Paper on Obsessive-Compulsive Disorder
Diagnostic Overview
Obsessive-compulsive disorder (OCD) is characterized by uncontrollable repetitive thoughts that lead to the patient’s anxiety and obsessions as well as by repetitive behaviors aimed at alleviating anxiety (referred to as compulsions). A patient with OCD might suffer from obsessions, compulsions, or both. Typical examples of obsessions are the desire to organize things (e.g. to have them symmetrical or in order), fear of dirt, contamination or germs, aggressive thoughts, etc. Examples of compulsions include continuous checking on things, excessive hand washing or cleaning, compulsive counting, excessive arranging and ordering things, etc.
OCD is a chronic and long-lasting disorder that significantly affects the patient’s life and well-being. The disorder is relatively common: about 1% of U.S. adult population 12-month OCD prevalence or higher, and around 50.6% of these cases are classified as severe (around 0.5% of the U.S. adult population) (Jenike, 2004). The average onset of OCD takes place at the age of 19. At the moment, the causes of OCD are not known, but there are risk factors that increase the probability of OCD. These factors include genetics, brain functioning and structure, and the environment.
Genetically, people with first-degree relatives who have OCD have a higher probability of OCD, too, and the risk increases if the relative’s onset was in childhood or adolescence (Jenike, 2004). Brain imaging research shows that patients with OCD have brain anomalies in the subcortical structures and in the frontal cortex (Jenike, 2004). These findings might be used for early diagnosing of OCD and, with further elaboration, for developing personalized treatments. With regard to environmental factors, it is known that people who experienced trauma or abuse in childhood have higher risks of developing OCD.
According to DSM-5, the criteria for diagnosing OCD are the following: the presence of obsessions, compulsions, or both; obsessions and/or compulsions should either be time-consuming or cause clinically significant impairment or distress in one or more areas of functioning (Gluck, 2013). It is important to note that DSM-5 defines obsessions as persistent thoughts/urges that cause distress and anxiety, and the individual tries to suppress these urges or tries to neutralize them with some actions (compulsions) (Gluck, 2013). Furthermore, DSM-5 mentions that compulsions are defined as repetitive actions that emerge in response to the obsession and that are aimed to reduce anxiety or prevent distress but are either excessive or unrelated to the obsessions.
Case History
The patient’s name is Susan (the name was changed). She is 29 years old, married, with two daughters (age 7 and 6) (Haddad, 2016). She is a housewife, her husband is 4 years older and works as a mechanic. Susan finished high school. Her main complaints relate to the following problems: obsessions, inability to function normally at home, recurring thoughts about corrupted things, the feelings of being bound (Haddad, 2016). Susan’s thoughts are focused on perfection: if an object has a stain or is scratched, she has two conflicting urges: to throw away the object and to keep it while using a new one (without stains or scratches). Susan might spend a lot of time cleaning the stove or neighboring areas and uses strong chemical substances to ensure that everything is perfectly clear. In addition, Susan has urges toward symmetry: if she touches one drawer, she feels compelled to touch all other drawers to keep symmetry (Haddad, 2016).
Susan’s obsessions began nine years ago when she married. There were no obsessive episodes before marriage, and the first episode took place during the honeymoon. Susan’s obsessions and compulsions impact her life: children complain about their mother’s behavior, her relationships with her husband are tense (he tried to help her, but eventually gave up), and her husband’s parents criticize her for the loss of money.
Susan experienced sexual abuse in her childhood (when she was 7) from a relative who was 14 (Haddad, 2016). After that, she started fearing men and marriage. Eventually, she decided to date men too to who she wasn’t attracted in order to avoid danger (Haddad, 2016). She was also not attracted to her husband when she decided to marry him (Haddad, 2016). Her main motivation was to lead a socially approved life and to be a respected member of society. Susan grew up in a conservative community where the views on social roles and responsibilities were very patriarchal.
Analysis
The major cause of the symptoms is most likely rooted in Susan’s childhood. It is highly likely that after experiencing sexual abuse at the age of 7, she assumed it made her unworthy or flawed, and started craving perfection. Another possible explanation is that she developed a fear of men (especially of those who seemed attractive to her) and a fear of relationships. In any case, the trauma experienced in childhood triggered the development of OCD in the adult age.
There is no information about the incidence of OCD in Susan’s history in the case. There is a probability that genetic factors also came to play in her case, and that the predisposition to OCD might have been triggered by traumatic childhood experiences. In addition, socio-cultural factors are important in Susan’s case. She grew up in a quite conservative community, and she might have experienced social pressure to get married, have a family, and become a housewife. Her fear of relationships conflicted with social expectations, and it is likely that Susan resolved this dilemma by dating men with who she was not interested. However, after getting married her fear and desire to be socially compliant might have contributed to the development of the disorder.
The perspective that effectively explains the cause of the symptoms is the cognitive theory. According to the cognitive perspective, people with OCD misinterpret their beliefs and thoughts, exaggerate their importance, and perceive them as actual threats (while in reality, the situations are not threatening) (Jenike, 2004). Their thoughts and beliefs scare them and cause anxiety. This perspective emphasizes that people with OCD have previously acquired false beliefs (Jenike, 2004). For example, in Susan’s case, she has the belief that mistakes cannot be accepted and everything has to be perfect (including herself, her marriage, their house, items, etc.). Therefore, she tries to get rid of these thoughts and does excessive cleaning as she believes it can help to avoid the threat of imperfection.
Treatment
OCD is most commonly treated with psychotherapy, medication, or a combination of these approaches. Currently, Susan’s condition is not acute, so it might be reasonable to start with psychotherapy. However, if her condition worsens, it might be recommended to use medication – selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine or fluvoxamine (Hales, Yudofsky & Gabbard, 2011). The medication intake should last between 8 and 12 weeks, depending on the speed of improvement. At the moment the first choice of treatment for Susan is psychotherapy.
The most effective psychotherapy treatment for OCD is cognitive-behavioral therapy (CBT) (Hales, Yudofsky & Gabbard, 2011). In Susan’s case, a particular kind of CBT is recommended – Exposure and Response Prevention (ERP) (Hales, Yudofsky & Gabbard, 2011). The exposure part of ERP relates to exposing the patient to the objects or situations that trigger obsessions, and response prevention helps the patient not to give in to compulsions despite the obsessive triggers (Hales, Yudofsky & Gabbard, 2011). This treatment is expected to work optimally for Susan because if she manages to withdraw from compulsions, her anxiety level and obsessions are also expected to decline, and therefore her condition will improve.
Other psychotherapy techniques might include analysis of Susan’s beliefs and testing her beliefs using cognitive methods (Hales, Yudofsky & Gabbard, 2011). For example, the therapist could address her beliefs about perfection and help her locate examples of socially approved and supported imperfections in the surrounding world (that confront her beliefs). The desired outcomes of the treatment for Susan are the following: reduction or complete elimination of obsessive thoughts, absence of compulsions, restored everyday functionality, reduced anxiety, and improved well-being.
Personal Reflection
From analyzing Susan’s story, I found out that OCD could be triggered by trauma or abuse that took place in childhood. I also learned new methods of treating OCD and identified new perspectives related to OCD. In particular, the idea that OCD could be caused by wrong beliefs was quite new to me. The associated method of confronting false beliefs and helping the patient find examples disproving these beliefs also appeared quite new to me.
References
Gluck, S. (2013). OCD diagnosis: OCD criteria and characteristics in DSM-5. Healthy Place. Retrieved from http://www.healthyplace.com/ocd-related-disorders/ocd/ocd-diagnosis-ocd-criteria-and-characteristics-in-dsm-5/
Haddad, J. (2016). OCD- Case Report. Journal of Psychology & Clinical Psychiatry, 6(3), 1-3.
Hales, R.E., Yudofsky, S.C. & Gabbard, G.O. (2011). Essentials of Psychiatry. American Psychiatric Pub.
Jenike, M.A. (2004). Obsessive-compulsive disorder. The New England Journal of Medicine, 350(3), 259-265.
