Obsessive slowness : a case report.
ABSTRACT Obsessive slowness is described to be a syndrome of extreme slowness in ways various tasks are performed. Its existence as an independent syndrome is challenged by authors, who regard it to be a part of obsessive compulsive disorder. Behavioural techniques of prompting, pacing and shaping are recommended for treatment of this condition. We describe here a case of a 21 year old male patient who presented with debilitating slowness. Patient responded to a combination of behaviour therapy (thought habituation and exposure) and pharmacotherapy (fluoxetine and thyroxine). Diagnostic difficulties and management issues are highlighted.
INDIAN JOURNAL OF PSYCHIATRY. 2003. 45(1), 60-61
Obsessive Slowness : A Case Report
GAGANDEEP SINGH. PRATAP SHARAN & SANDEEP GROVER
Obsessive slowness is described to be a syndrome of extreme slowness in ways various
tasks are performed. Its existence as an independent syndrome is challenged by authors,
who regard it to be a part of obsessive compulsive disorder. Behavioural techniques of
prompting, pacing and shaping are recommended for treatment of this condition. We
describe here a case of a 21 year old male patient who presented with debilitating
slowness. Patient responded to a combination of behaviour therapy (thought habituation
and exposure) and pharmacotherapy (fluoxetine and thyroxine). Diagnostic difficulties
and management issues are highlighted.
KeyWords: Obsessive slowness, Diagnosis, Behaviour
Rachman(1974) introduced a tare
syndrome, termed "primary obsessive
slowness". It is characterized
prominent debilitating slowness especially
in sclfcarc behaviour,
mcticulousncss, absence of an increase in
anxiety or discomfort either before or
following the behaviour (or with initiation
of treatment) and relative lack of
resistance. Subsequently, others published
case reports or case series (4-10 patients)
that detailed features of this syndrome
(Bilsubury and Morely, 1979; Bennun,
1980; Clark et al., 1982; Hymas et al.,
1991; Ratnasuriya ct al., 1991; Takcuchi
et al., 1997). Vcale (1993) challenged the
proposed syndrome by pointing out that
slowness in most of these patients is
secondary to behavioural or mental rituals,
aimed at suppressing or neutralising
a very (minutely) detailed plan for future
It may be due to
We described here a case of a 21 year
old male who presented with extreme slow-
Mr. P.K., 21 years old unemployed man from
middle socio-economic Hindu nuclear family of
urban background pcesenied with a 6 years history
of doing things very slowly.
presentation, the patient was taking 6-7 hours to
bathe and 13-14 hours in self-care activities. He
would divide each act of self-care (egbathing) into
number of small steps. For each of these steps,
he would spend variable periods of time deciding
on whether to do it or not, after considering the
pros and cons of each behaviour.
At the time of
At 20 years of age, he started walking in a
peculiar manner. He would repeatedly take steps
forward and backward and stop and start in an
attempt to prevent his face from getting distorted.
He regarded this thought as senseless and tried to
resist it, but he could not do so. He also developed
obsessional doubts with repetitive checking (e.g for
Six months prior to admission, patient started
passing stool in his clothes. This was reportedly due
to his inability to decide on whether to go to the
toilet or not.
Investigations including haemogram, blood
encephalography and computerized tomograph of
the head did not reveal any abnormality. Thyroid
function tests revealed moderately raised TSH levels
(7.75 IU/ml; normal range-0.6-6.0- IU/ml) and
strongly positive thyroid microsomal antibodies.
After consulting an endocrinologist, the patient was
started on thyroxine (50 microgram per day).
Patient was diagnosed to have obsessive-
compulsive disorder (()CD) with secondary slowness.
He was started on fluoxetine 20 mg dairy, which
was subsequently increased to 40 mg daily.
Patient's family was educated about his illness.
After behaviour analysis, behaviour therapy
was instituted with father as a cotherapist. At
the baseline, time taken for various activities
included: bathing-6 hours, toilet activities- 2
hours, reading one page-4 hours, combing hair-
30 minutes, coming out of bed-60 minutes and
moving a distance of 10 meters-30 minutes.
Behavioural principles of prompting, pacing and
shaping as suggested by Rachman (1974) were
used. Therapy was attemped in this manner for
3 weeks but patient would not comply with the
instructions. The behaviour therapy was then
modified to incorporate thought habituation,
and exposure and response prevention to target
obsessional doubts regarding distortion of face
and having left something behind. After 8 weeks
of treatment (approximately 100 sessions each of
thought habituation and exposure), time spent
in bathing, moving out of bed, and in moving
from one place to another reduced by half. He
stopped passing stool in his clothes and started
bathing on his own on alternate days. But he
continued to walk in a peculiar manner and no
change in repetitive checking rituals was noted.
During the course of therapy, he frequently
showed resistance by refusing to co-operate for
After 3 month of
to be discontinued as patient's father had pressing
official engagements. Outpatient treatment was not
possible as the patient was from another township.
At 9 months follow up, he continued to maintain
ward stay, therapy had
The present case highlights the difficul-
ties inherent in the concept, diagnosis and
management of a patient with slowness.
Though the term obsessional slowness is
established, some authors (Veale, 1993) argue
that a separate syndrome of "primary
obsessional slowness" proposed by Rachman
(1974) may not be needed. Rachman (1974)
described a syndrome where other obses-
sions were not present nor the slowness was
in response (secondary) to other obsessions
found in OCD. Other authors (Veale, 1993;
Ratnasuriya et al.,1991) suggest that there
is a substrate of other obsessions in
obsessional slowness, hence giving rise to
the concept of "primary" and "secondary"
obsessional slowness (Veale.1993). Veale
(1993) stated that most of the cases be-
longing to this syndrome suffer
OCD with secondary slowness. According
to the author, in most of the cases of
"primary obsessive slowness", slowness
can often be reanalysed as part of avoid-
ance of disorder, unmeticulousness and
inexactness. Components of obsessional
slowness are multiple, the excessive time
spent is not just related to orderliness or
meticulousness but usually a wide
of activities adopted by patient (Veale,
1993). In an attempt to find biological
correlates of obsessional slowness, Hymas
ct al.(1991) studied basal ganglia pathology
of 17 patients with obsessional slowness.
All patients exhibited slowing in self-care
and goal directed behaviour. All patients
were shown to have soft signs, delay in
initiating limb movements, difficulty in
swithching from one motor act to
other, difficulty in carrying out two motor
acts simultaneously, speech and gait
abnormalitites and general clumsiness.
However, similar features were reported in
adult patients with OCD (without slow-
ing). So far no validation attempt either on
brain pathology, neuropsychology or
multivariate analysis has been able to
dclicnate subgroup of slowness symp-
toms with in the syndrome of OCD.
Hence, it appears more logical to organize
classification around recognized phenom-
enon of OCD than to single out order-
liness and meticulousness as seperate syn-
In the index case, patient's compulsive
rituals such as repeated checking for his
wallet, combing and gazing in the mirror,
and the peculiar way in which he walked
contributed to his slowness. The
obsessionality of these behaviours can not
be doubted because they were regarded as
absurd by the patient Extreme slowness
in bathing and passage of stool in clothes
appears to be due to indecisiveness and
procrastination. As proposed by Veale
(1993), these behaviours can also be un-
derstood as avoidance strategies to deci-
siveness and quickness which are parts of
the obsessive-compulsive spectrum.
Salkovaskis and Kirk,1989) have advocated
esposure (and response prevention) to
inexactness and unmeticulousness and
exposure to obsessional thoughts by
audio-tape feed back as methods to
overcome slowness. Cognitive work and
supportive therapies have also been
advocated as a part of the package of OCD
(Salkovaskis and Kirk, 1989), but these
have not been tested specifically in the
treatment of slowness. Poor motivation
to comply with prompting and pacing
appears to be the principal factor for failure
of mese strategies in the index case. With
expousre, a reasonable
improvement was noted. Improvement
was sustained over follow-up outside die
hospital and it generalized to areas odier
dian that of exposure (e.g. patient became
effectiveness of this therapeutic strategy.
There is a need to examine the role of
thyroid abnormality and thyroxine and
serotonergic drugs as also observed by
Hamlin et al., (1989) in obsessive slowness
as observed in die index case.
The report supports Veale's (1993) position
of viewing slowness as a phenomenon
secondary to OCD. A careful behavioural
analysis might indicate exact strategies required
for treatment of such patients.
Bennun I. (1980) Obsessional slowness: a
meticulous replication and an extension. Behav-
iour Research and Therapy, 18, S95-S98.
Bilsubury C. & Morley S. (1979) Obsessional
slowness: a meticulous replication. Behaviour
Research and Therapy, I, 405-408.
Clark D.A, Sugrim I. & Bolton D. (1982)
Primary obsessional slowness: a nursing treat-
ment programme and a 13-year-old
adolescent Behaviour Research and Therapy. 20,
Hamlin C.L, Swayne L.C. & Liebowitz M.R.
(1989) Striatal IMP-spect decrease in obsessive-
compulsive disorder, normalized by pharmaco-
therapy. Neuropsychiatry, Neuropsy-chology, and
Behavioural Neurology . 2, 290-300.
Hymas N.Less A, Bolton D, Epps
Head D. (1991) The neurology of obsessional
slowness. Brian. 117, 2203-2233.
Rachman S. (1974) Primary obsessional slow-
ness. Behaviour Research and Therapy, 12, 9-
Ratnasuriya R.H, Marks I.M,
St Hymas N.F.S.(I99I) Obsessional slowness
revisited. British Journal of Psychiatry, 159, 273-274.
Obsessional disorder. In: Cognitive Behaviour
Therapy for Psychiatric
Hawton,K.. Salkovskis.P.M. & KirkJ.. PP. 129-169.
Oxford: Oxford Medical.
& Kirk J.W. (1989)
Takeuchi T, Nakagawa A, Harai H Nakatani
E, Fujikawa S, Yashizato C. & Yamagami
T. (1997) Primary obsessional slowness: long
term findings. Behaviour Research and Therapy,
Veale D. (1993) Classification and treatment
of obsessional slowness. British Journal of Psy-
chiatry, 162, 198-203.
•GAGANDEEP SINGH, M.D.. Senior Resident; PARTAP SHARAN. M.D., Associate Professor; SANDEEP GROVER. M.B.B.S., Junior Resident; Department
of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh-160012(email@example.com).