A Case Study of Obsessive Impulsive Disorder

A typeface Study of Obsessive-Compulsive Disorder Some Diagnostic Considerations INTRODUCTION Prior to 1984, psychoneurotic- tyrannical unhealthiness (OCD)wasconsideredarare disquiet andone difficultto negotiate (I). In 1984 theEpidemiologic CatchmentArea (ECA) sign survey resultsbecame available for the initiatory time, andOCD prevalence figuresshowed that2. 5%ofthepopulation met diagnosticcriteriafor OCD (2,3). final examinationsurvey 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 oftentimes the enduringspresentto physicians in limitedties new(prenominal) than psychiatry. Another factor contri exclusivelying to under diagnosing ofthis sicknessis thatpsychiatrists ma y fail to ask screening questionsthat would identifyOCD. The future(a) faux pas study isan exampleofa enduringwith moderately severe OCDwhopresentedtoaresidentpsychi atryclinicten historic period prior to being diagnosedwith OCD. The uncomplainingwascompliant without tolerant treatment for theentire time periodand was treatedformajordepressivedisorderand border line per male childality disorder with music s and accessarypsychotherapy.The uncomplaining never discussedher OCD manifestationswith her doctorsbut in retrospect had offered some cluesthat might ask allowedaswifterdiagnosis and treatment. sheath annals Simran Ahuja was a 29 yearold,divorced,indian female who carry away onedas a file clerk. Shewas followed as anout patientat the uni varietyresidentclinic since1971. Ifirst saw her 2012. PAST PSYCHIATRIC invoice Simran had beenseen in theresidentout patientclinic since July of 1984. Priortothis shehad non beenin psychiatric treatment. Shehad never been hospitalized.Her initialcomplaints were depression and misgivingand she had been placed onan phenelzineand responded well. Herdepressionwasinitially thoughtto besecondary to amp hetamine withdrawal, since shehad been usingdietpillsfor 10years. She statethat at firstshetook them to lose weight,butcontinued forsolong beca practice session volume at work had noted that shec at one timentratedbetterand that her job capital punishment had improved. In addition,her past doctors hadallcommented on her limitedibility to pitchand her neediness, insecurity,lowself-esteem,and brusque boundaries. In addition,her past doctors had notedher promiscuity.All notedher pathetic attention span and limited capacityfor insight. Neurologicaltesting during her initialevaluation had shown thepossibility of non-dominant parietallobedeficits. Testingwas repeatedin 1989 andshowed problems in attention ,recent visual and verbal memory(witha great deficitin visual memory),abstract thought, cognitive flexibility, useof mathematical operations, and visual analysis. A possibility of right temporal disfunction issuggested. IQ testing showed acom bine d score of 77 on the Adult Weschle rIQ test ,whichindicated perimetermentalretardation.Over the yearsthe patient had been maintainedon differentantidepressantsand antianxiety jump onnts. These ack directly takegedphenelzine,trazadone, desipramine, alprazolam, clonazapam,and hydroxyzine. Currentlyshewas on fluoxetine20mg periodic and clonazaparn 0. 5 mgtwicea day and 1. 0 mg at bedtime . The antidepressantshad been effective over the years in treating her depression. Shehasnever employmore clonazapam than prescribed and there was no register ofabuseof alcoholic drink or street drugs. Also, there was no historyof discreetfrenzied episodes andshewasnever treated with neurolepics.PAST MEDI CAL HISTORY She suffered fromgastroesophageal reflux andwas maintainedsymptom free on a combinationofranitidineandomeprazole. PSYCHOSOCIALHISTORY Simran was born(p)andraise d inalarge city. She had a familiar who was3 years younger. Shedescribedher fatheras morose , withdrawn,and recalledthat he has said, I dontlikemychildren. He rfather wasphysically andverbally abusive throughout herchildhood. Shehadof all time longedfor a good relationshipwith him. Shedescribedher bugger off asthefamily martyr and theglue thatheldthefamily to write downher.She stated thatshewasverycloseto her set nearlyher bring eternally listenedto her and wasalwaysavailable to talk with her. Shewas a curt student,had fuss all through school , and described herselfas always disruptingtheclass by talking or runningaround. Shehada opera hat friend through grade school whomshestated deserted herin full(prenominal)school. 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. abafte r thedivorce,she movedbackto her parentshomewith her sonandremained there until getting herown apartment3 years ago. FAMILY HISTORY Simransm otherhad twoserioussuicide attempts atage 72 and wasdiagnosed with majordepressivedisorder with psychotic featuresand OCD. She also had non-insulin dependentdiabetesmellitus and unevenbowelsyndrome. 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 place EXAM Shewas athin,bleachedblond womanwho appeared herstatedage. Shewas dressed inskintight,provocativec attractorhing,costume jewellery earringsthat eclipsed her earsand hung to hershoulders, heavymake-up andelaboratelystyled hair. Shehad difficultysittingstilland fidgeted unceasinglyinherchair. Her body language through outthe interviewwassexually provocative. Her speech wasrapid,mildly pressured,andsherarely finisheda sentence.Shedescribedher bodily fluidas anxious. Her affect appeared anxious. Herthoughtprocesses show ed mildcircumstantiality and tangentiality. More significantwas her softness to finish athoughtas exhibited by her in blastsentences. COURSEOF TREATMENT Initialsessions with thepatient werespentgathering historyand forming a workingalliance. Althoughsheshowed agoodresponseby retarddown enough to finishsentences and focus onconversations,shecould not leavethe sideeffects andrefusedtocontinue taking the medication. Thewinterof1993-94was oddlyharsh.Thepatientmissed many an(prenominal) sessions because ofbad weather. A patternbeganto go awayofa consistentincreasein the numberof forebodecalls thatshe doto the space voicemail tocancela session. Whenshe was questioned somewhat her phonemessages she stated,I always repeatcalls to make sure mymessageis received. Sincethe approximately recent cancellation generatedno less than six phone calls ,shewas asked why asecond call wouldntbeenough to besure . Shelaughednervously andsaid,Ialways repeatthings. With careful questioningthe followi ngbehaviorswere uncovered.The patient checkedall locksand windows repeatedlybeforeretiring. Shechecked theiron a dozen timesbefore leaving the house . Shecheckedher portallockahundredtimes beforeshewas able toget in hercar. The patientwashed her hands frequently. She carried disposablewashcloths inher base so Ican wash asoftenas I need too. Shesaid peopleat work laughat herfor washingsomuch. But shestated,Ican t help it. Ive been this waysinceI wasalittle girl. Whenquestioned round telling formerdoctors virtually 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 became efflorescethat her argumentswith her fashion plate centeredonhis annoyance with her needtoconstantly repeatthings. This waswhat shealways referred toas talking too much. Inses sions itwasobserved thatheranxiety,neediness and poor boundariesarose over issues of misplacing things in her purse and insurance forms that were incorrectlyfilledout.Infact,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 nervous impulses, which enter the individuals mind in a stereotyped manner and against his will. Often such thoughts are absurd, libidinous 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 revere of contamination by dirt, germs or grease, leadi ng to compulsive cleaning rituals. other(a) themes of obsessions embroil 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. closely 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(p) that sheddone it wrong, her anxiety would increase, andshewouldgetthe forms outand checkthem again. Herneed to includeme in thischeckingwasso greatthat shewas almost physically on heydayofmychair. In thefollowingweeks,session sfocusedoneducating thepatient aboutOCD. Herdose of fluoxetinewas change magnitudeto 40 mgaday but discontinued becauseof severe restlessness and insomnia.She continued totake 20mg offluoxetine a day. Startinganother medication inaddition to fluoxetinewas difficult becau se of the patientsobsessivethoughtsaboutweight gain, thenumberofpillsshewastaking, and thepossible side effects . Finally,thepatient agreed to try addingclomipramine to her medications. Theresults weredramatic. She mat upmore 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 cause behavioral therapy withthepatientinaddition to medication sandsupportive therapy todeal with herdifficulties with relationships. DISCUSSION This isa complicated eggshellwith multiple diagnoses borderlinementalretardation,attention deficit disorder,borderline geniusdisorder,ahistoryofmajor depressive disorder andobsessive compulsive disorder. given over thelevelofcomplexity ofthiscase and thepatient sown hush upabout hersymptoms,itisnot urprisingtha t thispatients OCD remainedundiagnosedforsolong. However,inreviewingthe literatureand the case,it is informative 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 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,andalthoughextremelythin, she continue d to be obsess with notgaininga single pound. This wasapatient who took dietpills for 10years and whosee earliest memoriesinvolvedher fathers disapproval ofher bodyhabitus. Eatingdisorders areviewed bysome cliniciansasa formofO C D. OC D.Swedo and Rapoport (II)also notean increased incidenceofeating disorders in childrenandadolescentswithOCD. Whilethis wasno doubt true,the profoundobsessionalcontent 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 studyfrom thebeginningas it shouldimmediatelyraise a suspicion of OCD in a patientpresentingwith complaintsofdepression and anxiety. Finally,her diagnosis of borderline dispositiondisordermadeiteasier to passoff her observablebehaviorin the office asfurtherevidenceofhercharacter structure. The diagnosis of borderline personalitydisorder wasclear. Sheused thedefense of splittingas evide nce 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. Sheexhibited emotional instability, markeddisturbance of bodyimageand impulsive behaviors. However, it was difficult to blob 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 muchthatshefrequently drove chisel 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 thefaceofOCD. One might also beginto wonder how manypatien tswith personalitydisordershave undiagnosedOCD? Rasmussenand Eisenfound a very high comorbidity ofother Axis I diagnoses in patientswith OCD. Thirty-onepercent of patients studiedwerealso diagnosed with majordepression, andanxiety disorders accounted for twenty-four percent.Other coexistent 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. given overthefrequency 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 membe rhasOCDmaynotelicittheinformation, sincefamily members mayalso be undiagnosed. Insummary, thiscaserepresents a complicateddiagnosticpuzzle. Herpast physiciansdid not have theinformationwe dotodayto unravelthetangled skeinsof symptoms. Itis of the essence(p) to bealertforthepossibilitythat thispatient s story is not anuncommon one.BIBLIOGRAPHY * Psychology book (NCERT) * Identical * Suicidal notes * A psychopath test journey through the world of madness * Disorder of impulse control by Hucker INDEX * Introduction * Case study * configuration of treatment * Discussion * Bibliography ACKNOWLEDGEMENT I would like to express my special thanks and gratitude to my teacher Mrs. Girija Singh who gave me the golden opportunity to do this wonderful control 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 proj ect. 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 Singh. Also this project project is as per cbse guidelines 2012-2013. instructors signature (Mrs. Girija Singh) (Head of psychology department) 2012-2013 PSYCHOLOGY PROJECT NAME OF THE outlook JAILAXMI RATHORE CLASS XII ARTS B SCHOOL MGD GIRLS SCHOOL