A case history of obsessive-compulsive disorder with nose picking and lip biting.
Article Type: Case study
Subject: Mental illness (Risk factors)
Mental illness (Diagnosis)
Mental illness (Care and treatment)
Mental illness (Case studies)
Obsessive-compulsive disorder (Case studies)
Obsessive-compulsive disorder (Care and treatment)
Obsessive-compulsive disorder (Complications and side effects)
Obsessive-compulsive disorder (Diagnosis)
Authors: Farooque, Rokeya S.
Stout, Ronnie G.
Pub Date: 12/22/2009
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2009 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Winter, 2009 Source Volume: 12 Source Issue: 4
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 216961287

Obsessive-compulsive disorder is classified as an anxiety disorder in DSM-IV (American Psychiatric Association, 1994). Schizophrenia and the other psychotic disorders are different diagnoses. However, in clinical practice we sometimes encounter cases where these two types of disorders converge. We describe the case of a man who had obsessive-compulsive disorder and a history of Tourette's disorder. He exhibited self-damaging nose picking and lip biting, accompanied by auditory hallucinations. He responded well to atypical antipsychotics and an SSRI in high dosages. More research is needed to illuminate the similarities between obsessive-compulsive disorder and the psychotic disorders, especially schizophrenia.

Obsessive-compulsive disorder (OCD) is categorized within the broad spectrum of disorders termed anxiety disorders. This disorder has two components: obsessions, or repetitive thoughts that cause marked anxiety or distress, and compulsions, repetitive behaviors that neutralize this anxiety. According to DSM-IV (American Psychiatric Association, 1994), the criteria for this disorder are that a person has either obsessions or compulsions, the presence of which causes marked distress or anxiety, and that the person recognizes at some point that the obsessions or compulsions are excessive or unrealistic.

The relationship between obsessive-compulsive disorder and the psychotic disorders is not well delineated in the current literature. The DSM-IV draws no parallels between obsessive-compulsive disorder and schizophrenia or the other psychotic disorders, although it is recognized that patients who lack insight regarding the abnormal nature of their obsessive concerns may be considered delusional, and therefore psychotic. In their review, Fineberg, Saxena, Zohar, and Craig (2007) discussed the view of European psychiatrists that the persistence of certain ideational themes, hallucinatory experiences, delusional qualities, and magical rituals are more important in the understanding of OCD than are depression, anxiety, and repetitive behaviors. Bottas, Cooke, and Richter (2005) presented evidence that comorbid schizophrenia and obsessive-compulsive disorder may represent a special subcategory of schizophrenia, one that might be termed "schizo-obessive." Although the use of antipsychotic medications has long been an accepted treatment for schizophrenia and other psychotic disorders, and certain antidepressants have proven useful against OCD (e.g., Baldessarini, 1999), there is almost no literature discussing treatment of conditions that share features of both types of syndromes. Furthermore, the literature points to associations between Tourette's disorder, attention deficit disorder, and OCD (Maia, Barbosa, Menezes, & Filho, 1999). In many cases of Tourette's disorder, there is comorbid attention deficit disorder accompanied by impulsivity, emotional lability, and often obsessive-compulsive symptoms that warrant clinical attention (Daniels, Baker, & Norman, 1996). Cocaine use may also exacerbate tics in Tourette's disorder (Goodman, Storch, Geffken, & Murphy, 2006).

We here describe the case of a patient who presented with compulsive, self-damaging behaviors including nose picking and lip biting. The patient also experienced auditory command hallucinations in the form of voices telling him to perform these acts. Alongside the auditory hallucinations, he had persistent obsessive thoughts about performing these acts. Performing the compulsive acts would temporarily terminate the voices and the obsessive thoughts. Our patient had attention deficit disorder and Tourette's disorder earlier in his life, and he developed OCD in his early 20s. The case was also complicated by cocaine use. Because he had been charged with a violent felony, the patient was admitted to a specialty forensic unit. His symptoms impaired his functioning to such a degree that he would have been considered incompetent to stand trial without treatment. The patient was treated with atypical antipsychotics and an SSRI in high doses. The patient showed improvement by the end of his hospital stay, with decreases in repetitive thoughts, auditory hallucinations, nose picking, and lip biting. His mental condition improved so sufficiently that he was found competent to stand trial.


The patient was a 29-year-old African American man. He had a tenth grade education and received special education services while in school. The past psychiatric history indicated that the patient was diagnosed with Tourette's disorder when he was 13 years of age and was treated with haloperidol for two years. He received disability benefits on the basis of Tourette's until age 18. Reportedly, he had formerly washed his hands with bleach, but he did not report any repetitive counting or checking behaviors. He started sniffing cocaine at the age of 18. He also had a history of marijuana and alcohol abuse. There was no family history of mental illness.

About six years before admission he started forcing his fingers into and picking at his nose. Over time this behavior resulted in chronic ulcerations and tissue damage. Although the ulcerations had healed when the patient was admitted, there was a noticeable defect in the right nasal tissue. The patient reported that he started this behavior in response to auditory command hallucinations instructing his "conscience" to "destroy" his nose and to inflict pain on himself. He found that when he performed the behaviors as commanded, the voices would cease temporarily, and there was a corresponding reduction in anxiety. Then, about one year prior to admission, the patient began biting his lower lip, again in response to auditory hallucinations commanding him to do so. Eventually, he chewed away the right half of his lower lip.

Cognitive testing showed a borderline level of intellectual functioning. Personality testing indicated anxious, depressive, and obsessive-compulsive features. The unit nursing staff observed the patient putting tape around his fingers to stop him from putting his fingers in his nose. During his stay on the unit he was observed closely by staff and prompted to cease whenever he was observed biting his lips. Initially, he continued to complain of hearing voices commanding him to bite his lip and put his fingers in his nose.

Soon after admission the patient was started on olanzapine (15 mg a day) and fluoxetine (40 mg a day). He slowly responded to treatment with less lip biting. Olanzapine was increased to 20 mg per day and fluoxetine was increased to 60 mg per day, and additional improvement was seen with respect to reductions in obsessive thoughts, auditory hallucinations, lip biting, and nose picking. At that point, we began to suspect that the olanzapine was causing excessive appetite stimulation. Thus the olanzapine was changed to risperidone, and the patient was also placed on lorazepam for short time to decrease his anxiety and nervousness. The patient expressed considerable improvement with his medications and reported fewer thoughts of biting his lips and putting his fingers in his nose.

The risperidone was increased to 3 mg twice a day and the fluoxetine to 40 mg in the morning and at midday. Lorazepam was discontinued concomitantly. By the end of his one-month hospital stay, the patient was reporting fewer auditory hallucinations, and denied any thoughts of biting his lips or putting his fingers in his nose. He reported associated improvements in self-image and expressed a willingness to consult with a plastic surgeon at whatever point his circumstances would permit. The discharge diagnoses were obsessive-compulsive disorder and borderline intellectual functioning. He was discharged with risperidone 3 mg twice a day and fluoxetine 40 mg in the morning and at midday. At the time of discharge, the patient's drooling was minimal and there was no lip biting or urges toward nose picking. The lacerated portion of his lower lip was healthy looking.

Although antipsychotic monotherapy is of little benefit with OCD, combination therapy with an atypical antipsychotic and a SSRI may be beneficial for treatment-resistant OCD as well as for OCD comorbid with Tourette's syndrome (Goodman, Storch, Geffken, & Murphy, 2006). Moreover, current models of OCD and schizophrenia suggest a role for both the serotonergic and dopaminergic systems in both disorders (Bottas et al., 2005). Thus, the combination of an atypical antipsychotic drug and a SSRI appears to be a rational approach in a patient with "schizo-obsessive" features, and especially so when there is a history of Tourette's disorder. The patient described here appeared to display marked improvement with this pharmacologic approach. We look forward to further research identifying neurobiological commonalities between obsessive-compulsive disorder, schizophrenia, and Tourette's disorder.


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Rokeya S. Farooque, MD, is a forensic psychiatrist in the Forensic Services Program at Middle Tennessee Mental Health Institute, and she was an associate professor at Meharry Medical College in Nashville, Tennessee. She performs forensic evaluations of pretrial detainees and inpatient treatment for court-committed defendants from throughout the state of Tennessee. She frequently testifies as an expert witness in criminal proceedings. Her primary interests are family violence and psychopharmacology.

Ronnie G. Stout, PhD, is a forensic psychologist in the Forensic Services Program at Middle Tennessee Mental Health Institute, Nashville, Tennessee, and has a private practice in Gallatin, Tennessee. Dr. Stout is responsible for assessment and treatment of pre-trial and post-trial detainees within Tennessee's sole maximum security inpatient psychiatric facility. Dr. Stout's interests include to stand trial, psychotherapy, interpersonal violence, competence and severe mental disorder.
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