A Case Study of Obsessive Impulsive Disorder

A Case Study of Obsessive-Compulsive Disorder more or less Diagnostic Considerations INTRODUCTION Prior to 1984, psychoneurotic inconvenience (OCD)wasconsideredarare disorder andone difficultto treat (I). In 1984 theEpidemiologic CatchmentArea (ECA) initial scene resultsbecame available for the first time, andOCDprevalence figuresshowed that2. 5%ofthepopulation metdiagnosticcriteriafor OCD (2,3). Finalsurvey results publishedin 1988(4) confirmed theseearlier reports. Inadd-on, a 6-monthpoint prevalence of1. 6%was observed,andalifetimeprevalenceof 3. 0% wasfound.OCD isan illness of secrecy, and often thepatientspresentto physicians inspecialties another(prenominal) than psychiatry. Another factor contri besidesing to under diagnosis ofthis disorderis thatpsychiatrists ma y fail to ask screening questionsthat would identifyOCD. Thefollowing case contract isan exampleofa patientwith moderately severe OCDwhopresentedtoaresidentpsychiatryclinicten years prior to existence diagnosed with OCD. The patientwascompliant with step to the fore patient treatment for theentire timeperiodand was hard-boilight-emitting diodeformajordepressivedisorderand border line nature disorder with medication s and appurtenantpsychotherapy.The patient neer discussedher OCD symptomswith her doctorsbut in retrospect had offered m both cluesthat might have allowedaswifterdiagnosis and treatment. CASEHISTORY Simran Ahuja was a 29 yearold,divorced,indian female who workedas a file clerk. Shewas followed as anout patientat thesameresidentclinic since1971. Ifirst saw her 2012. other(prenominal) PSYCHIATRIC HISTORY Simran had beenseen in theresidentout patientclinic since July of 1984. Priortothis shehad not beenin psychiatric treatment. Shehad never been hospitalized.Her initialcomplaints were low gear and anxietyand she had been placed onan phenelzineand responded swell up. Herdepressionwasinitially thoughtto besecondary to amphetamine withdrawal, since shehad been usingdietpillsfor 10years. She expressthat at firstshetook them to lose weight,butcontinued forsolong because people at work had noted that sheconcentratedbetterand that her job performance had improved. In addition,her past doctors hadallcommented on her limitedibility tochangeand her regardiness, insecurity,lowself-esteem,and poor boundaries. In addition,her past doctors had notedher promiscuity.All notedher poor attention deny and limited capacityfor insight. Neurologicaltesting during her initialevaluation had sh throw the mishap of non-dominant parietallobe famines. Testingwas repeatedin 1989 andshowed problems in attention ,recent ocular and verbal memory(witha greater deficitin visual memory),abstract thought, cognitive flexibility, useof mathematical operations, and visual analysis. A possibility of right temporal dysfunction issuggested. IQ testing showed acom bine d score of 77 on the Adult WeschlerIQ test ,whichindicated borderlinementalretardation.Over the yearsthe patient had been ma intainedon variousantidepressantsand antianxiety agents. Theseincludedphenelzine,trazadone, desipramine, alprazolam, clonazapam,and hydroxyzine. Currentlyshewas on fluoxetine20mgdaily and clonazaparn 0. 5 mgtwicea day and 1. 0 mg at bedtime . The antidepressantshad been effective over the years in treating her depression. Shehasnever applymore clonazapam than prescribed and there was no history ofabuseof intoxicant or street drugs. Also, there was no historyof discreetmanic episodes andshewasnever treated with neurolepics.PAST MEDI CAL HISTORY She suffered fromgastroesophageal reflux andwas maintainedsymptom free on a combinationofranitidineandomeprazole. PSYCHOSOCIALHISTORY Simran wasbornandraise d inalarge city. She had a brother who was3 years younger. Shedescribeher goas morose , withdrawn,and recalledthat he has said, I dontlikemychildren. Her be occurter wasphysically andverbally abusive throughout herchildhood. Shehadal agencys longedfor a good relationshipwith him. Shedes cribedher impart asthefamily martyr and theglue thatheldthefamily together.She stated thatshewasverycloseto hermotherher mother always angle of dipenedto her and wasalwaysavailable to talk with her. Shewas a poor student,had difficulty all through school , and described herselfas always disruptingtheclass by talking or runningaround. Shehadabest friend through grade school whomshestated woebegone herin superiorschool. Shehad maintainedfew closefriends sincethen . She graduated high school with much difficulty andeffort. Shedated ongroup datesbut never alone. Her husbandleft herwhileshe waspregnant with herson.The husbandwas abus driverand had not hadarole in theirlivessince thedivorce. Afte r thedivorce,she movedbackto her parentshomewith her sonandremained there until getting herown apartment3 years ago. FAMILY HISTORY Simransmotherhad twoserioussuicide attempts atage 72 and wasdiagnosed with majordepressivedisorder with psychotic featuresand OCD. She in like manner had non- insulin dependentdiabetesmellitus and irritablebowelsyndrome. Herbrother was treatedfor OCDas an outpatientfor thepast20 years and also has Hodgkins Disease, currently in remission.The brothers diagnosis ofOCD was kept secret fromherand did not becomeavailableto her until her mother died. Her fatherisalive and well. MENTAL STATUS EXAM Shewas athin,bleachedblond womanwho appeared herstatedage. Shewas dressed inskintight, instigativeclothing,costume jewelry earringsthat eclipsed her earsand hung to hershoulders, heavymake-up andelaboratelystyled hair. Shehad difficultysittingstilland fidgetedconstantlyinherchair. Her body language through outthe audiencewassexually provocative. Her speech wasrapid,mildly pressured,andsherarely finisheda sentence.Shedescribedhermoodas anxious. Her affect appeared anxious. Herthoughtprocesses showed mildcircumstantiality and tangentiality. More significantwas her inability to finish athoughtas exhibited by her incompletesentences. COURSEOF TREATMENT I nitialsessions with thepatient werespentgathering historyand forming a workingalliance. Althoughsheshowed agoodresponsebyslowingdown enough to finishsentences and focus onconversations,shecould not toleratethe side cause andrefusedtocontinue taking the medication. Thewinterof1993-94wasparticularlyharsh.Thepatientmissedmany sessions because ofbad weather. A patternbegantoemergeofaconsistent augmentin the numberof phonecalls thatshemadeto the office voicemail tocancela session. Whenshe was questioned roughly her phonemessages she stated,I always repeatcalls to make sure mymessageis received. Sincethemost recent cancellation generatedno less than six phone calls ,shewas asked why asecond call wouldntbeenough to besure . Shelaughednervously andsaid,Ialways repeatthings. With careful questioningthe following carriageswere uncovered.The patient check offedall locksand windows repeatedlybeforeretiring. Shechecked the urge on a dozen timesbefore leaving the house . Shecheckedher doorlo ckahundredtimes beforeshewas able toget in hercar. The patient aftermathed her hands frequently. She carried disposablewashcloths inher purse so Ican wash asoftenas I need too. Shesaid peopleat work laughat herfor washingsomuch. But shestated,Ican t answer it. Ive been this waysinceI wasalittle girl. Whenquestionedabout telling formerdoctorsabout this,thepatientstated that shehad nevertalkedabout it with her doctors.Shestatedthateveryone that knewhersimply knewthatthiswasthewayshewasItsjustme . Infact , shestated, I didntthink my doctorswouldcare .Ive alwaysbeen thiswaysoitsnot somethingyou canchange . Over the attachedfew sessions, it became micturatethat her argumentswith her boyfriend centeredonhis annoyance with her needtoconstantly repeatthings. This waswhat shealways referred toas talking too much. Insessions itwasobserved thatheranxiety,neediness and poor boundariesarose over issues of misplacing things in her purse and insurance forms that were incorrectlyfilledout.Infac t,when Iattempted to correct theinsurance forms for her, I had difficulty because of her need to repeat theinstructions to meover and over. The Introduction Obsessive compulsive disorder (OCD) is an anxiety disorder characterised by persistent obsessional thoughts and/or compulsive acts. Obsessions are recurrent ideas, images or impulses, which enter the individuals mind in a stereotyped manner and against his will. Often such thoughts are absurd, obscene or violent in nature, or else senseless. Though the patient recognises them as his own, he feels powerless over them.Similarly,compulsive acts or rituals are stereotyped behaviours, performed repetitively without the completion of any inherently useful task. The commonest obsession problematical is fear of contamination by dirt, germs or grease, leading to compulsive cleaning rituals. other(a) themes of obsessions include aggression, orderliness, illness, sex, symmetry and religion. Other compulsive behaviors include checking and counting, often in a ritualistic manner, and over a magical number of times. About 70% of OCD patients suffer from both bsessions and compulsions obsessions alone occur in 25%, whilst compulsions alone are rare. 1nshe spentten minutes checking and recheckingtheformagainst the receipts. Shebecame convinced that sheddone it wrong, her anxiety would increase, andshewouldgetthe forms outand checkthem again. Herneed to includeme in thischeckingwasso greatthat shewas almost physically ontopofmychair. In thefollowingweeks,session sfocusedoneducating thepatient aboutOCD. Herdose of fluoxetinewas increasedto 40 mgaday but discontinued becauseof severe restlessness and insomnia.She continued to seize 20mg offluoxetine a day. Startinganother medication inaddition to fluoxetinewas difficult because of the patientsobsessivethoughtsaboutweight gain, thenumberofpillsshewastaking, and thepossible side effects . Finally,thepatient agreed to try addingclomipramine to her medications. Theresults were dramatic. Shefeltmore relaxed and had less anxiety. Shebegan to talk, forthefirsttime, about herabusivefather. She said,His behavior was always supposedto be the familysecret. I feltso afraidandanxious I didntdare tellanyone.But nowIfeel better. I dont care whoknows. Itscost mymothertoomuchtostaysilent. Atthis timetheplan is to begin behavioral therapy withthepatientinaddition to medication sandsupportive therapy todeal with herdifficulties with relationships. DISCUSSION This isa complicatedcasewith multiple diagnoses borderlinementalretardation,attention deficit disorder,borderlinepersonalitydisorder,ahistoryofmajor depressive disorder andobsessive compulsive disorder. Given thelevelofcomplexity ofthiscase and thepatient sown silenceabout hersymptoms,itisnot urprisingthat thispatients OCD remainedundiagnosedforsolong. However,inreviewingthe literatureand the case,it is instructive tolookat theevidence thatmighthaveledto an earlier diagnosis. First ofall,therewas thefindingof soft neurological deficits. The patients Neuropsychological testing suggestedproblemswithvisuospacialfunctioningn visual memory,as well asattentional difficultiesandalow IQ. In thepast,her doctors were so impressedwith her history ofcognitive difficultiesthatneuropsychological testing wasorderedon two elucidate occasions.Fourstudies in therecent literature haveshown consistent findings ofright hemispheric dysfunction,specificallydifficultiesin visuospatialtasks, associatedwith OCD(6,7,8,9). The patient also had a historyof chronic dieting,andalthough exceedinglythin, she continue d to beobsessed with notgaininga single pound. This wasapatient who took dietpills for 10years and whosee earliest memoriesinvolvedher fathers disapproval ofher bodyhabitus. Eatingdisorders areviewed bysomecliniciansasa formofO C D. OC D.Swedo and Rapoport (II)also notean increased incidenceofeating disorders in childrenandadolescentswithOCD. Whilethis wasno doubt true,the underlyingobsessionalcontent pointed directlyto OCD and should havegenerated a list of screening questionsfor OCD. This underscorestheneed to bevigilant for diagnostic clues and to perform onesown diagnostic assessment whenassuming the treatmentof anypatient. While theliteraturemakesit clear that OCDruns in families,thepatient was unaware of theillnessin her familyuntil afterher diagnosiswas made.Itwould have beenhelpful to know this informationfrom the springas it shouldimmediatelyraise a suspicion of OCD in a patientpresentingwith complaintsofdepression and anxiety. Finally,her diagnosis of borderlinepersonalitydisordermadeiteasier to stand outoff her observablebehaviorin the office asfurtherevidenceofhercharacter structure. The diagnosis of borderlinepersonalitydisorder wasclear. Sheused the defense lawyers of splittingas evidence d by her descriptionsof her fightswith her boyfriend . He was eitherwonderful or acomplete bastard. Herrelationships werechaoticand unstable.She had no close friends outsideof her family . Sheexhibitedaffective instability, markeddisturbance of bodyimageand impulsive behaviors. However, it was difficult to discern whether hersymptoms were trulycharacter logicalor referableinsteadto her underlyingOCD and relatedanxiety. For instance,theinstabilityin her relationships was,inpart,the resultofher OCD, sinceonce shebegan to obsessonsomething,sherepeatedherself so muchthatshefrequentlydrove others intoarage. Astudy by Ricciardi,investigatedDSM-III-R Axis II diagnoses following treatment for OCD.Overhalfofthepatients in the studyno longer met DSM-III-Rcriteria for personality disorders afterbehavioraland/or pharmacological treatmentoftheirOCD. Theauthorsconclude thatthisraises questionsaboutthe validityof an AxisII diagnosisin the display caseofOCD. One might also beginto wonder how manypatientswith personalitydisordershave undiagnosedOCD? Rasmussenand Eisenfound a very high comorbidity ofother Axis I diagnoses in patientswith OCD. Thirty-onepercent of patients studiedwere also diagnosed with majordepression, andanxiety disorders accounted for twenty-four percent.Other coexisting disordersincluded eating disorders, alcoholabuseand dependence, and Tourettes syndrome. Baer,investigatedthe comorbidityof AxisII disordersin patientswith OCDand found that 52percentmetthe criteria forat least onepersonalitydisorderwith mixed,dependentand histrionic beingthemost common disorders diagnosed. Giventhefrequency of comorbidity in patientswith OCD,it wouldbe wise to includescreening questionsineverypsychiatricevaluation. Theseneednotbe elaborate. Questions aboutchecking,washing,and ntrusive,unwanted thoughts can besimpleand direct. Ineliciting afamily history,specificquestions aboutfamily memberswho checkrepeatedlyorwashfrequentlyshouldbe included. Simply asking ifanyfamily memberhasOCDmaynotelicittheinformation, sincefamily members mayalso be undiagnosed. Insummary, thiscaserepresents a complicateddiagnosticpuzzle. Herpast physiciansdid not have theinformationwe d otodayto unravelthetangled skeinsof symptoms. Itisimportant to bealertforthepossibilitythat thispatient s story is not anuncommon one.BIBLIOGRAPHY * Psychology book (NCERT) * Identical * Suicidal notes * A psychopath test pilgrimage through the world of madness * Disorder of impulse control by Hucker INDEX * Introduction * Case study * Course of treatment * Discussion * Bibliography acknowledgment I would like to express my special give thankss and gratitude to my teacher Mrs. Girija Singh who gave me the golden opportunity to do this wonderful project on the topic obsessive-compulsive disorder, which also helped me in doing a lot of research and I came to know about so many new things.Secondly I would also like to thank my family and my friends who helped me a lot in finishing this project. CERTIFICATE This is to certify that Jailaxmi Rathore of class 12 has successfully completed the project on psychology titled obsessive-compulsive disorder under the guidance of Mrs. Girija Si ngh. Also this project project is as per cbse guidelines 2012-2013. Teachers signature (Mrs. Girija Singh) (Head of psychology department) 2012-2013 PSYCHOLOGY PROJECT NAME OF THE campaigner JAILAXMI RATHORE CLASS XII ARTS B SCHOOL MGD GIRLS SCHOOL