Indian Journal of Health Social Work
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A CLINICAL CASE STUDY OF INDIVIDUAL WITH OBSESSIVE COMPULSIVE DISORDER (OCD)
Prashant Srivastava1, Kavya Ahu2, Vani Narula3
1Psychiatric Social Worker, Dept. of Psychiatry, Kalpana Chawla Government Medical College and Hospital, Karnal, Haryana, 2M.Sc Clinical Psychology, Amity University, Gurugram, Haryana. 3Associate Professor, Dept. of Social Work, Jamia Millia Islamia, New Delhi. Correspondence: Kavya Ahu, e mail: lifelikekavyaahuja92@gmail.com
ABSTRACT
Background:
Obsessive Compulsive Disorder (OCD) is a severe and debilitating anxiety disorder with a lifetime prevalence of 0.6% in Indian population. It is twice as prevalent as schizophrenia and bipolar disorder, and the fourth most common psychiatric disorder.
Aim:
The present study aims to explore the course of obsessive compulsive disorder and to assess the effectiveness of obsessive compulsive disorder management in alleviating the symptoms associated with obsessive compulsive disorder and to improve the client’s overall functioning.
Research design:
Case study.
Sample and method:
This study was carried out in Karnal at KCGMC and 36 years old married male was included. The treatment plan was formulated according to psychotherapeutic management in which different techniques were utilized to improve the client’s associated compulsive behavior and his beliefs.
Results:
Findings of the assessment showed a significant change in overall functioning. Psychosocial management techniques successfully changed his beliefs, anxiety and remarkably improved his overall functioning.
Conclusion:
On the basis of the results shown in the report it can be determined that psychotherapeutic management is an effective approach to treat obsessive compulsive disorder.
Keywords: Psychotherapeutic, belief, case study
INTRODUCTION
Obsessive Compulsive Disorder (OCD) is an impairing anxiety disorder portrayed by disquieting, undesirable perceptions (obsession) serious and tedious repetitive compulsion. (American Psychiatric association, 2000) OCD is characterized by means of obsessive thoughts, impulses, or images and compulsions which might be tough to suppress and take a large amount of time and energy far away from residing your life, taking part in your own family and friends or maybe doing your activity or any work. The average age of onset is 19 years antique. Sometimes the circumstance manifests itself tempo rar i l y a nd in some c as es i t i s conventional for an entire life. OCD may be extraordinarily burdensome to the victim, regularly impacting the everyday life of now not handiest the man or woman with OCD but their households as nicely. Most individuals with OCD understand that their obsessions are not just immoderate issues approximately real problems and that the compulsions they perform are immoderate or unreasonable. The quantity to which a person with OCD realizes that his or her ideals and actions are unreasonable is known as his or her “insight.” OCD includes issues in conversation among elements of the brain. These troubles can be because of insufficient ranges of sure mind chemi cal s ubs tances , k nown as neurotransmitters. Drugs that increase the mind awareness of those chemical substances often assist enhance OCD symptoms. Cormier and Nur ius (2 00 3) cla r i f ie d t ha t t he insignificant demonstration of watching and checking one’s very own conducted and encounters can create changes. As individuals watch themselves and gather information about what they watch, their conduct might be impacted. Rao, Sudarshan, Pai (2005) conclude that antipsychotics have a restricted role in OCD and are best constrained to the circumstances.
Although a causal role of a sense of guilt in the genesis and maintenance of obsessive compulsive disorder (OCD) has not been fully demonstrated, many publ ications have identified investment in protection from guilt or one of its elements as a central factor in the disorder. Even in the initial 17th century descriptions of the disorder, OCD was related to marked scrupulousness and excessive preo ccupat i on (Mancini , 2005) . Many descriptions of the role of an exaggerated sense of responsibility have been reported in the development and maintenance of OCD (Salkovskis , 1985; 2002; Salkovskis & Forrester, 2002; Rachman, 1993; 1997, 2002; Ladouceur et al., 1995).
A CASE REPORT
Mr. S, 36 years old Male, Muslim, Married, Less than matric, 6k- 9k per month, was brought to the department of psychiatry, outpatient department of Kalpana Chawla Gov. Medical College and Hospital, Karnal, Haryana came along with his wife with the chief complaints of repetitive counting, follow the same routine, repetitive arranging things, worry some thoughts, loss of interest, irritability, low mood.
According to patient till august 2014, he was functioning well. In September 2014, when he was working in his shop someone told him that eating things 3 time is not good pick one more from that day this thing fix in his mind , on the same day he forget his diary in his shop there is no specific thing or important thing in that according to patient but because of that he can’t able to sleep he even asked his father to go to shop and take that diary he get anxious in the night and in the morning when he got the diary he feel relaxed. Patient said” meri bechani tab se badh gayi hai”. He reported some incidence he said if he switch on the light he only switch off that, if he came from the lift then he came back to the lift only not from the stairs mentioned by her wife. Patient said “agar kisi ko kuch hota hai to mujhe lagta hai mujhe bhi vo ho jayega.” Patient went to the PGIMS, Rohtak for the treatment on September 20, 2014. Here, the patient was diagnosed with OCD and he was on the medication. On feb 8 2017, he came to KCGMC for the treatment same medicine were continue with the major chief complaints of suspi cious nes s , di s turbance in s leep, repetitive arranging things, do things four time, anxious. At present, he is also suffering from high blood pressure issues and also tensed about having a girl child fourth time. The patient has been taking medication from various places but is not serious due to which the illness has been deteriorating since many years. IQ assessment was done and IQ came out to be 90 which mean average level of intellectual functioning at present. The patients stay in a nuclear family and first among five siblings. There is no family history of psychiatric illness and major medical illness. According to his personal history the patient completed his studies upto IInd standard and he is an average student. Presently, he is a tailor and the patient interaction with his family is limited due to his compulsive activities. On mental state examination (MSE), the patient is wel l gr oomed and dr es s ed pr ope r l y. Hi s psychomotor activity is normal. He makes eye contact, and rapport is easily established. He has no tics and cooperative. The patient’s speech i s spontaneous and coherent . Subjectively, the patient says he is okay and objectively he appears anxious. The patient has no hallucination, delusion and illusions. The patient could not able to perform digit forward and backward for attention and concent ration. Hence i t appears to be inadequate. The patient is well oriented to time, place and person. The patient remote, recent and immediate memories were intact. Abstract thinking found to be inadequate. The patient judgement is intact. The patient level of insight is Grade-III.
REASONS FOR TAKING AN INTERVENTION
To reduce the anxiety and thoughts that coming in his mind to perform compulsive activities, enhance the quality of life, poor coping skills, to reduce distress. Also provide awareness regarding the manifestation of OCD and to reduce his illness from stagnation. Specific areas to be focused
Short-term objectives
1. Establish a firm therapeutic alliance with the patient.
2. Educate the pat ient regarding the manifestations of the disorder.
3. To reduce the severity of the symptoms.
4. To manage any other psychiatric or medical emergencies.
5. Maintain regular, consistent contact with the client for his recovery.
6. Long- term objectives
7. To motivate the client towards recovery rather than eliminating the symptoms and trying to cope up with symptoms too. 8. To engage the client in various activities for improvement in daily basis working.
9. Maintain or improve patient’s level of function and quality of life.
TYPES AND TECHNIQUES OF INTERVENTION Psycho education:
The patient and his family members were offered psych educated to make the patient and his family well aware about the nature of the illness, course, treatment, and prognosis and to clear any misconceptions about the illness. This was done so that the patient is in a better position to deal with the illness as he had no hope for any improvement with his illness. Proper guidance for medication and to be prompt was also directed to the patient and his family members so that they take proper care as well.
Jacobson’ s progressive mus cular relaxation(JPMR):
JPMR is generally used to manage and reduce anxiety and automatic arousal. The major steps associated with it are learning to identify excessive tension in specific muscles and learning to unwind and if conceivable, wipe out that strain. This procedure is rehashed with different muscle gatherings of the body.
Supportive psychotherapy:
Supportive psychotherapy was aimed at validating the distress the client is undergoing. The patient is given reassurance, support, and his ability to cope with distress is reinforced.
Exposure Response Prevention Therapy (ERP Therapy):
This therapy includes the individual with OCD confronting his or her feelings of dread and after that ceasing from ritualizing. This can be very nervousness inciting at first, yet in the long run the uneasiness begins to fade and can now and then even vanish. Studies demonstrate that introduction and reaction counteractive action can really “retrain” the mind, forever diminishing the event of OCD indications (Singer,2018)
Cognitive Distraction and Restructuring technique:
By using various distraction strategies such as focusing on other work rather than thinking on same thought, involve in di fferent activities. And also find out illogical cognition and to modify maladaptive cognitions and replace with adaptive thoughts.
THERAPY PROCESS
Session-1
Rapport is build up with the patient firstly so that he is comfortable wi th sharing his thoughts and feelings and then psychoeducation was given to the patient reason for expanding awareness about the illness. This helped them in seeing how his indication started. Firstly therapist listened him with care and consolation and sympathy was given to him. And he was educated about the disorder which he thought he harboured. Supportive psychotherapy was given to his wife as she was very anxious and worried. Supportive measures for example, Consolation and influences were utilized furthermore, were approached to support the patient. This helps him to develop trust and confidence. JPMR was introduced to the patient. Therapist clarified JPMR components and its basis. He was educated about his illness, JPMR, and its implications.
Session-2
Patient was reviewed. The client was told about importance of relaxation of his problem and also explained the rationale for the same. Second session of JPMR was held. Before the session the therapist illustrated to the patient how to tense and loosen up different gathering of muscles. He was approached to come successively for four days of relaxation training. After the relaxation, the client was offered chance to ventilate his sentiments and consolation was given to the client that the issues could be i l luminated over some undefined time frame.
Session-3
Patient was seen. Third session of JPMR was conducted and al s o ERP therapy was introduced patient was given a brief about exposure response therapy. Therapist makes him touch the switch board once then stop patient for doing this again three times as resul ted patients anxiety increases then therapist make patient relaxed by doing deep breathing exercise. As that day patient came from lift and were told to go from stairs. He was told that firstly you anxiety will increases and slightly it will decrease down.
Session-4 & 5
Fourth session of JPMR was conducted. Patient reported that he was getting some relief from his anxiety from the relaxation pr oce dure. Co gni t i ve di s t r act io n a nd restructuring technique was done to find out the illogical cognition he has, he was instructed to replace with more adaptive thoughts or engage himself in some other activities. On the same time again he was asked to switch on the light but don’t off that. He was getting anxious for at least half an hour but when he started talking with his wife and get distracted from that situation he gets normal. Patient was seen. Patient seemed to be more comfortable and confident. He seems to be very positive and told his therapist that he feel so motivated and thinks that he will overcome with all his problems. After the session therapist explained about the importance of regular practice of relaxation and advice the client to practice it at home. For further review, appointment was scheduled.
CONCLUSION AND OUTCOME
In this case study five sessions were held with the patient. Later the patient came for follow up and reported the therapist considerable improvement in terms of his symptoms. He reported that his distress, his worries, and taking unnecessary medicines reduced and felt confident. His mood continued to improve and he became more comfortable and confident. His obsessive thoughts got reduced. Several years ago, OCD was regarded as one of the least treatable illnesses. However, in the last three decades this picture has changed with the development of effective treatment methods such as exposure and response prevention therapy [ERP] and cognitivebe hav ior al thera py [CB T] as we l l as antiobsession medication (Cordioli, 2008; Cordioli & Braga, 2011; Vivan, Bicca, & Cordioli, 2011).
1. Establish a firm therapeutic alliance with the patient.
2. Educate the pat ient regarding the manifestations of the disorder.
3. To reduce the severity of the symptoms.
4. To manage any other psychiatric or medical emergencies.
5. Maintain regular, consistent contact with the client for his recovery.
6. Long- term objectives
7. To motivate the client towards recovery rather than eliminating the symptoms and trying to cope up with symptoms too. 8. To engage the client in various activities for improvement in daily basis working.
9. Maintain or improve patient’s level of function and quality of life.
TYPES AND TECHNIQUES OF INTERVENTION Psycho education:
The patient and his family members were offered psych educated to make the patient and his family well aware about the nature of the illness, course, treatment, and prognosis and to clear any misconceptions about the illness. This was done so that the patient is in a better position to deal with the illness as he had no hope for any improvement with his illness. Proper guidance for medication and to be prompt was also directed to the patient and his family members so that they take proper care as well.
Jacobson’ s progressive mus cular relaxation(JPMR):
JPMR is generally used to manage and reduce anxiety and automatic arousal. The major steps associated with it are learning to identify excessive tension in specific muscles and learning to unwind and if conceivable, wipe out that strain. This procedure is rehashed with different muscle gatherings of the body.
Supportive psychotherapy:
Supportive psychotherapy was aimed at validating the distress the client is undergoing. The patient is given reassurance, support, and his ability to cope with distress is reinforced.
Exposure Response Prevention Therapy (ERP Therapy):
This therapy includes the individual with OCD confronting his or her feelings of dread and after that ceasing from ritualizing. This can be very nervousness inciting at first, yet in the long run the uneasiness begins to fade and can now and then even vanish. Studies demonstrate that introduction and reaction counteractive action can really “retrain” the mind, forever diminishing the event of OCD indications (Singer,2018)
Cognitive Distraction and Restructuring technique:
By using various distraction strategies such as focusing on other work rather than thinking on same thought, involve in di fferent activities. And also find out illogical cognition and to modify maladaptive cognitions and replace with adaptive thoughts.
THERAPY PROCESS
Session-1
Rapport is build up with the patient firstly so that he is comfortable wi th sharing his thoughts and feelings and then psychoeducation was given to the patient reason for expanding awareness about the illness. This helped them in seeing how his indication started. Firstly therapist listened him with care and consolation and sympathy was given to him. And he was educated about the disorder which he thought he harboured. Supportive psychotherapy was given to his wife as she was very anxious and worried. Supportive measures for example, Consolation and influences were utilized furthermore, were approached to support the patient. This helps him to develop trust and confidence. JPMR was introduced to the patient. Therapist clarified JPMR components and its basis. He was educated about his illness, JPMR, and its implications.
Session-2
Patient was reviewed. The client was told about importance of relaxation of his problem and also explained the rationale for the same. Second session of JPMR was held. Before the session the therapist illustrated to the patient how to tense and loosen up different gathering of muscles. He was approached to come successively for four days of relaxation training. After the relaxation, the client was offered chance to ventilate his sentiments and consolation was given to the client that the issues could be i l luminated over some undefined time frame.
Session-3
Patient was seen. Third session of JPMR was conducted and al s o ERP therapy was introduced patient was given a brief about exposure response therapy. Therapist makes him touch the switch board once then stop patient for doing this again three times as resul ted patients anxiety increases then therapist make patient relaxed by doing deep breathing exercise. As that day patient came from lift and were told to go from stairs. He was told that firstly you anxiety will increases and slightly it will decrease down.
Session-4 & 5
Fourth session of JPMR was conducted. Patient reported that he was getting some relief from his anxiety from the relaxation pr oce dure. Co gni t i ve di s t r act io n a nd restructuring technique was done to find out the illogical cognition he has, he was instructed to replace with more adaptive thoughts or engage himself in some other activities. On the same time again he was asked to switch on the light but don’t off that. He was getting anxious for at least half an hour but when he started talking with his wife and get distracted from that situation he gets normal. Patient was seen. Patient seemed to be more comfortable and confident. He seems to be very positive and told his therapist that he feel so motivated and thinks that he will overcome with all his problems. After the session therapist explained about the importance of regular practice of relaxation and advice the client to practice it at home. For further review, appointment was scheduled.
CONCLUSION AND OUTCOME
In this case study five sessions were held with the patient. Later the patient came for follow up and reported the therapist considerable improvement in terms of his symptoms. He reported that his distress, his worries, and taking unnecessary medicines reduced and felt confident. His mood continued to improve and he became more comfortable and confident. His obsessive thoughts got reduced. Several years ago, OCD was regarded as one of the least treatable illnesses. However, in the last three decades this picture has changed with the development of effective treatment methods such as exposure and response prevention therapy [ERP] and cognitivebe hav ior al thera py [CB T] as we l l as antiobsession medication (Cordioli, 2008; Cordioli & Braga, 2011; Vivan, Bicca, & Cordioli, 2011).
REFERENCES
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Me nta l Di sor edr s , 4th E dn. Washington, DC: American Psychiatric Association.
Cordioli, A. V. (2008). A terapia cognitivocompo r t ame nta l no t ra ns tor no obses s i v o-compul s i v o. Rev i s ta Brasileira de Psiquiatria, 30( 2), 65- 72.
Cordioli, A. V., & Braga, D. T. (2011). Terapia co gni t i vo- compo r t ame nta l do transtorno obsessivo-compulsivo. In B. Ra ngé, Ps i cot er api as co gni t i vocompor tament ai s : Um diálogo com a psiquiatria, 325-343. Porto Alegre: Artmed
Cormier, L. S., Nurius, P., & Cormier, L. S. (2003). Interviewing and change strategies for helpers: Fundamental s k i l l s and cogni t i ve beha vior al interventions. Paci fic Grove, CA: Thomson/Brooks/Cole.
Ladouceur, R., Rhéaume, J., Freeston, M.H., Aublet, F., Jean, K., Lachance, S., Langlois, F. & De Pokomandy-Morin, K. (1995). Experimental manipulations of responsibility: An analogue test for model s of obses sive-compulsi ve disorder. Behaviour Research and Therapy, 35, 955-960.
Ra chman, S. ( 199 3) . Obse s s ions , responsibility and guilt. Behaviour Research and Therapy , 31, 149-154.
Rachman, S. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy , 31, 793-802.
Rachman, S. (2002). A cognitive theory of compul sive checking. Behaviour Research and Therapy, 40, 625-640.
Rachman, S., Thordarson, D., Shafran, R., & Wo ody, S.R. ( 199 5) . Per cei v ed re spo ns i bi l i t y: St r uct ur e a nd significance. Behaviour Research and Therapy, 33, 779-784.
Rao K.N., Sudarshan, C.Y., & Pai Pai, P. (2005). Obsessive-compulsive disorder: An interface with possible psychotic features. Indian journal of Psychiatry, 47, 175-8.
Salkovski s , P.M. (1985) . Obsess ional – compulsive problems: A cognitivebehavioural analysi s. Behaviour Research and Therapy, 23, 571-583. Salkovskis, P.M., & Forrester, E. (2002).
Responsibility. In R.O. Froste, & G. Steketee (Eds), Cognitive Approaches to Obsessions and Compulsions. Oxford: Pergamon Press.
Singer, J. (2018). ERP Therapy-A Good Choice for Treating Obsessive Compulsive Disorder (OCD) An American Addiction ce nte r s Re sour c e. ht tps : / / psychcentral.com/lib/erp-therapy-agood- choice-for-treating-ocd/
Vivan, A. S., Bicca, M. G., & Cordioli, A. V. (2 011 ) . Mode lo co gni t i vocompor t ame nt al do transtorno obsessivo-compulsivo. In I. Andretta, & M. S. Oliveira (Eds.), Manual prático de terapia cognitivocomportamental (pp. 373-388). São Paulo: Casa do Psicólogo.
Conflict of interest: None
Role of funding source: None
American Psychiatric Association (2000). Diagnostic and Statistical Manual of Me nta l Di sor edr s , 4th E dn. Washington, DC: American Psychiatric Association.
Cordioli, A. V. (2008). A terapia cognitivocompo r t ame nta l no t ra ns tor no obses s i v o-compul s i v o. Rev i s ta Brasileira de Psiquiatria, 30( 2), 65- 72.
Cordioli, A. V., & Braga, D. T. (2011). Terapia co gni t i vo- compo r t ame nta l do transtorno obsessivo-compulsivo. In B. Ra ngé, Ps i cot er api as co gni t i vocompor tament ai s : Um diálogo com a psiquiatria, 325-343. Porto Alegre: Artmed
Cormier, L. S., Nurius, P., & Cormier, L. S. (2003). Interviewing and change strategies for helpers: Fundamental s k i l l s and cogni t i ve beha vior al interventions. Paci fic Grove, CA: Thomson/Brooks/Cole.
Ladouceur, R., Rhéaume, J., Freeston, M.H., Aublet, F., Jean, K., Lachance, S., Langlois, F. & De Pokomandy-Morin, K. (1995). Experimental manipulations of responsibility: An analogue test for model s of obses sive-compulsi ve disorder. Behaviour Research and Therapy, 35, 955-960.
Ra chman, S. ( 199 3) . Obse s s ions , responsibility and guilt. Behaviour Research and Therapy , 31, 149-154.
Rachman, S. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy , 31, 793-802.
Rachman, S. (2002). A cognitive theory of compul sive checking. Behaviour Research and Therapy, 40, 625-640.
Rachman, S., Thordarson, D., Shafran, R., & Wo ody, S.R. ( 199 5) . Per cei v ed re spo ns i bi l i t y: St r uct ur e a nd significance. Behaviour Research and Therapy, 33, 779-784.
Rao K.N., Sudarshan, C.Y., & Pai Pai, P. (2005). Obsessive-compulsive disorder: An interface with possible psychotic features. Indian journal of Psychiatry, 47, 175-8.
Salkovski s , P.M. (1985) . Obsess ional – compulsive problems: A cognitivebehavioural analysi s. Behaviour Research and Therapy, 23, 571-583. Salkovskis, P.M., & Forrester, E. (2002).
Responsibility. In R.O. Froste, & G. Steketee (Eds), Cognitive Approaches to Obsessions and Compulsions. Oxford: Pergamon Press.
Singer, J. (2018). ERP Therapy-A Good Choice for Treating Obsessive Compulsive Disorder (OCD) An American Addiction ce nte r s Re sour c e. ht tps : / / psychcentral.com/lib/erp-therapy-agood- choice-for-treating-ocd/
Vivan, A. S., Bicca, M. G., & Cordioli, A. V. (2 011 ) . Mode lo co gni t i vocompor t ame nt al do transtorno obsessivo-compulsivo. In I. Andretta, & M. S. Oliveira (Eds.), Manual prático de terapia cognitivocomportamental (pp. 373-388). São Paulo: Casa do Psicólogo.
Conflict of interest: None
Role of funding source: None
It’s a matter of great pride for me that All India Association of Medical Social Work Professionals is launching first issue of “Indian Journal of Health Social Work” on the auspicious occasion of 6th Annual National Conference of AIAMSWP, 2019.
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