Case Study Obsessive Compulsive Disorder

In a previous article we reviewed a range of treatments that are used to help clients suffering from obsessive-compulsive disorder (OCD). In this edition we showcase the case study of Darcy [fictional name], who worked with a psychologist to address the symptoms and history of her OCD.

Marian, a psychologist who specialised in anxiety disorders, closed the file and put it into the filing cabinet with a smile on her face. This time she had the satisfaction of filing it into the “Work Completed” files, for she had just today celebrated the final session with a very long-term client: Darcy Dawson. They’d come through a lot together, Darcy and Marian, during the twelve years of Darcy’s treatment for Obsessive-Compulsive Disorder, and they had had a particularly strong therapeutic alliance.

Marian reflected on the symptoms and history which had brought Darcy into her practice.

Obsessions at age nine

Now 37, Darcy reckoned that she had begun having obsessions around age nine, soon after her beloved grandma had died. Already grieving the loss of the person she was closest to in life, Darcy experienced further alienation – and resultant anxiety — when her father relocated the family from the small town in Victoria where they lived to Melbourne. Adjusting to big-city life wasn’t easy for someone as anxious as Darcy, and she soon found that she was obsessing. She had fears of being hit by a speeding car if she stepped off the kerb. She feared that the new friends she began to develop in Melbourne would be kidnapped by bad people. And she was terrified that, if she didn’t do an elaborate prayer routine at night, all manner of terrible things would befall her family.

The prayer routine, relatively simple at first, grew to gigantic proportions, containing many rules and restrictions. Darcy believed that she had to repeat each family member’s full name 15 times, say a sentence that asked for each person to be kept safe, promise God that she would improve herself, clap her hands 20 times for each person, kneel down and get up 5 times, and then put her hands into a prayer position while bowing. She “had” to do this routine at least 10 times each night, and if she made a mistake anywhere along the way, she had to start totally over again from the beginning, or else something bad would happen to her parents or little brother. Once she went flying to her mother’s side in the kitchen, tears streaming down her face, because she couldn’t get her “prayers” right. Darcy was certain that she was a huge disappointment to God and everybody.

Just like Granddad

Marian had asked Darcy if her parents were similar at all, and Darcy couldn’t think of many ways in which they were. Then she remembered something. “Ah,” she said, “my parents aren’t having these awful thoughts like me, but I remember my mum often telling me, ‘You’re just like your grandfather.’” Darcy’s grandfather had died when she was only five, so she didn’t have strong recollections of him, but there were two images that she always remembered about him: Grandfather standing by the kitchen sink in their farmhouse, washing his hands – always washing his hands. And if they decided to take a walk around the farm, he would take a seeming eternity to check that all the windows and doors were locked, even though they were on good terms with everyone within a ten-mile radius!

Obsessions and compulsions worsen through Uni

Marian had felt huge compassion for Darcy as she outlined the course that the disorder had taken. While the intrusive thoughts waxed during high-stress times and waned when Darcy felt relatively stable, there was nevertheless a general broadening of the obsessions – and resultant compulsion to do certain repetitive acts – throughout Darcy’s growing-up years. In high school, for instance, Darcy began to have an aversion to looking at any woman with a scoop-neck top on, going so far as to grab a glass and pretend to be holding it high up near her lips (as if to drink) if she had to talk to someone dressed in any but the most conservative top. In that way, she felt, she would be blocked from seeing what she should not see and thus sinning. Short skirts were also a problem, as Darcy feared that she was looking at people in inappropriate ways, and was offensive.

If anyone at a party crossed their legs while she was looking at them, Darcy assumed that they had done that because they were offended by her having glanced at them; she feared that they would think she was looking at their crotch area. She prayed constantly for forgiveness, but ended up ceasing hugs to family and friends because she felt like a hypocrite. Of course, not feeling that she could/should touch anyone made for huge social problems, and dating anyone became impossible: a huge punishment for a friendly extravert like Darcy. She petitioned God relentlessly, asking to be a better, less sinful person. It did not seem to help.

When Darcy began University, the experience was defined by a series of irrational obsessions. She would worry incessantly about having written something offensive on an email or an assignment. Walking around campus, she would pick up rubbish: papers that she had never seen before; she would worry that she might have written something on one of them. She feared that she would accidentally hurt one of her fellow students by something that she might do or say. By this time Darcy was repeating certain phrases over and over again to ward off disaster. She was amazed that she was getting through school at all (she often made straight A’s), because her rampant perfectionism caused her to take at least twice as long as other students to complete assignments, and she still wasn’t happy then. The anxiety and depression were overwhelming Darcy to the point where she recognised that she could barely function and something needed to change.

The Uni psychologist says, “You’re fine”

Marian shook her head in amazement as she recalled how Darcy’s first attempts to find out what was wrong with her had been fruitless; all the health professionals had completely missed the OCD! Upon first coming to Marian, Darcy had recounted how getting along to the University psychologist in her senior year was a “non-event”. He had asked a few questions, chatted to her about her schoolwork, told her she was basically fine, and then told her to go see a psychiatrist, who merely prescribed a sleeping pill. Darcy had taken this, as instructed, because the intrusive thoughts in her mind often did keep her from sleeping, but when she was awake she still had the thoughts and the horrible compulsion to perform the anxiety-alleviating acts: routines which now occupied several hours each day. Moreover, Darcy’s parents still didn’t believe that anything was wrong with her; they even found it funny that she was “quirky” like her grandfather.

Age 25: Treatment begins

Darcy was to graduate and spend another three years being held prisoner by her out-of-control mind before a chance meeting of her mother with a specialist in OCD at a conference. The specialist didn’t live in Melbourne, but – by incredible coincidence – he had a highly recommended colleague who did: Marian. Marian recalled with some fondness how Darcy had sat in her office during the first session, shedding tears of joy at being truly “seen”: both as a person and in her disorder. When Marian had issued the magical words, “Obsessive-Compulsive Disorder”, Darcy had been surprised – after all, her sense of OCD was people who continually washed their hands – but she also felt like she had just been given the key to her prison. Her treatment began soon after.

Marian worked intensively with Darcy at first, and then steadily. She helped Darcy get onto an even keel emotionally first by raising her serotonin levels (which had been quite low). Marian then began the laborious process of helping Darcy to change her habits of thinking: the assumptions that she made, the irrationalities that controlled her behaviour, and the intrusive obsessions that seemed to take over her life. Marian helped Darcy to see the importance of an exercise regimen, a good diet, and a stillness practice. Darcy joined an online support group, and Marian and Darcy enlisted the help of Darcy’s family and a few close friends. Partway through the therapy, Darcy was even able to come off the medications: a goal she had long sought, because she had married a “wonderful” man and they wanted to start a family.

Epilogue

At 37, Darcy is a happy and fulfilled person, with a solid marriage and an eight-year-old daughter. She believes that she worries about her “like a normal mother”, rather than in the obsessional way she used to pray in order to protect her family from imagined harm. She still petitions God, as she is active in her church, but now the petitions are free of the superstitious routines she used to perform, and she is quick to be thankful for her many blessings.

Unwanted thoughts still come to her, but now she has tools to focus elsewhere, and when the intrusive thoughts come, Darcy knows how to keep them from causing her to repeat irrational acts in a compulsive way. She knows that she will probably always be managing her disorder, as there is no cure for OCD. But the difference now is that she controls it, rather than having it control her. As far as Darcy is concerned, Marian gave her back her life.

Marian smiled again as she recalled Darcy’s journey and her original fear of being a “disappointment to God and everyone”. Indeed, Marian felt blessed to have had Darcy as a client.

This article is an extract of the upcoming Mental Health Academy “OCD and OCPD Case Studies” CPD course. Click here for a full list of currently available MHA continuing professional development courses.

OBSESSIVE COMPULSIVE DISORDER

Background History

Paul is a 40 year old man diagnosed with Obsessive Compulsive Disorder. He has always lived with his parents and remains in the family home. He had maintained an office job for over 15 years but was reliant on his 75 year old mother to drive him to and from work. He experienced intrusive thoughts that his actions have caused, or will cause, harm to others and constantly rechecked his steps or actions.

Reason For Referral

Paul was referred for occupational therapy by his Consultant Psychiatrist due to concerns regarding his over-reliance on his ageing parents, his limited activities in daily living and a decrease in personal hygiene. Paul's safety behaviours enabled him to operate within his office at work and his bedroom at home but he avoided any other activities for fear he may cause someone harm.

Occupational Therapy Assessment

An initial Occupational Therapy Assessment was conducted which drew on a number of occupational therapy models and treatment strategies including the Model of Human Occupation, the Assessment of Motor and Process Skills (AMPS) and a more informal one to one interview.

The assessment identified that:-

  • Paul's OCD and intrusive thoughts were having a significant impact on his processing skills – his process scores on the AMPS were below the level expected for someone of his age;
  • Paul’s personal care had deteriorated as his intrusive thoughts impacted on his ability to get up and ready for work in the morning - he would often just get dressed without washing as he could do this whilst remaining in his room;
  • Paul had never used public transport having always been reliant on his mother for transport;
  • If Paul was to repeat a task the intrusive thoughts would lesson over time.

Occupational Therapy Treatment Plan

Paul participated in an Occupational Therapy Programme consisting of 24 sessions over a six month period which focussed on:-

  • Enabling Paul to develop a person centred prompt list in the morning to help him improve his levels of personal care;
  • Developing a graded exposure plan focussing on increasing his confidence in public places enabling him to travel to work on public transport;
  • Identifying strategies to enable Paul to extend the period of time he was able to tolerate, and not act on, his intrusive thoughts/urge to check.

Outcome

On completion of his Occupational Therapy programme, Paul was able to:-

  • Improve his levels of self care leading to a positive impact on his relationship with colleagues at work;
  • Undertake a graded activity plan with the support of his Occupational Therapist enabling him to use public transport initially with his therapist and then independently;
  • Increase his confidence interacting with others and spending more time outside his room at home and being able to play and interact with his nieces.
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