in g a s s e s s m e n t o f th e n e u ro lo g ic a l s o ft-s ig n s . E le v e n p a tie n ts (7 3 .3 p e rc e n t) a n d fo U r c o n tro ls (2 6 .7 p e rc e n t) p re s e n te d a b n o rm a litie s o n e x a m in a tio n . T h e m a in fin d in g s a m o n g th e p a tie n ts w e re : p a lm o m e n ta l re fle x (s ix c a s e s ); m irro r m o v e m e n ts (fiv e c a s e s ); a g ra p h e s te s ia a n d d y s d ia d o c h o k in e s ia (th re e c a s e s ). T h re e o u t o f th e fo u r p a tie n ts w h o h a d a n o rm a l e x a m in a tio n w e re o n c lo m ip ra m in e . P a lm o m e n ta l re fle x w a s th e m a in fin d in g a m o n g th e c o n tro ls . T h e s e re s u lts , a lth o u g h p re lim in a ry , s tre s s th e in te re s t a n d u s e fu ln e s s o f p e rfo rm in g a d e ta ile d n e u ro lo g ic a l e x a m in a tio n in O C D .
U N IT E R M S : O b s e s s iv e -C o m p u ls iv e D is o rd e r. N e u ro lo g ic a l e x a m in a tio n . C lo m ip ra m in e .
IN T R O D U C T IO N
E
C o m p u lsiv ev id en ce o f a n eu ro lo g icalD iso rd er (O C D ) h as su rfacedd y sfu n ctio n in O b sessiv e-o v er th e last ten y ears. O C D h as b een rep o rted to o ccu r after en cep h alitis, h ead trau m a, C N S tu m o rs an d in farcts, ep ilep sy , an d in asso ciatio n w ith G illes d e la T o u rette's sy n d ro m e.1 .2 F u rth erm o re, recen t n eu ro im ag in g an d n eu ro p h y sio lo g ical stu d ies h av e sh o w n so m e ab n o rm alities in O C D p atien ts, su g g estin g a p o ssib le p articip atio n o f th e cau d ate n u cleu s, cin g u late co rtex , an d th e o rb ito fro n tal reg io n s in its p h y sio p ath o lo g y .3 -sA d re s s fo r c o rre s p o n d e n c e : P a u lo C a r a m e lli
R u a / t a p e v a , 5 1 8 , c o n j. 6 0 1 1 6 0 2 S a o P a u lo / S P - B r a s il- C E P 0 1 3 3 2 - 0 0 0
P rev io u s stu d ies h av e estab lish ed a co rrelatio n b etw een th e p resen ce o f so -called n eu ro lo g ical so ft-sig n s (N S S ) an d certain p sy ch iatric d iseases, in clu d in g O C D .6 N S S are n o n -lo calizin g sig n s o f altered p erfo rm an ce o n
m o to r o r sen so ry task s in th e ab sen ce o f a fo cal
n eu ro lo g ical d istu rb an ce. T h e in v estig atio n o f th ese sig n s rep resen ts a b ro ad en in g o f th e n eu ro lo g ical ex am in atio n , cu rren tly p erfo rm ed b y clin ician s. F u rth erm o re, ev en if th ey are n o n -lo calizin g , so m e N S S can su g g est d y sfu n ctio n in p articu lar n eu ral n etw o rk s, an d th u s can g iv e ad d itio n al in fo rm atio n co n cern in g ab n o rm alities in th e fu n ctio n al o rg an izatio n th at ch aracterize so m e p sy ch iatric d iseases. In creasin g effo rts h av e b een m ad e in p sy ch iatry in o rd er to clarify th e p h y sio p ath o lo g y o f sev eral d iseases. M o d ern n eu ro im ag in g m eth o d s are o f sp ecial v alu e an d m o st o f th e ad v an ces in th e field are d u e to an im p ro v em en t in th ese tech n iq u es. H o w ev er, sin g le-p h o to n em issio n co m p u ted to m o g rap h y (S P E C T ) an d p o sitro n em issio n to m o g rap h y (P E T ), u n fo rtu n ately , are stiII n o t av ailab le w o rld w id e. T h erefo re, if sim p le an d accessib le assessm en ts
C A R A M E L L I, P ; L IM A , M .A ; S T IP , E & B A C H E S C H I, L .A . - N e u ro lo g ic a l e x a m in a tio n in o b s e s s iv e -c o m p u ls iv e d is o rd e r
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(s u c h a s a d e ta ile d n e u ro lo g ic a l e x a m in a tio n ) c a n re v e a l
a b n o rm a litie s , th e y s h o u ld b e c u rre n tly c o n s id e re d in th e
in v e s tig a tio n o f p s y c h ia tric p a tie n ts . M o re o v e r, th e
p o s s ib ility o f e s ta b lis h in g c o rre la tio n s b e tw e e n c lin ic a l
a s s e s s m e n t a n d n e u ro im a g in g h a s e x p a n d e d , w ith th e m o re
p re c is e a n a to m o -fu n c tio n a l d a ta a v a ila b le to d a y .
W e h a v e e v a lu a te d a g ro u p o f O C D p a tie n ts a n d a g e
-m a tc h e d c o n tro ls b y m e a n s o f a d e ta ile d n e u ro lo g ic a l
e x a m in a tio n , in c lu d in g a N S S b a tte ry . T h e p u rp o s e o f th is
s tu d y w a s to v e rify th e c lin ic a l v a lu e o f a n e u ro lo g ic a l
e x a m in a tio n in O C D .
S U B J E C T S A N D M E T H O D S
T h e O C D g ro u p in c lu d e d 1 5 p a tie n ts (n in e fe m a le
a n d s ix m a le ), a g e d b e tw e e n 1 7 a n d 6 6 y e a rs (m e a n = 3 8 .2 ,
S D = 1 5 .0 ), fo llo w in g D S M -III-R d ia g n o s tic c rite ria fo r
O C D , w ith n o e v id e n c e o f fo c a l n e u ro lo g ic d is o rd e r. M e a n
d u ra tio n o f illn e s s w a s 1 4 .9 y e a rs , S D = 1 0 .2 y e a rs (ra n g in g
fro m 4 to 4 0 y e a rs ). T e n p a tie n ts w e re m e d ic a tio n -fre e a n d
th e re m a in in g fiv e w e re re c e iv in g c lo m ip ra m in e (2 5 to 3 5 0
m g /d a y ). S e v e rity o f s y m p to m s w a s a s s e s s e d b y th e Y a le
-B ro w n O b s e s s iv e -C o m p u ls iv e S c a le (Y B O C S ). T h e c o n tro l
g ro u p c o n s is te d o f 1 5 s u b je c ts (n in e fe m a le a n d s ix m a le ),
w ith m e a n a g e o f 3 8 .1 y e a rs , S D = 1 4 .6 (ra n g in g fro m 1 8 to
6 8 y e a rs ), w ith n o e v id e n c e o f O C D s y m p to m s , n o h is to ry
o f n e u ro lo g ic a l o r p s y c h ia tric d is e a s e s , a n d n o u s e o f a n y
m e d ic a tio n a ffe c tin g th e c e n tra l n e rv o u s s y s te m . A ll p a tie n ts a n d c o n tro ls a g re e d to p a rtic ip a te in th e s tu d y .
N e u ro lo g ic a l a s s e s s m e n t in c lu d e d e v a lu a tio n o f th e fo llo w in g a s p e c ts :
I. C o o rd in a tio n : fin g e r-to -n o s e , h e e lto k n e e to
-to e , d ia d o c h o k in e s ia , m irro r m o v e m e n ts , ta n d e m
w a lk in g .
2 . P rim iti v e re fle x e s : s n o rt, g ra s p , s u c k in g a n d
p a lm o m e n ta l re fle x e s .
3 . A b n o rm a l m o v e m e n ts : a s s e s s m e n t o f tre m o r,
c h o re a , a th e to s is , d y s to n ia a n d o f p o s tu re
a b n o rm a litie s .
4 . S e n s o ry fu n c tio n s : a rth re s te s ia , g ra p h e s te s ia .
5 . V is u o s p a tia l a b ilitie s : rig h t-le ft o rie n ta tio n o n
s e lf a n d e x a m in e r.
R E S U L T S
E le v e n p a tie n ts (7 3 .3 p e rc e n t} fro m th e O C D g ro u p
a n d fo u r c o n tro ls (2 6 .7 p e rc e n t) p re s e n te d a b n o rm a litie s
u p o n n e u ro lo g ic a l e x a m in a tio n . In th e O C D g ro u p ,
a b n o rm a litie s in c lu d e d p a lm o m e n ta l re fle x (n = 6 ), m irro r
m o v e m e n ts (n = 5 ), a g ra p h e s te s ia (n = 3 ),a n d d y s d ia d o
-c h o k in e s ia (n = 3 ). T a b le 1 p re s e n ts th e o v e ra ll d a ta o f th e
O C D g ro u p . A m o n g th e fo u r c o n tro l s u b je c ts w h o
p re s e n te d a b n o rm a litie s , p a lm o m e n ta l re tle x w a s o b s e rv e d
in th re e (a g e d 2 4 , 2 6 a n d 3 9 ), a n d in th e fo u rth (a g e d 6 8 ),
th e p a lm o m e n ta l re fle x o c c u rre d in a s s o c ia tio n w ith m i Id
m irro r m o v e m e n ts .
T h e re w a s n o c o rre la tio n b e tw e e n s e v e rity o f O C D
s y m p to m s , a s in d ic a te d b y th e Y B O C S s c o re , a n d th e
n u m b e r o f n e u ro lo g ic a l s ig n s . T h is w a s th e c a s e e v e n if
th e s e v e rity o f th e o b s e s s io n s a n d th e c o m p u ls io n s w e re
c o n s id e re d s e p a ra te ly (d a ta n o t s h o w n ).
T h re e o u t o f fo u r p a tie n ts w h o p re s e n te d n o
a b n o rm a litie s o n e x a m in a tio n w e re o n m e d ic a tio n
(c lo m ip ra m in e ). T h e re m a in in g tw o p a tie n ts o n m e d ic a tio n
p re s e n te d b ila te ra l p a lm o m e n ta l re fle x e s (C a s e I) a n d
b ila te ra l p a lm o m e n ta l re fle x e s , a g ra p h e s te s ia a n d m irro r
m o v e m e n ts (C a s e 6 ).
D I S C U S S I O N
T h e p re s e n c e o f n e u ro lo g ic a l d y s fu n c tio n in O C D
h a s b e e n s u g g e s te d in re c e n t y e a rs b y d iffe re n t
in v e s tig a to rs . N e u ro im a g in g s tu d ie s u s in g P E T a n d
S P E C T h a v e s h o w n a b n o rm a litie s in o rb ito fro n ta l re g io n ,
c in g u la te g y ru s , a n d in th e c a u d a te n u c le u s o f O C D
p a tie n ts .3
-5 M o re o v e r, th e m e ta b o lic h y p e ra c tiv ity o b s e rv e d
in P E T s c a n s te n d s to d e c re a s e a fte r p h a rm a c o lo g ic a l
tre a tm e n t, p ro v id in g a d d itio n a l s u p p o rt to a b ra in
d y s fu n c tio n in O C D .7 .x
T h e re h a v e b e e n re p o rts d e s c rib in g n e u ro p s y
-c h o lo g i-c a l c h a n g e s in O C D . S p e c ific a lly , re c e n t n o n v e rb a l
m e m o ry d e fic its ,9 v is u o s p a tia l a b n o rm a litie s /' a n d fe a tu re s
o f a fro n ta l lo b e -lik e s y n d ro m e1 o h a v e b e e n o b s e rv e d in
s o m e p a tie n ts . S o m e o f th e s e fin d in g s s u g g e s t a rig h t
h e m is p h e ric d y s fu n c tio n in a t le a s t a s u b s e t o f c a s e s o f O C D .6 .9
R e c e n tly , H o lla n d e r e t a l.6 h a v e u s e d a N S S b a tte ry
to e v a lu a te a g ro u p o f O e D p a tie n ts a n d c o n tro ls . T h e
a u th o rs fo u n d s ig n ific a n tly m o re N S S in th e O C D g ro u p ,
in c lu d in g a b n o rm a litie s in fin e m o to r c o o rd in a tio n ,
in v o lu n ta ry m o v e m e n ts a n d v is u o s p a tia l fu n c tio n s .
M o re o v e r, 3 9 o u t o f th e 4 1 p a tie n ts e x a m in e d p re s e n te d
a t le a s t o n e N S S , a n d th e N S S c o rre la te d w ith th e s e v e rity
o f o b s e s s io n s .
In th e p re s e n t s tu d y , a g ro u p o f O C D p a tie n ts w e re
s u b m itte d to a d e ta ile d n e u ro lo g ic a l e x a m in a tio n , in c lu d in g
1 2 5 7
T a b le 1
M a in d a ta o f th e O C D g ro u p
C a s e A g e S e x D u ra tio n o f illn e s s Y B O C S * N e u ro lo g ic a l M e d ic a tio n (y e a rs ) (m a x = 4 0 ) E v a lu a tio n (c lo m ip ra m in e )
1 1 7 M 4 2 9 p a lm o m e n ta l re fle x (b ila t.) Y e s (1 5 0 m g )
2 2 2 M 1 0 3 5 m irro r m o v e m e n ts (b ila t.) N o
3 6 3 F 2 0 2 9 m irro r m o v e m e n ts (le ft) N o
p a lm o m e n ta l re fle x (b ila t.)
a g ra p h e s te s ia (b ila t.)
4 4 1 M 4 4 m irro r m o v e m e n ts (rig h t) N o
p a lm o m e n ta l re fle x (b ila t.)
5 2 6 M 1 1 3 5 n o rm a l Y e s (3 5 0 m g )
6 4 7 F 5 2 6 m irro r m o v e m e n ts (le ft) Y e s (2 5 m g )
p a lm o m e n ta l re lfe x (b ila t.)
a g ra p h e s te s ia (b ila t.)
7 2 3 F 1 6 3 2 n o rm a l Y e s (5 0 m g )
8 3 1 M 7 6 n o rm a l Y e s (1 5 0 m g )
9 5 1 F 2 6 3 7 m irro r m o v e m e n ts (le ft) N o
1 0 2 5 F 9 2 5 p a lm o m e n ta l re fle x (b ila t.) N o
d y s d ia d o c h o k in e s ia (le ft)
1 1 5 2 F 2 0 3 7 a g ra p h e s te s ia (b ila t.) N o
1 2 3 6 F 6 3 0 d y s d ia d o c h o k in e s ia (b ila t.) N o
1 3 6 6 F 4 0 3 8 d y s d ia d o c h o k in e s ia (b ila t.) N o
1 4 7 F 2 3 3 5 p a lm o m e n ta l re fle x (rig h t) N o
1 5 3 6 M 2 2 2 7 n o rm a l N o
*Y B O C K S : Y a le -B ro w n O b s e s s iv e C o m p u ls iv e S c a le
assessm ent of the so-called N SS and certain prim itive
reflexes. A lthough som e of these reflexes can be observed in norm al subjects, their frequency is increased in several
neurological diseases. Thus, pyram idal and extrapyram idal
dam age as w ell as diffuse cerebral involvem ent can lead
to the em ergence of prim itive reflexes, such as snout, grasp,
sucking, and palm om ental reflexes. H ow ever, the latter
can be elicited in a considerable num ber of norm al subjects and its frequency seem s to increase w ith age.I I
A com m on finding in the O C D group w as the occurrence of m irror m ovem ents. This feature can
suggest basal ganglia dysfunction, and w as observed in
six patients and in only one control. A s m entioned
previously, PET studies report m etabolic abnorm alities
in the caudate nucleus of O C D patients.3-s H ence, m irror m ovem ents m ay actually be a clinical indicator of som e
kind of dysfunction in the basal ganglia circuit.
A graphestesia in the absence of other sensory
disturbance is consistent w ith parietal lobe involvem ent,
and w as found in 3 patients. D ysdiadochokinesia is a
disturbance that usually indicates a cerebellar disorder, but
is also associated w ith lesions of the cerebellar and
vesti bu lar con necti ons. Th ree pati en ts presen ted dysdiadochokinesia on exam ination. H ow ever, further
research is needed to investigate the relationships betw een
these tw o signs and O C D .
R ecent PET studies show that the m etabolic rates
observed in O C D patients before treatm ent, particularly
in the caudate nucleus and in orbitofrontal regions, change significantly after pharm acological treatm ent.7.X In the
present study, three out of four patients w ho presented no
abnorm alities on exam ination w ere under m edication. O f
the rem aining tw o patients w ho w ere receiving clom ipram ine, one (C ase 6) had just started treatm ent at
the tim e of exam ination and w as recei ving a very low dose
C A R A M E L L I, P ; L IM A , M .A ; S T IP , E&B A C H E S C H I, L .A . - N e u ro lo g ic a l e x a m in a tio n in o b s e s s iv e -c o m p u ls iv e d is o rd e r
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(25 m g); the other patient (case I) presented only palm om ental reflex. Thus, it is possible to conceive that clom ipram ine treatm ent m ay elim inate the neurological findings in O C D .
These overall results, even if observed in a sm all group of patients, stress the interest and usefulness of perform ing a careful neurological exam ination on subjects w ith O C D . Further longitudinal studies are needed in order to clarify the significance of these neurological signs in O C D , and also to m onitor possible effects of m edication on them .
A C K N O W L E D G M E N T S
P. C aram elli, M D holds a scholarship from C A PES (C oordenadoria de A perfeic;oam ento de Pessoal de N fvel Superior), B razil. W e gratefully acknow ledge D r. V alentim G entil for his helpful com m ents.
RESUMO
E s tu d o s r e c e n te s te m s u g e r id o a e x is te n c ia d e d is fu n 9 a o n e u r o l6 g ic a n o D is tu r b io O b s e s s iv o - C o m p u ls iv o ( D O C ) . 0 o b je tiv o d o p r e s e n te e s tu d o fo i v e r ific a r 0v a lo r c lfn ic o d o e x a m e n e u r o l6 g ic o e m p a c ie n te s c o m e s ta p a to lo g ia . Q u in z e p a c ie n te s c o m
d ia g n 6 s tic o d e D O C ( c in c o d o s q u a is e m u s o d e c lo m ip r a m in a ) e 1 5 c o n tr o le s fo r a m s u b m e tid o s a e x a m e n e u r o l6 g ic o d e ta lh a d o , in c lu in d o a v a lia 9 a o d e s in a is n e u r o l6 g ic o s le v e s . O n z e p a c ie n te s ( 7 3 .3 % ) e q u a tr o c o n tr o le s ( 2 6 .7 % ) a p r e s e n ta r a m
a n o r m a lid a d e s a o e x a m e . N o g r u p o d e p a c ie n te s . a s a lte r a 9 0 e s p r in c ip a is fo r a m r e fle x o p a lm o m e n to n ia n o ( s e is c a s o s ) , m o v im e n to s e m e s p e lh o ( c in c o c a s o s ) , a g r a fe s te s ia e d is d ia d o c o c in e s ia ( tr e s c a s o s ) . D o s q u a tr o p a c ie n te s c o m e x a m e
n e u r o l6 g ic o n o r m a l. tr e s e s ta v a m e m u s o d e c lo m ip r a m in a . E n tr e o s c o n tr o le s , 0a c h a d o p r in c ip a l fo i0 r e fle x o p a lm o m e n to n ia n o . E s te s r e s u lta d o s , m e s m o q u e p r e lim in a r e s , r e fo r 9 a m 0in te r e s s e e a u tilid a d e d e s e r e a liz a r e x a m e n e u r o l6 g ic o d e ta lh a d o n o D O C .
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