A Case Study of Obsessive Impulsive Disorder

A Case Study of Obsessive-Compulsive oerthrow Some Diagnostic Considerations INTRODUCTION Prior to 1984, psychoneurotic everyplaceturn (OCD)wasconsidereda obsolescent roughness andone difficultto treat (I). In 1984 theEpidemiologic Catchment area (ECA) initial survey resultsbecame available for the prototypic time, andOCDprevalence figuresshowed that2. 5%ofthepopulation metdiagnosticcriteriafor OCD (2,3). Finalsurvey results publishedin 1988(4) confirmed theseearlier reports. Inaddition, a 6-monthpoint prevalence of1. 6%was observed,andalifetimeprevalenceof 3. 0% wasfound.OCD isan illness of secrecy, and a enceinte deal the enduringspresentto physicians inspecialties other than psychiatry. Another factor contri buting to under(a) diagnosis ofthis roughnessis thatpsychiatrists ma y fail to hire screening questionsthat would identifyOCD. Thefollowing baptismal font champaign isan exampleofa long-sufferingwith moderately severe OCDwhopresentedtoaresidentpsychiatryclinic cri stal age prior to being diagnosedwith OCD. The patientwascompliant with forth patient discourse for theentire timeperiodand was hardenedfor studydepressivedisorderand border line personality disorder with medication s and adjunctpsychotherapy.The patient never discussedher OCD symptomswith her doctorsbut in retrospect had off-keyered umteen cluesthat capability have eitherowedaswifterdiagnosis and treatment. CASEaccount 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. PAST PSYCHIATRIC HISTORY Simran had beenseen in theresidentout patientclinic since July of 1984. Priortothis shehad non beenin psychiatrical treatment. Shehad never been hospitalized.Her initialcomplaints were natural depression and anxietyand she had been placed onan phenelzineand responded well. Herdepressionwasinitially suppositionto besecondary to amphetamine withdrawal, since shehad b een victimisationdietpillsfor 10years. She statedthat at firstshe withalk them to lose weight,but shroudd forsolong because people at work had storied that sheconcentratedbetterand that her job performance had improved. In addition,her past doctors hadallcommented on her limitedibility tochangeand her neediness, insecurity,lowself-esteem,and poor boundaries. In addition,her past doctors had notedher promiscuity.All notedher poor attention span and restrict capacityfor insight. Neuro rational exam during her initialevaluation had sh bear the hap of non-dominant parietallobedeficits. Testingwas recuredin 1989 andshowed problems in attention ,recent optical and verbal memory(witha greater deficitin optic memory),abstract design, 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 borderline mentalretardation.oer the yearsthe patient had been maintainedon variousantidepressantsand antianxiety agents. Theseincludedphenelzine,trazadone, desipramine, alprazolam, clonazapam,and hydroxyzine. Currentlyshewas on fluoxetine hydrocholoride hydrocholoride20mgdaily and clonazaparn 0. 5 mg in two flairsa day and 1. 0 mg at bedtime . The antidepressantshad been effective oer the years in treating her depression. Shehasnever usedmore clonazapam than prescribed and in that respect was no history ofabuseof intoxi squeeze outt or street drugs. similarly, on that point 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 engenderas morose , withdrawn,and recalledthat he has said, I dontlikemychildren. Herfather wasphysically and verbally abusive nailedout herchildhood. Shehad invariably longedfor a good relationshipwith him. Shedescribedher find asthefamily martyr and the chewing gum thatheldthefamily to rideher.She stated thatshewasverycloseto hermotherher mother al carriages listenedto her and was constantlyavailable to talk with her. Shewas a poor student,had difficulty all by dint of school , and described herselfas forever disruptingtheclass by talk or runningaround. Shehadabest friend through class school whomshestated deserted herin highschool. Shehad maintained hardly a(prenominal) closefriends sincethen . She graduated high school with much difficulty andeffort. Shedated ongroup datesbut never alone. Her husband left hand herwhileshe waspregnant with herson.The husbandwas abus driverand had not hadarole in theirlivessince thedivorce. Afte r thedivorce,she gobackto her parentshomewith her sonandremained there until getting herown apartment3 years ago. FAMILY HISTORY Simransmotherhad twoseri oussuicide attempts atage 72 and wasdiagnosed with majordepressivedisorder with psychotic featuresand OCD. She as well had non-insulin dependentdiabetesmellitus and irritablebowelsyndrome. Herbrother was treatedfor OCDas an outpatientfor thepast20 years and too 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 a sparse,bleachedblond womanwho appeared herstatedage. Shewas dressed in trimtight,provocativeclothing,costume jewelry earringsthat eclipsed her earsand hung to hershoulders, heavymake-up and elaboratelystyled hair. Shehad difficultysittingstilland fidgetedconstantlyinherchair. Her corpse address through outthe interviewwassexually provocative. Her speech wasrapid,mildly pressured,andshe rarely finisheda sentence.Shedescribedhermoodas keen. Her affect appeared anxious. Herthoughtprocesses showed mildcircumstantialit y and tangentiality. More signifi provoketwas her inability to finish athoughtas exhibited by her incompletesentences. COURSEOF TREATMENT initial posings with thepatient were dog-tiredgathering historyand forming a workingalliance. Althoughsheshowed agoodresponsebyslowingdown enough to finishsentences and focus onconversations,shecould not toleratethe sideeffects andrefusedtocontinue taking the medication. Thewinterof1993-94wasparticularlyharsh.Thepatientmissedmany sessions because ofbad weather. A patternbegantoemergeofaconsistent change magnitudein the deedof phonecalls thatshemadeto the office voice dismount tocancela session. Whenshe was questioned well-nigh her phonemessages she stated,I always recallcalls to make sure mymessageis received. Sincethemost recent cancellation generatedno little than six phone calls ,shewas asked why asecond call wouldntbeenough to besure . Shelaughednervously andsaid,Ialways repeatthings. With careful questioningthe followingbehaviorswere un coered.The patient slowedall locksand windows repeatly earlierretiring. Shechecked theiron a dozen timesbefore leaving the house . Shecheckedher doorlockacenturytimes beforeshewas able toget in hercar. The patient swear out her hands frequently. She carried disposablewashcloths inher purse so Ican wash asoftenas I need besides. Shesaid peopleat work laughat herfor washsomuch. But shestated,Ican t help 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 nextfew sessions, it becameclearthat her argumentswith her boyfriend centeredonhis shame 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.Infact,when I act to correct theinsurance forms for her, I had difficulty because of her need to repeat theoperating instructions 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 perennial ideas, images or impulses, which enter the individuals mind in a stereotyped path 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 involved is fear of contamination by dirt, germs or grease, leading to compulsive cleaning rituals. other(a) t hemes 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 some(prenominal) 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 lay off becauseof severe restlessness and insomnia.She continued totake 20mg offluoxetine a day. Startinganother medication inaddition to fluoxetinewas difficult because of the patientsobsessivethoughtsaboutweight gain, then umberofpillsshewastaking, and thepossible side effects . Finally,thepatient agreed to try addingclomipramine to her medications. Theresults weredramatic. She mattemore 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 mymothertoomuchto extendsilent. Atthis timetheplan is to begin behavioral therapy withthepatientinaddition to medication sandsupportive therapy todeal with herdifficulties with relationships. DISCUSSION This isa intricatecasewith 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 remained unknownforsolong. However,inreviewing the literatureand the case,it is instructive tolookat the raise 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 separate 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 passingthin, she continue d to beobsessed with notgaininga unmarried pound. This wasapatient who took dietpills for 10years and whosee earlier 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 todayto OCD and should havegenerated a list of screening questionsfor OCD. This underscorestheneed to be wide-awake for diagnostic clues and to perform onesown diagnostic assessment whenassuming the treatmentof anypatient. While theliteraturemakesit clear that OCDruns in families,thepatient was oblivious(predicate) of theillnessin her familyuntil afterher diagnosiswas made.Itwould have beenhelpful to know this teachingfrom thebeginningas it should in a flashraise a suspicion of OCD in a patientpresentingwith complaintsofdepression and anxiety. Finally,her diagnosis of borderlinepersonalitydisordermadeiteasier to passoff her observablebehaviorin the office asfurtherevidenceofhercharacter structure. The diagnosis of borderlinepersonalitydisorder wasclear. Sheused the defense reaction of splittingas evidence d by her descriptionsof her fightswit h her boyfriend . He was eitherwonderful or acomplete bastard. Herrelationships were topsy-turvyand unstable.She had no close friends outsideof her family. Sheexhibitedaffective in stability, markeddisturbance of bodyimageand impulsive behaviors. However, it was difficult to discern whether hersymptoms were trulycharacter logicalordueinsteadto 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 rigorof an AxisII diagnosisin thefaceofOCD. One might also beginto wonder how manypatientswith personalitydisordershave unknownOCD? Rasmussenand Eisenfound a very high comorbidity ofother Axis I diagnoses in patientswith OCD. Thirty-onepct of patients studiedwerealso 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 theatrical 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 ma yalso be undiagnosed. Insummary, thiscaserepresents a complicateddiagnosticpuzzle. Herpast physiciansdid not have theinformationwe dotodayto unravelthetangled skeinsof symptoms. Itisimportant to bealertforthepossibilitythat thispatient s story is not anuncommon one.BIBLIOGRAPHY * Psychology have got (NCERT) * Identical * Suicidal notes * A psychopath test journey through the world of madness * Disorder of impulse control by Hucker powerfulness * Introduction * Case study * Course of treatment * Discussion * Bibliography credit I would like to express my special thanks and gratitude to my teacher Mrs. Girija Singh who gave me the halcyon 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. security system This is to certify that Jailaxmi Rathore of cla ss 12 has successfully completed the project on psychology titled obsessive-compulsive disorder under the guidance of Mrs. Girija Singh. Also this project project is as per cbse guidelines 2012-2013. Teachers signature (Mrs. Girija Singh) (Head of psychology department) 2012-2013 PSYCHOLOGY PROJECT NAME OF THE CANDIDATE JAILAXMI RATHORE CLASS XII humanities B SCHOOL MGD GIRLS SCHOOL