Psychological Disorders Case Study: Guiding a 25-Year-Old Through the Maze of Obsessive-Compulsive Disorder
Patient Information:
- Age: 25
- Gender: Male
- Background: Graduate student studying biomedical sciences from Austin, Texas. Comes from a family with middle-class education and credentials. Roommate. No history of use or abuse or any serious physical health issues. Very smart and perfectionistic.
History or Cause:
Thomas (not his real name) was always described as "meticulous." In high school, it helped him become a top student and the Honour Student Award winner, but in graduate school, it became torturous. He became fixated on things and spent inordinate amounts of time verifying his lab work, rewriting notes, and washing his hands until they became raw.
His obsessions began innocently enough – checking if he locked the door or turned in the lab equipment. Then, the thoughts would become distressing, intrusive and compulsive.
He began to develop irrational fears that he made an insignificant error in the lab about causing a major catastrophe. And would obsessively review protocols even when he was told everything he was doing was fine.
When he finally sought help, Thomas was spending an estimated 5-6 hours each day on rituals: tapping doors, meticulously arranging his books in a specific manner, rewriting an email multiple times, Googling the signs and symptoms of diseases he may have caused or been collected for by being careless in the lab. His studies started to suffer, and he had become socially nonexistent.
Diagnosis:
Thomas presented to a psychiatric clinic affiliated with the university and diagnosis was formulated through:
- Comprehensive Psychiatric Interview:
The diagnostic interview reviewed the history of Thomas’s symptoms, developmental history, and family psychiatric history.
- Yale-Brown Obsessive Compulsive Scale (Y-BOCS):
The score obtained was 30 indicating severe symptoms of Obsessive Compulsive Disorder.
- Mini-International Neuropsychiatric Interview (MINI):
The purpose of the MINI was to rule out the primary diagnosis containing psychosis, major depression, or generalized anxiety.
Complete Treatment Guide: Generalised anxiety disorder.
- Family History:
Thomas's uncle has OCD and anxiety indicating a possible genetic contribution to anxiety disorders.
Final Diagnosis (DSM-5 Criteria):
- Obsessive-Compulsive Disorder (OCD) - Severe
- Comorbid: Mild Social Anxiety
Treatment:
Approach:
An organized and evidence-supported treatment plan was created to disrupt the obsessive-compulsive cycle and enhance functioning in life. The general method involved many aspects, with an emphasis on exposure-based therapy as well as pharmacological treatment.
Program:
1. Medication:
Prescribed by a psychiatrist:
- Fluoxetine (Prozac) – Starting dose at 20 mg/day and titrated up to a maximum of 60 mg/day over. SSRIs are considered the first-line pharmacological treatment for OCD.
- Optional adjunct: Hydroxyzine (used occasionally to spike anxiety).
2. Psychotherapy:
A. Cognitive-Behavioral Therapy (CBT) with Exposure and Response Prevention (ERP):
- The central strategy employed was to expose Thomas to triggers (for example, touching door handles, and leaving equipment unattended) and to prohibit him from engaging in the ritual (compulsive activity) associated with the trigger.
- Thomas would see his trained ERP specialist once a week for a 90-minute session.
- Homework consisted of self-guided exposure to the various triggers and documenting distress using the SUDs scale (Subjective Units of Distress).
B. Social Skills Coaching (Biweekly):
- The focus of this intervention was Thomas' anxiety about being judged for his compulsions.
- Using a behavioural approach, Thomas would practice social situations struggled with in simulated situations with explicit targeted feedback.
C. Group Therapy (Week 4 onward):
- Peer support group for OCD with therapist guidance.
- This provided a therapeutic community, normalised the experience, and shared coping strategies among peers.
3. Lifestyle Support:
- Mindfulness Training: Weekly group meeting focused on the ability to detach from, and control, obsessive thoughts without engaging them (i.e., thinking without reacting).
- Time Management Coaching: Help Thomas structure his day to reduce time in rituals.
- Digital Detox Interventions: Screen-time limits imposed to reduce compulsive web searching.
Improvements / Recovery Timeline:
Week 1-2:
- Started Fluoxetine.
- Thomas showed resistance to ERP ("I don't think I can just not check things"), but he agreed to do some small exposures.
- Started recording the time and intensity of his daily rituals.
Week 3-4:
- His anxiety decreased when he did small exposures (e.g., touching the doorknob without washing his hands).
- Thomas attended the group therapy sessions and was quiet but attentive.
- Y-BOCS score decreased to 26.
Week 5-6:
- Did ERP. He managed to forget about the lab equipment and dealt with it a day later, without anxiety around it.
- He described having his first full evening without doing any rituals- a first for him!
- He began to develop some healthy social time with his classmates.
Week 7-8:
- Thomas went from 6 hours of rituals a day to 2 hours.
- He reported sleeping better without laying awake trying to obsess over his rituals as much.
- We increased Fluoxetine to 60 mg; it had no major side effects.
- He was now actively participating in our group work.
Week 9-12:
- Y-BOCS score of 18 (moderate).
- For the first time, he started to challenge his core beliefs: he left his lab notes unchecked for peer review.
- He reported feeling "mentally freer".
- He was able to go without doing his rituals.
Month 4-6:
- His rituals were now excluded from his wake-up and bedtime rituals.
- He did not experience much distress at all around doing exposures.
- He presented his research paper without obsessively checking his slides 30 times.
- Y-BOCS: 10 (mild). OCD is now in remission with maintenance treatment.
Our Success:
Impact on Patient’s Life:
Thomas went from living a life bound by obsessive rituals to one grounded in confidence and control. He successfully defended his thesis and received accolades for his research, and he now spends time with a science outreach group, a social activity he never believed he could do.
He described his recovery as "getting hours of life back that he didn't know he was losing." His energy had gone from avoidance to action, and he found that uncertainty means incompatible possibilities, not danger; it's life.
Family and Community Impact:
Thomas transitioned from a life controlled by obsessive rituals to living with confidence and agency. He completed his thesis and was able to share it and his findings with award-winning research, he is now participating in a science outreach program, a social activity of which he never thought was possible.
He described his recovery as "getting hours of life back that he didn't know he had lost". His energy had shifted from avoidance to action, and he began to realize that uncertainty is incompatible possibilities, not a risk; it is simply life.
Final Words:
Obsessive-Compulsive Disorder can be all-consuming, making all tasks of daily living agonizing and consuming with uncertainty. Thomas's journey, a testament to the power of early diagnosis, evidence-based treatment, and diligent effort, provides a clear example of how strong compulsions can be diminished in strength.
Psychiatric disorders like OCD are not personality defects or weaknesses, they are neurological and psychological issues that can be recovered from when treated with practical skill and compassion.
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