What is obsessional slowness?
Obsessional slowness is an apparent form of obsessive-compulsive disorder that appears to be more common in people with Down syndrome. At this point, much more needs to be learned about obsessional slowness. Some authors have questioned whether obsessional slowness is actually a medical entity at all (in people without Down syndrome) or whether the symptoms may just be part of some other diagnosis. However, over the years, we have seen a clear obsessional slowing in several adolescents and adults with Down syndrome, and we will therefore describe this slowing with the understanding that there is uncertainty about the diagnosis.
The pace of life in our society seems to be ever increasing. The persistent stress of the rapidly moving environment can lead to anxiety, depression, or other psychological problems in some people. People with Down syndrome can also perceive the stress of the fast-paced world. One particularly difficult response to this stress is obsessional slowness, which we have also labeled “The Pace.”
For some people with Down syndrome, the world seems to move too fast. High expectations (whether real or just perceived by the person with Down syndrome) may play a role in the development of this problem. They may sense a need to perform at a level or pace that they can’t keep up with. They may feel as if they don’t have control of their lives.
When they cannot keep up with the pace of the world, some adolescents and adults with Down syndrome (consciously or unconsciously) slow down. We have seen people who eat slowly, walk slowly, and take an inordinate amount of time to do daily tasks. They seem to slow down or even shut down when they can’t live up to the expectations of the normal, fast-paced society. This slowing down may be a direct “benefit” to them; for example, if they move slowly enough, they miss the bus and don’t get to their stressful job. For others, there doesn’t seem to be anything they are directly avoiding. These people have a more global avoidance of activity. They are not avoiding something specific but have slowed down in all (or nearly all) activities.
For a long time, we could only speculate that some of the individuals with obsessional slowness perceived that the world was going too fast. However, a few individuals who moved very slowly confirmed our suspicions by reporting that they feel that “the world is too fast.”
Obsessional slowness often (but not always) begins abruptly. We have found that usually there is not one triggering event. Instead, it seems more likely that a chronic buildup of frustration or desperation causes the problem.
Treatment
Treatment must start with an acknowledgement that for these individuals, part of the acceptance of their disability (Down syndrome) must include an acceptance by those around them of their need to move at a slower pace than others. They will probably not move at the pace that society sets. They will probably not be able to function at their previous pace because that rate eventually led to their decline. Hopefully, an equilibrium can be reached between “too fast” and the exceedingly slow pace they are now moving.
While acceptance of a slower pace is a large part of the therapy, there are some additional helpful approaches. Giving an allotted time for some activities and then moving on or discontinuing the activity at the end of the time can be helpful. For example, some people who eat very slowly will suddenly start eating more rapidly as they see the clock reach the final minutes of the allotted time for eating.
Telling the person to hurry up is usually not effective and instead may contribute to agitation. Occasionally, the person may become aggressive or very angry if you take away his food, turn off his shower, etc. We don’t recommend physically forcing the person to hurry up. However, it might be beneficial to help him do tasks in some situations. For example, if he is in danger of losing his job because of tardiness, you might consider helping him get his shoes on so he can get to work on time. However, it is also important to assess whether the job is appropriate for the person or is a cause of stress that could be contributing to the problem with obsessional slowness.
Counseling may provide some limited benefit in giving the person an opportunity to share his concerns. A change of environment—such as having the person switch to a job where the pace is slower, or to a residence where the other people are more sedentary—may also be helpful.
We have not had tremendous success in treating obsessional slowness with medications. In some patients, however, we have seen some improvement with the use of medications for obsessive compulsive disorder or for anxiety or agitation.
Other considerations
Some individuals who move slowly have been diagnosed with catatonia or Down Syndrome Regression Disorder (DSRD). It is not clear if obsessional slowness, catatonia, or DSRD are variants of the same problem or separate problems. We more frequently see that the person with obsessional slowness can move fast in certain situations. For example, one man with obsessional slowness who typically moved very slowly and spoke softly suddenly and rapidly jumped out of the chair while watching a sporting event on TV and yelled very loudly about his displeasure with a play on the field. This sort of occurrence is less likely with DSRD. Those with DSRD typically don’t have dramatic, episodic differences in behavior. Furthermore, individuals with obsessional slowness typically seem to retain the skills they have previously learned (although that is not always clear) but just use them at a slow (or incredibly slow) pace. Our understanding of these conditions is incomplete and evolving.
Additional information
Mental Health Resources
Decline in Skills and Regression Resources