Prior to 1984, obsessive-compulsive disorder (OCD) was considered a rare disorder and one difficult to treat (I ) . In 1984 the Epidemiologic Catchment Area (ECA) initial survey results became available for the first time, and OC D prevalence figures showed that 2.5 % of the population m et diagnostic criteria for OCD (2,3) . Final survey results published in 1988 (4) confirmed these earlier reports. In addition, a 6-month point prevalence of 1.6% was observed, and a life time prevalence of 3.0% was found. OCD is an illness of secrecy, and frequently the patients present to physicians in specialties other than psychiatry. An other factor contributing to under diagnosis of this disorder is that psychiatrists m a y fail to ask screening questions that would identify OCD. The following case study is an example of a patient with moderately severe OCD who presented to a resident psychiatry clinic ten years prior to being diagnosed with OCD. The patient was compliant with out patient treatment for the entire time period and was treated for major depressive disorder and border line personality disorder with medication s and supportive psychotherapy. The patient never discussed her OCD symptoms with her doctors but in retrospect had offered many clues that might have allowed a swifter diagnosis and treatment.
Simran Ahuja was a 29 year old, divorced, indian female who worked as a file clerk. She was followed as an out patient at the same resident clinic since 1971. I first saw her 2012.
PAST PSYCHIATRIC HISTORY
Simran had been seen in the resident out patient clinic since July of 1984. Prior to this she had not be en in psychiatric treatment. She had never been hospitalized . Her initial complaints were depression and anxiety and she had been placed on an phenelzine and responded well. Her depression was initially thought to be secondary to amphetamine withdrawal, since she had been using diet pills for 10 years. She stated that at first she took them to lose weight, but continued for so long because people at work had noted that she concentrated better and that her job performance had improved. In addition, her past doctors had all commented on her limit edibility to change and her neediness, insecurity, low self-esteem, and poor boundaries. In addition, her past doctors had noted her promiscuity. All noted her poor attention span and limited capacity for insight. Neurological testing during her initial evaluation had shown the possibility of non-dominant parietal lobe deficits. Testing was repeated in 1989 and showed " problems in attention , recent visual and verbal memory (with a greater deficit in visual memory), abstract thought , cognitive flexibility, use of mathematical operations, and visual analysis. A possibility of right temporal dysfunction is suggested." IQ testing showed a co m bine d score of 77 on the Adult Weschler IQ test , which indicated borderline mental retardation .
Over the years the patient had been maintained on various antidepressants and antianxiety agents. These included phenelzine, trazadone, desipramine, alprazolam, clonazapam, and hydroxyzine. Currently she was on fluoxetine 20 mg daily and clonazaparn 0.5 mg twice a day and 1.0 mg at bedtime . The antidepressants had been effective over the years in treating her depression. She has never used m ore clonazapam than prescribed and there was no history of abuse of alcohol or street drugs. Also, there was no history of discreet manic episodes and she was never treated with neurolepics.
PAST MEDI CAL HISTORY
She suffered from gas troesophageal reflux and was maintained symptom free on a combination of ranitidine and omeprazole.
Simran was born and raise d in a large city. She had a brother who was 3 years younger. She described her father as morose , withdrawn, and...