Detailed Case study on Obsessive
compulsive disorder (OCD)
Payal Chhangani
B.A (H) Applied Psychology
Semester V
INTRODUCTION
• Obsessive-compulsive disorder (OCD) is a mental health condition that involves:
• Obsessions. These symptoms involve unwanted thoughts or ideas that disrupt your life
and make it hard for you to focus on other things.
• Compulsions. These symptoms involve things you feel you have to do in a specific way
in response to the obsessions.
SYMPTOMS
– Some obsessions include:- – Some common compulsions include:
• Aggressive thoughts about other people • Counting things over and over again
or one's self
• Excessive washing or cleaning
• A need to have everything in a certain • Ordering things in a particular or
order
symmetrical way
• Fear of germs • Repeated checking (such as checking
• Unwanted thoughts of forbidden or taboo that the door is locked or that the oven is
topics such as sex, religion, or harming off)
others.
ERP Therapy
• ERP – Exposure Response Prevention, commonly referred to as ERP, is a therapy that
encourages you to face your fears and let obsessive thoughts occur without ‘putting them
right’ or ‘neutralising’ them with compulsions.
• Exposure therapy starts with confronting items and situations that cause anxiety, but
anxiety that you feel able to tolerate. After the first few times, you will find your anxiety
does not climb as high and does not last as long. You will then move on to more difficult
exposure exercises.
TYPES OF EXPOSURE THERAPY
• During exposure therapy, a therapist guides you through the process of confronting
whatever causes you anxiety. There are three types of exposure therapy:
• in vivo,
• imaginal, and
• flooding.
CBT Therapy
• CBT – Cognitive Behavioural Therapy helps the patient explore and understand
alternative ways of thinking and challenging their beliefs through behavioural exercises
• CBT makes use of two evidence-based behaviour techniques, Cognitive Therapy (C) that
looks at how we think, and Behaviour Therapy (B) which looks at how this affects what
we do. In treatment we consider other ways of thinking (C), and how this would affect
the way we behave (B).
COMPONENTS OF CBT THERAPY
• The goal of CBT is to help the individual understand how their thoughts impact their acti
ons
. There are three pillars of CBT, which are
• Identification
• Recognition
• Management
CASE STUDY
• This case study is done by Ana Paula Justo, Evandro Gomes de Matos, Marilda E N Lipp
in 2015 with title of the paper Cognitive-behavioural therapy of a case of obsessive
compulsive disorder.
• This study is on brief Cognitive behavioural therapy and some psychological assessment
conducted by a therapist with the idea of infection, illness and compulsions were
cleanliness and hygiene.
IDENTIFICATION OF DATA
• Name – Marlee
• Age – 35
• Sex – female
• Education – high school level
• Occupation – housewife
• Socio economic status – Average
• Martial status – married
• Informant – self, husband and mother
• Information – self
PRESENTING COMPLAINTS
• Childhood isolation had a negative effect on the development of her social rapport
• Self depreciation emphasis of her father in physical health
• High blood pressure
• Diagnosis of hypertension, which later on led to panic attacks
• She became afraid of feeling unwell and would avoid doing anything which seemed to
trigger symptoms similar to those of the attack.
HISTORY OF PRESENT ILLNESS
• Maria showed compulsive behavior in both her childhood and teenage years. In these
phases, the compulsions were more about checking things and did not have a direct
impact on her routine. At the beginning of adulthood, however, the compulsions started
being more related to cleanliness.
• In her teens, Maria demonstrated behavior and symptoms consistent with a diagnosis of
social phobia, which, when she entered adulthood and started dating, were minimized.
Nevertheless, it produced a significant impact on the development of her social skills.
ASSOCIATED DISTURBANCE
• Fearful thoughts
• Feeling unwell
• Feeling infected
• Being judged by others
• Lack of future prospects
• Difficulty in establishing the interpersonal relationships.
PAST HISTORY
• In her teens, Marlee demonstrated behavior and symptoms consistent with a diagnosis of
social phobia, which, when she entered adulthood and started dating, were minimized.
Nevertheless, it produced a significant impact on the development of her social skills.
When she was about 29 years old and received a diagnosis of high blood pressure, she
got panic attacks which led to her quitting her job. The anxiety attacks fueled the fears
that Maria was already presenting (feeling unwell, going out alone, being in enclosed
spaces) and led to her isolating herself more at home.
FAMILY HISTORY
• Marlee’s life history was considered important to the understanding of the development of the
OCD. The father’s pattern of behaviour is connected with the development of various symptoms
presented by the client
• Her father was authoritarian and imposed heavy control over Marlee’s behavior. He insisted on
achievement and excessively monitored her behavior. He also was seen to be excessively
concerned with illness and so did not allow his daughter to play with other children or let her
invite them over to the house believing that this action would thus avoid infection and the
possibility of falling sick.
• He kept the house exceedingly clean and made Marlee clean up as well, mainly after having
visitors to the house. Her mother did not have the same excessive concern with cleanliness and
illness, but she was very submissive to the demands of her husband.
STRENGTHS OF CLIENT
• Interested in reading
• Her interest in knowing more about her symptoms benefitted her involvement in the
therapeutic process and her efforts in respect of the activities required of her.
• also demonstrated a determination to get involved in new activities.
TREATMENT GOALS & PLANS
• Based on the cognitive-behavioral evaluation and formulation of the case, the therapeutic
objectives were defined as follows: reduce the frequency of compulsive behavior in
cleaning and hygiene, reduce obsessive thoughts associated with infection and illness,
reduce the fear of going out of the house alone and feeling unwell, break down the belief
in her vulnerability, incapacity and lack of esteem and further the development of social
skills.
• The ERP technique and the cognitive restructuring represented the basis for the treatment
plan offered to the client. However, other interventions were associated, such as: psycho
education, modeling, shaping, social skills training, and problem resolution training, with
the aim of achieving better results and fulfilling the needs that materialized during
treatment
BEHAVIOURAL OBSERVATION
• initially shy to share
• Quite apathetic
• Disbelieving in treatment
• Gathering information of various complaints
• Psycho education about the treatment and model being offered
• She spoke very little during the session and the therapist sought to motivate her in
relation to the treatment
ASSESSMENT USED
• In order to carry out the assessment of OC symptoms, the Yale-Brown Obsessive
Compulsive Scale [Y-BOCS] was employed (Asbahr et al., 1992, apud Asbahr, 2000),
and for the evaluation of Maria’s levels of anxiety and depression, the Beck Inventories
were used (Cunha, 2001), for Anxiety [BAI] and Depression [BDI].
• By using as a reference the US National Institute for Mental Health 15 Point Global
Obsessive Compulsive Scale [NIMH Global OC Scale] (Asbahr, 2000), which evaluates
the severity of obsessive-compulsive behaviors, it was possible to identify an intense
degree of severity in the behaviors in the case studied.
CASE CONCEPTUALISED
• Marlee, aged 35, began psychological treatment after referral by her psychiatrist,
presenting severe obsessive-compulsive symptoms [OC ] which had a significantly
adverse impact on her social and occupational function and on her health.
• Her obsessions were associated with the idea of infection and illness and her
compulsions were cleanliness and hygiene. She also presented avoidance behaviors
associated with these obsessions and deficit in social skills
CLIENT’S STUDY
• There were four main reasons that determined the choice of Maria’s case for this study:
the OCD diagnosis, the severity of the OC symptoms, the lack of prior psychological
treatment, and the cognitive-behavioral treatment carried out.
• This case illustrates the incapacitation caused by OC symptoms and the influence of life
history on the development and permanence of the disorder. An analysis of the records
kept during the psychological therapy session also allowed us to ascertain the progress
made with the cognitive-behavioral treatment
COURSE OF THERAPY
• Over a period of 15 months, 35 individual sessions of fifty minutes each were conducted
based on the cognitive- behavioral model. The procedure included the psychological
contract, assessment, and intervention. Due to the therapy being abandoned because of
financial difficulties, it was not possible to carry out a final assessment and follow-up.
• In order to better understand the process of therapy, it will be presented in two stages.The
first describes the first 27 sessions, while the second describes the eight sessions
conducted after the client’s three month break.
TREATMENT OVERVIEW
• In the first session, Maria showed herself to be quite apathetic and disbelieving of the
treatment, saying she was only there because of her mother and her husband. She spoke
very little during the session and the therapist sought to motivate her in relation to the
treatment.
• In the second session, Marlee participated more and managed to better describe her
complaints. At the end of this session, the psychological contract was restated and it was
possible to see an improvement in the client’s level of involvement in relation to the
process of therapy
STAGE ONE
• The psychological evaluation was conducted between the third and sixth sessions. This
process started with the collection of data on her life history, followed by a description of
her routine and the application of the instruments of evaluation.
• At the closing of the assessment process, the results feedback was conducted, and, based
on these data, the objectives of the therapy were defined.
• Furthermore, Marlee had put her psychological symptoms down to her state of
depression. With the feedback, however, it was possible to inform the client about her
level of anxiety and about OCD. This new information was well received, which gave
her a better understanding of her OC symptoms.
• Between the seventh and final session of the first stage, psychological interventions were
carried out. Even prior to the carrying out of the OC symptom related interventions, the
client was already recounting her initiatives to reduce the frequency of house cleaning
and hand washing
• As Marlee demonstrated an intense level of OC symptoms connected with a severe level
of anxiety, before commencing the ERP exercises, the introduction of anxiety
management strategies was deemed as priority.To this end, psycho education was
provided about anxiety, followed by training on breathing and muscle relaxation. The
breathing training was used as a preliminary step in the muscle relaxation training, but
was also recommended as a practice in itself.
• Equipped with a better understanding of the anxiety and how to manage it, the focus of
the sessions moved to the OC symptoms. The psycho education on the OCD, already
begun after the assessment feedback, became more intense at this point. Understanding
what obsessions and compulsions are is fundamental to the cognitive-behavioral
treatment of the OCD
• Around about the eighth session, still during the process of psycho education on anxiety,
Maria was asked to record the frequency of her cleaning and hygiene behaviour.
• The client was also informed that, for each exposure exercise carried out, the anxiety
triggered by the exposure situation would be lower. The ERP exercises were started
in the tenth session and exposure was being carried out on a gradual basis.
• At around session number 20, when the ERP exercises were already showing results, it
was sought to introduce cognitive techniques into the therapeutic process. At this
moment, as a consequence of the exposure process, obsessive thoughts were
materializing and becoming the focus of the intervention. Questions such as “But aren’t I
more relaxed about cleaning my house?”;“Are you sure this is right?”;“Aren’t I doing
myself some harm!”and “Do you think I will really be able to do this!” became frequent
during the session and enabled the process of cognitive restructuring. It was sought to
create a more suitable reference with regard to cleaning the house and to hygiene, based
on evidence obtained from the exposure process.
• Given the increase in situations of social contact, it was possible to initiate the training of
her social skills. Even the appointment with the dermatologist was simulated in one of
the sessions as Maria was embarrassed to show her hands to the doctor and she also felt
insecure about describing her symptoms. She was constantly worried about what other
people thought of her, which inhibited her in various situations.
SECOND STAGE
• After a break of three months, Maria resumed therapy. In the first two sessions, the
therapeutic contract and goals were revisited and a fresh assessment of her OC symptoms
was performed. Despite the relapse, her nails had recovered and she wore her hair down,
which she had never done before
• At this time, the client was quite frustrated that she had not been able to embark upon
any course, but she did report that she was visiting her mother’s house more frequently,
where she would use her brother’s computer. She also talked of her desire to buy a
computer for her own house.
• After this initial assessment, the client was asked to record the quantity of cleaning and
hygiene products used on a monthly basis and the details of the water bills. The aim was
to reduce expenses on these types of product and also of water consumption, which
would in turn reduce compulsive cleaning and hygiene behavior. It was proposed to
Maria that, with the savings made on these expenses, she could invest in the purchase of
a computer.
• Given this new proposal, a new type of ERP exercise arose. Maria needed to cut down on
the quantity of cleaning products, which would expose her to a situation that produces
anxiety because it triggers the idea of infection. A target was established in each session
so that gradually the client would reduce the quantity of products that she uses to clean
the house and for personal hygiene.
RESULTS
• The best results observed related to the reduction
in the consumption of detergents, soap powder
and bars of soap. Maria had reached a point
where she was using more than three units of
detergent per day, but by the last month she had
managed to reduce this figure to almost one unit a
day. Another important result was in regard to the
use of chlorine. The client stopped using pure
chlorine and started using only bleach.
CONCLUDING EVALUATION OF THE
THERAPY PROCESS AND OUTCOME
• The primary objective of the therapeutic process was to diminish compulsive behaviors.
• The second therapeutic objective was the reduction in obsessive thoughts.
• Despite the reduction in OC symptoms, full remission of the symptoms did not occur by
the time the process was suspended, which represents a greater risk of a future relapse.
• The third objective was to reduce the fear of going out alone or feeling unwell while out
• The fourth therapeutic objective was the breaking down of beliefs connected with the
notion of vulnerability, incapacity and lack of esteem
• As for the final objective, this corresponded to the development of the client’s social
skills. Out of all the goals, this was the one that received the shortest period of
intervention.
• Through the training of social skills and modeling, it was sought to raise her social
repertoire. Based on clinical observation, Maria improved her eye contact and increased
the frequency with which she would ask questions and express opinions.
References
• Cognitive behavioural therapy of a case of obsessive compulsive disorder,
2015• 11• (1) pp.24 DOI: 10.5935/1808-5687.20150003. http://
pepsic.bvsalud.org/pdf/rbtcc/v11n1/v11n1a03.pdf
• erp
://thelightprogram.pyramidhealthcarepa.com/what-is-exposure-therapy/
• https://www.ocduk.org/ocd/types/
Thank you :)
