Obsessive Compulsive Disorder (OCD) Case
1. Mental Status Exam
Lola Martin is a 19-year-old, biracial, female college student. On first appearance, Lola is well-groomed and presented an aura of confidence, self-awareness and contentment in both the physical and mental presentation. However, the physical examination of the patient demonstrated her to have red, chapped hands, constantly repeated behaviors such as double-checking the alignment of her phone on the table, with fixated eye contact that was directly towards the clinician. Lola is constantly having obsessive thoughts on being a dirty individual, and she is obsessed with ensuring that her environments are constantly clean. Her compulsive behaviors are related to constantly washing, bathing, cleaning and organizing. . Lola has insight of her obsessions and compulsions since she does not actually believe that failing to ritualize them would result in something she is trying to avoid happening (Foa et al., 2012).
Notably, the questioning process with the clinician was seamless with Lola not hesitating on answering any of the questions. Nonetheless, one thing that was evident as he constantly checked to provide the well-defined sentences that were at times complex and would frequently stop to explain herself further. She had several packs of agitation when the desired sentence of explanation did not come out as expected. She indicated that he currently holds no meaningful relationship either with a friend or for intimacy which have always ended due to her insecurity. Many of these issues she faced within those relationships were related to her fear of uncertainties and whether that particular partner was there for the long-haul. She points out that she spent extensive time on compulsions that caused challenges in her relationships. Also, she has not been able to hold down a job for several months which would leave her without a place to stay. Failure within her relationships and lacking employment prompted her to move back to living with her parents.
Her parents actually acknowledge her intense anxiety during her teens when things were not going her way such as in academics. Also, the anxiety got intense after she was raped at the age of 15 which led her to being out of control. Notably, she would be enrolled into psychodynamic therapy that helped in repressing the rape memories and handle the anxiety. During the less-intense outbursts, Lola states that her parents learned to stay with her, remained calm and would be provided with what she needed. For sometime, the outbursts became predictable and her parents would know that she was experiencing anxiety. However, the last few months have seen the anxiety condition worsen. She typically would self-medicate with cannabis vape pens that helped her remain chilled for some time but the drug seems not to be helping her anymore with the anxiety.
Lola has insight that her behaviors are related to having OCD as the thoughts of being dirty won’t go away. In actual fact, her father was diagnosed with OCD around the same age as Lola is currently and was enrolled into therapy which enabled him to manage it much better with time.
a. Diagnosis and History of Presenting Problem
From the conversation that Lola had with the medical professional, her reported history and the outlined experiences of her close family members, it is highly likely that Lola is suffering from Obsessive Compulsive Disorder (OCD). With her father having been diagnosed with the same condition when he was the same age as Lola at the time together with Lola acknowledging that it could have conditions related to OCD. The increased anxiety levels together with constantly having the obsessive thoughts of dirt and contamination is leading her to engage with compulsive conducts affecting her individual physical and social life. Considering that she did drop out of college due to these issues, these challenges continue to cause her too much distress hence approaching the mental health clinician for treatment. The behaviors have been occurring for four years since she was 15 but therapy would aid her to repress the rape memories that were a major trigger. Nonetheless, the last six months has seen the behaviors occur in intensity and levels of anxiety reach peak levels. Notably, Lola has been trying to repress the anxiety using cannabis vape pens for the self-medication. She stated that the drugs helped chill her out but it has since stopped working making the anxiety even worse. Lola does attest that she is demonstrating OCD symptoms affecting her relationships and occupation hence would require remedies to manage the condition.
The DSM-5 provides an accurate criterion to aid in affirming whether Lola would be suffering from OCD hence choosing it for her diagnosis. According to The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), the clinical definition of OCD is that it is a chronic illness that could cause marked distress and disability the ailment does have a substantial effect on one’s quality of life and the level of functioning. Notably, for one to be diagnosed with OCD, they are required to have symptoms that substantially fit the stipulated criteria.
The first element in the criteria is the presence of obsessions or compulsions or both of them. Obsessions are the recurrent and persistent thoughts or impulses experienced at a time during a disturbance while a compulsion is the repetitive behaviors that the person is driven into performing while responding to the obsession or adhering to particular rules. Notably, Lola is experiencing both obsessions and compulsions. She clearly indicates that she is obsessed with the thoughts of being a dirty individual despite constantly ensuring that her environment is extensively clean to avoid contamination. . Her compulsive behaviors insurance she is clean include constant handwashing, bathing, cleaning and organizing the constant cleaning is evident in her red capped hands. During the anxious periods, Lola recounts being very anxious and at the time, engaging the stated behaviors aids her in preventing a particular situation such as being contaminated and being the dirty person.
The second element in the DSM-5 criteria is that the compulsions are time-consuming or will lead to substantial impairments in an individual’s social and occupational functioning among other fundamental aspects of one’s life. Currently, she has no relationships whose main reason for failing were her compulsive behaviors that took a lot of time. The fear of losing control over her life was also very apparent in her relationships which her partners would find very controlling. The third element is that the obsessive-compulsive symptoms are not attributable to physiological consequences of a substance which is aligned with Lola’s conditions. Lola has not demonstrated being addicted to a particular substance with the drug cannabis being only used to repress the anxious symptoms. The final element is that the disturbance cannot be better explained through the symptoms of another mental disorder. While the rape she experienced at the age of 15 could be indicative of Post-traumatic Stress Disorder (PTSD). The memories have been repressed through therapy and also she has not demonstrated other fundamental symptoms of PTSD such as the nightmares or flashbacks, nor has she avoided external reminders considering she has tried to be in a relationship or having consistent changes in moods or thinking (Rogers Behavioral health, 2020).
The fact that Lola acknowledges that her behaviors could be related to OCD, and she did approach the medical professional to remedy the extensive anxieties and life disruptions, does illustrate an individual that is looking to change and lead a normal life. The self-medication was a step towards remedying the situation and since it did not work, she had to look for further help. Her education had been affected negatively after dropping out of school, she cannot keep a job nor have meaningful relationships were enough triggering reasons to find a solution
b. Psychosocial and Mental Health History
Lola indicates that she had dropped out of college due to her conditions hence needed to urgently seek help. On further inquiries, Lola was constantly distracted in class as they are always distracted by compulsions and obsessions. These distractions included having to constantly ask the tutors and colleagues whether she was safe in school and the class was properly cleaned. When she read paragraphs, she constantly had to repeat them several times and constantly touched objects a number of times to ensure the pressure from her obsessions was relieved. However, these distractions ensured that she was not focussing on the core reasons for being in college, her education and passing the courses.
Lola also notes that most of her relationships are non-existent due to the excess time she spent on compulsions. Failed relationships meant that her social functioning was greatly affected which would mean most time would be spent dealing with her obsessions and compulsions. The anxiety and negative thoughts that something would go wrong scared others away yet what Lola wanted was a surety that everything was going as planned. The only working relationships were with her parents who have over time understood her issues and will constantly assure her not to be afraid.
The last fundamental note was that Lola was not in a position to hold down any job hence prompting her to move in with her parents. Also, considering that she could not have meaningful relationships, her disorder clearly does impede her from getting any help from friends or her intimate partners. Her obsessive thoughts of being a dirty person and the compulsive behaviors such as constant cleaning and handwashing would evidently impede how she related with other individuals.
Her father was diagnosed with OCD while he was at the same age and therapy did help her in managing the condition effectively. It is highly possible that genetics have played a fundamental role in the disorder Lola is presently dealing with. Therefore, she does understand that she could get help to manage her condition and would be open to suggested treatment plans.
c. Treatment Plan and Course of Treatment
Over time, Lola did try self-medication of the anxiety using cannabis vape pens which demonstrated her responsiveness to medication for some time but their effectiveness was not long-lasting. Nonetheless, OCD does have effective behavioral therapy that Lola could undertake to manage the condition in the long haul. In consideration of her symptoms, Cognitive Behavioral therapy is the preferred treatment method. Lola is among the many patients of OCD who are invaded with improper thoughts of being dirty but will not give these thoughts any special meaning. This model will focus on considering the excess of responsibility being a fundamental issue to the source of the obsessions (Cordioli & Vivan, 2012). Lola’s belief that she does have the responsibility of preventing harm to herself and also others is a fundamental ingredient prompting her to engage in safety behaviors focussed on neutralizing these potential risks. The persistence of the obsessions occurs due to the persistence of the erroneous beliefs, and they would reduce with a weakening of the interpretations (Cordioli & Vivan, 2012). Therefore, the lesser the importance given by these patients to the thoughts, the lower the impulse to carry out her compulsions.
Cognitive therapy will fundamentally involve Lola testing her triggers and expectations hence learning to manage the anxiety while not engaging in the compulsive behaviors. For Lola, it will be done gradually following a planned exposure schedule. In conjunction with a supportive and empathetic relationship from her parents, the cognitive behavioral therapy is expected to be of quality and effective to manage Lola’s condition. For each of the negative obsessions and compulsive behaviors she was having, it would have a countermeasure so that she could learn on how to handle them when they occur.
Lola is a person that has constantly demonstrated to be open-minded and open to therapy. The cognitive therapy followed three important stages. The first stage which was the initial stage entailed the therapist assessing Lola’s motivations and treatment expectations. Lola had tried medication which was not effective hence was open to therapy. She has had the first actual experience with her father and believed that it was also feasible on her part. The second stage was the middle phase that entails cognitive and behavioral strategies for addressing the unhelpful behaviors and thoughts that the goal was having. The third phase which is the ending phase involves emphasizing on the relapse prevention plan and the termination plan.
d. Follow-Up Report: 12-month Follow Up
Lola demonstrated outstanding results throughout her 12-month therapy sessions with her family demonstrating that her anxiety levels have reduced so much and the compulsive behaviors are almost non-existent. This was commendable considering the treatment plan did not integrate with respective OCD medication. Her anxiety levels were tremendously reduced with any stimulus that caused prior triggers not happening again. To deal with compulsive behaviors, Lola was enrolled into handling different particular situations that she was allowed to be in control. For instance, her compulsive behaviors wanted her to ensure that she was constantly in a clean environment to avoid particular dangers. She was then gradually exposed in clean environments but not as organized as she would have wanted to see whether the anticipated adversarial consequences would happen. Over time, she learned that some events were preventable even with things not being a certain way.
While she has been able to wade off the distractions that led to the obsessive thoughts and compulsive behaviors, Lola is still trying to get back to education. She first tried to engage in online classes prior to going back to the classroom. Having to listen to an online class for a particular duration has helped her to try and concentrate in class. This would gradually re-enforce the concentration abilities required in the classroom.
e. Discussion
OCD is a prevalent mental disorder across the world with the average age of its onset being the late adolescents ages for men and early twenties for women. This would be evident in Lola and her father’s cases whose OCD started at the same time. Notably, an early sign boss is an enforcement for effective treatment plans that would aid in managing the conditions. Notably, an effective treatment plan is achieved by asking the right questions to determine the extent of distress an individual is dealing with (Bouvard et al., 2004. It is evident that the questions that demonstrate symptoms that are extensively distressing or interfering with an individual’s life include the time and extent of washing or cleaning, whether one is constantly checking things, any bothering thoughts that one would want to dispose, time taken to finish daily activities, and whether the different challenges both a person. Some of these questions could be affirmed through observation of either an individual’s hands even when the patient affirms the activities through his or her answers (Veale & Roberts. 2014).
An integrated approach of therapy and medication has proven very effective for patients with OCD (Biondi & Picardi, 2005). The process would encompass first starting medication prior to psychotherapy and gradually discontinuing it before the therapy ends. Using medication at the start helped in facilitating the subsequent patient’s engagement in psychotherapy. Nonetheless, the effectiveness of these strategies highly depend on proper diagnosis since some patients such as Lola demonstrated that therapy alone was also effective (University of Pennsylvania, 2020).
Also, some patients will have other psychiatric conditions coupled with the OCD which can pose a challenge in coming up with the right plan. Therefore, it is prudent that the diagnosis does consider whether other conditions do exist and whether the comorbidity will affect the selected treatment plan (Pallanti & Quercioli, 2006). For instance if an individual is depressed, the treatment plan would consider stabilizing these symptoms prior to exposing them to the triggers of the obsessive thoughts and compulsive behaviors related to OCD.
References
Biondi, M., & Picardi, A. (2005). Increased Maintenance of Obsessive-Compulsive Disorder Remission after Integrated Serotonergic Treatment and Cognitive Psychotherapy Compared with Medication Alone. Psychotherapy and Psychosomatics, 74(2), 123–128. doi:10.1159/000083172.
Bouvard, M., Milliery, M., & Cottraux, J. (2004). Management of Obsessive Compulsive Disorder. Psychotherapy and Psychosomatics, 73(3), 149-157. doi:10.2307/48510817
Cordioli, A.V & Vivan, A.S. (2012). Cognitive-Behavioral Therapy of Obsessive-Compulsive Disorder. Standard and Innovative Strategies in Cognitive Behavior Therapy.
Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure and response (ritual) prevention for obsessive compulsive disorder: Therapist guide. Oxford University Press.
Pallanti, S., & Quercioli, L. (2006). Treatment-refractory obsessive-compulsive disorder: methodological issues, operational definitions and therapeutic lines. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 30(3), 400-412.
Rogers Behavioral Health. (2020). PTSD: 5 signs you need to know. Retrieved 3 December 2020, from https://rogersbh.org/about-us/newsroom/blog/ptsd-5-signs-you-need-know
UNIVERSITY OF PENNSYLVANIA. (2020). Understanding CBT for OCD | Center for the Treatment and Study of Anxiety | Perelman School of Medicine at the University of Pennsylvania. Retrieved 3 December 2020, from https://www.med.upenn.edu/ctsa/forms_ocd_cbt.html#:~:text=Cognitive%2Dbehavior%20therapy%20is%20a,called%20Exposure%20and%20Ritual%20Prevention.
Veale, D., & Roberts, A. (2014). Obsessive-compulsive disorder. BMJ, 348(apr07), g2183–g2183. doi:10.1136/bmj.g2183.
