British Journal of Psychiatry (1993), 162, 198—203

Classification and Treatment of Obsessional Slowness

DAVID VEALE

Obsessionalslownessisregardedas an uncommon but severelydisablingvariantofobsessive—compulsivedisorder. This paper examines the psychopathology, classification,pathophysiologyandtreatmentofobsessionalslowness.Itarguesthatprimaryobsessionalslownessdoesnotrequireclassificationasa separatesyndromebecauseitcanbefoundtobe secondary to recognised phenomena of obsessive—compulsivedisorder or anankasticpersonalitydisorder.Thetreatmentdescribedintheliteratureisnotthoughttobesuccessfulinthelongterm,andcontrolledtrialsarerequiredtoevaluatenew strategiesandantidepressantmedication.

Rachman (1974) first described 10 cases of ‘¿�primaryobsessional slowness', and that paper was laterelaborated on in a book chapter (Rachman &Hodgson, 1980). The main feature described was ameticulous concern for orderliness in which a patientwould take hours to carry out daily tasks of selfcare such as washing, shaving, brushing his teeth orgetting dressed. The term ‘¿�orderliness'refers to theway patients tended to have a fixed pattern ofundertaking tasks in a precise and ‘¿�correct'sequence.A case history was provided of a man who spent

hours shaving single hairs in a precise order.Similarly, brushing his teeth involved preparing thetoothbrush and paste meticulously and placing it ina set position. Rachman (1974) acknowledged thatobsessional slowness can be secondary to rituals, butwanted to draw attention to a new syndrome. Heproposed the term ‘¿�primaryobsessional slowness'because the activities concerned were not rituals -there was no reduction in anxiety or dysphoria beforeor after the activity. He noted in such patientsthe relative absence of obsessional thoughts, andsuggested that one of the possible purposes of theslowness was that it prevented the development ofobsessions. All the cases studied had an anankasticpersonality and their estimate of objective time wasnormal. The treatment programme described forsuch patients involved prompting, pacing, andshaping with regular reminders of the passage of time.

Since then, a number of cases of primary slownesshave been reported, by Bilsbury & Morley (1979),Bennun (1980), Clark et a! (1982), Marks (1987a),and Hymas et a! (1991). For example, Clark et a!(1982) described an adolescent male who wasconcerned with performing tasks in the “¿�correctmanner―, his feared consequence being that hewould make a mistake and thus feel compelled torecommence the sequence. Marks (1987a) noted thatobsessional slowness mainly affects self-initiated

actions and does not affect automatic behaviour suchas driving a car or playing squash, in which a patientis continually responding to ongoing cues.

The concept of primary obsessional slowness hasbeen generally accepted in textbooks (Gelder et a!,1983), although an unsigned editorial in the British

MedicalJournal(1974)questionedtheexistenceofa separate syndrome. Ratnasuniya et a! (1991) haveconducted a retrospective case survey of 665 patientswith obsessive-compulsive disorder (OCD) who werereferred to the Maudsley Hospital over 15 years andconcluded that 22 (3.3°lo)had features of slowness.In all but one, they identified other features ofavoidance behaviour, ruminations or rituals. Theystate that the sample should have included the 10patients originally described by Rachman (1974) ashaving primary obsessional slowness, but they couldnot be identified. A retrospective study based onclinical notes has serious flaws as the clinicians didnot examine each patient in a structured interviewand it was not mandatory to record all the findings.Khanna et a! (1990) have conducted the only studyto date on the clustering of symptoms in OCD. Theyrecruited 410 patients over a decade and found nopatients with obsessional slowness.Theaimofthispaperistoprovidesomestructure

tothephenomenologyofobsessionalslownessasameans to its further understanding and in thedevelopment of new treatment strategies.

Classification

This paper will not argue for the term ‘¿�obsessionalslowness' to be discarded —¿�it is an extremely aptdescription of the excessive time spent by suchpatients initiating and completing a range of activities.However, the concept of a separate syndrome of‘¿�primary'obsessional slowness is unnecessary forfour main reasons, outlined below.

198

CLASSIFICATIONAND TREATMENTOF OBSESSIONALSLOWNESS 199

Firstly, the phenomena in the cases of primaryobsessional slowness can be reanalysed as secondaryto recognised avoidance strategies or rituals. Thepsychopathology in the cases described by Rachman(1974), Bilsbury & Morley (1979), Bennun (1980),Clark et al(1982), and Marks (1987a)can be regardedin part as avoidance of disorder, unmeticulousness,and inexactness.

Secondly, the components of obsessional slownessare usually multiple (see cases reported by Bennun,1980; Marks, 1987a) —¿�the excessive time spentcompleting an activity is not just related to orderlinessor meticulousness, but usually a wide range ofstrategies adopted by the patient. None of thecomponents of obsessional slowness are mutuallyexclusive; they may interact with one another in acomplex fashion. The various components of theslowness may be difficult to determine - patients mayhave difficulty in articulating the nature of theirobsession or their feared consequences and may bereluctant to disclose them because of embarrassmentor stigma. However, every effort should be made tocomplete a full behavioural analysis in order todetermine a rational treatment strategy.

Thirdly, there are patients who are concernedabout orderliness and meticulousness, but are notexcessively slow. It is more logical to organise theclassification around recognised phenomena of OCDthan to single out the orderliness and meticulousness.

Fourthly, the separation of a syndrome withinOCD requires some validation against either brainpathology or neuropsychology or multivariate analysis to delineate subgroups of symptoms. None of thishas yet been done. Hodgson & Rachman (1977) haveused the Maudsley Obsessive Compulsive questionnaire to assess the extent of different types ofobsessive—compulsivesymptoms, and slowness wasone of the four components delineated (together withwashing, checking, and doubting). However, the itemson the questionnaire do not make it clear whether theslowness is primary or secondary to other phenomena.

The concept of obsessional slowness is thereforewider, and needs to be viewed as an indication ofthe severity of the disorder and handicap sufferedby the patient. It is regarded as secondary to anumber of different components which can bedetermined by a more detailed behavioural analysis.The concept assumes the exclusion of either severepsychomotor retardation of a major depressivedisorder or a major learning disability —¿�either ofwhich could be confused with obsessional slownessor in the presence of obsessional slowness couldcomplicate the presentation.

Each of the components of obsessional slownesswill now be considered in more detail. The list

provides a testable hypothesis for a prospective studyon the phenomenology of obsessional slowness anda checklist for a clinician as each of the componentsmay require a different treatment strategy.

Avoidance strategies

In a standard behavioural analysis, avoidance preventsthe occurrence of an obsession and the concomitantanxiety or dysphoria, and is therefore reinforcing.Overt avoidance behaviour can easily be recognised:patients use numerous strategies to prevent touchingor being close to a perceived contaminant or toprevent the transfer of a contaminant from oneobject to another. All these avoidance strategies maycontribute to the slowness. The avoidance of mainlydisorder and unmeticulousness is the key featureidentified by Rachman (1974) and in other casereports. Rachman noted that the orderliness andmeticulousness were not rituals as their execution wasnot preceded or accompanied by any significantanxiety or dysphoria. Anxiety occurred in “¿�fouroutof ten of the patients when they were speeded up bya prompter―. It is not known whether the other sixpatients were able to maintain the same order orexactness under the time pressure and therebycontinue to avoid anxiety. The lack of any anxietymay also be related to an anankastic personality inwhich there is frequently very little emotional life.Turner & Beidel (1989) also describe a treatmentprogramme which created significant anxiety in thepatients with obsessional slowness. Slowness due tometiculousness or orderliness may therefore be aform of avoidance as it prevents the concomitantdysphoria and is used to ensure either:

(a) that an activity is done in the ‘¿�correct'manneror done just ‘¿�right',or

(b) that no part of a sequence is left out and thatno mistakes are made thus necessitating havingto start all over again.

The behaviour of such patients merges with theperfectionism, rigidity, and meticulousness foundin anankastic personality disorder which will bediscussed later.

It seems that while some of the activities areperformed slowly because of the correct order andmeticulousness - for example shaving hairs in anorderly sequence to make sure none are left out - theymay also be repetitive, in the sense that some patientsmay in addition shave the same area over and overagain to ensure they are clean-shaven and perfect.Similarly a patient may rinse out a basin meticulouslyto ensure there are no hairs left in the basin and endby repeating the sequence several times to ensure that

200 VEALE

it is clean. Established rituals in OCD are sometimesused to prevent anxiety. It thus becomes a matterof semantics whether they are termed rituals oravoidance behaviour or both. However, the primaryaim of such strategies seems to be the short-termprevention of dysphoria which has implications forbehavioural treatments.

Patients may have difficulty in articulating theirfeared consequences and do not appear to report anyautomatic thoughts during the activity. For somepatients, the cognitive schema or dysfunctionalassumptions may be summarised as —¿�“¿�Imust beperfect, thorough, exact, clean and tidy at all timesor it will be absolutely terrible―.In such cases theremay be a close association with social anxiety orphobia —¿�the patient may fear being rejected orisolated because of the perceived criticism of othersif he was unclean or imperfect. This may be animportant component of any behavioural analysisand require additional treatment.

I have observed other examples of avoidancebehaviour in which a significant component ofthe slowness involved the patient remaining motionless in order to prevent the aggravation of hisobsessional thoughts.

Case one

The patient was a 65-year-old man with a 52-year historyof OCD which had fluctuated over the years. His mainproblem was obsessional thoughts in which named membersof his family were killed or injured. This resulted in anxietyand guilt as he felt responsible for their death. The thoughtscould be triggered by certain movements of his limbs sothe patient reported that he would “¿�getstuck―in certainpositions for up to 5 hours - if he moved it would aggravatethe obsessional thoughts which he believed might injure amember of his family. On occasions he neutralised thethoughts by a number of covert rituals which consisted ofmaking an image of himself being killed or by repeatingthe phrases “¿�Stopit―,or “¿�It'sme―13 times (there were13 members of his family).

Covert avoidance is more difficult to observe.This strategy may involve the patient distractinghimself. It is sometimes described by patients ascompartmentalising unacceptable thoughts in onepart of one's mind. It is similar to physical avoidanceof an external contaminant in which certain contaminated areas are cordoned off. These strategies mayrequire intense concentration and therefore muchtime to maintain them.

Rituals

therefore reinforcing. An excessive length of timemay be spent completing an activity because of anovert ritual such as washing, checking, or repeatingwhich thus contributes to the slowness.

Covert rituals are more difficult to determinebecause they cannot be observed and are moredifficult to treat as they are portable by the patient.Patients may attempt to suppress or neutralise theirobsessional thoughts (similar to an overt cleaningritual) —¿�this may require intense concentration andcan lead to slowness. It is illustrated in the followingcase vignette.

Case two

The patient was a 30-year-old single unemployed womanwho had a 12-year history of OCD. She was a practisingChristian and her main problem was of blasphemousthoughts about Jesus Christ and God. She experienced guiltwhenever the thoughts occurred, and avoided specific roomswhere she believed she might “¿�contaminate―the room bydepositing her thoughts. She was excessivelyslow in her selfcare and would arrive up to two hours late for out-patientappointments. She would remain motionless for up to threehours in the bathroom trying to concentrate on “¿�clearingout―or suppressing her obscene thoughts and talking overthem. She also performed various overt rituals such as handwashing and checking to neutralise the thoughts which

contributed to the excessive time she spent on self-care.

Other covert rituals include mental checking asreported by Bennum (1980) in which a patientwith obsessional slowness went over the previousperformance of his overt rituals or ordinary actions inhis mind. The author suggests that the rituals provideda guiding function. Alternatively, a patient may bementally planning a future ritual in minute detail.

Lastly, patients may be slow because they repeatin their mind or count an act a set number of timesin order to erase or neutralise the obsession. Anexample of this can be found in case one.

Anankastic personality disorder

The relationship between OCD and anankasticpersonality disorder (or, in DSM—III—R,obsessivecompulsive personality disorder (American PsychiatricAssociation, 1987)) is a complex one and frequentlydebated.Mostpsychiatristswouldagreethatthetwodisorders may coexist or occur separately. Somewould regard OCD and anankastic personalitydisorder as on the same continuum of psychopathology but they are listed as separate disorders inDSM-III-R and ICD-9 (World Health Organization,

1978).Mavissakalianeta!(1985)havesuggestedthe

obsessionalslownessmightresultfromhypertrophicIn a behavioural analysis, rituals are repetitiveactions which reduce anxiety or dysphoria and are

201CLASSIFICATIONAND TREATMENT OF OBSESSIONALSLOWNESS

obsessive—compulsivepersonality traits. Reed (1985)has collated 33 attributes of an anankastic personalitywhich have been described in the literature. Someof the traits overlap but half of them might beregarded as components of slowness. They includeaccuracy, concentration, stress on trivial details,doubt, inconclusiveness, indecisiveness, meticulousness, orderliness, over-categorisation, patterning,perfectionism, perseveration, persistence, precision,rigidity, rules, symmetry, thoroughness, and tidiness.

The criteria for obsessive—compulsivepersonalitydisorder in DSM—III—Rare more restrictive but thecomponents of slowness may be associated with threeout of the ten criteria:

(a) perfectionism that interferes with task completion

(b) preoccupation with details, rules, lists, order,organisation, or schedules to the extent thatthe major point of the activity is lost

(c) indecisiveness: decision making is eitheravoided, postponed or protracted, e.g. theperson cannot get an assignment done on timebecause of ruminating about priorities.

Indecisiveness and procrastination can be discernedin a number of the reported cases of slowness. Forexample Marks (1987a) describes a man who tookfive hours to bath in the morning —¿�a significantcomponent of this was the time he took to decideto have a bath. Sometimes anankastic personalitydisorder is the only diagnosis in the absence of anysignificant features of OCD, as shown in thefollowing case.

Case three

The patient was a 36-year-old single man who was amathematics graduate and employed to work three daysa week as a computer programmer. His main problem,which was of 17 years' duration, was an inability to observeany time-keeping or meet any deadlines. He was ineffectivein his job but would often ‘¿�work'through the night. Hisemployers had been remarkably tolerant of his behaviourand were the main instigators of the referral. The majorreason for his slowness was that he would spend much timemotionless, ‘¿�pottering'or procrastinating over decisionssuch as having a bath. He would become preoccupied withminor details and fail to complete the main purpose of hisactivity. He would spend much time collecting sets of items,such as free quiz cards, and hoarded a number of wornout or worthless objects or papers. There was no evidenceof any need for orderliness or meticulousness. He was notclinicallydepressedbut wasrestrictedinhisabilityto expressany emotion. All his life he was pessimistic and hadlow self-esteem. He said he would contemplate suicideif his mother, on whom he was very dependent, should

die. He was difficult to motivate to comply with anybehavioural programme.

Pathophysiology of obsessional slowness

There is some evidence that most patients withobsessional slowness are male (Sanavio & Vidotto,1985; Ratnasuriya et al, 1991).This suggests a geneticor biological predisposition to the condition (Comings& Comings, 1986).

At present, the most likely pathophysiology forobsessional slowness is in the neuronal loops betweenthe basal ganglia and the frontal lobe (Wise &Rapaport, 1989). Central to the hypothesis is theconcept of innate motor programmes in the basalganglia and that the basal ganglia function is, in part,a gating mechanism for sensory input. There arereported cases of obsessional slowness in which basalganglia dysfunction is manifested clinically as amovement disorder. For example, the patient reportedby Clark et al(1982) had “¿�multipletics, writhing neckmovements and jerking actions of his upper limbs―.The association with basal ganglia dysfunction hasbeen studied by Hymas et al (1991) and discussedby Lees (1989). They studied 17adult in-patients withOCD who were selected by a questionnaire as beingexcessively slow in their self-care and initiatinggoal-directed behaviour. It is worth noting thattheir diagnostic criteria of slowness are widerthan Rachman's (1974) original concept of primaryslowness. All the patients had a number of softneurological signs including a delay in initiating limbmovements, difficulty in switching from one motorprogramme to another, difficulty in carrying outtwo motor acts simultaneously, speech and gaitabnormalities, and a general clumsiness and distractibility. Similar neurological findings have beendocumented in adult patients with OCD (but notselected as excessivelyslow) by Hollander et al(1990)and in adolescents by Denkla (1988). If obsessionalslowness is a more severe variant of OCD then theneuropathological abnormalities may be more likelyto show up in such patients.

Basal-ganglia dysfunction may be important in thepathophysiology of obsessional slowness because ofthe slowness of thinking (sometimes described asbradyphrenia). Bradykinesia (slowness in movement)is normally an important component of basal-gangliadisorders, such as Parkinson's disease, but it is notseen in OCD. The slowness in movement in OCDis highly selective and related to rituals or avoidancebehaviour. Bradyphrenia has been reported to occurin the absence of bradykinesia in some basal gangliadisorders (Laplane et a!, 1984). They describe threepatients recovering from an encephalopathy of whom

202 VEALE

two showed compulsive counting without anxiety.In all patients, computerised tomography scansshowed bilateral lesions of the basal ganglia, mainlywithin the globus pallidus.

The term subcortical dementia has subsumed theold term bradyphrenia, which describes the syndromeof slowness of thinking, initiating any activity, poorattention, and difficulty in making decisions (Rogers,1986; Lees, 1989). Deficits in thinking time havebeen documented on neuropsychological testing inParkinson's disease (Morris et a!, 1988) and infrontal lobe lesions (Owen et a!, 1990). Furtherresearch is being conducted on whether similardeficitsinthinkingtimealsooccurinOCD andinpatients with obsessional slowness.

Treatment implications

Controlled trials of treatments for patients withobsessional slowness will be difficult to organisebecause such patients are uncommon and such a studywould therefore require multicentre cooperation.Furthermore, it has been stressed that such patientsare heterogeneous with a number of differentcomponents to their slowness, so that ideally thesubjects would need to be a closely defined homogeneous group. For example, subjects for onetrial would need to be defined as “¿�Obsessionalslowness primarily related to avoidance of disorderand imperfection―.At present,behaviouralpsychotherapyisthe

most common treatment described for patients withobsessional slowness. The patients described byRachman (1974), Bilsbury & Morley (1979), Bennun(1980), and Clark et a! (1982) were treated by a

combination of pacing, prompting and modelling.Patients are given a time limit in which to completeeachtaskwhichisgraduallyreduced.At firstthetherapist should be present to encourage and promptthe patient. Unlike other patients with OCD treatedby behaviour therapy, they have more difficulty incompleting the task on their own and do not tendto retain many gains at long-term follow-up (Clarketa!, 1982; Marks, 1987b). This may be because thetreatment has been directed at the slowness ratherthantheunderlyingavoidanceandrituals.InOCD,avoidancebehaviourisbesttreatedbyself-exposureandtheritualsbyresponsepreventionuntilhabituationhasoccurred(Rachman& Hodgson,1980;Marks, l987c). The prompting and pacing describedby Rachman (1974) may be interfering with theavoidance behaviour or rituals but may not bethemost efficientmeans of exposure.A moredetailed behavioural analysis is therefore requiredof all the strategies used by the patient before

anybehaviouraltreatment,todeterminewhatthepatient is avoiding.

In the cases described in the literature, a strategyof prompting, pacing and modelling may initiallyhelp because at the faster speed the patient is nolonger able to maintain the desired order or exactness.However, such strategies are too difficult to maintainwhen the patient is on his own. In theory, the mainstrategy for patients with orderliness, exactness,or meticulousness would be repeated exposure todisorder, inexactness or unmeticulousness. The targettimes may be a useful outcome measure but areincidental to the task of exposure to disorderand unmeticulousness. This requires testing in acontrolled trial.

Covert rituals or ruminations are more difficult totreat because they are portable and more difficultto control. The most promising treatment for ruminations has been exposure to obsessional thoughtsby audiotaped feedback. The patient is instructed torecord his obsessional thoughts on a loop tape andto listen to the tape continuously with a pair ofheadphones without performing any overt or covertrituals (Salkovskis & Kirk, 1990).

The principles of exposure can also be applied toindividuals with an anankastic personality disorder.The nature of all personality disorders is veryrigid schema or personal rules. Once convinced ofthe need for change, the most powerful way ofchanging schema is to act repeatedly against them.So perfectionism is overcome by ‘¿�exposure'toimperfection; indecisiveness by ‘¿�exposure'to makingdecisions —¿�the therapist may need to be quiteingenious to negotiate suitable tasks that are not toodifficult but can be repeated and are of sufficienttherapeutic potency to change the schema. Thedifficulty in anankastic personality disorder (and inthe approximately 25% of cases of OCD who refusetreatment or drop out) is persuading the patient tocarry out exposure tasks —¿�a detailed rationale of theprinciples of exposure will not suffice to motivate suchpatientstocomply.Cognitivechallengesthatarebased on logic or empiricism as an adjunct to exposureare also usually unhelpful. Challenges based onpragmatism may be more fruitful (e.g., focusing onthe disadvantages and advantages of their behaviourin the short term and in the long term to themselvesand to others, or asking “¿�Ifyou continue to believethis, where will this lead?―).There is more resistanceto change in personality disorders and the therapyis likely to be lengthier (Beck & Freeman, 1990).Another complication in patients with anankasticpersonality disorder can be the lack of any emotionallife. Whether habituation to dysphoria can still occurin such individuals is not known.

CLASSIFICATION AND TREATMENT OF OBSESSIONAL SLOWNESS 203

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David Veale, MBBS,BSc,MPhil,MRCPsych,DipCACP,Consu!tant Psychiatrist, Grovelands Priory Hospital,TheBourne, Southgate,London N14 6RA; Honorary ConsultantPsychiatrist,BarnetandEdgwareGeneralHospitals, London