Obsessive-Compulsive Disorder Associated With a Left Orbitofrontal Infarct
SIR: Obsessive-compulsive disorder (OCD) is a syndrome characterized by recurrent intrusive and inappropriate thoughts (obsessions) and repetitive, irrational behaviors (compulsions). Although the pathogenesis of OCD remains incompletely understood, the importance of the frontal lobe and striatum in the development of OCD have been suggested from functional neuroimaging studies1 and case reports for secondary OCD following structural brain lesion.2 We report late-onset OCD in a man with an infarct in the left orbitofrontal region documented on MRI.
Case Report
>A 66-year-old man suddenly developed obsessive-compulsive symptoms 6 months before presenting to our clinic. His symptoms included obsessions that “something wrong” would happen. These fears led to checking rituals, usually, but not solely, before bedtime. Every night he unlocked and relocked every doorknob in his house three times to confirm that they were locked, and turned on and off every tap in the house three times to confirm that they were not leaking. He also checked the time and place of every appointment at least two or three times, and tidied up the shoes in the doorway several times a day. He did not feel relieved from tension until he completed those rituals. Although he himself thought that his own behaviors were excessive, he was not much distressed by or concerned about his condition. The Yale-Brown Obsessive-Compulsive Scale score was 15.
The patient had no previous history of any mental or physical disorder except hypertension. He did not demonstrate any symptoms of either depression or attention deficit disorder. Physical and neurological examinations and routine laboratory examinations, including thyroid function tests and serum folate and vitamin B12, were normal. On neuropsychological examination using the Korean version of the CERAD Neuropsychological battery3 and the Korean version of the Mattis Dementia Rating Scale,4 no impairment was found in memory and executive function or in other cognitive domains. Brain MRI revealed a single infarct confined to the medial portion of left orbitofrontal cortex (OFC) including left gyrus rectus and left medial orbital gyrus.
He had had no previous medication trial for the OCD symptoms, and an ongoing trial of sertraline 50 mg/day provided little relief.
Comment
To our knowledge, this is the first report of an OCD case associated specifically with left medial OFC, although many previous reports have connected the other frontal areas and/or basal ganglia with OCD.2 On the basis of an extensive review of functional neuroimaging studies, Saxena et al.1 suggested that an imbalance of direct and indirect orbitofrontal–subcortical pathways mediates OCD symptoms. Recently, Adler et al.5 reported that the change of OCD symptoms by provocation was inversely correlated with the extent of activation in the left OFC measured by functional MRI, suggesting the inhibitory role of left OFC in OCD symptom provocation. In our case, disinhibition caused by damage to the left OFC, especially its medial portion, may have produced obsessive-compulsive symptoms. If so, our case further supports the inhibitory role of left OFC in the development of obsessive-compulsive symptoms.
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