Case Report Session

OBSESSIVE COMPULSIVE DISORDER

OLEH:

Isnainia Azarine Khairul P.1790A/1110312014

Tyara Debi Arrisha P.1793A/120313035

Perseptor:

dr. Yaslinda Yaunin, Sp.KJ (K)

BAGIAN PSIKIATRI FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS

RSUP DR. M. DJAMIL - RSJ PROF. HB SAANIN PADANG

PADANG

2015
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 CASE PRESENTATION

A 27 years old man went to mental health clinic at RSJ HB Saanin, on 19th of March,
2016 by him self.

Patient Identity:

Name and Age : Mr. MA / 27th y.o

Gender : Male

Date of birth : Mei 15th , 1986

Marital status : married

Address : Koto Anau, Lembang Jaya, Solok.

Occupation and School : cloves vendor / junior high school

Religion : Islam

Citizen : Indonesian

Tribe : Minangkabau

Allo-anamnesis was given by:

Name : Mrs.R

Age : 22 y.o

Address : Koto Anau, Lembang Jaya, Solok.

Phone number : 0823xxxxxxx

Occupation : Staff of Wali Nagari Office

Relationship with patient : Wife

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A. Internal Status
General appearance : Compos Mentis
Blood pressure : 120/80 mmHg
Pulse rate : 88x per minute
Temperature : 36,50C
Cardiovascular system : No disorder was found
Digestive system : No disorder was found
Specific disorder : No disorder was found

B. Neurological Status
Central nervous system : No disorder was found
Eyes : No nystagmus, no diplopia
Motoric : Eutonus, tremor (-)
Sensibility : No disorder was found
Specific disorder : No disorder was found

AUTO ANAMNESIS at March 19th, 2015

Quaestion Answer

Asslamualaikum Pak, kami dokter muda Walaikumsalam, boleh Buk.

Nia dan Ara. Boleh kami tanya-tanya
sebentar Pak?

Nama bapak siapa? Muhammad Arif

Umur Bapak berapa? 27 tahun Buk

Bapak datang kesini dengan siapa? Sendiri Buk.

Apa keluhan Bapak sampai datang kesini? Jadi gini buk, saya itu sering melakukan
pekerjaan berulang-ulang, misalnya saya
baru selesai mandi, terus dipikiran saya

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 nyuruh mandi lagi. Atau pasang baju, bisa
berulang kali dilakukan. Sakit kepala saya
jadinya Buk.

Pekerjaan apa saya yang bapak lakukan Semuanya buk. Mandi, makan, pasang
berulang? baju, nyisir rambut. Semuanya buk.

Ada yang spesifik pak? Misalnya hanya di Ndak buk. Semuanya terganggu saya
masalah kebersihan saja? Atau kerapian
saja?

Sudah berapa lama bapak seperti itu? Sudah lama buk. Pertama kali itu waktu
tahun 2005. Tapi yang paling parah itu
tahun 2009.

Jadi tahun 2005 itu, awalnya itu apa Pak, Jadi tahun 2005 itu saya bertemu seorang
bisa bapak ceritakan? ibu usianya sekitar lebih dari 50tahun. Saya
merasa ibu itu suka sama saya, saya seperti
diguna-guna, karena pikiran saya selalu
kepada ibu itu. Ibu itu terus yang ada
dipikiran saya. Saya coba pergi ke orang
pintar, kata orang pintar itu saya diguna-
guna oleh ibu itu. Sejak itu lah muncul
penyakit saya ini muncul buk.

Ada kejadian apa selain itu Pak? Apa bapak Tidak pernah buk.
pernah terkena kotoran hewan, lalu merasa
badannya selalu kotor? Atau pernah
kecurian di tempat kerja?

Kalau yang paling parah tahun 2009 itu apa Penyakit saya ini sering muncul kalau saya
Pak? merasa tertekan buk. Tahun 2009 itu saya

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 mulai kerja di pasar solok jual cengkeh.
Saya merasa tertekan karena bos saya. Saya
takut dan merasa tertekan. Tambah parah
penyakit saya itu buk.

Seperti apa tambah parahya Pak? Sakit kepala saya jadi nya buk. Berulang-
ulang apa yang saya kerjakan itu. Pikiran
itu terus berulang-ulang muncul.

Apa yang bapak rasakan kalau penyakit Capek saya jadi nya buk. Pasang sepatu
bapak kambuh? berulang-ulang, pakai baju berulang, sholat
berulang. Capek jadi nya.

Dalam 1 minggu kira-kira berapa kali Setiap hari buk. Apa lagi kalau saya merasa
kambuh penyakit bapak? tertekan. Sering mucul penyakit ini buk.

Jadi penyakit bapak tambah parah kalau Iya buk. Tambah sering muncul pikiran-
bapak stress dan tertekan? pikiran yang berulang itu buk.

Waktu kambuh itu berapa kali bapak Bisa sampai 3 x saya mengulang-ulangnya
mengulang-ulang suatu kegiatan? buk.

Bapak pernah mncoba melawan pikiran Pernah saya coba tahan, tapi ndak bisa buk,
bapak itu supaya tidak melakukan kegiatan langsung pucat, gemetaran dan sakit kepala
berulang-ulang? saya buk.

Jadi apa yang bapak lakukan kalau bapak Ya saya lakukan saja beulang-ulang buk.
tidak bisa menahan pikiran tersebut Tapi saya jadi capek buk.

Bapak sejak sakit ini bagaimana perasaan Kadang terasa sedih saja saya bu. paibo
bapak? hati. Karena saya sakit, sedangkan orang
lain tidak sakit. Kadang istri saya tidak

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 mengerti kalau saya sakit.

Bapak sudah punya anak? Belum buk.

Karena penyakit ini bapak ada pikiran Alhamdulillah tidak ada pikiran bunuh diri
untuk bunuh diri? itu buk. Cuma ya badan saya jadi capek,
kepala sakit.

Orang tua atau saudara ada yang punya Ada buk. Bapak saya jug sama seperti saya
penyakit yang sama dengan bapak? buk. Berulang-ulang melakukan sesuatu itu
buk.

Usia ayah bapak berapa? 68 tahun buk

Sejak kapan ayah bapak punya keluhan Baru buk, 5 bulan ini
yang sama?

Apa ayah bapak terlihat pikun? Sering Nah, iya buk.

lupa?

Baiklah pak, mungkin itu saja yang saya Tidak buk.

tanyakan dulu. Bapak ada yang ingin
ditanyakan?

Allo-anamnesis:

1. Main complaint:

Anxious thought and repeating actions since 2005

2. History of present illness:

a. Anxious thought since 2005. The anxious mind is felt disturbing and can not

be abandoned. Patient repeatedly thinking about something, for example, wish

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 to shower repeatedly, repeatedly brushing teeth and cause restless to patient.

In this patient, there is no spesific obsession.

b. Anxious thought also increased by non-stop desire to think about any problem

endlessly. Patient anxious each time especially when going to work. Patients

claimed depressed with his job, but could not explain what to fear.

Restlessness is reduced when the patient come back home from work or when

going for a walk.

c. Patients repeating actions since 2005. Repetitive actions is not specific to one

kind of subject. Irs not only about cleanliness, but for all of the things he did.

For example, wearing clothes repeatedly, bathing repeatedly, brushing teeth

repeatedly, and others. Repetition done as much as 2-3x. Repetition felt

disturbing to the patient so he tried to resist. But when he tried not to repeat

such actions, his legs were shaking, face became pale and got a headache.

d. Sleep disorder, difficult to fell asleep since 2005, but the complaint reduced

since he took medicine from hospital.

e. There is no decreased appetite

f. There is no feeling of irritability

3. History of Past Illness

2005

Patients first felt the change in the minds and behavior on 2005. Patients were a

high school students and everyday help his parents cutting grass to feed cattles.

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 Patients felt he had bewitched by a woman, and could not stop thinking about

her. Patients even dropped out of school because of it. Patients admitted that he

had no problem with school and parents before the onset of illness. At first,

patient was going to see a shaman to cure his ilness, but because the complaint

was not reducing, he started going to see a doctor.

2009

Patients began working as a cloves seller in the Solok market. When starting this

new job he experienced more severe illness. He got headache more often and

more anxious. At that time patient did not feel comfortable with the job and his

boss. Although the patient himself can not explain what made him anxious.

Patients treated irregularly, only once in 3 months or when the complaint feels

very disturbing.

2016

Patients went to RSJ HB Saanin with complaints of anxiety and perform

repetitive actions. Previously, patient got treated at RSUD Solok, but this time

on his own will, he went to Padang.

4. Premorbid history

Infant : born spontaneously, birth was assisted by midwife, no

history of jaundice, cyanosis, and seizure.

Childhood : growth and development suitable for his age children.

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 Adolescence : had a lot of friends,easy making new friends and outgoing

person

5. Social economy background

He lives in Solok with his wife and mother in law. He has no child. He work as a

clover seller at Pasar Solok and get paid 1.500.000/months. The medicine he is

taking is paid by BPJS now.

6. Educational background

Elementary School in SDN 06 Batu Anau, graduated in 6 years, average

achievement.

Junior High School in SMP Batu Anau, graduate in 3 years, average achievement

Senior High School in SMA Batu Anau, unfinished his second year because he

choose to stop studying after got his thought disturbed.

7.
8. Family history of illness
Patients father had a symptom like him since 5 months ago and get treated in
RSUD Solok.

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 Keterangan: Laki-laki
Perempuan
Pasien
Sakit
Tinggal serumah

Summary of psychiatric examination

1. General appearance
Consciousness/sensorial : compos mentis/good
Attitude : cooperative
Motoric : active
Facial expression : rich
Verbalization : spontaneus, speak clearly
Physic contact : could be done/appropriate/long enough
Attention : good
Initiative : present
2. Specific condition
A. Affective
1. Affective condition : wide
2. Mood : eutim
3. Emotional :
a. Stability : stable
b. Control : normal
c. Echt/unecht : echt
d. Einfulung : adequat
e. Deep/shallow : deep
f. Differentiation scale : average
g. Emotional flow : fast
h. Mood : Eutim
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B. Intellectual condition of function
a. Memory : good
b. Concentration : good
c. Orientation : good (time, place, personal,
situation)
d. Knowledge : normal
e. Discriminative insight : normal
f. Intelligence prediction : average normal
g. Discriminative judgment : normal

C. Sensation and perception abnormalities

1. Illusion : none
2. Hallucination
Acoustic : none
Visual : none
Olfactory : none
Tactile : none
Gustatory : none

D. Thought process condition

1. Speed of thought processs : fast
2. Quality of thought process
a. Clear and sharp : clear and sharp enough
b. Circumstantial : none
c. Incoherent : none
d. Sperrung : none
e. Hemmung : none
f. Flight of ideas : none
g. Verbigeration : none
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 h. Preservation : none

3. Thought condition
a. Central pattern : none
b. Phobia : none
c. Obsession : present
d. Delusion : none
e. Suspicion : none
f. Confabulation : none
g. Repulsion : none
h. Inferior feeling : none
i. Much/little : much
j. Feeling guilty : none
k. Hypochondria : none
l. Others : none

E. Instinctual drive and behavior abnormalities

a. Abulia : none
b. Stupor : none
c. Raptus/impulsivity : none
d. Excitement state : none
e. Sexual deviation : none
f. Echopraxia : none
g. Vagabondage : none
h. Pyromania : none
i. Mannerism : none
j. Others : none
F. Over anxiety : present, much
G. Reality testing ability : normal

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RESUME MULTIPLE AXIS

Axis I. Clinical Syndrome

Anxious thought, repetitive acts, sleep disorder

Phsyciatric examination:

General Appeareance: compos mentis, cooperative, calm, rich, can speak clearly,
psychic contact could be done, appropriate and long enough.

Specific condition:

a. Affective condition: eutim, stable, normal control, echt, adequate, deep,

average, fast.

b. Intellectual condition and function: good memory, good concentration, good

orientation, knowledge normal, discriminative insight and judgment normal

c. Sensation and perception abnormalities: no illusion, no hallucination

d. Thought process condition: fast, clear and sharp enough, obsession presence

e. Instinctual drive and behavior abnormalities: none

f. Overt anxiety: presence

g. Reality testing ability: normal

Axis II : Personality Disorder and Mental Retardation Disorders

Personality: no spesific personality

Mental retardation: none

Axis III : General Medical Condition

Theres no history of seizure and head trauma based on patients explanation.

No other history found.
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Axis IV : Phsychosocial Stressor and Environment

Works as a cloves seller at Pasar Solok. He felt burdened by his boss, and
increasing his anxiety and compulsions behaviour.

Axis V: Global Assessment of Function

Social relationship could be done

MULTIPLE AXIS DIAGNOSIS

I. F.42 Obsessive Compulsive Disorder

II. No Diagnosis.

III. No Diagnosis

IV. Workplace problem

V. GAF 90-81, minimal symptom, good function, quite satatisfied, no more

problems other than daily problem

Differential diagnosis: General anxiety disorder (F41.1)

Therapy

Fluoxetin 1x20 mg

Alprazolam 1x0,5 mg

Prognosis

Clinical : dubia at bonam

Functional : dubia at bonam

Social : dubia at bonam

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Revisions explanation

1. Elaborate the obsession and predisposition factor

Explanation are available in autoanamnesis table and history of present
illness.
2. Genetic Factor
Patients father suspected to have alzheimer, not OCD.

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 OBSESSIVE COMPULSIVE DISORDER

A. Definition

Obsessive compulsive disorder (OCD) is a common, often debilitating

neuropsychiatric disorder, characterized by obsessions and compulsions.1 Obsessions

which include persistent, distressing thought, images, or impulses that affected people

generally recognized as products of their own minds, cause substantial anxiety and

distress. Patients with OCD attempt to neutralize the anxiety and discomfort from the

obsession with compulsions, repetitive behaviours intended to reduce or prevent

2
distress and undesirable situations or events. Contrary, for some people this

compulsive acts does not reduce the anxiety but increasing it. 3

OCD may be defined as the irruption in the mind of uncontrollable,

egodystonic and recurrent thoughts, impulses or images. In OCD, repetitive ritual

serve to counteract the anxiety precipitated by obsessions. The OCD patients realize

the irrational nature of thoughts and rituals but feel helpless and hopeless about

controlling them.4

Recent changes in diagnostic criteria have involved reclassification of OCD

from being an anxiety disorder to a new group of obsessive compulsive and related

disorder with a focus on repetitive behaviours. This change is potentially important

when considering the underlying neurocircuitry and potential treatments in OCD. 2

B. Etiology

The exact process that underlies the development OCD has not been

established. Research and treatment trials suggest that abnormalities in serotonin (5-
16
HT) neurotransmission in the brain are meaningfully involved in this disorder. This is

strongly supported by the efficacy of serotonin reuptake inhibitors (SRIs) in the

treatment of OCD. 5

Attention has also been focused on glutamatergic abnormalities and possible

glutamatergic treatments for OCD. Although modulated by serotonin and other

neurotransmitters, the synapses in the cortico-striato-thalamo-cortical circuits thought

to be centrally involved in the pathology of OCD principally employ the

neurotransmitters glutamate and gamma-aminobutyric acid (GABA).5

Both computed tomography and MRI of untreated children and adults with

OCD have revealed smaller volumes of basal ganglia segments compared to normal

controls. In children, there is suggestion that thalamic volume is increased. Adult

studies have provided evidence of hypermetabolism of frontal cortical-striatal-

thalamo-cortical networks in untreated individuals with OCD.3

OCD is a heterogenous disorder that has beem recognized for decades to run

in families. Family studies have documented an increased risk of at least fourfold in

first degree relatives of individuals with early onset OCD. Molecular genetic studies

have suggested linkage to regions of chromosomes 2 and 9 in certain pedigree with

multiple members exhibiting early onset OCD.3

Individuals with OCD frequently have other psychiatric comorbid disorders,

prominently including major depressive disorder, alcohol and/or substance use

disorders, other anxiety disorders, impulse control disorders (eg, trichotillomania,

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skin-picking), and Tourette and tic disorders. (Perhaps 40% of individuals with

Tourette disorder will have OCD).5

In Freudian psychoanalytic theory OCD originates at the anal training stage

development. When in early childhood, the anal sadistic phase was disturbed while

this is the stage when the child began to understand self autonomy. Due to harsh toilet

training this child began to confuse his own autonomy and others. The anal sadistic

phase will regress together with the anxiety related to oedipal conflicts at present thus

then began to build reinforcement of anal or aggressive impulses.

The anankastic personality trait will be disguised by the reaction formation

and when this is not enough the new defenses mechanism is created. The defenses

mechanism are isolation of affect that contributed for the obsessive thought, undoing

which then contributed for the compulsion, and displacement that acted out as

phobias.

In the isolation of affect, the ego removes the affect from the anxiety-causing

idea. The idea is thus weakened, but remains still in the consciousness. The affect

however becomes free and attached itself to other neutral ideas by symbolic

associations. Thus these neutral ideas become anxiety-provoking and turn into

obsession. This happens only when isolation of affect is not fully successful. When

both the idea and affect are repressed and there is no obsession. The undoing will

leads to compulsion which prevents or undoes the fear consequences of obsession.

This mechanism has been explained in slight detail as this theory attempts to

describe the probable causation of OCD in remarkably systematic manner. However,

18
it must be remembered that this is only a theory and whether it is true or not, is a

matter of conjecture.

C. Epidemiology

Obsessive compulsive disorder is common among children and adolescents,

with a point prevelance of about 0,5 percents and a lifetime rate of 1 to 3 percents.

The rate of OCD rises exponentially with increasing age among youth, with a rate of

0,3 percents in children between the ages of 5 years and 7 years and rising to 0,6

percent among teens. Rates of OCD among adolescents are greater than rates for

disorders such a schizophrenia and bipolar disorder.3

The overall prevalence of OCD is equal in males and females, although the

disorder more commonly presents in males in childhood or adolescence and tends to

present in females in their twenties. Childhood-onset OCD is more common in males.

Males are more likely to have a comorbid tic disorder. It is not uncommon for women

to experience the onset of OCD during a pregnancy, although those who already have

OCD will not necessarily experience worsening of their symptoms during

pregnancy.5

Women commonly experience worsening of their OCD symptoms during the

premenstrual time of their periods. Women who are pregnant or breastfeeding should

collaborate with their physicians in making decisions about starting or continuing

OCD medications.5

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D. Sign and Simptom

ICD-10 classifies OCD into three clinical subtypes which are :

1. Predominantly obsessive thought or ruminations,

2. Predominantly compulsive acts (compulsive rituals), and
3. Mixed obsessional thoughts and acts

Depression is very commonly associated with OCD. It is estimated at least

half the patient of OCD have major depressive episodes while many other have mild

depression. There are several clinical syndromes have been described in literature,

although admixtures are commoner than pure syndromes. Those major clinical

syndromes are:3

i. Washers (contamination)

This is the most common type. Here the obsession is of contamination with

dirt, germs, body excretions and the like. The compulsion is washing of

hands or the whole body, repeatedly many times a day. It usually spreads

onto washing of clothes, bathroom, bedroom, door knobs and personal

articles, gradually. The person tries to avoid contamination but unable to, so

washing becomes a ritual.

ii. Checkers (doubt)

In this type the person has multiple doubts, for example the door has not

been locked, kitchen gas has been left open, counting of money was not

exact and etc. the compulsion, of course, is checking repeatedly to remove

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 the doubt. Any attempts to stop the checking leads to mounting anxiety

before one doubt has been cleared, other doubts may creep in.

iii. Pure obsession (intrusive thought)

This syndrome is characterized by repetitive intrusive thoughts, impulses or

images which are not associated with compulsive acts. The content is usually

sexual or aggressive in nature. The distress associated with these obsessions

is dealt usually by counter-thought for example praying, undoing actions,

asking for reassurance and counting but not with rituals.

iv. Primary obsessive slowness (symmetry)

It is characterized by several obsessive ideas and or extensive compulsive

rituals, in the relative absence of manifested anxiety. This leads to marked

slowness in daily activity. Usually the person demand on being need for

symmetry and precise arranging so in order to neutralize it they will continue

Ordering, arranging, balancing, straightening until "just right" or perfect in

their eyes.

v. Other symptoms patterns

There are other types such as hoarders who will found it hard to give or

throw away their things even if it not valuable at all. Others include the

religious obsession.

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Table 1. List of typical obsessive thoughts compelling repetitive actions4

Obsessions Compulsions

Concern with cleanliness Excessive and ritualized bathing,

washing, and cleaning

Concern with exactness (symmetry and Ritualized arranging and rearranging

order)
Concern with household tools Checking, rechecking and keeping
inventory with detailed description of
tools, objects, and appliances

Concern about body secretions (saliva, Ritual to remove body secretions

urine, stool)
Sexual obsessions Ritualized and rigid sexual relationship

E. Diagnose

Working diagnose for OCD, the symptoms of obsessive and compulsive must

presence, and almost everyday for at least two weeks in a row. This condition cause

substansial anxiety, distress, and activity disturbing for patient.

Symptomps of obsessive must include :

- Recognized as the thoughts are self-generated or impulse by their self

- At least, there are one thought or action can not success to

- Mind to do such action is not a thing that gives satisfaction or pleasure (just a

sense of relief from tension or anxiety)

- The impuls must something unpleasantly repetitive6

Some common obsessions involve contamination, doubts about whether an

important task has been performed, or worries that an action will harm another

22
person. Compulsions are repetitive activities or mental rituals designed to counteract

the anxiety caused by obsessions. Common compulsions include handwashing,

checking, ordering, praying, counting, and seeking reassurance.7

There is a relation between obsessional symptoms, particularly obsessive

thoughts with depression. People with obsessive-compulsive disorder often also show

depressive symptoms. 6

Diagnose for OCD is made only when there are no symptoms of a depressive

disorder at the time of the obsessive compulsive present. The chronic disorder, the

priority given to the most symptoms persist when other symptoms disappear.7

F. Treatment of OCD

Pharmacological treatments

The Serotonin Selecive Reuptake Inhibitor (SSRI) are consistently effective in

patients of Obsessivecompulsive disorder. The anti-obsessional effects of potent

SSRI produce progressive desensitization of the presynaptic autoreceptors.

Clomipramine was the first to show beneficial effects on OCD symptoms. The newer

generation of antidepressant drugs like Fluvoxamine, fluoxetine, paroxetine,

sertraline and citalopram have also been found useful in management of OCD. The

mean daily dosage is 50200 mg for sertraline, 2080 mg for fluoxetine, 4060 mg

for paroxetine and 150300 mg for fluvoxamine. The atypical antipsychotics such as

risperidone act as new therapeutic options for refractory OCD. 4

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 Approximately 60% to 70% of patients experience some degree of

improvement in OCD symptoms with SSRI treatment. If medical therapy is

successful, it should be continued for at least one to two years. If the patient chooses

to discontinue pharmacotherapy, the dosage should be gradually tapered over several

months. If symptoms worsen during this time, the original dosage should be resumed,

and further attempts at discontinuing medication should be approached with

reservation. Some patients require lifelong medical therapy. 4

Psychological treatments

Psychological treatments are effective for OCD. These treatments should be

administered by a properly trained health care professional, most commonly a

psychologist or social worker. Cognitive behavior therapy (CBT) is the method of

psychotherapy most often used; there is no evidence for the use of psychodynamic

psychotherapy or talk therapy for treatment of OCD. Exposure and response

prevention is a key element of CBT that has been proven effective in the treatment of

OCD. Patients are taught to confront situations that create fear related to their

obsessions, and to avoid performing compulsive behaviors in response. Patients

refrain from performing rituals until the level of anxiety dissipates. Exposure and

response prevention is usually performed in 13 to 20 weekly sessions, with each

session lasting one to two hours.7

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G. Prognosis8

The average age of onset for OCD varies among men and women. Men may

experience childhood onset, between ages 6 and 15, while women typically

experiance adult onset, between ages 20 and 30. 80% also had symptoms of

depression.

Although OCD usually develops gradually, psychosocial stressor like changes

in living situations, relationship problems, or work problems can cause sudden onset.

About 70% of people experience a chronic and lifelong course, with worsening and

improving symptoms.

Regardless of a persons age at onset, the content of obsessions does nt

determine prognosis. The factors associated with a good prognosis include the

following :

- Milder symptoms

- Brief duration of symptomps

- Good functioning before full onset

Some people have only obsessions and do not behave compulsively. These

people may attempt to suppress their distrubing, intrusive, or inappropiate thoughts

by thinking healthy thougths. This may lead to mental exhaustion, distraction, or

concentration problems.

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