A Case Study of Obsessive Impulsive Disorder

A Case Study of Obsessive-Compulsive Disorder: Some Diagnostic Considerations INTROD  UCTION 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. CASE  HISTORY 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 pati ent  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 ini tial  evaluation had shown the  possibility of non-dominant parietal  lobe  deficits. Testing  was repeated  in 1989 and  showed †Ã‚  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. †Ã‚  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. PSYCHOSOCIAL  HISTORY 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 recalled  that he has said, †Ã‚  I don't  like  my  children. Her  father was  physically and  verbally abusive throughout her  child  hood. She  had  always longed  for a good relationship  with him  . She  described  her mother as  the  family martyr and the  glue that  held  the  family together.She stated that  sh e  was  very  close  to her  mother;  her mother always listened  to her and was  always  available to talk with her. She  was a poor student,  had difficulty all through school , and described herself  as †Ã‚  always disrupting  the  class by talking or running  around. †Ã‚  She  had  a  best friend through grade school whom  she  stated †Ã‚  deserted† her  in high  school. She  had maintained  few close  friends since  then . She   graduated high school with much difficulty and  effort. She  dated on  group dates  but never alone. Her husband  left her  while  she was  pregnant with her  son.The husband  was a  bus driver  and had not had  a  role in their  lives  since the  divorce. Aft  e r the  divorce,  she moved  back  to her parent  s'  home  with her son  and  remained there until getting her  own apartment  3 years ago. FAMILY HISTORY Simr an’s  mother  had two  serious  suicide attempts at  age 72 and was  diagnosed with major  depressive  disorder with psychotic features  and OCD. She also had non-insulin dependent  diabetes  mellitus and irritable  bowel  syndrome. Her  brother was treated  for OCD  as an outpatient  for the  past  20 years and also has Hodgkin's Dis  ease, currently in remission.The brother's diagnosis of  OCD was kept secret from  her  and did not become  available  to her until her mother died. Her father  is  alive and well. MENTAL STATUS EXAM She  was a  thin  ,  bleached  blond woman  who appeared her  stated  age. She  was dressed in  skin  tight  ,  provocative  clothing,  costume jewelry earrings  that eclipsed her ears  and hung to her  shoulders, heavy  make-up and  elaborately  styled hair. She  had difficulty  sitting  still  and fidgeted  constantly  in  her  chair. H er body language through out  the interview  was  sexually provocative. Her speech was  rapid,  mildly pressured,  and  she  rarely finished  a sentence.She  described  her  mood  as â€Å"anxious. † Her affect appeared anxious. Her  thought  processes showed mild  circumstantiality and tangentiality. More significant  was her inability to finish a  thought  as exhibited by her in  complete  sentences. COURSE  OF TREATMENT Initial  sessions with the  patient were  spent  gathering history  and forming a working  alliance. Although  she  showed a  good  response  by  slowing  down enough to finish  sentences and focus on  conversations  ,  she  could not tolerate  the side  effects and  refused  to  continue taking the medication  . The  winter  of  1993-94  was  particularly  harsh.The  patient  missed  many sessions because of  bad weather. A pattern  began  to   emerge  of  a  consistent  increase  in the number  of phone  calls that  she  made  to the office voice  mail to  cancel  a session. When  she was questioned about her phone  messages she stated,  Ã¢â‚¬ Ã‚  I always repeat  calls to make sure my  message  is received. † Since  the  most recent cancellation generated  no less than six phone calls ,  she  was asked why a  second call wouldn't  be  enough â€Å"to be  sure . † She  laughed  nervously and  said,  Ã¢â‚¬ Ã‚  I  always repeat  things. † With careful questioning  the following  behaviors  were uncovered.The patient checked  all locks  and windows repeatedly  before  retiring. She  checked the  iron a dozen times  before leaving the house . She  checked  her door  lock  Ã¢â‚¬ Ã‚  a  hundred  times† before  she  was able to  get in her  car. The patient  washed her hands frequently. Sh e carried disposable  washcloths in  her purse †Ã‚  so I  can wash as  often  as I need too  . †Ã‚  She  said people  at work laugh  at her  for washing  so  much. But she  stated  ,  Ã¢â‚¬Å"I  can' t help it. I've been this way  since  I was  a  little girl. † When  questioned  about telling former  doctors  about this,  the  patient  stated that she  had never  talked  about it with her doctors.She  stated  that  everyone that knew  her  simply knew  that  this  was  the  way  she  was:  Ã¢â‚¬ Ã‚  It's  just  me . †Ã‚  In  fact , she  stated, †Ã‚  I didn't  think my doctors  would  care†¦ .  I've always  been this  way  so  it  Ã¢â‚¬Ëœs  not something  you can  change . † Over the next  few sessions, it became  clear  that her arguments  with her boyfriend centered  on  his annoyance with her need  to  const antly repeat  things. This was  what she  always referred to  as †Ã‚  talking too much  . †Ã‚  In  sessions it  was  observed that  her  anxiety,  neediness and poor boundaries  a  rose over issues of misplacing things in her purse and insurance forms that were incorrectly  filled  out.In  fact,  when I  attempted to correct the  insurance forms for her, I had difficulty because of her need to repeat the  instructions to me  over and over. The Introduction Obsessive compulsive disorder (OCD) is an anxiety disorder characterised by persistent obsessional thoughts and/or compulsive acts. Obsessions are recurrent ideas, images or impulses, which enter the individual's mind in a stereotyped manner and against his will. Often such thoughts are absurd, obscene or violent in nature, or else senseless. Though the patient recognises them as his own, he feels powerless over them.Similarly,compulsive acts or rituals are stereotyped behaviou rs, performed repetitively without the completion of any inherently useful task. The commonest obsession involved is fear of contamination by dirt, germs or grease, leading to compulsive cleaning rituals. Other themes of obsessions include aggression, orderliness, illness, sex, symmetry and religion. Other compulsive behaviors include checking and counting, often in a ritualistic manner, and over a â€Å"magical† number of times. About 70% of OCD patients suffer from both bsessions and compulsions; obsessions alone occur in 25%, whilst compulsions alone are rare. 1n  she spent  ten minutes checking and rechecking  the  form  against the receipts. She  became convinced that she'd  done it wrong, her anxiety would increase, and  she  would  get  the forms out  and check  them again. Her  need to include  me in this  checking  was  so great  that she  was almost physically on  top  of  my  chair. In the  following  weeks,  se ssion s  focused  on  educating the  patient about  OCD. Her  dose of fluoxetine  was increased  to 40 mg  a  day but discontinued because  of severe restlessness and insomnia.She continued to  take 20  mg of  fluoxetine a day. Starting  another medication in  addition to fluoxetine  was difficult because of the patient  Ã¢â‚¬Ëœs  obsessive  thoughts  about  weight gain, the  number  of  pills  she  was  taking, and the  possible side effects . Finally,  the  patient agreed to try adding  clomipramine to her medications. The  results were  dramatic. She  felt  Ã¢â‚¬ Ã‚  more relaxed † and had less anxiety. She  began to talk, for  the  first  time, about her  abusive  father. She said,  Ã¢â‚¬ Ã‚  His behavior was always supposed  to be the family  secret. I felt  so afraid  and  anxious I didn't  dare tell  anyone.But now  I  feel better. I don't care who  knows. It  Ã ¢â‚¬Ëœs  cost my  mother  too  much  to  stay  silent. †   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  At  this time  the  plan is to begin behavioral therapy with  the  patient  in  addition to medication s  and  supportive therapy to  deal wit  h her  difficulties with relationships. DISCUSSION This is  a complicated  case  with multiple diagnoses: borderline  mental  retardation,  attention deficit disorder,  borderline  personality  disorder,  a  history  of  major depressive disorder and  obsessive compulsive disorder. Given the  level  of  complexity of  this  case and the  patient ‘s  own silence  about her  symptoms,  it  is  not urprising  that this  patient's OCD remained  undiagnosed  for  so  long. However,  in  reviewing  the literature  and the case,  it is instructive to  look  a  t the  evidence that  might  have  led  to an earlier diagnosis. Fir st of  all,  there  was the  finding  of soft neurological deficits. The patient  Ã¢â‚¬Ëœs Neuropsychological testing suggested  problems  with  visuospacial  functioning  n visual memory,  as well as  attentional difficulties  and  a  low IQ. In the  past,  her doctors were so impressed  with her history of  cognitive difficulties  that  neuropsychological testing was  ordered  on two separate occasions.Four  studies in the  recent literature have  shown consistent findings of  right hemispheric dysfunction,  specifically  difficulties  in visuospatial  tasks, associated  with OCD  (6,7,8,9). The patient also had a history  of chronic dieting,  and  although  extremely  thin, she continue d to be  obsessed with not  gaining  a single pound. This was  a  patient who took diet  pills for 10  years and who  see earliest memories  involved  her father's disapproval of  her bod  y  ha bitus. Eating  disorders a  reviewed by  some  clinicians  as  a form  of  O C D. O  C D.Swedo and Rapoport (II)  also note  an increased incidence  of  eating disorders in children  and  adolescents  with  OCD. While  this was  no doubt true,  the underlying  obsessional  content pointed directly  to OCD and should have  generated a list of screening questions  for OCD. This underscores  the  need to be  vigilant for diagnostic clues and to perform one's  own diagnostic assessment when  assuming the treatment  of any  patient. While the  literature  makes  it clear that OCD  runs in families,  the  patient was unaware of the  illness  in her family  until after  her diagnosis  was mad  e.It  would have be  en  helpful to know this information  from the  beginning  as it should  immediately  raise a suspicion of OCD in a patient  presenting  with complaints  of  depression and anxiety. Finally,  her diagnosis of borderline  personality  disorder  made  it  easier to pass  off her observable  behavior  in the office as  further  evidence  of  her  character structure. The diagnosis of borderline  personality  disorder was  clear. She  used the  defense of splitting  as evidence d by her descriptions  of her fights  with her boyfriend . H  e was either  Ã¢â‚¬Å"wonderful† or a  Ã¢â‚¬Å"complete bastard. † Her  relationships were  chaotic  and unstable.She had no close friends outside  of her family. She  exhibited  affective instability, marked  disturbance of body  image  and impulsive behaviors. However, it was difficult to discern whether her  symptoms were truly  character logical  or  due  instead  to her underlying  OCD and related  anxiety. For instance,  the  in  stability  in her relationships was,  in  part,  the result  of  her OCD , since  once she  began to obsess  on  something,  she  repeated  herself so much  that  she  frequently  drove others into  a  rage. A  study by Ricciardi,  investigated  DSM-III-R Axis II diagnoses following treatment for OCD.Over  half  of  the  patients in the study  no longer met DSM-III-R  criteria for personality disorders after  behavioral  and  /  or pharmacological treatment  of  their  OCD. The  authors  conclude that  this  raises questions  about  t  he validity  of an Axis  II diagnosis  in the  face  of  OCD. One might also begin  to wonder how many  patients  with personality  disorders  have undiagnosed  O  CD? Rasmussen  and Eisen  found a very high comorbidity of  other Axis I diagnoses in patients  with OCD. Thirty-on  e  percent of patients studied  were  also diagnosed with major  depression, and  anxiety disorders accounted for twenty-four per cent.Other coexisting disorders  included eating disorders, alcohol  abuse  and dependence, and Tourette's syndrome. Baer,  investigated  the comorbidity  of Axis  II disorders  in patients  with OCD  and found that 52  percent  met  the criteria for  at least one  personality  disorder  with mixed,  dependent  and histrionic being  the  most common disorders diagnosed  . Given  the  frequency of comorbidity in patient  s  with OCD,  it would  be wise to include  screening questions  in  every  psychiatric  evaluation. These  need  not  be elaborate. Questions about  checking,  washing,  and ntrusive,  unwanted thoughts can be  simple  and direct. In  eliciting a  family history,  specific  questions about  family members  who check  repeatedly  or  wash  frequently  should  be included. Simply as  king if  any  family member  has  OCD  m  ay  not  elicit   the  information  , since  family members may  also be undiagnosed. In  summary, this  case  represents a complicated  diagnostic  puzzle. Her  past physicians  did not have the  information  we d  o  today  to unravel  the  tangled skeins  of symptoms. It  is  important to be  alert  for  the  possibility  that this  patient ‘s story is not an  uncommon one.BIBLIOGRAPHY * Psychology book (NCERT) * Identical * Suicidal notes * A psychopath test: journey through the world of madness * Disorder of impulse control by Hucker INDEX * Introduction * Case study * Course of treatment * Discussion * Bibliography ACKNOWLEDGEMENT I would like to express my special thanks and gratitude to my teacher Mrs. Girija Singh who gave me the golden opportunity to do this wonderful project on the topic ‘obsessive-compulsive disorder’, which also helped me in doing a lot of research and I came to know about so many new things.Secon dly I would also like to thank my family and my friends who helped me a lot in finishing this project. CERTIFICATE This is to certify that Jailaxmi Rathore of class 12 has successfully completed the project on psychology titled ‘obsessive-compulsive disorder’ under the guidance of Mrs. Girija Singh. Also this project project is as per cbse guidelines 2012-2013. Teacher’s signature (Mrs. Girija Singh) (Head of psychology department) 2012-2013 PSYCHOLOGY PROJECT NAME OF THE CANDIDATE: JAILAXMI RATHORE CLASS: XII ARTS B SCHOOL: MGD GIRLS’ SCHOOL