case study example for ocd

OCD Case Examples

OCD affects individuals from all races, religions, and ethnic groups. Onset of the disorder ranges from ages 11 to 18. Boys tend to develop symptoms earlier than girls. Of the children who are diagnosed with OCD, most will experience contamination obsessions. Adults are more likely to experience so called “bad thoughts” OCD, i.e. religious, sexual, harm and aggressive obsessions.

OCD is equally common in men and women. Symptoms may come-and-go, change in form, or spontaneously remit. They may be triggered by trauma, rapid change, illness, loss, developmental and hormonal changes, or in reaction to a life experience. OCD is considered a lifelong disorder.

No one knows exactly why a person develops certain obsessions. It has been suggested, however, that life experience and what one cares or feels passionate about may be a contributing factor.

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Case Examples

• A 13-year-old boy learns in health class that vomiting is an involuntary response to illness. While watching the news with his family one evening, he hears a story about a young man who aspirates vomit during his sleep and dies. He becomes obsessed about getting ill and vomiting. The boy shuns anyone who appears to be sick at school. His friends wonder why he isn’t talking to them. This boy carries hand sanitizer everywhere he goes, and avoids public restrooms. He won’t touch food that he thinks might be contaminated by germs. He avoids all the restaurants that he used to enjoy with his family.  The boy’s parents worry about him.
• A 21-year-old college woman is involved in her first serious dating relationship. Like many young women, she wants to look and feel her best. While flipping through a clothing catalogue, she notices the attractiveness of several female models. She wonders anxiously if it means she is gay. She repeatedly asks her boyfriend for reassurance, sometimes to his annoyance. The young woman avoids being alone with most other women for fear of somehow losing self-control and sexually acting out. She prays to God continually for forgiveness. When an obsessive idea is triggered, she tells herself three times that she loves her boyfriend, and mentally rehearses all the ways he makes her feel good.
• A 35-year-old man loses his beloved uncle suddenly to an accident. Two years later, he developed an obsession that harm would result to loved ones if he did not move or walk in a special way. He knew the idea was strange and silly, but he could not stop thinking about it. The man developed elaborate compulsions that involved stepping in a just right way. The process became time consuming and cumbersome. Going out in public by himself or with family became an ordeal.

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Case Study of a Middle-Aged Woman’s OCD Treatment Using CBT and ERP Technique

• Clinical Medical Reviews and Reports

Introduction

Case report, case formulation, intervention, preparation phase of erp, middle phase of erp, steps of hierarchy, booster sessions, quick links.

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Research Article | DOI: https://doi.org/10.31579/2690-8794/102

• Deepshikha Paliwal 1*
• Anamika Rawlani 2

1 M.Sc. Clinical Psychology, Dev Sanskriti University, Ranchi, India. 2 M.Phil Clinical Psychology, RINPAS Ranchi, India.

*Corresponding Author: Deepshikha Paliwal, M.Sc. Clinical Psychology, Dev Sanskriti University, Ranchi, India.

Citation: Deepshikha Paliwal and Anamika Rawlani (2022) Case Study of a Middle-Aged Woman’s OCD Treatment Using CBT and ERP Technique. Clinical Medical Reviews and Reports 4(3): DOI: 10.31579/2690-8794/102

Copyright: © 2022, Deepshikha Paliwal, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 01 September 2021 | Accepted: 04 December 2021 | Published: 10 January 2022

Keywords: OCD; CBT; ERP; salkovskis’s model

Introduction : This is a case report of a middle-aged woman, who was experiencing “obsessive” thoughts related to the “Bindi” (decorative piece wear by women on the forehead) and cleaning “compulsions”. Present case report discusses the patient’s assessment, case formulation, treatment plan and the effectiveness of the CBT and ERP sessions in reducing OCD symptoms.

Methodology: The patient was treated with Cognitive Behavior Therapy (CBT) along with Exposure Response Prevention (ERP) technique. The assessment of the case was done with the Y-BOCS rating scale, Beck’s Depression Inventory, Obsessive Beliefs Questionnaire, and Behavior Analysis Performa which suggested the higher severity level of the patient’s symptoms. Parallel to the assessment sessions, detailed case history related to the onset of the problem, difficulties faced because of the disorder, childhood incidences, family chart, marital issues, and medical history were discussed with the patient. Based on the reported details, the case was formulated according to the Salkovoskis inflated sense of responsibility model.  After the case formulation, the treatment plan was designed which involved ERP sessions and restructuring of the cognitive distortions (beliefs, thoughts, and attitude). 

Results: After the completion of the twenty-five therapy sessions, the patient reported improvement in the coping of anxiety-provoking thoughts and reduced level of the washing compulsions. The effects of the therapy were checked and found maintained up to two months follow up.

Conclusion: CBT and ERP technique is an effective treatment in reducing obsessive and compulsive symptoms of the patient. 

Have you ever felt like a sudden urge to hurt somebody? What if such urges continuously appear in your head? What would you do to stop these urges? Would you be able to continue your day to day life normally with such urges?  Clinical Psychologists studied the repetitive occurrence of unwelcoming thoughts, urges, doubts, and images which create anxiety. They gave it the term “Obsessions”. These obsessions are dreadful, frightening, and intolerable to the extent that they might hinder the natural flow of one’s personal, professional, and social life. The person who suffers from such anxiety-provoking thoughts tries to deal with the distress caused by such ‘obsessions’ by adopting some behavior or activity which temporarily relieve them from the anxiety and the feared consequences. This behavior could be anything like washing hands, cleaning, repeatedly checking the door, or repeating some phrases in the head. Psychologists called such repetitive behaviors or activities as “Compulsions”. According to APA (1994), if the presence of obsessions and/or compulsions is time-consuming (more than an hour a day), cause major distress, and impair work, social, or other important functions then the person will be diagnosed with Obsessive-Compulsive Disorder (OCD). Recent epidemiological studies suggest that OCD affects between 1.9 to 2.5% of the world population at some point in their lives, creating great difficulties on a professional, academic and social level (DSM-IV-TR, 2001). OCD affects all cultural and ethnic groups and, unlike many related disorders, males and females are equally affected by this disorder (Rasmussen & Eisen, 1992). OCD is one of the most incapacitating of anxiety disorders having been rated as a leading cause of disability by the World Health Organization (1996).  The major cause of OCD is still unknown; there could be some genetic components responsible for it (DSM-5). Child abuse or any stress-inducing event could be the risk factor involved in the history of OCD patients. The severity of the symptoms related to obsessions and compulsions provides the basis of the diagnosis in OCD which rules out any other drug-related or medical causes. Clinical Psychologists use rating scales like Y-BOCS (Fenske & Schwenk, 2009), self-reports, and Behavior Analysis Performa to assess the severity level of the symptoms. Based on the severity, the treatment plan is designed. Treatment of OCD involves psychotherapy and antidepressants. Psychotherapy such as Cognitive Behavior Therapy (CBT) is an effective psycho-social treatment of OCD (Beck, 2011). In CBT, a “problem-focused” approach is used to treat the diagnosed psychological disorder by challenging and changing core beliefs, negative automatic thoughts, and cognitive distortions of the patient. CBT involves Exposure Response Prevention (ERP) as a technique to treat OCD in which the patient is exposed to the cause of the problem and not allowed to repeat the ritual behavior (Grant, 2014).  ERP has promising results with 63% of OCD patients showing favorable responses after following the therapy sessions (Stanley & Turner, 1995). 

This is a case of a 31 years old woman, who belongs to a middle socio-economic background, currently living with her in-laws, husband, and daughter. The patient was experiencing obsessive thoughts related to the contamination spread by ‘bindi’ along with the compulsive behavior of washing and cleaning from the last five years. The patient reported that she always tried to check the contact of ‘Bindi’ with anything because that contact makes her incapacitate to control the situation. She took two and three hours (on daily basis) in washing and cleaning her home, scrubbing her daughter, cleaning the daughter’s school bag after returning from school, husband’s bag, and other usable items, so that she can stop the contamination from spreading everywhere. The patient has a history of facing interpersonal issues with family members since her childhood. Her father was alcohol dependent and the mother was the patient of depression. The financial condition of the family was not good. When the patient was 17 years old, her father died due to kidney failure, and her mother got hospitalized because of depression. From a very young age, the patient had to bear the responsibility of the family by taking tuitions. At first, she developed the fear of contamination at the age of 19, when she was in her graduation’s first year, for that she was taken to the Psychiatrist. She responded well to the medicines and stopped showing all the symptoms. At the age of 25, when the patient got pregnant she again developed the fear of contamination, which made her husband and in-laws uncomfortable and family disputes began. Her husband took her to the psychiatrist who referred her for the psychotherapy but she didn’t attend the psychotherapy sessions properly and continuously lived with the obsessions and compulsions up to the present referral where the patient was assessed with Y-BOCS rating scale, BDI, EBQ, and Behavioral Analysis Performa. Based on the assessment, she was diagnosed with OCD having symptoms of obsessions related to the contamination by ‘Bindi’ and washing compulsions. Detailed case history related to the onset of the problem, childhood incidences, family history, marital history, medical history, and other relevant information were also collected. The case was formulated according to Salkovoskis’s inflated sense of responsibility model as the patient’s reported details were signifying the negative interpretations of her responsibility for self and others. After the case formulation, the treatment plan was designed which involved sessions of ERP technique along with the alteration of cognitive distortions (ideas, beliefs, and attitudes) through the cognitive restructuring method of CBT. 

1. Yale-Brown Obsessive-Compulsive Scale (YBOCS): 

In cognitive-behavioral studies, Y-BOCS is used to rate the symptoms of OCD. This scale was designed by Goodman et al. (1989) to know the baseline and the recovery rate of the ‘severity of obsessions’, ‘severity of compulsions’ and ‘resistance to symptoms’. This is a five-point Likert scale that clinicians administer through a semi-structured interview in which a higher score indicates higher disturbances. The excellent psychometric properties of this scale quantify the severity of the obsessions and compulsions as well as provide valuable qualitative information which makes it very useful for both diagnosis of the OCD and the designing of its treatment plan. 

2. Beck Anxiety Inventory (BAI):

Aaron T. Beck (1988) developed BAI as a four-point Likert scale which consists of 21 items of ‘0 to 3’ scores on each item (Higher score means higher anxiety). If the Patient’s scores are from 0 to 7 then interpret as ‘minimal anxiety’, 8 to 15 as ‘mild anxiety’, 16 to 25 as ‘moderate anxiety’, and 30 to 63 as ‘severe anxiety’.  BAI assesses common cognitive and somatic symptoms of anxiety disorder and is considered effective in discriminating between the person with or without an anxiety disorder. This scale provides valuable clinical information but is not used by clinicians for diagnostic purposes. 

3. Obsessive Belief Questionnaire (OBQ):

OBQ is used to assess the beliefs and appraisals of OCD patients which are critical to their pathogenesis of obsessions (OCCWG, 1997, 2001). This scale consists of 87 belief statements within six subscales which represent key belief domains of OCD. The first subscale is ‘Control of thoughts’ (14 items), the second is ‘importance of thoughts’ (14 items), third is, responsibility (16 items), fourth is ‘intolerance of uncertainty’ (13 items), the fifth is an overestimation of threat (14 items), and sixth is ‘perfectionism’ (16 items). Response on this measure is the general level of agreement of the respondents with the items on a 7 point rating scale that ranges from (-3) “disagree very much” to (+3) “agree very much”. On the respective items summing of the scores is done to calculate the subscale scores.

4. Behavior Analysis Performa

This study used ‘Behavior Analysis Performa’ to do the functional analysis of the patient’s behavior. This Performa collects the details of the patient’s behavioral excess, deficits, and assets, his or her motivational factors behind maintaining and reinforcing ill behaviors, as well as, the medical, cultural, and social factors which contributed to the development of the illness. 

Based on the reported details and the assessment, the case was formulated according to the Salkovoskis model (1985). This model suggests that the patient’s main negative interpretation revolves around the idea that his or her actions might have harmful outcomes for self or others. This interpretation of responsibility increases selective attention and maintains negative beliefs (Salkovskis, 1987). Here, in this case, the patient had to face the disturbing family environment which significantly has a role in the formation of maladaptive schemas related to her negative view of self, the world, and the future. The patient’s beliefs assessment reports signified that her major dysfunctional assumptions were ‘if harm is very unlikely, I should try to prevent it at any cost’ and ‘if I don’t act when I foresee danger then I am to blame for any consequences’. Intrusive thought for her was that ‘bindi contaminates dirt’ and neutralizing action for this intrusive thought was ‘washing and cleaning things’. She paid her keen attention to the thought that ‘I should not be get touched with bindi’ and misinterpreted and over signified it by avoiding bindi and preventing the contamination. Her safety behavior included avoiding going out, (especially beauty parlors and cosmetic shops), and getting touched with anyone on roads and market places. The result of such avoidance was tiredness, anxiousness, aggressiveness, and distressed mood state. The graphical representation of the case formulation is shown in Appendix 1 at the end of this paper.

After the case formulation, the treatment plan was designed. The patient had dysfunctional assumptions related to her responsibility for self and others. She had obsessions related to the contamination spread by ‘Bindi’ associated with washing and cleaning compulsions. As she was taken by her husband for the therapy, so it was important to socialize her and her family with the OCD to develop insight for the disorder. After socializing them with OCD, they were taught the basic structure of the cognitive behavior model that how patient’s thoughts, emotions, physical sensations, and behavior all are interrelated and affect each other in a vicious circle. 

In the preparatory phase, the patient was introduced with the ERP technique, how does it work and how much her cooperation and will power are required for the success of this technique. After introducing the ERP technique to her, behavioral analysis was done with the patient by using a down-arrow method to make the list of the situations she uses as safety strategies and maintains her negative beliefs.

In the next session, the patient was told to imagine her exposure with different situations which she avoids and asked her to rate the level of anxiety in all the situations on a scale of 1 to 10. After this imaginary exposure, a hierarchy was made from the least anxiety-provoking event to the high anxiety-provoking event. Here is the list of different situations which the patient rated based on the level of anxiety:

In this phase, the patient was gradually exposed with the least anxiety-provoking situation to the highest-anxiety provoking situation. The patient’s husband worked as a co-therapist and accompanied her in all the situations and observed her anxiety levels and other behaviors. The patient was asked to rate her anxiety level on a scale of 1 to 10 after every exposure.

• In the first step of exposure, patient was instructed to go out with the husband in the market area where ‘Bindi’ was hanging on the walls , she was instructed to watch them from some distance and observe her level of anxiety varying with time . She was strictly instructed not to avoid the situation and to face the anxiety levels without skipping. In the next session, she was asked what she exactly felt when she was watching the bindi packets, she replied that at first sight of bindi she felt disgusted and wanted to go away but she gave self instructions to her that these are very far and cannot contaminate her so she kept sitting there and with time her anxiety level also came down.   
• In the second step of the hierarchy she was instructed for sitting at a distance from the cosmetics shop and observe the ladies entering and purchasing bindi there , her husband was told to work as a co-therapist and checks the anxiety levels and reactions of his wife during the exposure. In the next session, she was again asked for the thoughts and levels of anxiety during the observation, husband reported that at first she showed some anger and was looking very anxious while observing the ladies with bindi but when he reminded her about the nature of therapy, she managed to sit there and sometime later became relaxed.   
• In the third step of the hierarchy patient was instructed to enter into the cosmetic shop and remain stand there for a short while without purchasing anything and to face the levels of anxiety varying with time. In the session, she was asked to report the anxiety level. She reported that just when she entered the shop she was trying to not get touched with anything and felt like she would lose her control and became very anxious but with self instructions she managed herself to stand there after sometime anxiety level came down and she felt little relaxed.   
• In the fourth step, the patient was instructed to enter into the cosmetic shop and to purchase some common items other than ‘Bindi’ . In the next session, husband reported that she was attentively noticing the shopkeeper’s movements. Though, she purchased some ribbons but denied to touch them and asked him to put them in his bag and told him to give only the fixed amount of ribbon’s cost to the shopkeeper so that exchange could not be needed from shopkeeper’s contaminated hands. The husband also observed that during the whole exposure, the patient was looking very distressed and anxious and was involved in safety strategies and managed to calm down only when he reminded her about the process of therapy. The patient was then asked to report her anxiety level in this step of exposure.  
• In the fifth step, patient was instructed to go into the market and purchase a packet of small colorful bindi and face the anxiety levels . In the next session, she was asked to express the anxiety and rate it on a scale of 1 to 10. The patient reported that when she was purchasing the bindi, she felt dreadful and thought that she would take bath after returning home. Somehow, she purchased the packet and gave it to the husband to put it in his bag. After returning home, she got involved in her daughter’s work but thoughts of washing and bathing were going on in her mind. Later on, she could not get the time for bathing and she instructed herself to bath in the morning, after this thought she felt very relaxed and had this feeling of winning over her obsessions.   
• In the sixth step, patient was instructed to purchase some colorful bindi packets and try to keep them with herself and strictly prevent herself from hand-washing for one hour. In the next session, she reported that this time she was not that anxious while purchasing bindi packets but after putting them in her bags she was trying to avoid getting touched with her daughter and mother in law because her mother in law would enter into the kitchen and contaminate everything. Meanwhile, her daughter ran towards her and hugged her. Immediately, she became very restless and angry with the daughter and thought about to wash her. However, she felt incapacitated as her daughter ran everywhere in the house and touched everything. She got anxious but managed this thought of contamination and decided to not wash anything. After this, she felt relaxed.   
• In the seventh step of the hierarchy, the patient was instructed to apply a small bindi on her forehead and restricted to not wash her hands for at least four hours . In the next session, she reported that she applied the bindi and her husband and her mother-in-law were feeling very happy but she felt anxious and closed her fist for not touching anything till hand-washing. After some time, in other household works, she forgot about it but suddenly when she realized that she had applied bindi, she immediately washed her hands but even then kept wearing it for the whole day.   
• In the eighth step, the patient was instructed to apply red color velvet medium size Bindi and prevent hand washing for minimum of two hours . In the next session, she reported that now her level of anxiety has fallen down and now she feels less anxious after applying bindi and managed to not wash her hands for two hours without any much restlessness.   
• In the ninth step of the hierarchy, the patient was instructed to apply red color velvet medium size Bindi and prevent hand washing for minimum of four hours and try to make herself normal and gradually start touching things in these hours. In the next session, she reported that now she feels capable to face her feelings of disgust with bindi and manages to make her mind for not washing things after getting touched with the bindi. Though some thoughts of contamination keep coming in between but she immediately reminds herself that ‘Bindi’ can’t contaminate anything.  
• In the tenth step of hierarchy, the patient was instructed to apply bindi on her forehead and keep some of them in her bag preventing washing her hands for maximum hours possible. In the next session, she reported that now she feels more capable to conquer over her thoughts of contamination and more determined to not washing and cleaning after such obsessions.

With each ERP session, the patient came to realize that the nature of anxiety is that it goes up with the triggering event but with the passage of time, automatically comes down. She also developed the insight that she had fear from the thoughts of contamination and with its associated anxiety more than ‘Bindi’ itself. 

After the ERP sessions, the patient was given two booster sessions in which she was taught the ways to deal with the anxiety after the termination of therapy in her day to day life situations. In those sessions, she was asked to imagine her home, her room, and herself with Bindi on her forehead and doing household chores like cooking, cleaning the things, etc. When the patient was asked to express herself during the imagination, she reported that she is feeling more confident now to stick on her thought that bindi can’t contaminate, it’s her idea and there is no use of washing hands and other things because of the fear of contamination. Her husband and mother-in-law were also instructed to remind her again and again about the things she learned during the therapy sessions. After the declaration of the patient that she is feeling better now and ready to face the anxiety on her own, therapy sessions were terminated.

One month later, the patient was contacted for the follow-up and asked about her coping with the anxiety through telephonic conversation. She reported that thoughts of contamination came in her mind but she is in better condition than previous after taking the ERP sessions.

After two months, the patient came for the session again with the complaints that sometimes she became weak and washed her hands with the thought of contamination. After washing, she repented on her behavior which lowers down her confidence in conquering over the illness. Then she was instructed that washing hands strengthens the thought of contamination so she should avoid it as much as possible but this doesn’t mean that she has not gained anything with the therapy, she was reminded about her previous condition that how much it was unbearable for her to even think about the bindi but now she is applying it on her forehead which shows that only the traces of the illness left, most of it is already recovered. In this way, the patient became relaxed and felt more determined to continue with the learnings during the sessions.

After the termination of the therapy sessions, the patient’s obsessive and compulsive symptoms were found reduced on the Y-BOCS symptom checklist:

With the graded exposure sessions, her anxiety level also came down from the rating of 10 in the beginning sessions to the rating of 4 in the endings sessions on a scale of 1 to 10.

The patient’s BAI score was also fallen down from pre-intervention- 36 (Extreme level of anxiety) to post intervention- 13 (mild level of anxiety) which suggests 36% reduction in the anxiety level of the patient.

Previous research findings considered CBT as the most promising treatment of OCD (Stanley & Turner, 1995; Foa et al, 1999). CBT emphasizes the integration of cognitive-behavioral strategies like discussion techniques (Guided Discovery) and behavioral experiments (ERP) to formulate the problem and direct the treatment. Therapists try to identify the key distorted beliefs along with patients and allow them to test their beliefs which develop and maintain compulsive behaviors. This case identified the contamination with ‘Bindi’ as the pathological belief which was maintaining the compulsive behaviors of washing and cleaning. The cognitive hypothesis of Salkovoskis (1985) proposed that the origin of obsessional thinking lies in normal intrusive ideas, images, thoughts, and impulses which a person finds unacceptable, upsetting, or unpleasant. The occurrence and content of these intrusive cognitions are negatively interpreted as an indication that the person may be ‘responsible for harm’ or ‘prevent the harm’. Such an interpretation is likely followed by emotional reactions such as anxiety or depression. These emotional reactions lead to discomfort and neutralizing (Compulsive) behaviors like washing, cleaning, checking, avoidance of situations related to the obsessive thought, seeking reassurance, and attempts to exclude these thoughts from the mind. The present case supported this hypothesis of Salkovoskis’s model as intrusive thought of the patient was contamination spread by ‘Bindi’ which negatively interpreted as ‘I can avoid the likely harms by avoiding the contamination spread by Bindi’, such negative interpretation was raising her anxiety levels, making her attentive selective towards the ‘Bindi’, maintaining her compulsive acts and complying her to adopt the safety strategies.

Rachman (1983) predicted that behavioral experiments, in which the patient is exposed to the feared object, these intrusive thoughts are challenged by changing the pattern of thinking and behaving. Hodgson & Rachman (1972) initiated the series of clinical studies on patients with contamination and predicted that immediate washing reduces the anxiety. In one of their experimental study, they noted a similar degree of anxiety reduction when the patient was asked not to perform a compulsive act for one hour.  They termed this phenomenon as ‘spontaneous decay’ which was established as the basis of ERP. Also, Foa & Kozak (1986) proposed that exposure techniques activate the network of cognitive fear and patients get new experience which is different from the existing pathological beliefs. This case confirmed this hypothesis as the patient initially thought that her exposure with ‘Bindi’ might cause some uncertain consequence with her but prolonged exposures provided her new experience that she could manage with her fear and anxiety which resulted in the improved coping with obsessional beliefs about contamination and urge to wash and clean. Her improved coping is evident in the statistically significant reduction of her scores on the standard measures like the Y-BOCS symptom checklist, BAI, and OBQ. 

The results of this case study add on the value of CBT (that involves ERP technique) in the treatment of obsessive thinking related to the ‘fear of contamination’ and compulsive behavior of ‘washing and cleaning’. However, there is a need for more such case studies with more precision and effective treatment designs to provide valuable information related to the nature of OCD and its treatment.

In this case of OCD, patient’s symptoms were reduced to a manageable level and found maintained for two months which provides an evidence of the effectiveness of CBT and ERP technique in the treatment of OCD.

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• Case report
• Open access
• Published: 11 July 2020

Obsessive compulsive disorder in very young children – a case series from a specialized outpatient clinic

• Veronika Brezinka   ORCID: orcid.org/0000-0003-2192-3093 1 ,
• Veronika Mailänder 1 &
• Susanne Walitza 1  

BMC Psychiatry volume  20 , Article number:  366 ( 2020 ) Cite this article

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Paediatric obsessive-compulsive disorder (OCD) is a chronic condition often associated with severe disruptions of family functioning, impairment of peer relationships and academic performance. Mean age of onset of juvenile OCD is 10.3 years; however, reports on young children with OCD show that the disorder can manifest itself at an earlier age. Both an earlier age of onset and a longer duration of illness have been associated with increased persistence of OCD. There seems to be difficulty for health professionals to recognize and diagnose OCD in young children appropriately, which in turn may prolong the interval between help seeking and receiving an adequate diagnosis and treatment. The objective of this study is to enhance knowledge about the clinical presentation, diagnosis and possible treatment of OCD in very young children.

Case presentation

We describe a prospective 6 month follow-up of five cases of OCD in very young children (between 4 and 5 years old). At the moment of first presentation, all children were so severely impaired that attendance of compulsory Kindergarten was uncertain. Parents were deeply involved in accommodating their child’s rituals. Because of the children’s young age, medication was not indicated. Therefore, a minimal CBT intervention for parents was offered, mainly focusing on reducing family accommodation. Parents were asked to bring video tapes of critical situations that were watched together. They were coached to reduce family accommodation for OCD, while enhancing praise and reward for adequate behaviors of the child. CY-BOCS scores at the beginning and after 3 months show an impressive decline in OCD severity that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child was admitted to the next level / class.

Conclusions

Disseminating knowledge about the clinical presentation, diagnosis and treatment of early OCD may shorten the long delay between first OCD symptoms and disease-specific treatment that is reported as main predictor for persistent OCD.

Peer Review reports

Paediatric obsessive compulsive disorder [ 1 ] is a chronic condition with lifetime prevalence estimates ranging from 0.25 [ 2 ] to 2–3% [ 3 ]. OCD is often associated with severe disruptions of family functioning [ 4 ] and impairment of peer relationships as well as academic performance [ 5 ]. Mean age of onset of early onset OCD is 10.3 years, with a range from 7.5 to 12.5 years [ 6 ] or at an average of 11 years [ 7 ]. However, OCD can manifest itself also at a very early age - in a sample of 58 children, mean age of onset was 4.95 years [ 8 ], and in a study from Turkey, OCD is described in children as young as two and a half years [ 9 ]. According to different epidemiological surveys the prevalence of subclinical OC syndromes was estimated between 7 and 25%, and already very common at the age of 11 years [ 10 ].

Understanding the phenomenology of OCD in young children is important because both an earlier age of onset and a longer duration of illness have been associated with increased persistence of OCD [ 11 , 12 , 13 ]. One of the main predictors for persistent OCD is duration of illness at assessment, which underlines that early recognition and treatment of the disorder are crucial to prevent chronicity [ 10 , 14 , 15 ]. OCD in very young children can be so severe that it has to be treated in an inpatient-clinic [ 16 ]. This might be prevented if the disorder were diagnosed and treated earlier.

In order to disseminate knowledge about early childhood OCD, detailed descriptions of its phenomenology are necessary to enable clinicians to recognize and assess the disorder in time. Yet, studies on this young population are scarce and differ in the definition of what is described as ‘very young’. For example, 292 treatment seeking youth with OCD were divided into a younger group (3–9 years old) and an older group (10–18 years old) [ 17 ]. While overall OCD severity did not differ between groups, younger children exhibited poorer insight, increased incidence of hoarding compulsions, and higher rates of separation anxiety and social fears than older youth. It is not clear how many very young children (between 3 and 5 years old) were included in this study. Skriner et al. [ 18 ] investigated characteristics of 127 young children (from 5 to 8) enrolled in a pilot sample of the POTS Jr. Study. These young children revealed moderate to severe OCD symptoms, high levels of impairment and significant comorbidity, providing further evidence that symptom severity in young children with OCD is similar to that observed in older samples. To our knowledge, the only European studies describing OCD in very young children on a detailed, phenotypic level are a single-case study of a 4 year old girl [ 16 ] and a report from Turkey on 25 children under 6 years with OCD [ 9 ]. Subjects were fifteen boys and ten girls between 2 and 5 years old. Mean age of onset of OCD symptoms was 3 years, with some OCD symptoms appearing as early as 18 months of age. All subjects had at least one comorbid disorder; the most frequent comorbidity was an anxiety disorder, and boys exhibited more comorbid diagnoses than girls. In 68% of the subjects, at least one parent received a lifetime OCD diagnosis. The study reports no further information on follow-up or treatment of these young patients.

In comparison to other mental disorders, duration of untreated illness in obsessive compulsive disorder is one of the longest [ 19 ]. One reason may be that obsessive-compulsive symptoms in young children are mistaken as a normal developmental phase [ 20 ]. Parents as well as professionals not experienced with OCD may tend to ‘watch and wait’ instead of asking for referral to a specialist, thus contributing to the long delay between symptom onset and assessment / treatment [ 10 ]. This might ameliorate if health professionals become more familiar with the clinical presentation, diagnosis and treatment of the disorder in the very young. The purpose of this study is to provide a detailed description of the clinical presentation, diagnosis and treatment of OCD in five very young children.

We describe a prospective 6 month follow-up of five cases of OCD in very young children (between 4 and 5 years old) who were referred to the OCD Outpatient Treatment Unit of a Psychiatric University Hospital. Three patients were directly referred by their parents, one by the paediatrician and one by another specialist. Parents and child were offered a first session within 1 week of referral. An experienced clinician (V.B.) globally assessed comorbidity, intelligence and functioning, and a CY-BOCS was administered with the parents.

Instruments

To assess OCD severity in youth, the Children Yale-Brown Obsessive Compulsive Scale CY-BOCS [ 21 ] is regarded as the gold standard, with excellent inter-rater and test-retest reliability as well as construct validity [ 21 , 22 ]. The CY-BOCS has been validated in very young children by obtaining information from the parent. As in the clinical interview Y-BOCS for adults, severity of obsessions and compulsions are assessed separately. If both obsessions and compulsions are reported, a score of 16 is regarded as the cut-off for clinically meaningful OCD. If only compulsions are reported, Lewin et al. [ 23 ] suggest a cut-off score of 8. In their CY-BOCS classification, a score between 5 and 13 corresponds to mild symptoms / little functional impairment or a Clinical Global Impression Severity (CGI-S) of 2. A score between 14 and 24 corresponds to moderate symptoms / functioning with effort or a CGI-S of 3. Generally, it is recommended to obtain information from both child and parents. However, in case of the very young patients presented here, CY-BOCS scores were exclusively obtained from the parents. The parents of all five children reported not being familiar with any obsessions their child might have. In accordance with previous recommendations [ 23 ], a cut-off point of 8 for clinically meaningful OCD was used.

Patient vignettes

Patient 1 is a 4 year old girl, a single child living with both parents. She had never been separated an entire day from her mother. At the nursery, she suffered from separation anxiety for months. Parents reported that the girl had insisted on rituals already at the age of two. In the evening, she ‚had‘ to take her toys into bed and had got up several times crying because she ‚had to‘ pick up more toys. In the morning, only she ‚had the right‘ to open the apartment door. When dressing in the morning, she ‚had‘ to be ready before the parents. Only she was allowed to flush the toilet, even if it concerned toilet use of the parents. Moreover, only she ‘had the right’ to switch on the light, and this had to be with ten fingers at the same time. If she did not succeed, she got extremely upset and pressed the light button again and again until she was satisfied. The girl was not able to throw away garbage and kept packaging waste in a separate box. In the evening, she had to tidy her room for a long time until everything was ‚right‘. Whenever her routine was changed, she protested by crying, shouting and yelling at her parents. Moreover, she insisted on repeating routines if there had been a ‚mistake‘. In order to avoid conflict, both parents adapted their behavior to their daughter’s desires. In the first assessment with the parents, her score on the CY-BOCS was 15, implying clinically meaningful OCD. Psychiatric family history revealed that the mother had suffered from severe separation anxiety as a child and the father from severe night mares. Both parents described themselves as healthy adults.

Patient 2 is a four and a half year old boy, the younger of two brothers. He was reported to have been very oppositional since the age of two. Since the age of three, he insisted on a specific ritual when flushing the toilet – he had to pronounce several distinct sentences and then to run away quickly. Some months later he developed a complicated fare-well ritual and insisted on every family member using exactly the sentences he wanted to hear. If one of these words changed, he started to shout and threw himself on the floor. After a short time, he insisted on unknown people like the cashier at the supermarket to use the same words when saying good-bye.Moreover, he insisted that objects and meals had to be put back to the same place as before in case they had been moved. When walking outside, he had to count his steps and had to start this over and over again. In the morning, he determined where his mother had to stand and how her face had to look when saying good-bye. In order to avoid conflict, parents and brother had deeply accommodated their behavior to his whims. On the CY-BOCS, patient 2 reached a score of 15, which is equivalent to clinically meaningful OCD. Neither his father nor his mother reported any psychiatric disorder in past or present.

Patient 3 is a 4 year old boy referred because of possible OCD. Since the age of three, he had insisted on things going his way. When this was not the case, he threw a temper tantrum and demanded that time should be turned back. If, for example, he had cut a piece of bread from the loaf and was not satisfied with its form, he insisted that the piece should be ‘glued’ to the loaf again. Since he entered Kindergarten at the age of four, his behavior became more severe. If he was not satisfied with a certain routine like, for example, dressing in the morning, he demanded that the entire family had to undress and go to bed again, that objects had to lie at the same place as before or that the clock had to be turned back. In order to avoid conflict, the parents had repeatedly consented to his wishes. His behavior was judged as problematic at Kindergarten, because he demanded certain situations to be repeated or ‚played back‘. When the teacher refused to do that, the boy once run away furiously. On the CY-BOCS, patient 3 reached a score of 15. The mother described herself as being rather anxious (but not in treatment), the father himself as not suffering from any psychiatric symptoms. However, his mother had suffered from such severe OCD when he was a child that she had undergone inpatient treatment several times. This was also the reason why the parents had asked for referral to a specialist for the symptoms of their son.

Patient 4 is a 5 year old girl, the eldest of three siblings. Since the age of two, she was only able to wear certain clothes. For months, she refused to wear any shoes besides Espadrilles; she was unable to wear jeans and could only wear one certain pair of leggings. Wearing warm or thicker garments was extremely difficult, leading to numerous conflicts with her mother in winter. Socks had to have the same height, stockings had to be thin, and slips slack. When dressing in the morning, she regularly got angry and despaired and engaged in severe conflicts with her mother; dressing took a long time, whereas she had to be in Kindergarten on time. Her compulsions with clothes seemed to influence her social behavior as well; she had been watching other children at the playground for 40 min and did not participate because her winter coat did not ‚feel right‘. She started to join peers only when she was allowed to pull the coat off. She also had to dry herself excessively after peeing and was reported to be perfectionist in drawing, cleaning or tidying. Her CY-BOCS score was 15, equivalent to clinically meaningful OCD. Both parents described themselves as not suffering from any psychiatric problem in past or present. However, the grandmother on the mother’s side was reported to have had similar compulsions when she was a child.

Patient 5 was a four and a half year old girl referred because of early OCD. She had one elder brother and lived with both parents. At the age of 1 year, patient 5 was diagnosed with a benign brain tumor (astrocytoma). The tumor had been removed for 90% by surgery; the remaining tumor was treated with chemotherapy. The first chemotherapy at the age of 3 years was reasonably well tolerated. Shortly thereafter, the girl developed just-right-compulsions concerning her shoes. When the second chemotherapy (with a different drug) was started at the age of four, compulsions increased so dramatically that she was referred to our outpatient clinic by the treating oncologist. She insisted on her shoes being closed very tightly, her socks and underwear being put on according to a certain ritual, and her belt being closed so tightly that her father had to punch an additional hole. She refused to wear slack or new clothes and was not able to leave the toilet after peeing because ‘something might still come’; she used large amounts of toilet paper and complained that she wasn’t dry yet. She also insisted on straightening the blanket of her bed many times. She was described by her mother as extremely stressed, impatient and irritable; she woke up every night and insisted to go to the toilet, from where she would come back only after intense cleaning rituals. In the morning, she frequently threw a severe temper tantrum, including hitting and scratching the mother, staying naked in the bathroom and refusing to get dressed because clothes were not fitting ‚just right‘or were not tight enough. Shortly after the start of the second chemotherapy, the girl had entered Kindergarten which was in a different language than the family language. Moreover, her mother had just taken up a new job and had to make a trip of several days during the first month. Although the mother gave up her job after the dramatic increase in OCD severity, the girl’s symptoms did not change. As an association between chemotherapy and the increase in OCD symptoms could not be excluded, the treating oncologist decided to stop chemotherapy 2 weeks after patient 5 was presented with OCD at our department. At the moment of presentation, she arrived at Kindergarten too late daily, after long scenes of crying and shouting, or refused to go altogether. She reached a score of 20 on the CY-BOCS, the highest score of the five children presented here. Her father described himself as free of any psychiatric symptoms in past or present. Her mother had been extremely socially anxious as a child.

None of the siblings of the children described above was reported to show any psychiatric symptoms in past or present (Table  1 ).

The five cases described above show a broad range of OCD symptomatology in young children. Besides Just-Right compulsions concerning clothes, compulsive behavior on the toilet was reported such as having to pee frequently, having to dry oneself over and over again as well as rituals concerning flushing. Other symptoms were pronouncing certain words or phrases compulsively, insisting on a ‘perfect’ action and claiming that time or situations must be played back like a video or DVD if the action or situation were not ‘perfect enough’. The patients described here have in common that parents were already much involved in the process of family accommodation. For example, the parents of patient 3 had consented several times to undress and go to bed again in order to ‘play back’ certain situations; they had also consented turning back the clock in the house. The parents of patient 2 had accommodated his complicated fare-well ritual, thus having to rush to work in the morning themselves. However, all parents were smart enough not just to indulge their child’s behavior, but to seek professional advice.

Treatment recommendations

Practice Parameters and guidelines for the assessment and treatment of OCD in older children and adolescents recommend cognitive behavior therapy (CBT) as first line treatment for mild to moderate cases, and medication in addition to CBT for moderate to severe OCD [ 24 , 25 ]. However, there is a lack of treatment studies including young children with OCD [ 26 ]. A case series with seven children between the age of 3 and 8 years diagnosed with OCD describes an intervention adapted to this young age group. Treatment emphasized reducing family accommodation and anxiety-enhancing parenting behaviors while enhancing problem solving skills of the parents [ 27 ]. A much larger randomized clinical trial for 127 young children (5 to 8 years of age) with OCD showed family-based CBT superior to a relaxation protocol for this age group [ 14 ]. Despite these advances in treatment for early childhood OCD, availability of CBT for paediatric OCD in the community is scarce due to workforce limitations and regional limitations in paediatric OCD expertise [ 28 ]. This is certainly not only true for the US, but for most European countries as well.

When discussing treatment of OCD in young children, the topic of family accommodation is of utmost importance. Family accommodation, also referred to as a ‘hallmark of early childhood OCD’ [ 15 ] means that parents of children with OCD tend to accommodate and even participate in rituals of the affected child. In order to avoid temper tantrums and aggressive behavior of the child, parents often adapt daily routines by engaging in child rituals or facilitating OCD by allowing extra time, purchasing special products or adapting family rules and organisation to OCD [ 29 , 30 , 31 ]. Although driven by empathy for and compassion with the child, family accommodation is reported to be detrimental because it further reinforces OCD symptoms and avoidance behavior, thus enhancing stress and anxiety [ 4 , 32 ].

Parent-oriented CBT intervention

At the moment of first presentation, the five children were so severely impaired by their OCD that attendance of (compulsory) Kindergarten was uncertain. All parents reported being utterly worried and stressed by their child’s symptoms and the associated conflicts in the family. However, no single family wanted an in-patient treatment of their child, and because of the children’s young age, medication was not indicated. Some families lived far away from our clinic and / or had to take care of young siblings.

Therefore, a CBT-intervention was offered to the parents, mainly focusing on reducing family accommodation. This approach is in line with current treatment recommendations to aggressively target family accommodation in children with OCD [ 15 ]. Parents and child were seen together in a first session. The following sessions were done with the parents only, who were encouraged to bring video tapes of critical situations. The scenes were watched together and parents were coached to reduce family accommodation for OCD, while enhancing praise and reward for adequate behaviors of the child. Parents were also encouraged to use ignoring and time-out for problematic behaviors. As some families lived far away and had to take care of young siblings as well, telephone sessions were offered as an alternative whenever parents felt the need for it. Moreover, parents were prompted to facilitate developmental tasks of their child such as attending Kindergarten regularly, or building friendships with peers. The minimal number of treatment sessions was four and the maximal number ten, with a median of six sessions.

Three of the five children (patients 3, 4 and 5) were raised in a different language at home than the one spoken at Kindergarten. This can be interpreted as an additional stressor for the child, possibly enhancing OCD symptoms. Instead of expecting their child to learn the foreign language mainly by ‚trial and error‘, parents were encouraged to speak this language at home themselves, to praise their child for progress in language skills and to facilitate playdates with children native in the foreign language.

Three and six months after intake, assessment of OCD-severity by means of the CY-BOCS was repeated. Table  2 shows an impressive decline in OCD-severity after 3 months that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child was admitted to the next level of Kindergarten or, in the case of patient 4, to school.

We report on five children of 4 and 5 years with very early onset OCD who were presented at a University Department of Child and Adolescent Psychiatry. These children are ‚early starters‘with regard to OCD. As underlined in a recent consensus statement [ 10 ], delayed initiation of treatment is seen as an important aspect of the overall burden of OCD (see also [ 19 ]). In our small sample, a CBT-based parent-oriented intervention targeting mainly family accommodation led to a significant decline in CY-BOCS scores after 3 months that was maintained at 6 months. At 3 months, all children were able to attend Kindergarten daily, and at 6 months, every child was admitted to the next grade. This can be seen as an encouraging result, as it allowed the children to continue their developmental milestones without disruptions, like staying at home for a long period or following an inpatient treatment that would have demanded high expenses and probably led to separation problems at this young age. Moreover, the reduction on CY-BOCS scores was reached without medication. The number of sessions of the CBT-based intervention with the parents varied between four and ten sessions, depending on the need of the family. Families stayed in touch with the therapist during the 6 month period and knew they could get an appointment quickly when needed.

A possible objection to these results might be the question of differential diagnosis. Couldn’t the problematic behaviors described merely be classified as benign childhood rituals that would change automatically with time? As described in the patient vignettes, the five children were so severely impaired by their OCD that attendance of Kindergarten – a developmental milestone – was uncertain. Moreover, parents were extremely worried and stressed by their child’s symptoms and associated family conflicts. In our view, it would have been a professional mistake to judge these symptoms as benign rituals not worthy of diagnosis or disorder-specific treatment. One possible, but rare and debated cause of OCD are streptococcal infections, often referred to as PANS [ 33 ]. However, in none of the cases parents reported an abrupt and sudden onset of OCD symptoms after an infection. Instead, symptoms seem to have developed gradually over a period of several months or even years. In the case of patient 5 with the astrocytoma, first just-right compulsions appeared at the age of three (after the first chemotherapy), and were followed by more severe compulsions at the age of four, when – within a period of 6 weeks – a new chemotherapy was started, the mother took up a new job and the patient entered Kindergarten. Diagnosing the severe compulsions of patient 5 as, for example, adjustment disorder due to her medical condition would not have delivered a disorder-specific treatment encouraging parents to reduce their accommodation. This might have led to even more family accommodation and to more severe OCD symptoms in the young girl. Last but not least, a possible objection might be that the behaviors described were stereotypies. However, stereotypies are defined as repetitive or ritualistic movements, postures or utterances and are often associated with an autism spectrum disorder or intellectual disability. The careful intake with the children revealed no indication for any of these disorders.

Data reported here have several limitations. The children did not undergo intelligence testing; their reactions and behavior during the first session, as well as their acceptance and graduation at Kindergarten were assumed as sufficient to judge them as average intelligent. Comorbidities were assessed according to clinical impression and parents’ reports. The CBT treatment was based on our clinical expertise as a specialized OCD outpatient clinic. It included parent-oriented CBT elements, but did not have a fixed protocol and was adjusted individually to the needs of every family. Last but not least, no control group of young patients without an intervention was included.

Conclusions and clinical implications

We described a prospective 6 month follow-up of five cases of OCD in very young children. At the moment of first presentation, all children were so severely impaired that attendance of Kindergarten was uncertain. Parents were deeply involved in accommodating their child’s rituals. Because of the children’s young age, medication was not indicated. Therefore, a minimal CBT intervention for parents was offered, mainly focusing on reducing family accommodation. CY-BOCS scores at the beginning and after 3 months show an impressive decline in OCD severity that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child had been admitted to the next grade. OCD is known to be a chronic condition. Therefore, in spite of treatment success, relapse might occur. However, as our treatment approach mainly targeted family accommodation, parents will hopefully react with less accommodation, should a new episode of OCD occur. Moreover, parents stay in touch with the outpatient clinic and can call when needed.

The clinical implications of our findings are that clinicians should not hesitate to think of OCD in a young child when obsessive-compulsive symptoms are reported. The assessment of the disorder should include the CY-BOCS, which has been validated in very young children by obtaining information from the parent. If CY-BOCS scores are clinically meaningful (for young children, a score above 8), a parent-based treatment targeting family accommodation should be offered.

By disseminating knowledge about the clinical presentation, assessment and treatment of early childhood OCD, it should be possible to shorten the long delay between first symptoms of OCD and disease-specific treatment that is reported as main predictor for persistent OCD. Early recognition and treatment of OCD are crucial to prevent chronicity [ 14 , 15 ]. As children and adolescents with OCD have a heightened risk for clinically significant psychiatric and psychosocial problems as adults, intervening early offers an important opportunity to prevent the development of long-standing problem behaviors [ 10 , 19 ].

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Abbreviations

Obsessive compulsive behavior

Child Yale-Brown Obsessive Compulsive Scale

Cognitive Behavior Therapy

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V.B. conducted the diagnostic and therapeutic sessions and wrote the manuscript. V.M. was responsible for medical supervision and revised the manuscript. S.W. supervised the OCD treatment and research overall, applied for ethics approval and revised the manuscript. All authors have read and approved the manuscript.

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the study was approved by the Kantonale Ethikkommission Zürich, July 22nd, 2019.

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V.B. and V.M. declare that they have no competing interests. S.W. has received royalties from Thieme, Hogrefe, Kohlhammer, Springer, Beltz in the last 5 years. Her work was supported in the last 5 years by the Swiss National Science Foundation (SNF), diff. EU FP7s, HSM Hochspezialisierte Medizin of the Kanton Zurich, Switzerland, Bfarm Germany, ZInEP, Hartmann Müller Stiftung, Olga Mayenfisch, Gertrud Thalmann, Vontobel-, Unisciencia and Erika Schwarz Fonds. Outside professional activities and interests are declared under the link of the University of Zurich www.uzh.ch/prof/ssl-dir/interessenbindungen/client/web/

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Brezinka, V., Mailänder, V. & Walitza, S. Obsessive compulsive disorder in very young children – a case series from a specialized outpatient clinic. BMC Psychiatry 20 , 366 (2020). https://doi.org/10.1186/s12888-020-02780-0

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The Obsessive-Compulsive Patient - A Case Study

What's it like living with Obsessive-Compulsive Personality Disorder (OCPD? Take a look.

Notes of therapy session with Magda, female, 58, diagnosed with Obsessive-Compulsive Personality Disorder (OCPD)

Magda is distressed when I reschedule our appointment. "But we always meet on Wednesdays!" - she pleads, ignoring my detailed explanations and my apologies. She is evidently anxious and her voice trembles. In small, precise movements she rearranges the objects on my desk, stacking stray papers and replacing pens and pencils in their designated canisters.

Anxiety breeds frustration and is followed by rage. The outburst lasts but a second and Magda reasserts control over her emotions by counting aloud (only odd numbers). "So, when and where are we going to meet?" - she finally blurts out.

"On Thursday, same hour, same place" - I reiterate for the third time in as many minutes. "I must make a note of this" - Magda sounds lost and desperate - "I have so many things to do on Thursday!" If Thursday is not convenient, we can make it the next Monday, I suggest. But this prospect of yet another shift in her rigidly ordered universe alarms her even more: "No, Thursday is fine, fine!" - she assures me unconvincingly.

A moment of uneasy silence ensues and then: "Can you give it to me in writing?" Give what in writing? "The appointment." Why does she need it? "In case something goes wrong." What could go wrong? "Oh, you won't believe how many things often go wrong!" - she laughs bitterly and then visibly hyperventilates. What for instance? She'd rather not think about it. "One, three, five..." - she is counting again, trying to allay her inner turmoil.

Why is she counting odd numbers? These are not odd numbers, but prime numbers, divisible only by themselves and by 1( * ).

I rephrase my question: Why is she counting prime numbers? But her mind is clearly elsewhere: am I certain that the office isn't reserved by another therapist for Thursday? Yes, I am certain, I checked with the clinic's receptionist before I rescheduled. How reliable is she, or is it a he?

I try a different tack: is she here to discuss logistics or to attend therapy? The latter. Then why don't we start. "Good idea" - she says. Her problem is that she is overloaded with assignments and can't get anything done despite putting in 80 hour weeks. Why doesn't she get help or delegate some of her workload? She can't trust anyone to do the job properly. Everyone nowadays is so indolent and morally lax.

Has she actually tried to collaborate with someone? Yes, she did but her co-worker was impossible: rude, promiscuous, and "a thief". You mean, she embezzled company funds? "In a way". In what way? She spent the whole day making private phone calls, surfing the Net, and eating. She was also slovenly and fat. Surely, you can't hold her obesity against her? Had she eaten less and exercised more, she wouldn't have looked like a blob - demurs Magda.

These shortcomings aside, was she an efficient worker? Magda glowers at me: "I just told you, I had to do everything by myself. She made so many mistakes that often I had to retype the documents." What word processing software does she use? She is accustomed to the IBM Selectric typewriter. She hates computers, they are so unreliable and user-hostile. When "these mindless monsters" were first introduced into the workplace, the chaos was incredible: furniture had to be moved, wires laid, desks cleared. She hates such disruptions. "Routine guarantees productivity" - she declares smugly and counts prime numbers under her breath.

______________

( * ) Well into the middle of the previous century, 1 was considered a prime number. Currently, it is no longer thought of as a prime number.

This article appears in my book, "Malignant Self Love - Narcissism Revisited"

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APA Reference Vaknin, S. (2009, October 1). The Obsessive-Compulsive Patient - A Case Study, HealthyPlace. Retrieved on 2024, April 30 from https://www.healthyplace.com/personality-disorders/malignant-self-love/obsessive-compulsive-patient-a-case-study

Medically reviewed by Harry Croft, MD

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Case Report: Obsessive compulsive disorder in posterior cerebellar infarction - illustrating clinical and functional connectivity modulation using MRI-informed transcranial magnetic stimulation

Urvakhsh Meherwan Mehta Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Writing – Original Draft Preparation, Writing – Review & Editing Darshan Shadakshari Roles: Data Curation, Investigation, Resources, Writing – Review & Editing Pulaparambil Vani Roles: Data Curation, Investigation, Methodology, Supervision, Writing – Review & Editing Shalini S Naik Roles: Methodology, Project Administration, Writing – Review & Editing V Kiran Raj Roles: Data Curation, Formal Analysis, Visualization, Writing – Review & Editing Reddy Rani Vangimalla Roles: Data Curation, Formal Analysis, Visualization, Writing – Review & Editing YC Janardhan Reddy Roles: Supervision, Writing – Review & Editing Jaya Sreevalsan-Nair Roles: Formal Analysis, Investigation, Visualization, Writing – Review & Editing Rose Dawn Bharath Roles: Conceptualization, Formal Analysis, Investigation, Methodology, Supervision, Visualization, Writing – Review & Editing

This article is included in the Wellcome Trust/DBT India Alliance gateway.

Obsessive Compulsive Disorder, Cerebellar cognitive affective syndrome, Neuromodulation, Functional brain connectivity, Cerebellar infarct, Theta burst stimulation

Revised Amendments from Version 1

The new version provides more clinical details about the patient, in response to the review comments raised. These include details and justifications for past treatment, iTBS treatment details, rationale for performing an MRI scan and follow-up information beyond the earlier reported period of three months.

See the authors' detailed response to the review by Shubhmohan Singh See the authors' detailed response to the review by Peter Enticott

Introduction

Cortico-striato-thalamocortical circuitry dysfunction is central to an integrated neuroscience formulation of obsessive-compulsive disorder (OCD) 1 , 2 . However, more recent large-scale brain connectivity analyses implicate the role of the cerebello-thalamocortical networks also 3 . Here, we report a case of OCD secondary to a cerebellar lesion. We test the mediating role of the cerebellum in the manifestation of OCD by manipulating the frontal-cerebellar network using MRI-informed transcranial magnetic stimulation (TMS).

Case report

A 21-year-old male, an undergraduate student from rural south India, presented to our emergency with suicidal thoughts. History revealed three years of academic decline, pathological slowness in routine activities (e.g., bathing, eating, dressing up, and using the toilet), repetitive ‘just-right’ behaviors (e.g., wiping his mouth after eating, clearing his throat, pulling down his shirt, mixing his food in the plate and walking back and forth until ‘feeling satisfied’). As a result, he spent up to three hours completing a meal or his toilet routines. Before presentation to us, he had received trials with two separate courses of electroconvulsive therapy (ECT) – six bitemporal ECTs at first, followed by nine bifrontal) spaced about two months apart. ECT was prescribed because of a further deterioration in his condition over the prior 18-months, with reduced oral intake, weight loss, grossly diminished speech output, and passing urine in bed (as he would remain in bed secondary to his obsessive ambitendency, as disclosed later). His oral intake and speech output improved with both ECT treatments, only to gradually worsen over the next few weeks. Given the potential catatonic phenomena (withdrawn behaviour and mutism) in the background of ongoing academic decline, slowness and stereotypies, he was also treated with oral olanzapine 20mg for eight weeks and risperidone 6mg for six weeks with minimal change in his slowness and repetitive behaviors. He did not receive any antidepressant medications. Psychotherapy was also not considered given the limited feasibility due to the severe withdrawal and near mutism. We could not elicit any contributory clinical history of prodromal or mood symptoms from adolescence when we evaluated his past psychiatric and medical history. Two months after the last ECT treatment, he presented to our emergency services with suicidal thoughts. He was admitted, and mental status examination revealed aggressive (urges to harm himself by jumping in front of a moving vehicle or touching electric outlets) and sexual obsessions with mental compulsions and passing urine in bed (as he could not go to the toilet in time due to obsessive ambitendency). The Yale-Brown Obsessive-Compulsive Scale (YBOCS) severity score was 29 4 . He had good insight into obsessions, but not the ‘just right’ repetitive behaviors; it was, therefore, challenging to engage him in psychotherapy. We treated him with escitalopram 40mg and brief psychoeducation before being discharged. After three months, his obsessions had resolved, but pathological slowness, ‘just right’ phenomena, and passing urine in bed had worsened (YBOCS score 31).

We then obtained a plain and contrast brain MRI, to rule out an organic aetiology given the atypical nature of symptoms (apparent urinary incontinence) and the poor treatment response. The MRI revealed a wedge-shaped lesion in the right posterior cerebellum, suggestive of a chronic infarct in the posterior inferior cerebellar artery territory ( Figure-1A ). MR-angiogram revealed no focal narrowing of intracranial and extracranial vessels. Electroencephalography, cerebrospinal fluid analysis, autoimmune and vasculitis investigations were unremarkable. Echocardiogram was normal and the sickling test for sickle cell anemia was also negative. We specifically inquired about history of loss of consciousness, seizures or motor incoordination, but these were absent. His neurological examination with a detailed focus on cerebellar signs was unremarkable. The International Cooperative Ataxia Rating Scale (ICARS) score was zero. The Cerebellar Cognitive Affective Syndrome (CCAS) scale revealed >3 failed tests – in domains of attention, category switching, response inhibition, verbal fluency, and visuospatial drawing, suggestive of definite CCAS 5 .

Cerebellar lesion detection ( A & B ), its functional connectivity map ( C ) and MRI-guided transcranial magnetic stimulation delivery ( D ). Average blood oxygen level-dependent (BOLD) signal time-series were extracted from voxels within a binarized lesion-mask that overlapped with the right crus II ( 1A & 1B ). This was used as the model predictor in a general linear model to determine the brain regions that temporally correlated with the lesion-mask using FSL-FEAT 11 . The resultant seed-to-voxel connectivity map (z-thresholded at 4) was used to identify the best connectivity of the seed with voxels in the pre-supplementary motor area (pre-SMA; MNI x=3; y=13; z=58; 1C ). Six-hundred pulses were delivered as triplet bursts at theta frequency and 90% of the resting motor threshold (50 Hz; 2s on; 8s off) using a MagPro X100 (MagVenture, Denmark) device under MR-guided neuronavigation using the Brainsight stereotaxic system (Rogue Research, Montreal, Canada) with a figure-of-eight coil held with the handle in line with the sagittal plane, pointing toward the occiput to stimulate the pre-SMA site ( 1D ).

MRI-informed neuromodulation

Owing to inadequate treatment response and the possibility of OCD secondary to the cerebellar lesion, we discussed with the patient about MRI-informed repetitive transcranial magnetic stimulation (rTMS) and obtained his consent. The presence of a lesion involving a node (cerebellum) within the cerebello-thalamo-cortical circuit – a key pathway for error monitoring 6 and inhibitory control 7 – cognitive processes typically impacted in OCD prompted us to utilize a personalized-medicine approach to treatment. We acquired a resting-state functional-MRI echoplanar sequence (8m 20s; 250-volumes) in duplicate – before, and one-month after rTMS treatment on a 3-Tesla scanner (Skyra, Siemens), using a 20-channel coil with the following parameters: TR/TE/FA= 2000ms/30ms/78; voxel=3mm isotropic; FOV=192*192.

Image processing was performed using the FMRIB Software Library (FSL version-5.0.10) 8 . Figure 1 describes how we obtained a seed-to-voxel connectivity map to identify the best connectivity of the cerebellar lesion-seed with voxels in the pre-supplementary motor area (pre-SMA; MNI x=3; y=13; z=58) – a commonly used site for neuromodulation in OCD 9 . This area demonstrates connections with the non-motor (ventral dentate nucleus) parts of the posterolateral cerebellum 10 and contributes to error processing and inhibitory control along with the cerebellum 7 .

We augmented escitalopram with rTMS, administered as intermittent theta-burst stimulation (iTBS) to the pre-SMA coordinates ( Figure-1D ). Six-hundred pulses were delivered as triplet bursts at theta frequency and 90% of the resting motor threshold (50 Hz; 2s on; 8s off) using a MagPro X100 (MagVenture, Farum, Denmark) device under MR-guided neuronavigation using the BrainSight stereotaxic system (Rogue Research, Montreal, Canada) with a figure-of-eight (MagVenture MCF-B-70) coil held with the handle in line with the sagittal plane, pointing toward the occiput to stimulate the pre-SMA site. We hypothesized that iTBS 12 to the pre-SMA could adaptively engage the cerebellum lesion, with which it shares neuronal oscillation frequencies, and hence improve the disabling symptoms. He received 27 iTBS sessions, once daily over the next month. Following ten sessions, he began to show a reduction in his repetitive behaviors, and by the 15 th session, he acknowledged that his behaviors were irrational. The YBOCS severity score had reduced to 24 (~22.5% improvement), which remained the same, even at the end of 27 sessions of iTBS treatment. There was no change in the CCAS and ICARS scores. The clinical benefits remained unchanged until three months of follow-up. Subsequently, we observed a gradual reversal to pre-TMS symptom severity. Maintenance TMS was suggested but was not feasible due to logistic reasons and therefore he was initiated on oral fluoxetine that was gradually increased to 80mg/day, with which we observed minimal change in symptoms over the next four months.

Post-neuromodulation functional connectivity visualization

The pre- and post-rTMS scans 13 were parcellated into 48-cortical, 15-subcortical, and 28-cerebellar regions as per the Harvard-Oxford 14 and the Cerebellum MNI-FLIRT atlases 15 . Average BOLD-signal time-series from each of these nodes, obtained after processing within FSL version-5.0.10, were then concatenated to obtain a Pearson’s correlation matrix between 91 nodes, separately for the pre- and post-TMS studies.

We analyzed the two 91 × 91 matrices using the Rank-two ellipse (R2E) seriation technique for node clustering 16 ( Figure 2 ). This technique reorders the nodes by moving the ones with a higher correlation closer to the diagonal. Thus, blocks along the diagonal of the matrix visualization show possible functional coactivating clusters.

Rank-two ellipse seriation-based visualization of correlation matrix before ( A ) and after ( B ) rTMS treatment. The dotted-black boxes denote the cerebellar network and other connected networks, where the green boxes show the inter-network overlap. Thus, we see that the overlapped region in ( 2A ) has now transitioned to three different overlapped areas in ( 2B ), which shows the increase in the overlap between modular networks after treatment. Cerebellar nodes are denoted in black, cortical nodes in blue and subcortical nodes in green. The lesion node (right crus II) and the region of neuro-stimulation are given in red; R2E= Rank-two ellipse.

We observed (a) extended connectivity of the cerebellar network after iTBS treatment as evidenced through its diminished modularity – the larger cerebellar cluster/block had an increased overlap with both anterior and posterior brain networks as observed along the diagonal in ( Figure 2B ), and (b) formation of better-defined sub-clusters within the larger cerebellar cluster indicating improved within-network modularity of distinct functional cerebellar networks [e.g., vestibular (lobules IX and X) and cognitive-limbic (crus I/II and vermis)].

Conclusions

We illustrate a case of OCD possibly secondary to a posterior cerebellar infarct, supporting the role of the cerebellum in the pathophysiology of OCD 3 . That OCD was perhaps secondary to the posterior cerebellar lesion is supported by several lines of evidence. Firstly, there seemed to be a possible temporal correlation between the duration of OCD and the chronic nature of the cerebellar lesion. Despite the challenges in inferring a precise temporal relationship based on clinical history, the signal changes with free diffusion and atrophy indicated that the infarct was indeed chronic, supporting the symptom onset at about three years before presentation. Previous studies have indeed reported OCD in posterior cerebellar lesions 17 – 19 . Secondly, the clinical phenotype was somewhat atypical, characterized by severe ambitendency, precipitating urinary incontinence, and poor insight into compulsions along with comorbid CCAS. Thirdly, our patient was resistant to an anti-obsessional medication but improved partially with neuromodulation of the related circuit. The MRI-informed iTBS engaged the lesion-area by targeting its more superficial connections in the frontal lobe. The changes in clinical observations paralleled the changes in cerebellar functional connectivity – enhanced within-cerebellum modularity and expanded cerebellum to whole-brain connectivity.

This report adds to the growing evidence-base for the involvement of the posterior cerebellum in the pathogenesis of OCD. Drawing conclusions from a single case study and the absence of a placebo treatment will prevent any confirmatory causal inferences from being made. The opportunity to examine network-changes that parallel therapeutic response in an individual with lesion-triggered psychiatric manifestations not only helps mapping symptoms to brain networks at an individual level 13 but also takes us a step further to refine methods to deliver more effective personalized-medicine in the years to come.

Data availability

Underlying data.

Harvard Dataverse: PICA OCD Raw fMRI files NII format. https://doi.org/10.7910/DVN/X12BZD 20 .

This project contains the following underlying data:

- postTMS_fmri.nii (raw post TMS fMRI file)

- preTMS_fmri.nii (Raw pre TMS fMRI file)

Reporting guidelines

Harvard Dataverse: PICA OCD case report CARE guidelines for case reports: 13-item checklist. https://doi.org/10.7910/DVN/2XKSXL 21 .

Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

Written informed consent for publication of their clinical details and clinical images was obtained from the patient.

Acknowledgments

We thank our patient and his parents for permitting us to collate this data for publication.

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Comments on this article Comments (0)

Open peer review.

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Cognitive neuroscience

• Respond or Comment
• COMMENT ON THIS REPORT

Is the background of the case’s history and progression described in sufficient detail?

Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?

Is sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?

Is the case presented with sufficient detail to be useful for other practitioners?

• This is a very interesting case report, even without the intervention component (which itself is a fascinating approach to neuromodulation). I particularly appreciated the approach to regional (SMA)
• This is a very interesting case report, even without the intervention component (which itself is a fascinating approach to neuromodulation). I particularly appreciated the approach to regional (SMA) targeting, which involved resting state fMRI to detect functional connectivity with the affected cerebellar region. The report itself is very clear and well-written.
• ECT appears to have been provided in the context of a depressive episode, but were other (e.g., psychotherapy, pharmacotherapy) treatments initially trialled? It would be useful to present any clinical history from adolescence, although this may not be feasible.
• Please describe the reason for conducting MRI; why was this not undertaken earlier?
• Was iTBS the “standard” course (i.e., 600 pulses, trains comprising 3 pulses at 50 Hz, repeated for 2 seconds at 5 Hz, followed by an 8-second ITI)? How was intensity determined (e.g., 70%RMT, 80%AMT)? Specify the stimulator, coil type, and neuronavigation method.
• Given that the duration of both the cerebellar lesion and OCD symptoms seems quite unclear, it is somewhat difficult to suggest a temporal relationship (as stated in the Conclusion).
• Was the patient followed-up over a longer-term period? I would be interested to know if these improvements are lasting (i.e., longer than 3 months), although again this might not be possible. 

Reviewer Expertise: Neuromodulation, psychiatry

• Author Response 11 Sep 2020 Urvakhsh Mehta , Department of Psychiatry, National Institute of Mental Health and Neurosciences, India, Bangalore, 560029, India 11 Sep 2020 Author Response We thank this reviewer for the time taken to provide constructive feedback and the encouraging comments on this report.    Competing Interests: None We thank this reviewer for the time taken to provide constructive feedback and the encouraging comments on this report.    We thank this reviewer for the time taken to provide constructive feedback and the encouraging comments on this report.    Competing Interests: None Close Report a concern Reply -->

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Module 5: Obsessive Compulsive Disorder and Stressor Related Disorders

Case studies: ocd and ptsd, learning objectives.

• Identify OCD and PTSD in case studies

Case Study: Mauricio

Case Study: Cho

Possible treatment considerations for Cho may include CBT or eye movement desensitization and reprocessing (EMDR). This could also be coupled with pharmaceutical treatment, such as anti-anxiety medication or anti-depressants to help alleviate symptoms. Cho will need a trauma therapist who is experienced in working with adolescents. Other treatment that may be helpful is starting family therapy as well to ensure everyone is learning to cope with the trauma and work together through the painful experience.

Link to Learning

To read more about the ongoing issues of PTSD in violent-prone communities, read this article about a mother and her seven-year-old with PTSD .

Think It Over

If you were a licensed counselor working in a community that experienced a high rate of violent crimes, how might you treat the patients that sought therapeutic help? What might be some of the challenges in assisting them?

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Case Report

Case study of obsessive-compulsive disorder (ocd).

Muhammad Zafar Iqbal*

Department of Hypnotherapist and Psychotherapist, Islamabad, Pakistan

Corresponding Author

Muhammad Zafar Iqbal, Department of Hypnotherapist and Psychotherapist, Islamabad, Pakistan.

Received Date: April 05, 2019;   Published Date: May 08, 2019

Background: This document pertains of idiographic research; the case study of Obsessive-compulsive disorder (OCD). The objective of this case study was to reaffirm the efficacy of Fear-Stimuli Identification Therapy (FSIT). FSIT was used to eliminate the symptoms of OCD in a client, a successful treatment for disorders in different cases [1-8].

Method: Initially seven sessions of semi-structured interviews were conducted with client to dig out the reasons/causes of the disorder. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) was consulted for diagnosis [9]. Fear Stimuli Identification Therapy (FSIT) was used as therapeutic tool.

Results: After diagnosis, five sessions per week, a total of eighty-three sessions were conducted of FSIT. Positive behavioral change observed in client which proved the efficacy of FSIT.

Conclusion: Clinical observations during treatment indicated a gradual positive change in client’s personality. The client and her husband reported positive behavioral changes in different domains of life. The difference between pre-assessment and post- assessment confirmed precision of hypotheses and efficacy of FSIT.

Keywords: Obsessive compulsive disorder; Symptoms; Assessment; Case study; Idiographic

• Introduction

The subject of the disorder was Mrs. S.H. (Initials of real name), age 38 years, a Housewife. The client was referred to therapist clinic by a fellow psychologist from a metropolitan southern city. She had been under treatment of various psychiatrists and psychologists in her city, but the client did not improve. She contacted therapist online. Client reported about her compulsively repeating some acts in her daily life as obsession. She supposed that her mind was persistently occupied by some specific thoughts and her act of repeating some actions is a result of these thoughts. Therapist contacted her husband for more details about the behavior of client. Aggressive behavior, Sleeplessness, weeping without any apparent reason, Breath shortness, Uncontrollable thoughts, Repetition of some of her daily life acts Symptoms are reported by Client and her husband.

• Participants

Mrs. S.H, Client, Client’s Husband and Therapist.

• Instrument

No instrument/ Material used in this case study.

As already mentioned, in the first seven sessions, semistructured interviews were conducted with Mrs. S.H. and her husband. In the subsequent eighty-three sessions Mrs. S.H. was asked to write about specific topics suggested by therapist. Crossquestioning was carried out over the ideas mentioned in the writings by client. After diagnosis of OCD, treatment was started in the light of FSIT method. Five sessions per week were conducted and total of eighty-three sessions were conducted. It may be noted that all these sessions were carried out online [4].

Following facts were explored through initial interviews which were ‘Semi-structured’. These interviews revealed that at the age of 11 years, one day she (client) returned back from school in the company of her close friend N.S. After reaching home she and her parents received the shocking news of death of N.S. They were told that N.S. had eaten something poisonous and had died instantly. S.H., the client was shocked deeply. The incident of her friend’s death became a stimulant for fear instinct.

At the day of her funeral, she feared to see the face of her deceased friend and couldn’t enter the room where the dead body was laid. After the death of her friend another death happened that provoke more fear about the death. Her grandmother died six months later after her friend’s death. She, for the first time watched her grandmother’s dead body wrapped in white clothes which leaves bad marks on her memory that she stopped wearing white cloth especially white scarf or shawl for rest of her life.

Another incident happened after one year of marriage. Her father-in-law died in ambulance due to sudden attack. The ambulance became a stimulus for her fear. After developing death phobia, each death intensified the sense of fear in her unconscious mind. In the course of time she became a religious orator orator of a specific type as she used to narrate rhetorically upon the miseries and sorrows which had emerged from the unfortunate events of wars of Islamic history. By performing so, she felt some sort of relief as this became a source of catharsis for her. She was strongly obsessed by the idea of death that her mind often used to get stuck at the thought of her friend’s death. While doing random stuff she often found herself motionless due to the flashback of her friend’s death and to get rid from this obsession she used to force her mind to think of other things. Similarly, she taps her mobile phone with her fingers frequently while obsessing about her brother’s death. During one of Skype sessions she informed the therapist that after marriage she finds it more difficult to cope with the obsessive ideas.

Therapist and treatment

It is single case experimental study which is handled by only one therapist and after taking history, it was diagnosed that client was suffering from OCD and the treatment was carried out accordingly: As per procedure of SFW (specific free writing; one of procedures of FSIT), in very first session of treatment, client was asked to pen down her ideas freely on the topic “death”. She was asked to put a cross mark for each time whenever she feels stuck or blank-minded during writing process. The piece of writing was received by E-mail. She told that during the process of writing she felt burden at the occipital region of head and pain and burden on her shoulders. In the view of writing, client was cross-questioned over the ideas mentioned in the writing. After fifteen minutes, client went through a deep spell of drowsiness. The session was ended at this point. This drowsiness continued in the next five sessions during questioning over her writing. The extreme hate for and fear of her own death which had previously gripped her unconscious level of mind was identified and brought out clearly as it had been suppressed by patient’s unconscious for a very long time in past. Next topics given to write about were: “White shawl” (considered as coffin), “Bathing place” for a dead person at holy shrine, the “couch” upon which dead body is laid down after bath, “Ambulance”, “Funeral Bus” and “Thoughts about dead persons”. During writing practice, same mental and physical response was reported each time as it was observed first time that was a result of unconscious resistance to express fears. The thoughts of “white shawl”, “coffin” and ambulance etc caused the fear of her own death and ultimately became reason for OCD. In last sessions of treatment, the mentioned above things were rooted out and recovered from OCD.

The symptoms of disorder gradually removed during therapy. Feedback obtained from husband & client was obtained regularly which indicated the positive changes in client behavior of. Result also proved the efficacy of FSIT method empirically.

Brief description of a client’s social and family environment was obtained in order to comprehend the main causes of Mrs. S.H.’s disorder and this procedure is adopted in most of the cases treated by therapist. In this particular case following information came into knowledge of therapist. Mrs. S.H. was 38 years old, housewife and a lecturer in college. However, due to lack of concentration, disturbed sleep and unreasonable repetition of different acts of routine, her daily routine was badly affected, and it made her much depressed and disappointed. Mrs. S.H. was not much social person since her childhood. She had always tried to avoid social gatherings and people. After starting the problem of OCD, her social life became more difficult. It made her more depressed, but interestingly and contrarily, she had managed to carry out routine life activities as above the level of an ordinary social individual. She had been performing as an orator at religious gatherings. But she always avoided elaborating over the topics of death and afterlife in her speeches. No family history of OCD or any other psychiatric disorder was found and she. had no special medical/psychiatric problems in her childhood [10].

Fear Stimuli Identification Therapy (FSIT): Fear-Stimuli Identification Therapy (FSIT) is based upon the perception that some of the incidents (mostly the sudden incidents) in the early age of a child become stimuli for fear instinct which cast negative effects over the personality of a child and become reason for one or the other type of disorder. FSIT investigates and digs out such events from a person’s unconscious, which play as stimuli for fear instinct. In a later stage of life, if a person happens to face a situation or pass through an event having resemblance to that which he/ she had already faced in her/his childhood or early age of life, the present event becomes a strong stimulant for fear instinct as the previous incident is recalled.

Feedback & Clinical observations during treatment also indicated a gradual positive change in her personality. The difference between pre-assessment and post- assessment confirmed precision of hypotheses and efficacy of FSIT. Feedback was obtained on weekly basis for a period of three was confirmed that there was no reoccurrence of the disorder’s symptoms anymore.

• Acknowledgement
• Conflict of Interest

No conflict of interest.

• Ejaz M, Iqbal MZ (2016) Case Study of Major Depressive Disorder. J Clin Case Rep 6: 698.
• Iqbal MZ, Awan SN (2016) Case Study of Genophobia and Anxiety. J Depress Anxiety S2: 013.
• qbal MZ, Bibi S (2017) Case Study of Panic Attacks. J Psychol Psychother 7: 306.
• Iqbal MZ, Bibi S (2016) Treatment of Psychosis through Fear-Stimuli Identification Therapy (FSIT): A Case Report. Brain Disorders & Therapy 5(3): 221-224.
• Iqbal MZ, Ejaz M (2016) Case Study of Schizophrenia (Paranoid). J Clin Case Rep 6: 779.
• Iqbal MZ, Ejaz M (2016) Case Study of Functional Neurological Disorder (Aphonic). J Psychol Psychother 6(1): 243.
• Iqbal MZ, un Awan SN (2016) Case Study of Major Depression. J Med Diagn Meth 5: 214.
• Iqbal Z (2015) Case of Anxiety. J Psychol Clin Psychiatry 2(4): 79.
• American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders (DSM-IV-TR). Washington DC, USA.
• Muhammad Zafar Iqbal (2017) Case study of Obsessive-Compulsive Disorder (OCD). Journal of Behavioral Health 6(2): 99-102.
• Download PDF
• DOI: 10.33552/OJCAM.2019.01.000509
• Volume 1 - Issue 2, 2019
• Open Access

Muhammad Zafar Iqbal. Case Study of Obsessive-Compulsive Disorder (OCD). On J Complement & Alt Med. 1(2): 2019. OJCAM. MS.ID.000509.

Obsessive Compulsive Disorder, Symptoms, Assessment, Case Study, Idiographic, Therapist, Spirituality, Preventive, Health care, Physical fitness, Spiritual exercises, Soul, Human values, Stress, Complementary Medicine, Holistic education, Phenomenological study, Holistically, Facilitate, Spiritual care, Trigger depression, Spiritual work

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Case Study of an Adolescent Boy with Obsessive Compulsive Disorder

Susan S. Woods, Ph. D.

Youth Services, Department of Psychiatry, University of Michigan

P.Q. is a boy from Ohio, thirteen years, nine months of age. He was admitted to

Children’s Psychiatric Hospital on an emergency basis on 28 March 1975. He had

been noted by both parents to have had increasing emotional difficulties since the

previous summer. Thes.e became worse during the week prior to .his admission. His

symptoms were primarily of an obsessive ritualistic nature involving repetitious

behavior, compulsive repetitive hand washing, and gradual elaboration of rituals

around bedtime. During the week before admission he was described as

“immobilized to the point that he cannot get out of bed”, spending the larger part of

his waking hours in rituals, and being generally unable to function. His primary

symptom on.admission was that he found members of his family and certain objects

“germy” and was therefore “unable to deal with them” His father believed the

problem began in mild form during the previous summer, following a visit to his

maternal grandmother. One incident during this visit involved a trip to a

convalescent hospital, with P. subsequently being concerned and upset by sick or

damaged people, He started then by being unable to wear certain clothing because

“it was contaminated.” As time went by, areas of the house became off-limits to

him. Similarly, he felt that one of his stepbrothers “was unclean” (germy), a situation

that soon extended to all the members of the family. They were all felt to be

contaminated, with the exception of his father. His stepmother however felt that P.

had been having difficulty for a substantially longer period of time. in fact, it seems

that his symptoms had been apparent to some degree for several years, having

started some months after his mother’s death. The stepmother described the

appearance of what proved to be a long series of “strange habits” about five years

earlier during the summer. For instance, he began hopping every so many steps.

That was followed by repetitive smelling of the table and the walls, eye-blinking,

head-jerking and pausing with hands in

148 Obsessional Neuroses

praying position before entering rooms. Simultaneously, his peer relationships

deteriorated and for a year or so now his brothers and stepbrothers had been teasing him

about this behavior. More recently they had developed a strong hatred of him. Further, his

symptoms had been increasing very noticeably for the five months previous to the referral

to this institution. Thus, shortly before this happened, the Q.’s received a call from P.’s

school one evening stating that P, had been trying to get through the door and out of his

classroom for a period of over two hours. This Fall P. was referred for evaluation

somewhere else, and therapy was recommended and begun on a weekly basis with a

psychologist affiliated with the Department of Pediatrics of Ohio State University.

Three weeks prior to his admission here P. reported that he had “lost the key” to his

mental processes. His parents were uncertain as to the meaning of this and could think of

no precipitating events either within the family or with P.’s personal life.

Dr. and Mrs. Q. (P.’s stepmother) were eager for adMission at Children’s Psychiatric

Hospital and it has subsequently become obvious that they are relieved by his absence and

reluctant to have him rejoin the family unit. The Q.’s are involved in marital therapy at the

present time in Ohio, the marriage having become very rocky as a result of the stresses of

P.’s psychopathology.

P. expresSed concern upon admission that there would be retarded or weird children at

C.P.H. He was relieved after seeing the place because he saw no “weirdos” and found the

hospital to look “very clean.”

From the beginning P. has had a generally positive attitude toward admission, seeing it

as “the only way to get rid of my problem.” He can be expected at times to resent the

family’s splitting him off or scapegoating him as the one with the problems,

Description Of The Child

P. is a small, thin adolescent who has been described as an, Oliver Twist type. Indeed

he often walks around with a haunted expression, hair falling into his eyes, shirttail

hanging out, holes in.

hiS pants, etc.

Clinical Examples 149

He hardly gives the impression of a. compulsive personality, judging from his unkempt

appearance. There have been occasions when he takes care as to how he looks. These

times usually accompany a trip home or an outing with his family where he has enjoyed

Upon admission most of his clothes were rather old and shabby. He explained that he

had plenty of “cool” clothes but that they became germy after his trip to his grandmother’s

home. Finally P. was having to use safety pins to hold his pants together, wore no socks

and had large holes in his sneakers (the only shoes he would wear). He was upset, crying

when the staff finally felt that his father should be approached to ask him to buy P. some

new clothes. Dr. Q. was angry and somewhat embarrassed, explaining that P. had many

new articles of clothing including new shoes but to his and the family’s endless frustration

P. wouldn’t wear them. Dr. Q. finally bought P. some trousers and socks and a new pair of

sneakers. P. was amazed and overjoyed that his father had bothered to buy him clothes

and had spent so much money on him.

Generally P.’s behavior in the various areas of the milieu were consistent. Upon arrival

everyone was concerned about his need for repetition; for example, on his first morning at

breakfast he felt a need to throw away and retrieve his milk carton numerous times,

stating he had to “think right.” Showers and bedtime preparation were another source of

concern, often consuming the better part of the evening. Any attempt to interrupt the

rituals or hurry P. were met by his whining and crying that people didn’t understand him

or his problem. A staff member commented that he had rarely seen such pain in another

human being.

Group activities in the school and with his ward group also became problematic.

Briarwood Mall (a large, new shopping center near the hospital) for example was germy

because it was so “modern and weird.” The arboretum later became off-limits because it

bordered a cemetery. Most recently anything related to magic i.e., the color black,

sparkles, glitters, psychodelic posters, record album covers, or book covers, movies about

ghosts or witches, have produced enormous fear and given P. difficulties when trying to

“think right.”

Classroom behavior has been good and appropriate for the most part with occasional

problems with some students. After Passover P.

150 Obsessional Neuroses

developed an intense interest in Judaism, making a Star of David in Occupational

Therapy and wearing it around his neck. For a time another class member drew swastikas

on the blackboard, During TB’s vacation this rivalry became so intense that P. spent most

of his class time in the hall voluntarily and began to carry a transitional object, a ceramic

bunny, which he had made in Occupational Therapy. In P.’s Occupational Therapy group

he is the oldest member the other children ranging from ages eight to ten. The group has

changed from five to three members since P. was admitted. It is reported that P.’s

intelligence, gross and fine motor skills and creativity all appear to be age appropriate or

higher. Initially P. did not accomplish much, He spent much time•perfecting his projects.

The planning and organizational aspects of. the project were difficult for P. For example,

he wanted to make a Star of David and it was suggested to him to bend the wire to the

desired angles. He rejected this suggestion and became involved in finding a mathematical

formula to approach the problem. P. spent the remainder of the hour, approximately thirty

minutes, attempting to devise a mathematical formula. He became anxious and frustrated

with being unable to solve the problem. The next day however he was able to enter the

shop and just bend the wire to the desired angle, This seems to be P.’s approach to

problems—many times he must try to find a means of ordering or perfecting a project

before he is able to work at a more appropriate pace.

Initially P. remained apart from the group. He appeared very anxious and withdrawn.

He spoke only when addressed and interacted minimally with other group memberi. As he

became more comfortable with the others he began to interact more. He appeared to be

more at ease and seemed to enjoy the group. It appears that this group of younger children

allows him to regress to behavior inappropriate for his age i.e., making animal noises etc.

P. approached his occupational therapist on several occasions, asking about her

family and her. practice of Judaism. These conversations were precipitated by her

announcement to the group that she was taking several days off for Passover. Of late there

have been no questions concerning Judaism.

P.’s concern about a family have been brought up on a number of occasions in the

group. Once he made a family of ceramic rabbits and in a childlike manner stated “a

family—isn’t that cute?”

Clinical Examples 151

Generally P. relates N,vell to ward staff and peers and is not considered a behavior

P,’s relationship to two of his ward staff have been significant. K. and J. became

vehicles for P.’s lingering phallic-oedipal conflicts, and were loved objects. P.

frequently told K. that he wanted J. to tuck him in at night, He became anxious when

he discovered his liking for J. was greater than that for K., and he found it difficult to

understand that both could be loved .in different ways at the same time.

After K. left, P.’s liking for J. as a maternal object developed into a “crush.” He

discussed her constantly in therapy, voicing his anger after learning she was married

but seeing how futile his desires were because “she is a lot older than me,” He wanted

to be “mature” to win her attention.

During J.’s vacation P. decided that she was germy since she flew through the

“Bermuda Triangle.” Their relationship was over as far as P. was concerned. P. also

knew thatbpon J.’s return she would become a primary staff and thus have relatively

little to do with him, He attempted to leave her before she left him.

Family Background and Personal History

Mother: P.’s mother, H.Q., is deceased. A slim, dark-haired woman, she married P.’s

father in 1952, and suffered a reactive depression upon leaving her mother. After the

birth of each child except P. she suffered post-partum depressions. At each of these

times Mrs. Q.’s mother would come to aid her daughter. Mrs. Q. felt her mother could

“magically” help her to improve. Mrs. Q.’s mother was described in one report as an

“aggressive unloving woman. Mrs. Q. seemed to thrive on her criticism.”

Mrs. Q. was admitted to N,P,1. on four separate occasions for severe anxiety and

depression, She was expecting P. during her fourth hospitalization. This is a part of

the report of her psychiatrist:

If I were to speculate on some of the psychodynamics, I feel that unconsciously

Mrs. Q, felt she won the oedipal struggle against her mother. The patient’s mother is

a very hostile and aggressive woman who constantly yells and degrades the patient.

Mrs. Q. felt that she

152 Obsessional Neuroses

must have done something wrong and therefore felt guilty. We can see that since

childhood and especially since the patient has been married any symbolic libidinal or

aggressive energy (such as buying a house, having children, etc.) makes the patient

very anxious and depressed as a reaction to her guilt and she seeks the reassurance and

acceptance of her mother via the mother’s hostile and degrading comments. The patient

described a very hostile, symbiotic, sadomasochistic relationship that she had with her

mother. She felt she always had to go to her mother who in turn would berate and

belittle her, in order that Mrs, Q. should feel that she was still loved and accepted by

her mother.

The patient went on to describe that she would even provoke situations as a a child

which would ’cause her mother to yell at her and this would reassure the patient that

her mother still “cared for her,” Mrs. Q.’s mother exhibited both overtly hostile and

passive aggressive attitudes toward the child and the only way that Mrs. Q. could

retaliate was in her own passive-aggressive way by dawdling or doing things just the

opposite from the way that her mother wished.

During her hospitalization Mrs. Q. expressed suicidal thoughts and fears of harming

her children.

During her last pregnancy (P.) Mrs. Q. was told by her mother that she should never

have any more children because she couldn’t care for the ones she already had.

. Mrs. Q. went to her father as a child for emotional support and felt he loved her more

than he did his wife.

Mrs. Q. had a sister whom she viewed as “the bad daughter” and felt she had to be “the

good daughter.” Mrs. Q.’s sister has also been hospitalized for depression.

Mrs. Q. was always involved in aggressive battles throughout her life. In college she

and her husband-to-be were in the. same class. She was the valedictorian and he the

salutatorian. She went on to obtain a master’s in chemistry. On her third admission to the

psychiatric ward she talked about her husband’s attitude, stating he felt her

hospitalization was not necessary and that she was taking the easy way out.

Mrs. Q. was tremendously conflicted about motherhood. She felt

Clinical Examples 153

One can assume that during this period there was little emotional energy for nurturing

the young children in. the home.

she was still a child and wanted to be a child, Mother’s Day was apparently an enormous

symbol for her. She was admitted once just before Mother’s Day complaining that she

“couldn’t handle her life.” On another admission she became “preoccupied”, staring into

space and complaining of being frightened after a conversation among the patients

regarding Mother’s Day.

On Mother’s Day 1970 Mrs. Q. took an overdose of barbiturates and died two days

Father: R.Q. is a forty-five-year-old physician somewhere in the State of Ohio. He and

his wife were both originally from Boston where they met and married while attending

the university.

The couple moved several times early in the marriage, to Arizona, New Mexico, and

finally to Detroit, where Dr. Q. completed his residency in medicine..

Dr. Q. was seen twice on Mrs. Q.’s first admission in 1960. He was quite anxious and

seemed uncomfortable. He also seemed depressed and agitated, stating that he was unable

to concentrate on his work. He intellectualized -a great’ deal, saying that he thought his

reaction was a typical one to a depressed wife. He added that he was quite ldnely and did

not like being away from his wife. He felt that if he could be with her he could be

supportive of her as he had been in the past. Dr. Q. felt that the only person he could

accept reassurance from was a doctor who was treating his wife. Dr. T. (wife’s therapist)

called Dr. Q. daily to support him and tell him of his wife’s progress. Dr. Q.. felt that this

was not very effective in easing his anxiety but that it was all he had to hold onto. Dr. Q.

also stated that when his wife was depressed he felt depressed too and when she felt better

he felt better. The report of the treating psychiatrist goes as follows:

The highly interdependent nature of the relationship described above was confirmed

by Dr. Q.’s statements to me that he thinks his own willingness to be constantly

available to his wife tended to feed her dependency on him and that the two of them

seemed locked ,together in the ups and downs of this depressions

154 Obsessional Neuroses

Dr. Q. placed a great deal of emphasis on the kind or quality of therapy his wife

might be receiving. He was concerned that she be treated by a staff psychiatrist rather

than a resident, He resented seeing a social worker about-his adjustment to his wife’s

illness. Remnants of this are still visible in Dr. Q.’s wondering why neither he nor P.

saw psychiatrists at C.P.H. He asked about his son’s therapist’s credentials. P. too

shares these feelings, frequently asking what a social worker is, what M. S. W. stands

for, and on one occasion commenting that he believed his therapist could probably

help him as well as a senior psychiatrist. Dr. Q. is a rigid, obsessive-compulsive

character himself. This became evident in his endless ramblings from subject to

subject during the time of history taking. It was impossible for him to get through

recounting a simple event without trying also to include every minute detail of his

association to the event. He feels that his memory is poor and confused and he never

ends satisfied that he has really told the story “right.” He described himself as having a

“stubborn streak.”

Stepmother: This is the report of the parent’s therapist: During the summer

following P.’s mother’s death, – Dr. Q. arranged for a housekeeper, now Mrs. S. Q , to

come into the home. She had just divorced her first husband and was supporting three

sons from her first marriage. Her sons were away at camp during the first few weeks

after she came to the job, and she recalls that P. was the first of the Q. boys to make

friends with her, She had a great deal of time to devote to P. during these weeks and it

was only when her own children returned that she and Dr. Q. began going together. P.

then began to distance himself from her, When the marriage became imminent the

following fall, P.’s siblings reacted quite angrily and P.’s more quiet reaction seemed to

go unnoticed. Following the marriage P. became more and more withdrawn. He

especially had difficulty accepting her youngest son, who is described as being quite

different from P., i.e., rough and aggressive.

The family moved in 1971 to Toledo, where Dr. Q, practices. P.’s siblings were very

unhappy about the move and again their more obvious behavior pushed P.’s into the

background. One had problems in school and another became very depressed. O. cried

frequently, withdrew, developed colitis. At his school’s suggestion a began

Clinical Examples 155

psychiatric treatment of problems described as “similar to P.’s.” This treatment has

been ongoing to the present time. Mrs. Q. described the relationship between herself

and 0. at that time as very poor. 0. is described as being much like his mother, the first

Mrs. Q., bright and close to his dad. P. was closest to 0. of all his sibs and would often

try to emulate him (this relationship has now dete’riorated to the point that the boys

rarely speak). As relationships became more strained throughout this period it was

more and more difficult for Dr. and Mrs. Q. to communicate with each other about the

children. In 1971 the Q.’s daughter, B., was born. According to both parents her birth

was greeted quite positively by the older children. Currently B. is the only sibling

within the family with whom P. is willing to interact on his home passes and she is the

only child who inquires when he is coming home.

Developmental history: P.’s mother was hospitalized at N,13

.1, for the third and

fourth time during her pregnancy with P., for symptoms . of anxiety and depression.

She was admitted and discharged in May of 1961 and readmitted in June of 1961. Just

before Mother’s Day in 1961 she phoned her psychiatrist and described suicidal

thoughts. This pregnancy was obviously a strain for Mrs. Q. and increased her fears of

inadequacy about motherhood.

P. Was born two weeks early as was the pattern of all Mrs. Q.’s children. Labor

lasted one hour and ten minutes. P. was a six-pound, eleven-ounce infant delivered

under caudal, anesthesia. Mrs. Q. recovered quickly with no complications for either

mother or son. P. was breast-fed.

from birth and follow-up interviews with Mrs. Q. at

N. P.1. found she experienced this as pleasant and took pride in the care of her infant.

P. was described as a peaceful sleeper and he slept completely throughout the night

very early .on.

P. developed atopic dermatitis which Dr. Q. described as a red rash occurring in the

creases of his body. He said that P. did not seem to be uncomfortable with this. For

several weeks P. was put on a special diet in an attempt to determine the source of his

allergy. Dr. Q. again recalls no difficulty or food refusal during this time and the

special diet was finally stopped as the pediatrician seemed to feel it was not helping

diagnostically.

Dr. Q. says that he recalls very few specifics regarding the P.’s age at

156 Obsessional Neuroses

the various early developmental milestones, However he feels that P. accomplished most

things just a bit earlier than his two older brothers. For example, he believes his son held

his head up quite early, was responsive to external stimuli and began picking up. and

playing with crib toys at a very early age. Although he cannot recall when P. was weaned

it seems that it was fairly early and he does recall that by the age of one P. was feeding

himself, While recounting this history Dr, Q. often interjected that he recalled his wife

being troubled and anxious and on’many occasions emotionally tied up within herself. He

says that even though Mrs. Q. took good physical care of the children he feels now that

they probably were emotionally, neglected.

P. toilet trained himself at age two and half “almost overnight,” Dr. Q. does not recall

the development of P.’s speech but does remember that once he began talking he talked

almost incessantly. P, rarely played with children his own age, preferring to spend his

time with adults or playing with his older brothers,. When P. went to

kindergarten at age five, Dr. Q. recalls him telling long stories about what had happened

at the end of the day. He also recalls himself and P.’s mother being amused at what a long

story P. could make out of a very small event. The father remembers no difficulty in

separation from Mrs. Q. when P. began kindergarten.

The following information was learned from the second Mrs. Q.: Mrs. Q. said that by

the time she met P, at age seven almost all of his interests and interpersonal relationships

centered on adults. He struck her as being a very dependent but cooperative child. She

even described Him as “a model child.” She recalls that he always liked to have his things

in order although he was not really fastidious. It was always quite difficult for him to get

off to school•in the mornings as it was quite a chore to get through all of his routines. By

the age of twelve P,’s compulsive mannerisms and rituals had become a point of great

contention between him and his siblings. Mrs. Q. remembers that approximately ten

months prior to P.’s hospitalization his brothers began to noticeably withdraw from him

and make fun of him. Before long all of the siblings seemed to be angry with P. It was

also during this year, fall of 1973, that P,’s grandfather died. Although the parents would

not characterize P.’s relationship with his grandfather as a close • one, he did visit with the

grandparents annually and seemed to greatly

Clinical Examples 157

enjoy walking downtown with his retired grandfather and being a part of the

interaction with all of his grandfather’s “old cronies.” When the grandfather died the

maternal grandmother sent • the grandfather’s personal watch to O. rather than to P.

Dr. Q. •stated somewhat resentfully that this was typiCal of his former mother-in-law,

that is, to be more interested in a tradition of giving a gift to the oldest grandchild

rather than giving it to the one who had been closest to her husband.

The summer prior to this hospitalization all three of the older Q. boys were invited

to visit the grandmother. True to form, •only P. accepted the invitation and remained

with the grandmother for about three weeks. .Upon his return from this trip Mrs. Q.

states that she began really pushing for help for P.

Possibly Significant Environmental Circumstances

Timing of the Referral: The timing of the referral seems to have coincided with the

severe manifestation of the obseSsive compulsive neurosis, however the problem in

earlier more manageable stages seems to have been present for some time longer.

Since P. often has difficulties determining when events happened and how long he has

experienced difficulty, both the extent and duration of his symptoms are still

unknown, He believes, however, in agreement with his father, that the major

disturbance began last Summer after a visit to his maternal grandmother in

Connecticut.

This visit was an event for P. each year.. He was the only grandchild who enjoyed

these trips to Connecticut and last summer he went alone. This was P.’s first trip to his

grandmother’s after his grandfather had died of a heart ‘attack a year before. P. had felt

very close to his grandfather, more than to his grandmother whom he described as

“mean and al vays telling me what to do.” It is significant that P. was concerned to

maintain the ties with his mother’s parents. P. is also the only child who wants to

practice Judaism, something which is frowned upon by the rest of the family but

which was highly regarded by P.’s mother, It seems P. is trying very hard to keep his

mother alive in a sense by holding onto the significant objects in her life.

Causation of the Disturbance: Four areas can be delineated as causally significant:

1.158 ObsessionalNeuroses

2. The mother’s suicide. H.Q.’s suicide is a pivotal issue in P.’s psycho- pathology. He failed to mourn her loss, fearing that to express his feelings would be

against his father’s wishes. He is now engaged in the draining process of keeping

her alive (which he believes his father, a physician, failed to do) by holding onto

her traditions. as previously mentioned, Significantly P.’s stepmother is neither

Jewish nor religious and he resents the fact that the family has given up all Jewish

traditions. A particular blow came on P.’s thirteenth birthday when his father

offered him money and said that would take the place of being bar rnitzvahed. P.

felt this cheapened what is to him an important event – symbolizing his “becoming a

man.”.

In therapy P. had tremendous difficulty remembering his mother or any experiences

they shared. He vividly remembered, however, the day she died and described it several

times. The most significant aspects seem to have been when his mother was taken to the

ambulance. She opened her eyes for a second and looked at P. He also remembered how

angry his father became when P. told a neighbor that his mother was

1. The father’s remarriage. P. was initiallS

, warm and accepting of the present

Mrs. Q. before she married his father. After the marriage their relationship

deteriorated, She describes P. as acting like “a twoyearTold.”

The division between old family and new has continued to worsen. P. cannot accept

his stepbrothers especially now that they “have changed.” What this change entails

is their move into adolescence with a concommitant increase in foul language, rough

behavior and less care in personal hygiene.

1. The father-son relationship, ,In one session, P. described his relationship

with his father as being like the song, “Little Boy Blue and the Man in the Moon,”

where a little boy all through his life asks for time with his father but the father is

always too busy. Later the father retires and wants to be with his son but the son by

that time has his own life and says he’s too busy to see his father.

P. has tremendous difficulty expressing his feelings to his dad. He perceives him as

all-knowing and all-powerful but very inaccessible. P. is visibly elated by the grief times

he spends with his father but it seems he does not convey this when he is actually with

his father. Dr. Q. describes P.’s behavior when they are together as passive, bored and

Clinical Examples 159

angry toward sibs. When P. and his father are together they talk about science. P becomes

anxious when he runs out of things to say to his dad. (This happens in therapy too.) He

needs a mental script Well planned out before he feels comfortable.

Dr. Q. is a rigid, authoritarian person who seems to have provided an atmosphere

where P.’s feelings could not be exhibited. Childish emotions of glee or anger were

scorned. To show them meant to risk rejection and withdrawal of IOW. P. learned from an

early age to control himself, to measure up, to be adult in order to obtain parental

acceptance.

4. Adolescence. P. wants to be a man but fears outdoing his dad. He has tried to avoid

any competition with him so far, Now he is beginning to see that his father may have

problems but at the same time he has decided that all doctors are perfect and able to

overcome all difficulties.

Physically P. is small and underdeveloped. This concerns him because he wants to

be strong so he can “beat people” in games and frequently taLks of beating people up

when they upset him.

He likes to be with younger children so he can be superior but resents their childish

Adolescence has also raised the unresolved oedipal issues which are central to P.’s

difficulties.

Possibly Favorable Influences: P. is a bright, interesting, and interested child. He

relates well to peers and staff and relates warmly to particular staff, mainly women. He is

an attractive . child and is frequently described as cute.

His interests are varied and socially he is quite sophisticated.

His parents though severely troubled themselves have engaged in marital counseling. It

family is trying hard to get back on its feet. What place P. will have upon

reuniting with the family is hard to guess. P. has tremendous motivation in thearapy. He

is insightful and frequently makes his own interpretations which are often accurate.

160 Obsessional Neuroses

Assessments of Development

Drive Development

development

P. is developmentally a preadolescent. He has brodd interests in art, science, music,

especially popular music, i.e., John Denver and the Beatles. He has good relationships

with peers and adults but has difficulty when peers exhibit aggression which could be a

physical threat, or when staff is authoritarian. He expresses dislike for the rules that are

imposed and would like to liVe in the wilderness all alone, free from society’s restrictions.

Oral Phase: The oral remnants are seen in P.’s occasional sucking motions and sounds

at the end of therapy sessions, in. his dislike of young children, and in the oral-sadistic

rituals around food (putting food into his mouth and then taking it out, difficulty entering

the dining room). He also has difficulty swallowing (he must think right) and he cannot

eat, for example, at the Detroit Zoo because it is surrounded by cemeteries. (Notice the

anal-sadistic connotations of this.)

Anal phase: P. strives to control his anal-sadistic impulses and fantasies with rituals and

obsessive thoughts. One such fantasy he described as “the pool of imagination, a horrible,

dirty, black gooey place that wants to pull me into it. Sometimes my eyes fall in.”

Whenever he thinks of this he must repeat what he has been doing to avoid anxiety.

Unconsciously he is, as his stepmother described, “a two year .old” expressing

ambivalence, sado-maSochism, tendencies toward stubbornness and rebelliousness.

Rdaction formation is P.’s main defense. The move toward adolescence has undoubtedly

contributed heavily to this pattern,

Phallic-oedipal: P. describes himself as “curious George” and expresses an interest in

sex. He developed a “crush” on one of his female child-care-workers but he found this

relationship odd when in therapy he saw her as both girlfriend and mother and said “but

you can’t have sex with your mother,”

Generally P. idealizes adults, particularly men but fears his own adulthood because it

might lead him to be better than his dad,

Clinical Examples 161

P. is just beginning the adolescent phase and has not reached phase dominance. He is

expressing an interest in sex though he is having difficulty with feelings of

embarrassment. He has recently begun to discuss some of his sexual feelings in therapy.

Often they have a decided oedipal component. Recently too he has shown some interest in

a twelve-year-old girl in his class and behaved quite appropriately with her, as opposed to

infantile behavior with another girl.

b. Libido distribution

i. Cathexis of self,

Primary narcissism: P. does not have difficulty in primary narcissism. Secondary

narcissism: P. considers himself to be intelligent with a good sense of humor, however

physically his estimation of himself goes way down.. He fears he is

inadequate, not

strong, uncoordinated and thus unable to successfully compete in athletics or engage in

physical fighting with peers. To some degree his older brother’s move into adolescence

was threatening to P. and may be responsible for the symptom formation to some extent.

He believes he never got enough love or attention from his father. He desperately tries

to prove himself to his dad but is always disappointed to learn how his dad “didn’t notice”

how happy he was to be with him. His chief complaint now is that his dad is strong and

capable, so why shouldn’t he let P. come home on weekends?

P. has developed a split between his natural mother as a good mother and his

stepmother as the bad mother. He can no longer have needs satisfied by his real mother

and he fears rejection by 1-

tisstepmother.

P. is highly invested in his memories and fantasies of his mother. He recalls that when

he was about four he and his mother had mumps. The whole family was concerned about

them. P. became deaf in one ear because of his illness. He is identifying with his mother

now and says he is a replica of her because he is hospitalized “for being crazy,” He

fequently talks of suicide when difficult material is raised in therapy. One day he even

said that he tried to commit suicide by cutting his wrist with a comb but it only made

white scratches. He said that he wasn’t interested in really killing himself, he just

wondered what other people would think if he did.

His goal now is to be like his father. He wants to be a doctor (a

162 Obsessional Neuroses

neurologist) so he can learn how the brain works. He depends on his father to supply

him with the guidelines so he will not fail. His father told him “a healthy body is a

healthy mind,” after his admission to C. P. H. P. immediately began an exercising

.program. He runs contests with himself. He wants to set records, which mean

winning to him, for instance brushing his teeth every night for a year. His favorite

hero is Einstein.

His relationships with other people are warm and accepting. However, once a strong

relationship develops and any hint of rejection is present he rejects before he can be

rejected. When he learned K,D. was leaving, K. became “germy.” When P,’s primary

staff was taken away from him and assigned to another child, she became germy. He

now realizes what this behaVior means and says that if he likes someone a lot they

can’t be germy for very long,

P. is dependent on external objects to regulate his self-esteem. However he is

capable of independent action and thought, the only motivation seeming to be self- satisfaction. He has difficulty accepting praise, usually laughing or saying “sure, sure,”

but it is obvious that he likes it an agrees with it,

ii. Cathexis of objects

P. has the capacity to form and maintain relationships with peers and adults. It often

seems that the peers who become objects of competition are rejected, for example,

brothers, and a friend from Ann Arbor whom he had not seen in several years. P. was

excited about seeing this friend again but this fifteen-year-old had matured and grown

quite .a lot in the meantime. P. felt weak and small by comparison and has not

contacted his friend since. Very recently, he has expressed interest in seeing him

again. –

P, attempts to control adults with his problems. “1. can’t do that because of my

problem” This has led to concern on staffs part as to how much to push or give in to

“the problem.” At first P. would take over an hour for an evening shower, and bedtime

rituals were an agony for all involved in his care.

P.’s closest and most enjoyable relationships have been with female peers or staff.

He was very proud when a young girl from fourth level showed some interest in him

(gave him a yo-yo and sat next to him at a movie) but was somewhat embarrassed

since she was “too young” for him, His relationship with J, (female staff) has been

primarily positive

Clinical Examples 163

but very much tied to oedipal conflicts. Recently he has shown some interest in a twelve- year-old girl in his class and feels she is “the right age for him” “not half as old or twice as

old” as with his other two female interests. P.’s relationship with K.D. was good but he

felt K. was not strong enough at first. Later he felt that K. was one of the few people who

could “really understand me.” Strong authoritarian men are seen as “fair” by P. though he

resents their orders.

2. Aggression

The expression of aggressive impulses has been one of P.’s major areas of conflicts.

Until quite recently he has denied angry feelings, particularly those addressed toward his

father. However a great deal of aggressive energy is bound up in his rituals and obsessive

thinking, which ward off his expressed fantasy of hitting people over the head with coke

bottles (particularly vacationing staff) or sending authoritarian staff through a bologna

slicer! For example, if he thinks of putting someone through a bologna slicer he must put

them back through to make them all right again (thinking right).

Aggression is also seen in his tremendous need to control the environment. Angry

crying spells and stubborn refusals often accompany change of plans for any

unanticipated event,

P.’s aggression not only inflicts pain on the environment but is most often more painful

to him. He feels trernend ously *anxious and guilty over his aggressive thought, and the

rituals also serve as punishment for his self-peiceived “badness.”

Ego and Superego Development

a. Ego apparatus: his ego apparatuses are intact.

b. Ego functions:

Affected by and interfered with by his psychopathology, he is nevertheless clearly a

highly intelligent child with reading skills, mathematical reasoning, and mathematical

fundamental skills above his chronological age.

a. Ego reactions to danger situations:

P.’s fears are lodged in the external world in the form of fear of loss of objects. The id

impulses are also feared characteristically because they may force him to become out of

control and do things (show anger

164 Obsessional Neuroses

or aggression) which would be severely punishable by his superego. d. Defensive system:

Denial: P.’s obsessional substitutions utilize magic and rituals and are a defense which

fosters power and strength in a world where he feels helpless and weak.

Rationalization: Since P. fears the “weakness” he thinks is implied in tender feelings,

he recently denied his anger and sorrow at the vacation of an important P . C. W by

claiming she had a “right” to the vacation and he should not.feel bad because it was her

“right” to go away.

Intellectualization: Enormous energy is spent in .holding back feelings by

intellectualization. P. has such an explosive need to love and hate (punish) his father for

rejecting him and/ or his mother but the only way he can deal with his father is through

scientific discussion, He feels anxious if he is with his father without some specific

intellectual topic to discuss, Unfortunately his father relates to P. in the same way.

Reaction-formation: Classic obsessive concerns for cleanliness, order, being good, are

perceived as knowing the rules and following them, according to P.’s pattern.

Paradoxically, he expresses a great longing to live in the wilderness free from human rules

and regulations and living exactly the way he please.

P. also belches frequently and then immediately bows his head and whispers “excuse

me please” sometimes three or four tlines in a row.

Doing and undoing: P. uses this defense in many areas but perhaps the most suggestive

is his need to read a line and then “unread” it, For example, read backwards, This may

indicate his need to know or his fear of knowing or the ramifications of the quest for

knowledge, related to the suppression of information regarding his mother and her death.

Extensive use of displacement, isolation of affect and content are noticeable,

e. Secondary interference of defense activity with ego achievements:

P.’s defensive system keeps him vulnerable to the fears he experiences in every new

situation. It prevents him from learning by experience. He is so involved in creating

reasons not to be somewhere or not to express feelings that he is virtually paralyzed by a

system where there is no relief and where every day poses a threht of defeat, f, Affective

states and responses:

P. is capable of expressing a wide range of affective responses. He is

Clinical Examples 165 •

a sensitive child and the potential loss of loved objects evokes anger, hate and guilt. It is

only recently and only to certain staff members that P, is able to tell how he feels. Sad

affects are usually masked by imitation crying or sarcasm,

P.’s self-esteem is low and this is particularly evident when gifts or praise are given to

him, He says he never felt anyone gave him anything because they loved him but only

because they wanted to “satisfy him,” The only area where he acknowledges success and

accepts praise is with his intelligence. Though P. is capable of affective responses and

often displays them appropriately, his behavior becomes inappropriate when he is moved

by a person important to him

P. is still somewhat egocentric and narcissistic. For example, he feels everyone

thinks the way he does, and should, therefore, understand his problem, He is

terrified of the anger of others especially – if it might result in physical confrontation,

Authoritarian people are disliked and criticized even when he believes their rules are fair

and right. He whimpers and cries and impotently feigns rage when forced to do something

he doesn’t want to do.. Often his responses can be described as overreaction. Usually the

anger or hurt is not long-lasting though he tends to hold a grudge against those who have

caused him to display negative affects.

Superego Development

a. Superego:

P.’s superego is overly developed, punitive, nonpleasure-giving, unrelenting, and

constricting, The superego introjects which contribute to this pattern stem from the anal

and phallic-oedipal stage based primarily on his overly restrictive father and his perhaps

uninvolved, distant or permissively ambivalent mother. He felt he had to be good to win

parental approval. “Bad behavior” meant risking parental rejection, The id has a need to

discharge its persistent drive and the ego is left as the battleground for the two opposing

sides. Normal childish feelings of gratitude, happiness, excited joy, sorrow, or pain and

anger came to be viewed as weaknesses to be avoided, denied or isolated, so that he could

be the good, calm, placid child he felt his parents desired.

a. Superego ideals:

166 Obsessional Neuroses

The most obvious and most frequently mentioned superego ideal stems from his

identification with the aggressor (father) and his wish to outdo or overcome his father.

He wants to be a brain surgeon who will find the definitive cure for cancer and be the

first to perform successfully brain and spinal-cord transplants. Not only will he be the

first but he will be nationally famous and admired.

a. Other types of ideal formation:

Certainly his desire to become a physician is an appropriate ego ideal as his

intelligence and latent personality strengths suggest. It is clear also that even as an ego

ideal there is the apparenridentification with the aggressor” and his own self-desribed

“little-boy-blue” phenomenon.

a. Development of the total personality:

In general P. has not reached age-appropriate development and may be found in the

preadolescent stage. His over-all development suggests an initial ease in the

developmental milestones without disruption.

There is no noted separation-anxiety in Anna Freud sense of the word, and since he

was the youngest child in the original family there was no conflict there. His illness,

mumps, along with his mother at age four, served to increase his identification with

her and left a permanent reminder of their shared experience.

P. did not want to attend nursery school (possibly a fear of • separation). He recalls

(or has been told) that he stubbornly refused to go and would not dress himself or

allow himself to be dressed for the occasion. This is reminiscent of his present

aggressive behavior around bedtime rituals. Ile states with pride “and 1 never did go to

nursery school.”

School itself was not a problem and both parents recall delight in observing P.’s

reaction to it. We can only speculate that the kind of disturbance observed -now, with

its anal-sadistic qualities, indicates difficulties stemming from the anal phase, though

toilet training-wasn’t a problem. The mother’s frequent depressions may have

contributed to these difficulties along with his father’s authoritarianism. Mrs. Q.’s

depressions continued to the phallic-oedipal stage and we may assume P. felt he could

have given her more suppoil and protection than his father did. The mother’s suicide at

the beginning of his latency caused an upset in this relatively peaceful period and sent

P. back to using the

Clinical Examples 167

defenses of an earlier developmental level and caused a hiatus in further growth.

Latency was accomplished, as seen in his adequate move from play to work, but the

damage was there, P. recalls that his repetitions began at about eight or nine years of

age, soon after mother’s death and his father’s remarriage. The suppression of

information about his mother and the birth of another child served to reinforce P.’s

feeling of being.

left out and unncessary.

The threatening arrival of adolescence was probably the last straw in P.’s ability to

ward off the instinctual impulses and oedipal conflicts tha t we r e then r e ignit ed.

P, is now beginning to feel that he needs his father less than before and this can be

seen as a sign of the impending move into adolescence. P. finds this very upsetting

however, because of his paradoxical view of loving and hating his “all-powerful”

Assessment of Fixation Points and Regressions

There is a fixation to the anal-sadistic and phallic-oedipal stages, with defenses

against regression to oral wishes and fantasies, This can be seen in his obsessive

compulsi-ve behavior and need to re-enact the oedipal situation. There are also some

elements of regression to oral sadism as exemplified in his food rituals.

Assessment of Conflicts

P.’s conflicts have an internal and internalized nature. The internal conflicts are:

(1) general ambivalence—his decision making is tortured, as when he wanted to give

his stepmother a Mother’s Day present but felt to do so might make her unhappy, even

though he also thought it might make her happy; (2) masculinity vs. femininity; and

(3) sadism vs. Masochism.

The internalized conflicts reflect the internalization of previously external conflicts.

There are regressive traces of the oral, anal and phallic-oedipal phases: (1) oral: eating

difficulties previously mentioned; (2) anal: reflected in his fears of aggression, death,

and his reference to death wishes, concerns with germs and magic; (3) phallic-oedipal:

as seen in his crushes and wish to re-enact the oedipal triangle.

168 Obsessional Neuroses

The latter is expressed in jealousy of his therapist and a female ward staff whenever

separations are imminent or when they are observed by P. to be interacting with male

staff. P. is also expressing some concern that his problems will make his therapist

depressed, necessitating her treatment as an inpatient at N. P. I. There is an obvious

sadistic wish here since he is angry about her impending vacation but there is also

guilt .perhaps reminiscent of the guilt he felt for not “making his mother happy” and

thus preventing her depreisions and subsequent suicide, for which he no doubt feels

responsible.

Assessment of Some General Characteristics

Frustration tolerance: 1

1s frustration tolerance is poor because of the pervasive

nature of his obsessions and compulsions. He feels he must do his repetitions even

though they take up a lot of time, If he is pushed beyond his own limit he will cry and

become very stubborn and accuse people of not understanding him or his problem.

Attitude toward anxiety: P. is engaged in a constant struggle to avoid anxiety. The

defenses he uses create the illusion of power and control and temporarily reduce_

At present, P.’s anxieties are so severe that he invests more and more time in

warding them off. His obsessive rituals consume most of his time and overshadow all

other events in his life. Despite their initial intensity they became worse during a

period when P. began to ask questions about his mother and to criticize his father’s

handling of her death. After this the obsession took on a more magical representation

(voodoo), attempting to hide the death wish he felt toward his father.

Sublimation potential: In view of the -present behavior crisis it is difficult to judge

the true sublimation potential, One can assume that it is quite high judging by his

latency-age creativity. For example, P. is making a report on the state of Israel,-This

reflects his search for an identity and his questioning about his mother. However this

has been interfered with and is now a problem for P. He may substitute.the study of

Saudi Arabia because he ‘feels that –

too many magical events happened in the creation

of the state of Israel, that the number 13 appears very often in its history. The one

example he uses is that Israel

Clinical. Examples 169 .

was formed on 13 May 1948; Robert was born on the 13th of the month and his mother

died on the 13th of the month.

Progressive vs. regressive tendencies: P. has a tremendous desire to move forward

and be rid of his problem. He has the potential for progressive movement. He also

acknowledges a disbelief that he will ever be without it or that certain areas of conflict

will cease to concern him. There is also an element of fear of what would happen if he

were no longer obsessive.

He wants to become an adolescent, mature, date, marry, go to medical school but all of

these things pose the threat of failure or worse, success (outdoing father). Sometimes P.

regresses, especially in O.T. groups when he is with younger children. Fear of a

classmate and separation from a teacher several weeks ago prompted P.’s need for a

transitional object, a small clay rabbit which he had made in 0.T. was carried to school

and brought to therapy.

There are a cornbination of permanent regressions which cause extraordinary

developmental Strain, and crippling symptom formation according to the location of the

fixation point and the amount of ego superego involvement. The symptomatic picture is

that of an obsessive compulsive neurosis.

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CLINICAL CASE STUDY article

A clinical case study of the use of ecological momentary assessment in obsessive compulsive disorder.

• Brain, Behaviour and Mental Health Research Group, School of Psychology and Speech Pathology, Curtin University, Perth, WA, Australia

Accurate assessment of obsessions and compulsions is a crucial step in treatment planning for Obsessive-Compulsive Disorder (OCD). In this clinical case study, we sought to determine if the use of Ecological Momentary Assessment (EMA) could provide additional symptom information beyond that captured during standard assessment of OCD. We studied three adults diagnosed with OCD and compared the number and types of obsessions and compulsions captured using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) compared to EMA. Following completion of the Y-BOCS interview, participants then recorded their OCD symptoms into a digital voice recorder across a 12-h period in reply to randomly sent mobile phone SMS prompts. The EMA approach yielded a lower number of symptoms of obsessions and compulsions than the Y-BOCS but produced additional types of obsessions and compulsions not previously identified by the Y-BOCS. We conclude that the EMA-OCD procedure may represent a worthy addition to the suite of assessment tools used when working with clients who have OCD. Further research with larger samples is required to strengthen this conclusion.

Introduction

Obsessive-Compulsive Disorder (OCD) is a disabling anxiety disorder characterized by upsetting, unwanted cognitions (obsessions) and intense and time consuming recurrent compulsions ( American Psychiatric Association, 2000 ). The idiosyncratic nature of the symptoms of OCD ( Whittal et al., 2010 ) represents a challenge to completing accurate and comprehensive assessments, which if not achieved, can have a deleterious effect on the provision of effective treatment for the disorder ( Kim et al., 1989 ; Taylor, 1995 ; Steketee and Barlow, 2002 ; Deacon and Abramowitz, 2005 ).

Accurately assessing the full range of symptoms of OCD requires reliable and psychometrically sound diagnostic instruments and measures ( Taylor, 1995 , 1998 ; Rees, 2009 ) alongside the standard clinical interview. Although the most commonly used psychometric instrument for assessing OCD, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) ( Goodman et al., 1989a , b ), has acceptable reliability and convergent validity, it has been criticized by Taylor (1995) for weak discriminant validity. Taylor also highlighted that it remains susceptible to administration variance, relies on client memory recall, and is time consuming to administer. As with all measures completed retrospectively, selective memory biases affect the type of information reported by clients about their symptoms ( Clark, 1988 ; Stone and Shiffman, 2002 ; Stone et al., 2004 ). Glass and Arnkoff (1997 , p. 912) have summarized several disadvantages of structured inventories; first, they contain prototypical statements which may fail to capture the idiosyncratic nature of the client's actual thoughts; second, they can be affected by post-hoc reappraisals of what clients feel, as the data is subject to memory recall biases; and finally they may fail to adequately capture the client's internal dialog due to the limitations of the best fit question structure.

Discrepancies have been reported between data collected in the client's natural environment ( in situ ) and those based on the client's later recall ( de Beurs et al., 1992 ; Marks and Hemsley, 1999 ; Stone et al., 2004) . Such discrepancies may be further affected by factors such as the complexity and diversity of obsessions and compulsions, not to mention the ego-dystonic nature of many OCD clients' obsessional thoughts. It seems likely that clients with distressing ego-dystonic obsessions, for example, those involving sexual, aggressive, and/or religious themes may experience a heightened level of discomfort in reporting their obsessions in a face to face assessment with a clinician, thus reducing their willingness to accurately report ( Taylor, 1995 ; Newth and Rachman, 2001 ; Grant et al., 2006 ; Rees, 2009 ). This may contribute to an underreporting of these obsessions, and hence an inaccurate understanding and a restriction of the clinician's ability to adequately treat the client ( Grant et al., 2006 ; Rachman, 2007 ).

Exposure and response prevention, cognitive therapy, and pharmacological interventions have been shown to be effective in the treatment of OCD ( Abramowitz, 1997 , 2001 ; Foa and Franklin, 2001 ; Steketee and Barlow, 2002 ; Fisher and Wells, 2008 ; Chosak et al., 2009 ). Self-monitoring is a useful therapeutic technique that provides essential information to assist in the development of exposure hierarchies and behavioral experiments used in cognitive therapy ( Tolin, 2009 ). Clients typically observe and record their experiences of target behaviors, including triggers, environmental events surrounding those experiences, and their response to those experiences ( Cormier and Nurius, 2003 ). Such self-monitoring can be used to both assist assessment and/or as an intervention. Cormier and Nurius (2003) explained that the mere act of observing and monitoring one's own behavior and experiences can produce change. As people observe themselves and collect data about what they observe, their behavior may be influenced.

A form of self-monitoring and alternative to the typical clinic-based assessment of OCD is the use of sampling from the client's real-world experiences, a procedure known as Ecological Momentary Assessment (EMA) ( Schwartz and Stone, 1998 ; Stone and Shiffman, 1994 , 2002 ). EMA does not rely on measurements using memory recall within the clinical setting, but rather allows for collection of information about the client's experiences in their natural setting, potentially improving the assessment's ecological validity ( Stone and Shiffman, 2002 ). In situ sampling techniques have been successfully used in psychology, psychiatry, and occupational therapy (for a more detailed account see research by Morgan et al., 1990 ; de Beurs et al., 1992 ; Kamarack et al., 1998 ; Litt et al., 1998 ; Kimhy et al., 2006 ; Gloster et al., 2008 ; Putnam and McSweeney, 2008 ; Trull et al., 2008 ). Generally it is agreed that EMA offers broader assessment within the client's natural environment, as it includes random time sampling of the client's experience, recording of events associated with the client's experience, and self-reports regarding the client's behaviors and physiological experiences ( Stone and Shiffman, 2002 ). Because this assessment method accesses information about the client's situation, the difficulties of memory distortions like recall bias are reduced ( Schwartz and Stone, 1998 ; Stone and Shiffman, 2002 ).

Given that accurate assessment of obsessions and compulsions is a critical aspect of treatment planning and that reliance on self-report and clinician interview has some known limitations, the purpose of this study was to investigate the utility of EMA as a potential adjunct to the conventional assessment of OCD. Specifically, we sought to compare the amount and type of information regarding obsessions and compulsions collected via EMA vs. standard assessment using the gold-standard symptom interview for OCD. As this is a pilot clinical case study, we offer the following tentative hypothesis: (1) EMA will yield additional types of obsessions and compulsions not captured by the Y-BOCS.

Participants and Setting

Participants were recruited through clients presenting to the OCD clinic at Curtin University. They were assessed using the Structured Clinical Interview for DSM-IV (SCID-IV) ( First et al., 1997 ). Inclusion in the study was based on receiving a primary diagnosis of OCD, and a Y-BOCS ( Goodman et al., 1989a , b ) score of more than 16, placing their OCD symptom severity within the clinical range ( Steketee and Barlow, 2002 ). Participants were excluded if they presented with current suicidal ideation, psychotic disorders, apparent organic causes of anxiety, were severely depressed, or if they had an intellectual disability. One potential participant was excluded post evaluation despite meeting the inclusion criteria, as she did not own a mobile phone, and reported having “blackouts” throughout the day. The three participants all had OCD symptoms in the “severe” range according to the YBOCS. In order to ensure that participants remain anonymous, pseudonyms have been used.

Participant A

Mary was a 28-year-old female who lived with her husband and small dog. She reported that for approximately 1 year she had been experiencing distressing intrusive thoughts in relation to harming her loved ones, herself, or her dog; for example, by stabbing, electrocution, or breaking the dog's neck. Mary said that she also had reoccurring thoughts and images that her husband or other family members might die. She reported engaging in some rituals, for example straightening pillows and rearranging tea-towels; but mostly reported using “safety nets” in response to her unwanted cognitions; for example ensuring that she was not alone (to prevent self-harm); avoidance and removal of feared object; extensive reassurance seeking from family members. According to the Y-BOCS measure, Mary scored a subtotal of 14 for Obsessions and a subtotal of 18 for Compulsions, giving an overall total of 32, classifying her symptoms as “severe” ( Steketee and Barlow, 2002 ).

Mary reported that her OCD first occurred after her grandmother passed away about 6 years ago. She explained they had a very close relationship, she said she found it “unbearably distressing” to visit her while she was dying. Mary reported that on one occasion whilst in a coma, her grandmother sat up and gasped, which she found extremely frightening and still remembers it in vivid detail. She reported that she experienced thoughts that her grandmother was in pain and was going “into the unknown, to a scary place.” Mary reported feeling afraid of death and that if someone “even closer” to her died she “would not be able to cope” and that she would “lose control completely.” She stated that her biggest fear was that her husband, mother or father might die. Mary reported that she has been on various anti-depressants for about 10 years. She stated that recently her psychiatrist prescribed Solian (an antipsychotic) which she tried, and found was very effective at blocking out the intrusive thoughts. However, she ceased taking the medication due to nausea.

Participant B

John was a 5-year-old man who lived with his wife and adult son. He reported a long history of distressing intrusive thoughts, and compulsive behaviors. They are summarized in three ways. First, those that relate to religious obsessions, specifically the occult and satanic experiences/fear of being “possessed.” He reported responding to these unwanted cognitions by either washing his hands to cleanse himself; using more than six pieces of toilet paper to wipe after defecating to prevent the devil entering him via his anus; or looking for the number “555,” which represents “God. This is good.” John reported that failing to act in these ways would risk causing harm to his wife and son. Second, those that relate to checking compulsions, specifically when driving, and also checking that doors are locked—which he reported doing 4–12 times per night. He reported that if he thought he heard a “bump” when driving he would have to turn back to check he had not run anyone over, or would seek reassurance from his son or wife if they were passengers in the car with him. He stated that he feared that harm would come to his wife and son if he didn't perform these checks. Third, John said that he arranged shoes so that they were “lined up” and that the clothes in the cupboard were in the “right order.” He also reported the need to compulsively clean his son's bedroom, and that he wouldn't feel “right” until he had done so. According to the Y-BOCS measure, John scored a subtotal of 13 for Obsessions and a subtotal of 15 for Compulsions, giving an overall total of 28, classifying his symptoms as “severe” ( Steketee and Barlow, 2002 ).

John reported that his symptoms have been present for at least the last 29 years. He reported that his OCD first occurred after he had a “break-down” and tried to commit suicide by stabbing himself in the stomach before he turned 25 years of age. In the years leading up to this, John reported two poignant experiences which appear relevant to the development of his symptoms; he reported being involved in the euthanizing of two dogs whilst working as a Ranger's assistant; and that when he was young, he and his girlfriend at the time had a pregnancy termination. John reported feeling that these were “blasphemous” acts, and posed the question “Is God punishing me?” John reported that he had been on several different anti-depressants for about 19 years, with varying degrees of success and side-effects. He reported that he had seen a psychiatrist every 6 weeks for “many years” and finds being able to talk helpful.

Participant C

Paul was a 35-year-old man, who reported distressing intrusive thoughts and images in relation to harm coming to others as a consequence of him not checking that he had done what he is “supposed to do.” For example, he was concerned that someone at work would be harmed if he forgot to adequately cover shifts on the roster (something he is responsible for); or when a client of the service he coordinates was recently given a stereo, Paul reported that he feared that harm would come to the client if he didn't correctly check it to see if it was faulty, something he felt responsible to do.

Paul reported that only his partner knew of his difficulties. He stated that he did not allow his anxiety to interfere too much with his occupational functioning; however he did report that the main reason he does not practice in his profession is because of his OCD. According to the Y-BOCS measure, Paul scored a subtotal of 12 for Obsessions and a subtotal of 13 for Compulsions, giving an overall total of 25, classifying his symptoms as “severe” ( Steketee and Barlow, 2002 ).

Paul reported that his intrusive thoughts have “always been there.” He explained that one of the first clear memories he has of them, was when he was seven years old and he saw the film the “The Omen.” He reported remembering checking his head for the numbers “666.” Additionally, he reported remembering that he was concerned for his mother's safety. He reported that he had never taken medication for his OCD. He stated that he saw two therapists when he lived in the UK at an OCD center in London approximately 18 months ago. Paul said that he did not gain much from the first therapist, but believes that second therapist assisted him to look at his cognitions as “just thoughts.”

Materials and Methods

All screening of participants, interviewing and assessment, as well as administration of the study, was conducted by the first author, who was a provisionally registered psychologist undergoing postgraduate training at the time of the research, and was supervised by the second author, an experienced OCD clinician and academic. Potential participants were recruited from the Curtin OCD clinic. They were screened via telephone to ascertain their suitability for the study. A face-to-face assessment session using the Structured Clinical Interview for DSM-IV (SCID-IV; First et al., 1997 ) was conducted to determine a primary OCD diagnosis, followed by the administration of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) interview and checklist ( Goodman et al., 1989b ) to identify the participants' obsessions and compulsions and their symptom severity. The Y-BOCS is the most widely used scale for OCD symptoms assessment and is considered by researchers to be the “gold standard” measure for symptom severity ( Deacon and Abramowitz, 2005 ; Himle and Franklin, 2009 ). It consists of two parts; a checklist of prelisted types of obsessions, usually endorsed by the clinician based on disclosures made by the client; and the severity scale which requires the client to rate the severity of their experience by answering the questions based on their recall. Goodman et al. (1989) note that the Y-BOCS has shown adequate interrater agreement, internal consistency, and validity.

Suitable participants then attended a second session where they signed consent forms and were given instructions about the study procedure. During the data collection using the Ecological Momentary Assessment data (EMA-OCD), participants used an Olympus WS-110 digital voice recorder to record their experiences throughout a 12 h period. Participants used their existing mobile phones to receive prompts via the mobile phone Short Message Service (SMS) to record their responses to the research questions. All three participants were then provided with an envelope containing the Olympus WS-100 digital voice recorder, a spare battery, and the participant prompt questions (see Table 1 ).

Table 1. Prompt questions .

Participants were asked to turn their mobile phones on during the data collection day by 10 am, ready to receive their SMS prompts. The researcher manually sent SMS prompts to the participants at random intervals; at least every 2 h (across 1 day, from 10 am to 10 pm), for a minimum of 10 data entries in keeping with research using EMA procedures (see, Stone and Shiffman, 2002 ); asking them to complete their responses to all four questions as details on the EMA-OCD Participant Questions Sheet. Participants were instructed not to respond to the SMS prompts if driving, and were asked to respond as quickly as possible to the prompts. Data was then downloaded from the voice recorder to the researcher's computer, and transcribed. During this process all identifying details were removed. During the debrief session open-ended questions were used to gather as much information as possible regarding the participant's experiences of the study, and suggestions for improvements. During the data collection day the researcher completed a journal to record his observations and reflections related to the use of the EMA. At the completion of the EMD-OCD data collection, each of the participants was provided with a debrief session (Mary by phone, and John and Paul, face to face). The debrief session focused on their experiences of the research and use of the digital voice recorder; and provided the opportunity for them to discuss anything else that arose they wished to tell the researcher. As stated above, the data was downloaded and transcribed by the first author. The Y-BOCS obsession and compulsion categories were used as a framework to compare the data generated from the EMA-OCD procedure. After the complete de-identified data set was tabled, it was provided to a second person who was an expert in OCD for verification of categories. In the case of any discrepancies agreement was reached via consensus.

Number of reported symptoms

Table 2 provides a summary of the frequency and type of symptoms recorded during both the face-to-face session, which will be referred to as the Y-BOCS data and the EMA-OCD phase for the study, which will be referred to as the EMA–OCD data. As can be seen when comparing the data contained in the two columns, there are variations between the Y-BOCS data and the EMA-OCD data. All three participants reported more categories of both obsessions and compulsions in the Y-BOCS data, compared to that reported in the EMA-OCD data.

Table 2. Summary by participant of Y-BOCS data and EMA-OCD data .

Mary reported experiencing five categories of Y-BOCS Obsessions and six categories of Compulsions in the Y-BOCS data. In the EMA-OCD data she reported experiencing two categories of Y-BOCS Obsessions, and three categories of Y-BOCS Compulsions. John reported experiencing four categories of Y-BOCS Obsessions and five categories of Compulsions in the Y-BOCS data. In the EMA-OCD data he reported experiencing two categories of Y-BOCS Obsessions, and five categories of Y-BOCS Compulsions. Paul reported experiencing four categories of Y-BOCS Obsessions and two categories of Compulsions in the Y-BOCS data. In the EMA-OCD data he reported experiencing one category of Y-BOCS Obsessions, and two categories of Compulsions.

Comparison of content of symptoms

Both Mary and Paul reported previously unidentified Obsessions or intrusive thoughts in the EMA-OCD data, compared to the Y-BOCS data; and all three participants reported previously unidentified compulsions/rituals/responses in the EMA-OCD data. As can be seen in Table 2 , Mary reported two intrusive thoughts in the EMA-OCD data that were not recorded in the Y-BOCS data. Additionally, she reported a previously unreported obsession under the obsession category Obsession with need for Symmetry or Exactness , not reported in the Y-BOCS data. Mary also reported variations on her compulsive behaviors and the presence of thought suppression not identified during the administration of the Y-BOCS. The EMA-OCD data indicated that John substituted one of his compulsions for an alternative anxiety reducing act, which was not recorded in the Y-BOCS data and suggests the identification of a previously unreported compulsion. Additionally, the EMA-OCD data indicated that John engaged in thought suppression to neutralize his intrusive thoughts. Likewise, John's reported compulsive behaviors also varied between data sets. In the EMA-OCD data he reported three previously unreported compulsive behaviors, and like Mary also the presence of thought suppression. In addition to the above, the EMA-OCD data indicated that John substituted one of his rituals for another, when he touched a crucifix instead of performing his usual hand washing ritual to cleanse him-self of the potential satanic possession. This was not something reported in the Y-BOCS data.

This study investigated the utility of EMA as an adjunct assessment approach for OCD. Each of our study hypotheses was supported. As predicted the EMA procedure resulted in the identification of additional types of obsessions and compulsions not captured by the Y-BOCS interview. The finding that the EMA procedure identifies obsession and compulsion symptoms not captured by the Y-BOCS suggests that further studies in this area are warranted. As a pilot case study we cannot generalize from these initial findings but our results indicate that a larger study replicating the procedure used here, is justified. Importantly, the three participants in our study were representative of quite typical OCD clients in that they had severe levels of symptoms and had OCD for a number of years. The EMA procedure we used was found to be satisfactory to all three participants. Feedback from the participants at the de-briefing session included suggestions that this process would be helpful for therapy because it would provide the therapist and client with rich and current material regarding their symptom patterns. From a clinician's point of view, collecting the EMA data is not onerous because the entries are simply short answers collected on 12 occasions and thus is not a time-consuming exercise.

The EMA procedure as used in this study could provide clinicians with a new method by which to gain a current and accurate snap-shot of clients symptoms as they occur in real-time. This information could augment information gained from standard pencil and paper measures but also provide an “active” process which may help to engage clients in the therapeutic process. It seems likely that using a procedure like EMA with OCD clients will assist in understanding their OCD experiences, and thus assist in generating valuable information, supporting accurate assessment, client conceptualization, and ultimately treatment.

Despite these valuable findings, there are limitations of this study. As a pilot study and exploratory in nature, it is only possible to draw limited interpretations from the data provided. However, the preliminary findings of this study support the benefit of conducting further research into this procedure, where it may be possible to draw more empirically valid findings from a larger and more statistically powerful sample. Second, due to the lack of availability of date stamping, participants were asked to record the time they made each recording. Unfortunately this was not routinely provided by all participants, and hence creates an unanswerable question regarding the accuracy of the data recorded. As Stone and Shiffman (2002) discuss, a potential problem relates to participants recording their data based on their recall of what was occurring at the time of the SMS prompt, rather than immediately. Hence introducing possible memory bias, and undermining the premise of the study. Although this is certainly an unwanted variable, based on the EMA-OCD data provided it seems that except for Mary, both John and Paul responded promptly to the SMS messages, or recorded the time if they didn't. Mary on the other hand, reported during the debrief session that she was unable to record the time for the initial targets, but did so for subsequent SMS prompts. It was not possible to ascertain from her data the delay in time between the first SMS prompts and her recordings. In future applications of this procedure, it is recommended that the device used provides automatic date-stamping to address this limitation. Indeed, it may be possible to adapt the EMA methodology for use with smart phones via a dedicated OCD application.

Concluding Remarks

The findings from this study of three patients with severe OCD suggest that the use of EMA provides important additional information regarding obsessions and compulsions and may thus be a useful adjunct to the clinical assessment of OCD.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We thank the three participants for taking part in this study.

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Keywords: obsessive-compulsive disorder (OCD), ecological momentary assessment, ecological momentary assessment data, anxiety disorders, assessment

Citation: Tilley PJM and Rees CS (2014) A clinical case study of the use of ecological momentary assessment in obsessive compulsive disorder. Front. Psychol . 5 :339. doi: 10.3389/fpsyg.2014.00339

Received: 10 March 2014; Accepted: 01 April 2014; Published online: 17 April 2014.

Reviewed by:

Copyright © 2014 Tilley and Rees. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Clare S. Rees, Brain, Behaviour and Mental Health Research Group, School of Psychology and Speech Pathology, Curtin University, Perth, WA, Australia e-mail: [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Conceptualizing and managing risk in pediatric OCD: Case examples

Angela lewis.

South London and Maudsley NHS Foundation Trust, London, UK

Caroline Stokes

South London and Maudsley NHS Foundation Trust, London, UK; Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK

Isobel Heyman

Great Ormond Street Hospital and the Institute of Child Health, University College London, London, UK

Cynthia Turner

University of Queensland, Brisbane, Australia

Georgina Krebs

It is not uncommon for patients with obsessive-compulsive disorder (OCD) to present with symptoms that suggest possible risk. This can include apparent risk, which reflects the content of obsessional fears, and genuine risk arising as the unintended consequence of compulsive behaviors. In both situations, risk can cause confusion in relation to diagnosis and treatment. The current article adds to the small existing literature on risk in OCD by presenting case examples illustrating different types of risk in the context of pediatric OCD, along with a discussion of their implications for management. The cases highlight that it is crucial that risk in OCD is considered carefully within the context of the phenomenology of the disorder. Guidance is offered to support clinical decision making and treatment planning. (Bulletin of the Menninger Clinic, 83[X], 1–18)

Obsessive-compulsive disorder (OCD) is a debilitating condition affecting approximately 1%–2% of young people ( Douglass, Moffitt, Dar, McGee, & Silva, 1995 ; Heyman et al., 2001 ). The disorder is characterized by the presence of recurrent, unwanted, and distressing intrusive thoughts (obsessions) and/or repetitive acts that are performed in order to alleviate anxiety or prevent a feared outcome from occurring (compulsions) ( American Psychiatric Association, 2013 ; World Health Organization, 2018 ). Over the past two decades, a strong evidence base has emerged for the treatment of pediatric OCD. Cognitive-behavior therapy (CBT) has been shown to be efficacious, both alone and in conjunction with selective serotonin reuptake inhibitors (SSRIs) (e.g., Nair et al., 2018 ; Öst, Riise, Wergeland, Hansen, & Kvale, 2016 ; Watson & Rees, 2008 ). Despite the efficacy of CBT, approximately 30% of young people fail to respond to CBT for OCD, and nearly half of all patients are left with clinically significant symptoms ( Öst et al., 2016 ). Various factors have been identified as potential barriers to successful treatment, including certain comorbidities and family factors ( Garcia et al., 2010 ; Ginsburg, Kingery, Drake, & Grados, 2008 ; Krebs & Heyman, 2010 ; Torp et al., 2015 ). However, one potential barrier to change that has received little empirical attention is risk associated with OCD.

When considering risk in OCD, it is important to distinguish genuine risk from risk that is only apparent. Veale, Freeston, Krebs, Heyman, and Salkovskis (2009) defined primary risk as apparent risk that arises directly from an obsession. The apparent risk is that the patients will act on intrusive and unwanted thoughts and impulses, such as stabbing somebody or engaging in inappropriate sexual behavior. This “risk” is only apparent, not genuine, because patients with OCD do not act on obsessions. On the contrary, the content of the obsession is abhorrent to the sufferer, and the rituals or avoidance that form core symptoms of the OCD are carried out in the belief that this will prevent the obsessions from being realized ( Veale et al., 2009 ).

Secondary risk is defined as genuine risk arising as a direct consequence of performing compulsions or avoiding feared situations ( Veale et al., 2009 ). For example, in the case of contamination fears, an OCD sufferer may avoid eating, resulting in malnourishment. Such risk is unintended by the sufferer, but nevertheless has real potential for harm. There is limited literature on secondary risk in OCD, but previous case reports have highlighted some specific examples. For example, Hood, Baptista-Neto, Beasley, Lobis, and Pravdova (2004) describe a case of self-injurious behavior in an adolescent with OCD who repeatedly bit her tongue, resulting in bleeding and significant lacerations. After some initial confusion over the cause of this behavior, it was eventually formulated as a compulsion in the context of OCD. In another example, Storch, Gerdes et al. (2004) describe a child with OCD who reported fears of choking and contamination. As a result of these fears, the child stopped eating solid food, lost 10% of his body weight, and required hospitalization. Similarly, Jassi, Patel, Lang, Heyman, and Krebs (2016) described cases of young people with ritualized eating in the context of OCD, some of whom restricted their eating and became significantly underweight. Ion, Hameed, Pillay, and Drummond (2009) examined a sample of consecutive admissions to a specialist adult OCD service and found that approximately 58% of patients had clinical evidence of severe dehydration, which was most commonly a consequence of difficulties in preparing drinks due to compulsive behaviors or avoiding drinking in an attempt to reduce the need to urinate.

Although these case reports highlight the potential for adverse consequences arising from OCD, the majority do not offer guidance on how to manage risk while at the same time treating OCD effectively. This is an important issue because both primary and secondary risk associated with OCD in youth can impede successful treatment outcome for several reasons. First, therapists can become distracted from the OCD, focusing instead on extensive risk assessment, managing the risk itself or potentially misconceptualizing the risk as a separate or comorbid problem. Second, in cases of primary risk, therapists can misguidedly take measures to reduce the apparent threat. This is not only unnecessary, but it can also be counterproductive, fueling obsessional worries and exacerbating symptoms. For example, in a case of aggressive obsessions, extensive risk assessments could reinforce the patient’s belief that the obsessions are dangerous, leading the patient to act on the obsessions. Third, therapists may refrain from encouraging patients to engage in exposure with response prevention (ERP) tasks for fear of increasing risk, or even actively encourage avoidance of situations that trigger OCD symptoms. These issues may be particularly pertinent when working with young people, when more stringent safeguarding legislation typically means more cautious management of risk. In addition, children may be less able to articulate their symptoms compared to adults, making it harder for clinicians to accurately formulate the risk.

The current study describes four clinical case examples of young people with OCD and the associated primary (apparent) or secondary (genuine) risk. We aim to draw out the similarities and differences across a range of risk issues, highlighting the ways in which they might impede treatment, in order to give a comprehensive account of risk within the context of OCD and provide guidance on its management.

Four cases highlighting risk in pediatric OCD are described here. Patients were identified from the register of a National and Specialist OCD and Related Disorders Clinic in the United Kingdom. All cases presented met ICD-10 (World Health Organization, 1992) diagnostic criteria for OCD as their primary diagnosis, as confirmed by the specialist multidisciplinary team during a detailed assessment (described below). The cases have been anonymized, and the descriptions are presented in a truncated form, focusing specifically on the risk issues, in order to omit identifying information.

Assessment and treatment

The specialist multidisciplinary team assessment included an interview with parents to obtain a developmental history and an account of presenting difficulties, including evaluation of diagnostic criteria. A semistructured interview (Children’s Yale–Brown Obsessive-Compulsive Scale [CY-BOCS]; Scahill, Riddle, & McSwiggin-Hardin, 1997 ) was conducted with each young person to obtain a detailed account of OCD symptoms.

All patients received CBT through the specialist clinic, comprising 12–22 weekly sessions that were protocol-driven ( Turner, Krebs, & Volz, 2019 ) and delivered by experienced therapists who received regular supervision. CBT included psychoeducation about OCD and anxiety, ERP, and relapse prevention. Parents were included in sessions as appropriate, depending on a range of factors, including the extent to which they were involved in rituals and the age of the young person. The use of concomitant SSRI medication was also considered at assessment (further details provided in case descriptions).

Measurement

All patients completed the CY-BOCS at baseline and posttreatment. The CY-BOCS is a clinician-administered measure that assesses the frequency, interference, levels of resistance and control, and distress associated with obsessions and compulsive behaviors experienced by the young person. It yields a total score ranging from 0 to 40, which indicates the overall level of current OCD symptom severity. The CY-BOCS has been shown to have good reliability and validity ( Scahill et al ., 1997 ; Storch, Murphy, et al ., 2004 ).

Case 1: Primary risk in a patient presenting with pedophilic obsessions

Michael was a 15-year-old boy who presented with an 18-month history of severe OCD. He had previously received several trials of SSRI medication and CBT without improvement. Michael presented with a range of obsessions and compulsions, but his primary symptoms comprised abhorrent and intrusive sexual thoughts about babies and children. These thoughts gave rise to acute distress, marked avoidance of children, compulsive urges to confess the content of his thoughts to his mother, reassurance seeking, and rumination about his sexual orientation and risk to children. At assessment, Michael obtained a total CY-BOCS score of 32, indicating severe OCD.

Prior to assessment at the OCD Clinic, Michael’s obsessions had caused concern among family members and clinicians. This concern was exacerbated by Michael reporting that he might be enjoying his intrusive sexual thoughts. He described feeling sexually aroused when he experienced sexual thoughts about children. He also reported that he thought about children while masturbating, and he was uncertain as to whether he was purposefully bringing these thoughts to mind. Thus, although Michael had been diagnosed with OCD, previous clinicians had been uncertain as to whether his sexual thoughts about children were an OCD symptom, and so he had never been assured that they were part of his OCD. Furthermore, his previous treatment had not incorporated exposure to these thoughts.

Pedophilic obsessions are common in young people with OCD ( Fernández de la Cruz et al., 2013 ). Furthermore, it is not unusual for OCD patients to report physiological signs of sexual arousal when they experience sexual obsessions, even though the thoughts are unwanted ( Warwick & Salkovskis, 1990 ). Sexual arousal as a physiological response can be triggered in people even when the stimulus is not welcomed by the person or is perceived as threatening ( Levin & van Berlo, 2004 ). Physiological symptoms of anxiety can be difficult to differentiate from some of the sensations associated with sexual arousal. Selective attention to the genitalia, which might occur when “checking” for arousal, can increase blood flow to the genital area, triggering sensations that are indistinguishable from sexual arousal ( Veale et al., 2009 ). Many young people with sexual obsessions experience inappropriate sexual intrusions during masturbation and interpret this as meaning that they must find the thoughts pleasurable. However, this can be understood as a classic example of the paradoxical effects of thought suppression ( Wegner, Schneider, Carter, & White, 1987 ).

It was clear at assessment that Michael was suffering from OCD and that he presented no risk to children for a number of reasons. First, Michael described the intrusive thoughts about children as distressing and ego-dystonic. Although Michael reported being confused about whether he had occasionally found the thoughts enjoyable, this was formulated as occurring within the context of the conditioned physiological response to sexual thoughts, the overlap between anxiety and sexual arousal, and the role of thought suppression during masturbation. Second, he had no history of acting on these thoughts, and third, he was in fact going to extreme lengths to ensure that he could never act on his thoughts (e.g., avoidance of children).

The formulation was shared with Michael and his family at the end of his assessment. The family were informed that all symptoms could be understood within the context of OCD and that pedophilic obsessions are common in OCD. The family were given a clear and confident message that Michael was not a danger to young people, and that treatment would involve exposure to children rather than any attempts to keep him away from children. Michael received 22 sessions of CBT for his OCD, along with medication (fluoxetine 20 mg, augmented with risperidone 0.5 mg). Psychoeducation was adapted to include information regarding the normality of unwanted sexual intrusive thoughts, the inherent problems in differentiating arousal from anxiety, how selective attention can affect sensations in the body, and the role of thought suppression. Michael and his therapist devised a hierarchy in order to tackle previously avoided situations involving children, beginning with exposure to pictures of babies and children. The final step in his hierarchy was to have physical contact with a baby or child, and the therapist was able to arrange for Michael to hold and feed a colleague’s baby. By the end of therapy, Michael experienced only occasional intrusive thoughts of a sexual nature, but he was no longer engaging in avoidance of babies and children. At the end of treatment, Michael’s total CY-BOCS score was 18. The remaining OCD symptoms comprised more classical contamination fears surrounding dirt and germs, and Michael and his family were encouraged to continue to work on these using the knowledge they had gained throughout therapy.

Case 2: Primary risk in a patient presenting with obsessional thoughts of self-harm

Laura was a 16-year-old girl with an 18-month history of OCD, initially presenting as contamination obsessions with associated washing rituals. Laura also presented with a history of significant deliberate self-harm, which had resulted in a 3-month inpatient admission following an episode of cutting her wrists and legs with a razor blade. During this admission, Laura was placed on one-to-one observation after disclosing intrusive and persistent thoughts about harming herself.

Laura’s assessment at the specialist OCD clinic took place 3 months after she had been discharged from the inpatient unit. Laura and her parents reported that she had not engaged in any further self-harm while on the ward or since her discharge. However, since her discharge, Laura had become highly distressed by intrusive thoughts of cutting herself and as a consequence had begun to avoid knives and other sharp objects, including drawing pins, paper clips, and staples. Laura described spending large amounts of time checking for sharp objects and asking her parents to check whether she was carrying anything sharp. If her family inadvertently exposed her to a sharp object (e.g., her mother wearing a brooch), Laura would become highly distressed and violent toward them.

Following her discharge from the inpatient unit, Laura had received three outpatient appointments with another service. Laura’s reports of intrusive thoughts and worries about harming herself had been interpreted as being self-harm threats rather than a symptom of her OCD. As a result, exposure to sharp objects had not been encouraged and instead her parents had been advised to remove or hide sharp objects at home. Her therapist had stated that her “behavioral difficulties,” including threats of self-harm and her tendency to become angry toward her family, would need to be addressed separately from her OCD.

At the specialist OCD assessment, a number of factors were considered when formulating Laura’s symptoms. First, people with OCD do not have a history of acting on their intrusive thoughts. Although Laura had harmed herself in the past (to the extent of requiring inpatient treatment), during the assessment it became clear that Laura no longer had any desire to harm herself and in fact was now terrified of doing so. Thus, the thoughts of self-harm that Laura was currently experiencing were wholly ego-dystonic in nature, in stark contrast to how she had presented in the past, when she had deliberately entertained thoughts of self-harm without any attempt to resist them. Second, at assessment, a clear link was established between Laura’s ego-dystonic thoughts and her repetitive behaviors (e.g., checking), which were compulsive in nature (i.e., acts that she did not want to perform but felt she had to in order to prevent self-harm). Specifically, she felt compelled to carry out such behaviors in order to prevent self-harm. Laura’s fear of harming herself had generalized to a range of objects, including objects that would not typically be used for self-harm (e.g., drawing pins), and her attempts to remove these objects from her vicinity were clearly excessive. Her compulsions were far beyond the reasonable precautions that a person might take to resist the urge to self-harm, to the point where they were having a significant impact on her functioning. Third, Laura’s behaviors clearly fell within the recognized OCD symptom domains of checking, avoidance, and reassurance seeking. For these reasons, Laura was diagnosed with OCD, with her primary obsession being a fear of harming herself.

Laura’s total CY-BOCS score prior to specialist treatment was 26, indicating moderately severe OCD. Her medication was increased from 150 mg to 200 mg of sertraline, and she received 14 sessions of CBT. These sessions incorporated graded exposure to sharp objects, starting with exposure to drawing pins and progressing to knives, which were at the top of her hierarchy. While Laura was carrying out these tasks with her therapist, her parents were encouraged to gradually reintroduce sharp objects to the home. Laura was also helped to reduce checking and reassurance seeking. By the end of treatment, she was no longer distressed by intrusive thoughts of self-harm and no longer avoided knives or other sharp items. Her posttreatment CY-BOCS score was 10.

Case 3: Secondary risk in a case of self-neglect arising from avoidance

Lisa was a 17-year-old girl who presented with a 3-year history of OCD and a diagnosis of high-functioning autism. Lisa’s parents first noticed that she was taking longer than usual to carry out self-care activities, with rituals such as standing on one foot when washing. As Lisa’s symptoms worsened, she eventually became wholly dependent on her parents for basic self-care, such as washing and dressing. Lisa began to avoid showering and going to the toilet as a way of circumventing her rituals. She was eventually admitted to the hospital for 3 months due to the severity of her symptoms and lack of self-care. Following this admission, Lisa developed a fear of being poisoned and consequently stopped eating and drinking. She experienced significant weight loss with amenorrhea and was involuntarily readmitted to the hospital, where she required nasogastric feeding.

During Lisa’s second admission, the inpatient team established that she did not present with anorexic cognitions and that her dietary restriction was exclusively associated with her obsessional fear of being poisoned. Lisa received CBT for OCD and commenced fluoxetine (60 mg) in conjunction with risperidone (0.25 mg), with some benefit. Her weight increased and she started to menstruate again. However, overall her OCD remained severe and she was therefore referred for specialist OCD treatment.

At the specialist OCD assessment, Lisa scored 30 on the CYBOCS and her weight for height percentage was 85.5%. Because the acute risk of dehydration and malnourishment had resolved, it was recommended that she be discharged and continue with outpatient treatment. However, a key issue was ensuring that her fluid and dietary intake was maintained, not only to protect her physical health but also to optimize her response to CBT. Research in eating disorders suggests that being underweight can have a negative impact on cognitive functions that are required for CBT, such as flexibility and global integration ( Lang, Lopez, Stahl, Tchanturia, & Treasure, 2014 ; Tchanturia et al., 2011 , 2012 ). Furthermore, young people who are low in weight due to OCD-related dietary restriction have been shown to have a significantly poorer response to CBT for OCD, compared to patients with a healthy weight ( Jassi et al., 2016 ). Therefore, Lisa and her family were informed that she needed to maintain a minimum 85% weight for height in order to continue with CBT through the specialist clinic. Lisa agreed to have her weight continually monitored on a weekly basis throughout the course of her outpatient treatment.

Lisa continued to gain weight in outpatient care and engaged fully in a 20-session course of CBT for OCD. Treatment included exposure to eating a range of previously avoided foods without engaging in rituals such as examining the food. Her score on the CY-BOCS dropped to 15 by the end of treatment. She was able to carry out all self-care activities independently and was no longer restricting her dietary intake.

Case 4: Secondary risk in a case of self-injurious compulsions

Alex was an 8-year-old boy who presented with a 6-month history of OCD. At assessment, Alex’s CY-BOCS score was 19, indicating mild to moderate OCD symptoms. Alex reported “hearing voices” that told him to stick pencils, pens, and spoons down his throat and gouge out his eyes. This was in response to the intrusive thought that his family would be killed if he did not perform these compulsions. Thus, Alex presented with secondary risk of self-harm through performing unusual and potentially extremely harmful compulsions in an attempt to neutralize his obsessions. Prior to attending the specialist OCD assessment, Alex had presented to his general practitioner on several occasions and had been admitted his local Accident and Emergency (A&E) department after an incident of poking his eyes. Throughout this time, Alex’s OCD remained undiagnosed. Following his A&E presentation, he was prescribed risperidone (0.25 mg) in an attempt to reduce his agitation, with no effect.

Upon assessment at the specialist clinic, Alex presented with a range of more common OCD symptoms (e.g., counting and ordering). However, because Alex’s OCD included compulsions that involved causing harm to himself, it was necessary to prioritize managing this risk in parallel with planning OCD treatment. Alex’s parents were advised to ensure that cutlery, pens, and other potential implements were not easily accessible to him. It was emphasized that this would be a short-term measure, not a long-term solution. It was explained that CBT would include exposing Alex to these implements in a graded way so that Alex could practice resisting the urge to perform self-harming compulsions. He was also prescribed sertraline (50 mg) following assessment.

Alex received 12 sessions of CBT incorporating ERP, which included gradually exposing himself to sharp objects and statements and images of his family being killed, without ritualizing. As Alex progressed through CBT and his urge to carry out compulsions lessened, sharp objects were gradually reintroduced into his home environment. Alex responded well to treatment, and his self-injurious behavior completely resolved. His posttreatment CY-BOCS score was 9.

The four young people described here all presented with symptoms that had previously caused their treating clinicians alarm by virtue of their risky, or apparently risky, phenomenology. It is encouraging to note that in all cases clinicians considered OCD as a differential diagnosis and ultimately referred the young people to a specialist OCD clinic due to diagnostic uncertainty or treatment resistance.

The first two cases are examples of primary risk arising from obsessions. This risk is only apparent and, once correctly formulated as a symptom of OCD, should be no cause for alarm because patients do not act on their obsessions. Other examples of primary risk include intrusive thoughts of harming others, which can cause particular concern in young people with a history of conduct problems, and obsessional thoughts about theft and arson. The latter two cases presented here highlight types of secondary risk arising as an unintended consequence of engaging in compulsions. There are many and varied examples of secondary risk in young people with OCD, some of which include developing urinary tract infections due to avoidance of passing urine, damaging skin as a result of using bleach to clean hands, and developing rectal prolapse as a consequence of excessive straining to eliminate feces.

The cases described here highlight the importance of carefully considering the appropriateness of standard risk protocols prior to implementation in cases of OCD. Risk assessment and management are unnecessary in cases of primary risk and can be counterproductive. This is clearly demonstrated in the case of Michael, where standard risk protocols fueled his obsessional fears of being a pedophile and exacerbated his symptoms. In contrast, risk assessment and management are necessary and beneficial in cases of secondary risk. Alex’s self-injurious compulsions meant that it was imperative that he was not left unsupervised with sharp objects at the start of treatment. Similarly, in the case of Lisa, it was essential that her food and fluid restriction be managed effectively so that her physical health could be maintained at a level that would enable her to engage with CBT.

Implications for practice

The current review has clear implications for the management of risk in pediatric OCD. At assessment, cognitions and behaviors pertaining to risk should be assessed carefully and considered within the context of OCD, including differentiating whether the risk is genuine or apparent. As described in the four case examples, a number of questions can be posed at the point of assessment to help clinicians confidently determine whether a young person is presenting with primary or secondary risk in the context of OCD. Guiding principles for assessing and formulating risk in OCD are shown in Table 1 .

When young people present with seemingly dangerous intrusive thoughts, clinicians should assess for ego dystonia of thoughts, history of acting on thoughts, compulsions linked to these thoughts, and presence of other OCD symptoms (see Table 1 ). Consideration of these features in combination can enable clinicians to determine whether the risk is genuine or only apparent. Once formulated as OCD, primary risk should be managed by normalizing symptoms within the context of OCD and proceeding as usual with ERP-based CBT, with or without concomitant pharmacotherapy. A lengthy risk assessment, placing the patient on one-to-one observation, or ensuring that the patient does not come into contact with the object of his or her obsessions should be avoided. As highlighted in these case examples, such measures can be counterproductive in that they may serve to exacerbate the patient’s fear that he or she may act on the obsessions, thus making both obsessions and compulsions worse. In order to avoid this result, both therapist and patient should be confident in their diagnosis of OCD and in their knowledge that patients with OCD do not act on their compulsions. For patients presenting with obsessions that pose a primary risk, exposing themselves to their fears can seem dangerous and therefore the psychoeducation phase of treatment may need to be extended. It is particularly important to spend time ensuring that patients presenting with primary risk are engaged with the CBT model, and that they fully understand the rationale for conducting ERP. Psychoeducation about OCD and the role of anxiety can be helpful in illustrating the reasons for exposure to feared stimuli and the need to refrain from engaging in compulsions.

Cases of secondary risk should be managed by formulating the risk clearly within the context of OCD and proceeding as normal using standard evidence-based ERP protocols (see Table 1 ). Although it may be necessary to take practical steps to manage or minimize risk before commencing CBT (e.g., refeeding in the case of someone who has stopped eating as a result of contamination fears and is dangerously underweight), therapists should not be distracted in the overall management plan from treating OCD as the primary problem. In most cases, it is both possible and necessary to manage risk and treat OCD in parallel in order to achieve recovery. Treating the OCD is essential for the long-term reduction of such a risk, as illustrated in the cases presented here, and successful treatment should result in resolution of risk.

In summary, OCD in young people that is associated with either primary or secondary risk can be effectively treated with CBT incorporating ERP, and risk resolves with successful treatment. Exposure tasks can be particularly challenging for clinicians in the context of risky behavior, whether real or apparent, and it is therefore essential that they are well supported by a robust network of professionals with a solid understanding of OCD.

Acknowledgments

Georgina Krebs is funded by an MRC Clinical Research Training Fellowship (MR/N001400/1).

The authors have no competing interests to declare.

Contributor Information

Angela Lewis, South London and Maudsley NHS Foundation Trust, London, UK.

Caroline Stokes, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK.

Isobel Heyman, Great Ormond Street Hospital and the Institute of Child Health, University College London, London, UK.

Cynthia Turner, University of Queensland, Brisbane, Australia.

Georgina Krebs, South London and Maudsley NHS Foundation Trust, London, UK; Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK.

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Case Study: Obsessive-Compulsive Disorder

In a previous article we reviewed a range of treatments that are used to help clients suffering from obsessive-compulsive disorder (OCD). In this edition we showcase the case study of Darcy [fictional name], who worked with a psychologist to address the symptoms and history of her OCD.

Marian, a psychologist who specialised in anxiety disorders, closed the file and put it into the filing cabinet with a smile on her face. This time she had the satisfaction of filing it into the “Work Completed” files, for she had just today celebrated the final session with a very long-term client: Darcy Dawson. They’d come through a lot together, Darcy and Marian, during the twelve years of Darcy’s treatment for Obsessive-Compulsive Disorder, and they had had a particularly strong therapeutic alliance.

Marian reflected on the symptoms and history which had brought Darcy into her practice.

Obsessions at age nine

Now 37, Darcy reckoned that she had begun having obsessions around age nine, soon after her beloved grandma had died. Already grieving the loss of the person she was closest to in life, Darcy experienced further alienation – and resultant anxiety — when her father relocated the family from the small town in Victoria where they lived to Melbourne. Adjusting to big-city life wasn’t easy for someone as anxious as Darcy, and she soon found that she was obsessing. She had fears of being hit by a speeding car if she stepped off the kerb. She feared that the new friends she began to develop in Melbourne would be kidnapped by bad people. And she was terrified that, if she didn’t do an elaborate prayer routine at night, all manner of terrible things would befall her family.

The prayer routine, relatively simple at first, grew to gigantic proportions, containing many rules and restrictions. Darcy believed that she had to repeat each family member’s full name 15 times, say a sentence that asked for each person to be kept safe, promise God that she would improve herself, clap her hands 20 times for each person, kneel down and get up 5 times, and then put her hands into a prayer position while bowing. She “had” to do this routine at least 10 times each night, and if she made a mistake anywhere along the way, she had to start totally over again from the beginning, or else something bad would happen to her parents or little brother. Once she went flying to her mother’s side in the kitchen, tears streaming down her face, because she couldn’t get her “prayers” right. Darcy was certain that she was a huge disappointment to God and everybody.

Just like Granddad

Marian had asked Darcy if her parents were similar at all, and Darcy couldn’t think of many ways in which they were. Then she remembered something. “Ah,” she said, “my parents aren’t having these awful thoughts like me, but I remember my mum often telling me, ‘You’re just like your grandfather.’” Darcy’s grandfather had died when she was only five, so she didn’t have strong recollections of him, but there were two images that she always remembered about him: Grandfather standing by the kitchen sink in their farmhouse, washing his hands – always washing his hands. And if they decided to take a walk around the farm, he would take a seeming eternity to check that all the windows and doors were locked, even though they were on good terms with everyone within a ten-mile radius!

Obsessions and compulsions worsen through Uni

Marian had felt huge compassion for Darcy as she outlined the course that the disorder had taken. While the intrusive thoughts waxed during high-stress times and waned when Darcy felt relatively stable, there was nevertheless a general broadening of the obsessions – and resultant compulsion to do certain repetitive acts – throughout Darcy’s growing-up years. In high school, for instance, Darcy began to have an aversion to looking at any woman with a scoop-neck top on, going so far as to grab a glass and pretend to be holding it high up near her lips (as if to drink) if she had to talk to someone dressed in any but the most conservative top. In that way, she felt, she would be blocked from seeing what she should not see and thus sinning. Short skirts were also a problem, as Darcy feared that she was looking at people in inappropriate ways, and was offensive.

If anyone at a party crossed their legs while she was looking at them, Darcy assumed that they had done that because they were offended by her having glanced at them; she feared that they would think she was looking at their crotch area. She prayed constantly for forgiveness, but ended up ceasing hugs to family and friends because she felt like a hypocrite. Of course, not feeling that she could/should touch anyone made for huge social problems, and dating anyone became impossible: a huge punishment for a friendly extravert like Darcy. She petitioned God relentlessly, asking to be a better, less sinful person. It did not seem to help.

When Darcy began University, the experience was defined by a series of irrational obsessions. She would worry incessantly about having written something offensive on an email or an assignment. Walking around campus, she would pick up rubbish: papers that she had never seen before; she would worry that she might have written something on one of them. She feared that she would accidentally hurt one of her fellow students by something that she might do or say. By this time Darcy was repeating certain phrases over and over again to ward off disaster. She was amazed that she was getting through school at all (she often made straight A’s), because her rampant perfectionism caused her to take at least twice as long as other students to complete assignments, and she still wasn’t happy then. The anxiety and depression were overwhelming Darcy to the point where she recognised that she could barely function and something needed to change.

The Uni psychologist says, “You’re fine”

Marian shook her head in amazement as she recalled how Darcy’s first attempts to find out what was wrong with her had been fruitless; all the health professionals had completely missed the OCD! Upon first coming to Marian, Darcy had recounted how getting along to the University psychologist in her senior year was a “non-event”. He had asked a few questions, chatted to her about her schoolwork, told her she was basically fine, and then told her to go see a psychiatrist, who merely prescribed a sleeping pill. Darcy had taken this, as instructed, because the intrusive thoughts in her mind often did keep her from sleeping, but when she was awake she still had the thoughts and the horrible compulsion to perform the anxiety-alleviating acts: routines which now occupied several hours each day. Moreover, Darcy’s parents still didn’t believe that anything was wrong with her; they even found it funny that she was “quirky” like her grandfather.

Age 25: Treatment begins

Darcy was to graduate and spend another three years being held prisoner by her out-of-control mind before a chance meeting of her mother with a specialist in OCD at a conference. The specialist didn’t live in Melbourne, but – by incredible coincidence – he had a highly recommended colleague who did: Marian. Marian recalled with some fondness how Darcy had sat in her office during the first session, shedding tears of joy at being truly “seen”: both as a person and in her disorder. When Marian had issued the magical words, “Obsessive-Compulsive Disorder”, Darcy had been surprised – after all, her sense of OCD was people who continually washed their hands – but she also felt like she had just been given the key to her prison. Her treatment began soon after.

Marian worked intensively with Darcy at first, and then steadily. She helped Darcy get onto an even keel emotionally first by raising her serotonin levels (which had been quite low). Marian then began the laborious process of helping Darcy to change her habits of thinking: the assumptions that she made, the irrationalities that controlled her behaviour, and the intrusive obsessions that seemed to take over her life. Marian helped Darcy to see the importance of an exercise regimen, a good diet, and a stillness practice. Darcy joined an online support group, and Marian and Darcy enlisted the help of Darcy’s family and a few close friends. Partway through the therapy, Darcy was even able to come off the medications: a goal she had long sought, because she had married a “wonderful” man and they wanted to start a family.

At 37, Darcy is a happy and fulfilled person, with a solid marriage and an eight-year-old daughter. She believes that she worries about her “like a normal mother”, rather than in the obsessional way she used to pray in order to protect her family from imagined harm. She still petitions God, as she is active in her church, but now the petitions are free of the superstitious routines she used to perform, and she is quick to be thankful for her many blessings.

Unwanted thoughts still come to her, but now she has tools to focus elsewhere, and when the intrusive thoughts come, Darcy knows how to keep them from causing her to repeat irrational acts in a compulsive way. She knows that she will probably always be managing her disorder, as there is no cure for OCD. But the difference now is that she controls it, rather than having it control her. As far as Darcy is concerned, Marian gave her back her life.

Marian smiled again as she recalled Darcy’s journey and her original fear of being a “disappointment to God and everyone”. Indeed, Marian felt blessed to have had Darcy as a client.

This article is an extract of the upcoming Mental Health Academy “OCD and OCPD Case Studies” CPD course. Click here for a full list of currently available MHA continuing professional development courses.

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