LETTERS TO THE EDITOR
A case report on obsessive-compulsive disorder and low-grade astrocytomas
Department of Pediatrics, University of South Florida Morsani College of Medicine, Department of Psychology, University of South Florida, Tampa, Florida, USA
Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, Florida, USAEric A. Storch, PhD
Department of Pediatrics, University of South Florida Morsani College of Medicine, Department of Psychology, University of South Florida, Department of Psychiatry and Behavioral Neurosciences, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
KEYWORDS: obsessive-compulsive disorder, astrocytoma, children
ANNALS OF CLINICAL PSYCHIATRY 2013;25(4):309-310
TO THE EDITOR:
This case report describes an adolescent, age 14, with low-grade astrocytomas located in the midbrain, spinal cord (at the cervicothoracic junction and conus medullaris), and cauda equina who presented with obsessive-compulsive disorder (OCD). Given the role of the raphe nuclei in the midbrain in releasing serotonin, this case suggests the potential link between disruptions in serotonin-related structures and OCD. Further investigation of dysregulation in the midbrain and its relationship with OCD pathogenesis may reveal important etiological information.
Astrocytomas are gliomas that develop from astrocytes and typically remain contained within the CNS. Low-grade astrocytomas are grade 2 tumors that generally are slow-growing. There exist few data on the link between brain tumors and anxiety disorders, with 2 case studies specifically investigating gliomas and OCD. These cases detailed a grade 4 astrocytoma in the frontal lobe of a 53-year-old with acute anxiety, obsessional symptoms, and a history of alcohol abuse1; and a pontine mass in an 8-year-old displaying anxiety, OCD, and disordered eating.2 The specific location of gliomas in patients presenting with OCD may be suggestive of a link between dysregulation in serotonergic systems and obsessive-compulsive symptom expression. This case report describes an adolescent with low-grade astrocytomas who presented with OCD.
Larry, age 14, presented with a history of obsessive-compulsive symptoms that began at puberty. His obsessions originally manifested in aggressive, intrusive thoughts about harming others, causing him great distress. He later developed impairing and bothersome religious obsessions, which overshadowed his aforementioned symptoms. He displayed pathological doubt and engaged in mental compulsions, reassurance-seeking behaviors, and repetitive rituals, such as erasing and re-writing, tapping, or performing certain behaviors 4 times (until it was “just right”) for fear of something terrible happening. He exhibited good insight, but reported high distress because of his obsessive-compulsive symptoms, which contributed to dysphoric affect, anhedonia, and decreased motivation. Larry also expressed generalized anxiety symptoms independent of his OCD. There were no reported behavioral problems. Academically, Larry was achieving highly (eg, honor roll) in mainstream high school classes. Family history was negative for OCD, anxiety, or significant psychopathology.
Larry was diagnosed with low-grade astrocytomas in his brain and spinal cord at age 7. During his evaluation, there was a primary 1.5 × 1.5 cm mass located in the midbrain tectum/cerebral aqueduct of Sylvius, where a ventriculoperitoneal shunt was placed shortly after diagnosis. Nodular metastases located along the cauda equina and surface of his spinal cord were present. The tumors generally have remained unchanged since diagnosis. No functional limitations were noted secondary to the astrocytomas; Larry engaged in routine and pleasurable activities without restriction. Larry’s general developmental course was otherwise unremarkable and developmental milestones were reached on time.
This case describes a pediatric patient with low-grade astrocytomas and OCD with onset several years following diagnosis. The orbitofrontal cortex is implicated in OCD pathogenesis,2 with serotonin mediating OCD symptom expression.3 Decreased availability of serotonin transporters in the midbrain and brainstem have been shown in patients with OCD.4,5 Because Larry’s astrocytomas and raphe nuclei—which are primarily responsible for releasing serotonin, inclusive of frontal regions of the brain—are located in the midbrain, gliomas in this adolescent may be associated with OCD pathogenesis.2 Further investigation on the link between the disruption of areas responsible for synthesizing serotonin and OCD is warranted and may contribute to further understanding of etiology and treatment.
DISCLOSURE: The authors report no financial relationships with any company whose products are mentioned in this article, or with manufacturers of competing products.
- John G, Eapen V, Shaw GK. Frontal glioma presenting as anxiety and obsessions: a case report. Acta Neurol Scand. 1997;96:194–195.
- Oner O. Pontine mass presenting as anxiety obsessions, and severe eating problems: a case report. J Child Neurol. 2007;22:471–473.
- Whiteside SP, Port JD, Abramowitz JS. A meta-analysis of functional neuroimaging in obsessive-compulsive disorder. Psychiatry Res. 2004;132:69–79.
- Reimold M, Smolka MN, Zimmer A, et al. Reduced availability of serotonin transporters in obsessive-compulsive disorder correlates with symptom severity - a [11C]DASB PET study. J Neurol Transm. 2007; 114:1603–1609.
- Stengler-Wenzke K, Müller U, Angermeyer MC, et al. Reduced serotonin transporter-availability in obsessive-compulsive disorder (OCD). Eur Arch Psychiatry Clin Neurosci. 2004;254:252–255.
CORRESPONDENCE: Monica S. Wu, Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida, 880 6th Street South, Suite 460, Box 7523, St. Petersburg, FL 33701, USA; E-MAIL: MonicaWu@mail.usf.edu
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