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To the Editor: We found the recent Clinical Case Conference by Jennifer E. Pate, M.D., and Glen O. Gabbard, M.D. (1), fascinating and illuminating. A similar case has also been described in a compendium of "interesting cases"(2). Recently, we had the opportunity to treat a patient with similar thoughts and symptoms. This patient had a higher level of psychiatric morbidity than the patient of Drs. Pate and Gabbard, and some clinicians involved felt that his symptoms were best explained by an obsessive-compulsive disorder (OCD) spectrum illness.
Mr. A was a 32-year-old, single Caucasian man who was referred to the inpatient psychiatric unit for symptoms of depression and a suicide attempt. In addition, he had recurrent, intrusive thoughts and behaviors involving wearing diapers, crawling on the floor, "anything relating to babies," and becoming a baby. These secretive, ego-dystonic thoughts and behaviors had plagued him since the age of 7. Furthermore, he adamantly denied any sexual gratification related to or connected to these thoughts and behaviors. During his hospitalization, he was treated with fluoxetine (titrated to an oral dose of 60 mg/day). Risperidone at an oral dose of 1 mg b.i.d. was later added to target his psychotic symptoms. He reported good relief from these interventions with regard to depressive symptoms and the aforementioned thoughts and compulsions. On admission, his score on the Yale-Brown Obsessive Compulsive Scale (3) was 22 (3 at follow-up). During his hospitalization and subsequent outpatient treatment, a psychodynamic approach was helpful in attempting to understand Mr. A and his symptoms. This was coupled with supportive psychotherapeutic techniques. Over the course of two inpatient hospitalizations and several months of intensive outpatient treatment, he improved and eventually left the area to live near family.
When reviewing this case and studying that of the authors, several questions come to mind. Clinicians involved in the treatment of Mr. A often questioned whether his symptoms represented OCD, a paraphilia, or some new diagnostic entity. We respect the value of a psychodynamic understanding and approach in the case of the patient of Drs. Pate and Gabbard but also question if pharmacotherapy was considered during his brief presentation. Further information would have been useful, such as the extent to which he dwelt on the thoughts of "being a baby" throughout the day. In the case of Mr. A, the act of "being a baby" led to an episode of major depression with a suicide attempt. Other authors have postulated that some paraphiliacs may have subthreshold OCD and may benefit from serotonergic agents (4).
The views expressed are those of the authors and do not reflect the official position of the Department of Defense or the Department of the Army.
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