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Case #1

Obsessive-Compulsive Disorder with good or fair insight

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INTRODUCTION OF DISORDERS

BIO DATA

REASON FOR REFERRAL

PRESENTING COMPLAINTS

HISTORY OF PRESENT ILLNESS

FAMILY HISTORY

PERSONAL HISTORY

1. Birth and Early Development

2. Educational & Occupational History

3. Social History

PREMORBID PERSONALITY

PSYCHOLOGICAL ASSESSMENT

Assessment was done on two levels:

1. Informal psychological assessment

2. Formal psychological assessment

INFORMAL PSYCHOLOGICAL ASSESSMENT

Mental status examination

Appearances and behavior

Speech

The client’s rate of speech and tone was fast and was very talkative.

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Mood

The client’s subjective and objective mood was euthymic.

Thought pattern

His thought process and content was fine as he was in recovery state. Depersonalization,

derealisation, delusion, illusion and hallucination were not found in the client... No self harm

thoughts and suicidal ideation was found in the client

Cognition:

Attention and concentration

His attention and concentration was below average as some questions had to be asked twice for

him to answer.

Memory

The client’s memory was intact. His recent, remote and recent past memory were good, except

for the time spent with the religious group

Abstract thinking

His abstract thinking was average

Orientation

He was fully oriented to time, place and person

Judgement

His judgement was good.

Insight

He had good insight of his problem and was hopeful that he could go back to normal life.

Behavior symptom rating

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DIAGNOSTIC ASSESSMENT

TENTATIVE DIAGNOSIS ACCORDING TO DSM-V

300.3 (F42)Obsessive-Compulsive Disorder

CASE FORMULATION

MANAGEMENT PLAN

To eliminate obsessions and compulsions these therapies will be used:

1. Psycho-education

2. Behavioral Therapy

 Deep Breathing

 Activity Scheduling

 Thought Stopping and Covert Assertion

 Exposure and Response Prevention (ERP)

 Distraction Technique

3. Cognitive Therapy

4. Rational Emotive Behavior Therapy

 ABC Model

 Disputing

5. Cognitive Homework

6. Cognitive Behavioral Therapy (CBT)

SHORT TERM GOALS

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 Psycho-education will be used to give awareness about the illness, its causes, course

mode of treatment and role in the treatment to client and his family.

 Thought stopping technique will be implemented that will cognitively interferes with

obsessions by thinking of a stop sign and then a pleasant scene to interrupt obsessions.

 After thought stopping will be completed, covert assertion will be helpful to control the

behavior and maintain the effect and to strengthen the behavior.

 The client will be assisted in adopting coping strategies through involving him in

domestic affairs and social gatherings. Activity scheduling pleasure and mastery chart

will be organized for this purpose.

 Techniques of complete exposure will be introduced for reducing anxiety and giving

awareness how it falls down. He will be engaged in activities like watching T.V.,

calling a friend, walk etc.

 Relaxation methods will be used that are deep breathing, muscle tension and positive

imagery to counter-act high anxiety.

 REBT will be used to identify the irrational beliefs.

 Therapist will help the client in identifying his life goals, with his consent, an activity

schedule will be developed, which he has to follow at the best of his capabilities.

 ABC Model will be used to help the client to understand the healthy and unhealthy

ways of thinking and importance of healthy ways of thinking.

 Distorted thinking and belief errors will be identified and replaced. For reducing their

impact the client will be asked to complete exercises in daily functioning that focus on

cost benefit analysis and distorted thinking.

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LONG TERM GOALS

 Therapist will motivate the client to resolve key life conflicts and the emotional stress

that fuels obsessive compulsive patterns.

 The client will be asked to function daily at a consistent level with minimal interference

from obsessions and compulsions.

 The client will be helped in achieving controlled behavior, moderated mood, and more

deliberative speech and thought process through psychotherapy.

LIMITATIONS AND SUGGESTIONS

The limitations are as following:

 This case study is only for academic purposes, so time was very short for gathering all

information.

 Time period for building rapport with the client was very short.

 There was a little bit distraction in the room.

The suggestions are as follows:

 Time period for case study should be extended.

 Environment should be peaceful for good case study.

 Family should be educated to treat the patient in good manner.

REFERENCES

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Case #1

Obsessive-Compulsive Disorder with good or fair insight

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INTRODUCTION OF DISORDERS

BIO DATA

Name: Z.H.

Sex: Male

Age: 25 years

Education: Metric

Occupation army

Siblings: 4 brothers (1 dead) and 2 sisters

Birth Order: sixth

Religion: Islam

Informant: elder brother

Residence Lahore

REASON FOR REFERRAL

The client was referred from OPD in Services hospital Lahore and referred for the purpose of

psychological assessment and management.

PRESENTING COMPLAINTS

1. Complaints of excessive and irresistible thoughts and images

2. Compulsions of hand washing/bathing

3. Appetite disturbances

4. Restlessness

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5. Inability to concentrate

6. Disturbance in daily routine

7. Disturbed sleep

HISTORY OF PRESENT ILLNESS

The client visited services hospital Lahore with the complaints of excessive and

irresistible thoughts and images, compulsive actions of hand washing and bathing excessively,

changing his clothes because he thought they were dirty, appetite disturbances, restlessness,

sleep disturbances and disturbance in daily routine.

According to client, he could not handle the death of his brother well brother who died

in 2010. As the deceased was mentally not stable and had run away from home. His dead body

was found a few days later from a park, the cause of death was unknown. There was no

information about the mental illness of the client’s brother as they lived in Balakot and there is

no awareness of psychological problems there. The client was extremely shocked when the

news came of his brother’s death. The effect of this sad incident remained for a long time on

his mind.

After one year of his brother’s death he faced another traumatic event, it was his

father’s sudden death. The client’s father died in 2011. He was very close to his father as he

was the youngest son. He loved his father and served his duty in the armed forces because he

idolized his father who was a retired army servant. When his father passed away he was away

from home and was on duty. As he was a sensitive and emotional child and was very much

attached to his father, his mother and family did not inform him of the death on the phone but

told him to come home as it was urgent. He had a little issue getting holidays as it is not that

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easy to get holidays without a solid reason. But one of his seniors granted him leave after a

little pleading. The client reported that he had to talk to his brother that he could not get any

holidays but his brother insisted that it was extremely urgent that he got home soon. Client was

not informed of the death on phone. The client got home after 8 to 9 hours.

The client reported that when he reached home, at first, he did not realize why there

were so many people outside his house; the neighbors and relatives were there. The client

reported that it was like his brain stopped working and everything else faded and he could not

register his father laying there lifeless. He felt light headed and felt a sharp pang of pain in his

chest and abdomen. The informant reported that he stood there rooted to the spot and did not

move for a few minutes staring at his father and then he screamed as if in pain and fainted.

According to his brother (informant) the client had not handled the death of his brother well, so

he was not informed immediately of his father’s death. But the later had caused even more

stress and “tension” for the client. It took him 2-3 weeks to return to work after his brother’s

death and when his father died it took the client almost one month to return back to his routine

life but he still seemed disturbed. The client lived in Balakot, due to lack of awareness of

psychological problems there it is unknown if he suffered from any psychological illness. The

death of his father caused an even greater disturbance in the client’s functioning. It took the

client one month before he started talking and responding to other people and 7-8 weeks to join

duty again His cousins and neighbors did a lot of effort to change his state. The client reported

that his cousins and friends often took him outside even when he protested that he did not want

to go. Sometimes he went at others he did not. The client reported that a few of his friends from

the unit also called him and urged him to come back to join the duty. His elder sister who is

close to the client, advised the client to go back to duty as their father was proud of the fact that

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the client was serving in the armed forces. The informant reported that it took some time

convincing the client.

After he returned to his job, his state improved a lot. Then, about four months back the

client said he wanted to learn more about religion, as his mother stressed him to be regular in

prayers and know his religion well. The informant reported that his mother was a bit strict

about religion and stressed on praying regularly and reciting the Holy Quran on regular basis.

Most of the family members were regular in offering prayers. The client told that he wanted to

learn more about Islam to please his mother. Four months prior he got a few days off of work.

With a friend he went to Rawalpindi. There in a mosque he met a molvi sahib from whom he

asked for elaboration and guidance. He told the client that if he wanted to learn about religion

he should go to Raiwind that is in Lahore. He travelled to Lahore and spent almost 7 days with

the religious group. He said he formed a group of friends with his group members. He said he

was told by one of his superiors that he had blown up a mosque in Sialkot. Though the client

says he only remembers kissing the walls of the mosque, as the names of Allah were written on

them. The client believed that he had blown up a mosque. His brother however said the

evidence suggested that he had done no such thing, as blowing up a mosque would have been

over the news as this was a huge incidence. So the client had not actually blown up a mosque.

He came back to Lahore with the group.

The client reported that when he came back to Lahore the thought that he had

committed a heinous sin of blowing up a mosque made him feel very guilty and disturbed his

daily functioning a lot. The client reported that he joined the armed forces again on the advice

of his friend’s father. He was an elderly man and the client said that his friend’s father advised

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him very politely and in a fatherly manner. The client reported that the elderly man also

reminded him that he had joined the army to make his father proud. He had told him the basics

of Islam and told him to join his duty in the army as that was important for his life and for his

country and it was a noble profession. The client said that the elderly man reminded him of his

father, as he was the same age, so he listened to him. Although he joined his duty he said he

could not get the thought that he had blown up a mosque out of his head. He said “this gave me

a lot of tension in my head”. The client reported that tried to get rid of the repetitive thoughts

by pertaining to repetitive behavior that is he started washing hands excessively, taking baths at

least thrice daily, kept complaining that his clothes were dirty. The client reported that he could

not get rid of the thoughts that he had committed a heinous sin so he kept on repeating his

behaviors. Then on November 2013, he started yelling that he had not done anything wrong. He

had not committed any sins. His friends had bought him to the hospital. The client reported that

he was forced by his unit mates and visited the hospital (SHL). The client was dismissed from

the army and his friends informed about his illness to his family in Balakot.

On 4th November 2015 the client visited for psychological treatment. His unit mates

took him to hospital. No history of previous treatment was reported.

FAMILY HISTORY

The client’s father was dead. He was 65 years old at the time of death and his education

was up till F.A. He did single marriage. He was a soldier in the armed forces. His monthly

income was approximately fifty thousand. The client was very close to his father as compared

to his mother. No physical and psychological illness was reported in client’s father.

The client’s mother was alive. She was 60 years old and she was uneducated. She did

single marriage. She was a housewife. She was a nice, caring and humble woman. Her

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relationship with the client was very good as he is the youngest of her sons. No physical and

psychological illness was reported in client’s mother.

The client had 5 siblings i.e. 2 sisters and 3 brothers. On the first number was the

client’s brother, he was 37 years old. He is married. He studied till graduation. He did single

marriage he has two kids. He works currently in Saudi Arabia as a surveyor, though his wife

and kids live in Balakot with the rest of the family. He had very good relations with the client.

The client reported that after his father’s death, his brother was very kind to him. No physical

or psychological illness was reported in his brother.

On the second number was his brother, aged 32 years. He was unmarried. He studied till

F.A and was now an army soldier in Kuwait. His relationship with the client was very good.

Next was his brother on the third number. He died when he was 22 years old. The client

reported that he was mentally ill. The proper details of his psychological illness were unknown

as there was no psychiatry hospital where they lived One day he ran away from home and they

could not find him. His dead body was recovered from a park. The cause of death was

unknown. His relationship with the client was good.

Next was the client’s sister, aged 27 years. She completed her F.Sc. Next was the

client’s brother, he is 26 years old. He completed his education and has done B.com. He also

works currently in Saudi Arabia. He was also unmarried. He has taken a leave from work

because of the client’s condition. The client reported that as he and the client have very little

age difference, they are very close to each other. On the seventh number was the clients’

youngest sister. She is 23 years of age. She is unmarried. She has done F.A.

The client lived in joint family system. There were total 16 members in his family when

he was younger. Now there were only 7 members living at his home. He belonged to middle

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class. No financial problem was reported in his family. The authoritative figure in the family

was his father, but after the death of his father, it was his eldest brother. General home

atmosphere was religious and strict about discipline, the client reported that he loved being at

home and often got homesick when he was on duty.

PERSONAL HISTORY

Birth and Early Development

Client’s brother reported that client’s birth was normal. He was born at home. He

achieved all his developmental milestones at appropriate age. No neurotic traits like excessive

fears, stammering, sleep walking, bed wetting, temper tantrums, nail biting and thumb sucking

were reported. He was a friendly child and got along with children of his age group and older

children too.

Educational & Occupational History

The client started schooling at the age of 4 years of age. He was a good student. The

client reported that he was a position holder throughout his school years. Even though he was

not very much interested in studies but he always got a position. He liked playing cricket in

school. He won matches for his school. His brother told that he never had any problem in

studies and was an intelligent student. He respected his teachers. He was a friendly child. And

he makes many friends throughout his school years. He participated in extra-curricular

activities. He studied till metric in the same school. His friends were always welcome at home.

They spent time together and played cricket.

He did Metric in arts. But after completing Metric he fell in bad company. His new

friends were a bad influence on him. They lured him towards narcotics. He started smoking.

The client told that he smoked twice or thrice. But he did not continue his studies. His uncle

told him that the client was now eligible for army. As he did not have interest in studies he

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joined the army. His parents and siblings urged him to continue his studies but he joined the

army. The client reported that he pursued a career in army because he was impressed by his

father and uncle.

Social History

The client was a very gregarious person. He was a friendly, talkative and playful

person. He liked being social. He had many friends in school and even in his neighbors. He

was good friends with his unit mates. He trusted people very easily and made friends very

easily. He was always close to his siblings. He was even friends with his brother friends. He

became less social when his brother and father died.

PREMORBID PERSONALITY

The client reported that he was sensitive, emotional, friendly and social person. He was

very talkative. He offered his prayers regularly. He helped in daily chores around the house and

was also ready to help with the outside chores. He went to the market to buy the daily grocery.

He liked to watch television. He liked watching news and cricket. He also watched movies but

did not have interest in television dramas. He knew all the details of ever match Pakistan had

played. He was a caring and obedient son. He loved his family and was very much attached to

all of them. He liked to spend time with his siblings. He tried to do everything on his parents’

instructions. He loved his family. He shared his belongings with his siblings, mostly their

clothes and shoes and other belongings. The informant reported that he was one of those

children who keep the atmosphere at home friendly and lively, joking around and playful. He

was good at making friends. He was helpful towards others, his brother reported that he had

helped one of his friends study for Metric, and he passed with good grades after the clients’

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help. Now the client said that he wanted to pursue his education and complete his masters in

arts. He was hopeful about his future.

PSYCHOLOGICAL ASSESSMENT

Assessment was done on two levels:

3. Informal psychological assessment

4. Formal psychological assessment

INFORMAL PSYCHOLOGICAL ASSESSMENT

Mental status examination

Appearances and behavior

A 25 year old boy with normal height and weight, entered in the room with appropriate

gait. His self hygiene was maintained. His eye contact was proper. He behaved well. He was

cooperative while giving information. The client’s sitting posture was a little leaned forward.

Speech

The client’s rate of speech and tone was fast and was very talkative.

Mood

The client’s subjective and objective mood was euthymic.

Thought pattern

His thought process and content was fine as he was in recovery state. Depersonalization,

derealisation, delusion, illusion and hallucination were not found in the client... No self harm

thoughts and suicidal ideation was found in the client

Cognition:

Attention and concentration

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His attention and concentration was below average as some questions had to be asked twice for

him to answer.

Memory

The client’s memory was intact. His recent, remote and recent past memory were good, except

for the time spent with the religious group

Abstract thinking

His abstract thinking was average

Orientation

He was fully oriented to time, place and person

Judgement

His judgement was good.

Insight

He had good insight of his problem and was hopeful that he could go back to normal life.

Behavior symptom rating

These are the symptom ratings by client and informant (0-10) from lowest to highest:

Sr. No. Symptoms Client’s

rating

1 Complaints of excessive and 1

irresistible thoughts and

images

2 Compulsions of hand 2

washing/bathing

3 Appetite disturbances 1

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4 Restlessness 1

5 Inability to concentrate 2

6 Disturbance in daily routine 1

7 Disturbed sleep 2

_______________________________________________________________________

FORMAL PSYCHOLOGICAL ASSESSMENT

The client’s formal psychological assessment was done on following level:

Diagnostic Screening Assessment

 Symptom Checklist- R

 YALE-BROWN OBSESSIVE COMPULSIVE SCALE (Y-BOCS)

 Beck anxiety inventory (BAI)

DIAGNOSTIC ASSESSMENT

SYMPTOM CHECKLIST-R

The Symptom Checklist-R (SCL-R) is a relatively brief self-report psychometric

instrument (questionnaire) published by the Clinical Assessment division of the Pearson

Assessment & Information group. It is designed to evaluate a broad range of psychological

problems and symptoms of psychopathology. It is also used in measuring the progress and

outcome of psychiatric and psychological treatments or for research purposes.

According to the overview given by the publisher, the SCL-R is normed on individuals 13

years and older. It consists of 141 items and takes 12–15 minutes to administer, yielding nine

scores along primary symptom dimensions and three scores among global distress indices. The

primary symptom dimensions that are assessed are Somatoform, obsessive-

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compulsive, depression, anxiety, LFT, Schizophrenia. It is one of the most widely used

measures of psychological distress in clinical practice and research (wiki-SCL-R).

Subscales cutoff

Scale 1 Depression 27

Scale 2 Somatoform 28

Scale 3 Anxiety 39

Scale 4 OCD 14

Scale 5 LFT 34

Scale 6 Schizophrenia 11

Quantitative Analysis

Total Score cutoff

Scale 1 Depression 20 27

Scale 2 Somatoform 22 28

Scale 3 Anxiety 56 39

Scale 4 OCD 35 14

Scale 5 LFT 31 34

Scale 6 Schizophrenia 10 11

Qualitative Analysis

The scores on symptom checklist show the elevation on Anxiety and OCD subscales.

YALE-BROWN OBSESSIVE COMPULSIVE SCALE (Y-BOCS)

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The Yale–Brown Obsessive Compulsive Scale, sometimes referred to as Y-BOCS, is a

test to rate the severity of obsessive–compulsive disorder (OCD) symptoms.The scale, which

was designed by Wayne Goodman and his colleagues, is used extensively in research and

clinical practice to both determine severity of OCD and to monitor improvement during

treatment. This scale, which measures obsessions separately from compulsions, specifically

measures the severity of symptoms of obsessive–compulsive disorder without

being biased towards the type of content of obsessions or compulsions present. (wiki-YBOCS).

The scale is a clinician-rated, 10-item scale, each item rated from 0 (no symptoms) to 4

(extreme symptoms), yielding a total possible score range from 0 to 40. The scale includes

questions about the amount of time the patient spends on obsessions, how much impairment

or distress they experience, and how much resistance and control they have over these thoughts.

The same types of questions are asked about compulsions (e.g., time spent, interference, etc.) as

well. The results can be interpreted based on the total score:

 0–7 is sub-clinical;

 8–15 is mild;

 16–23 is moderate;

 24–31 is severe;

 32–40 is extreme.

Patients scoring in the mild range or higher are likely experiencing a significant negative

impact on their quality of life and should consider professional help in alleviating obsessive–

compulsive symptoms

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Test Administration

Y-BOCS was administered on client. It was administered in a well-lit and ventilated

room of SHL. There was a little bit distraction in room. Instructions were given to the client

according to the manual. The client was informed and explained the instructions twice. But

once he understood he completed the test easily. The client was allowed to work through the

whole test at his own pace. The client took 5 to 10 minutes to complete the test.

Quantitative Analysis

Total Score Ranges Remarks

Obsessional Subscale 9 8-15 mild to moderate

clinical

Compulsions Subscale 10 8-15 Mild to moderate

clinical

Full Scale 19 8-23 Mild to moderate

clinical

Qualitative Analysis

The client obtained a total raw score of 19 which shows the mild to moderate level of

obsessive compulsive disorder. It indicates that the client falls on mild to moderate level of the

disorder. The distribution of the scores is on the two sets. First 5 item based on obsession. The

maximum score in obsession is 20. The client obtained the 9 score in obsessive items portion

which shows mild to moderate level of obsession. The second set based on compulsive items.

The last 5 items based on compulsions. The maximum score in compulsion is 20. The client

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obtained 10 score in compulsion items portion which shows the mild to moderate level of

compulsion. Total score of subscales is used for check the severity of symptom. The highest

score on total score is 40. The client obtained 19 score which shows that the client is suffering

from mild to moderate level of obsessive compulsive disorder.

Discussion

The client’ result on Y-BOCS indicates that he is at the mild to moderate level of

obsessive compulsive disorder. The result of the test can be considered reliable as it correlates

with the client’s symptoms and informant's information. The client falls in the category of mild

to moderate level in subset of obsession and compulsion.

Beck Anxiety Inventory (BAI)

Test Administration

BAI was administered on client on December 14. It was administered in a well-lit and

ventilated room of SHL. There was a little bit distraction in room. Instructions were given to

the client according to the manual. When it appeared that the client had thoroughly understood

the instructions, the test was started. The client was allowed to work through the whole test at

his own pace. The client took 20 minutes to complete the test because the test was in English

and had to be translated and explained for him to answer.

Quantitative Analysis

Total Score Range Category

obtained

13 08-15 Mild Anxiety

Qualitative Analysis

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The client’s result on BAI results shows that the client had mild level of anxiety. The

client obtained raw score of 13 which fall in the range of 08-15 it indicates that the client is

suffering from mild level of anxiety.

Discussion

The client’s result on BAI indicates that he is suffering from mild anxiety. The result

was based on the last two weeks up till the date of the test administered. The client was on the

recovery stage as the symptoms had reduced a great deal. The result of BAI can be considered

reliable as it correlates with the client’s condition.

TENTATIVE DIAGNOSIS ACCORDING TO DSM-V

300.3 (F42)Obsessive-Compulsive Disorder

Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time

during the disturbance, as intrusive and unwanted, and that in most individuals cause

marked anxiety or distress.

2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to

neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g.,

praying, counting, repeating words silently) that the individual feels driven to perform

in response to an obsession or according to rules that must be applied rigidly.

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2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or

preventing some dreaded event or situation; however, these behaviors or mental acts

are not connected in a realistic way with what they are designed to neutralize or

prevent, or are clearly excessive.

CASE FORMULATION

The client was 25 years old unmarried male. He visited SHL with the complaints of

excessive and irresistible thoughts and images, compulsions of hand washing and bathing,

restlessness, inability to concentrate, disturbed sleep, disturbed appetite and disturbance in daily

routine from last six to seven months. The client lived in joint family system. There were 10

family members in client’s family. All family members loved the client. They showed care and

attention towards client. The client belonged to a middle class and a moderate religious family.

His father had died four years back. The client had 6 siblings i.e. 4 brothers (1 dead) and 2

sisters. The client had good relationship with all his family members. The client was dressed up

adequately in neat and clean shalwar kameez. His hair was combed. The client appeared to be

of normal height that is 5’7. He was of normal physique, neither too skinny nor too fat. He

appeared to be consistent with his reported chronological age that is 25 years. His speech rate

and volume was normal and no word finding difficulties in pronunciation were noted. He was

fully oriented to person, place, time and situation throughout the testing. His eye contact was

good and normal. No hallucinations and delusions were found in the client. His attention and

concentration was fine. At first he was a bit hesitant but after rapport building he answered all

the questions without hesitation. His memory and abstract thinking was good. He had insight of

his problem and was hopeful that he’d be better and wanted to continue his studies. He was also

aware of the fact that he had been fired from the army. He reported that this caused him distress

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in the beginning but now he was positive that he would get a better job once he completes his

studies.

Both formal and informal assessments were carried out to assess the client. Case

histories, clinical interview, MSE (Mental State Examination), Y-BOCS (Yale brown

Obsessive Compulsive Scale), BAI(Beck anxiety inventory), and Symptom checklist-R were

administered to assess the functioning and range of disorder of client.

Sigmund Freud theorized that OCD symptoms were caused by punitive, rigid toilet-

training practices that led to internalized conflicts. Other theorists thought that OCD was

influenced by such wider cultural attitudes as insistence on cleanliness and neatness, as well as

by the attitudes and parenting style of the patient's parents. Psychoanalytical theory explains

obsessions and compulsions are viewed as similar, resulting from instinctual forces, sexual or

aggressive, that are not under control because of overly harsh toilet training. The person is thus

fixed at the anal stage (Carson, 2001). The client’s father was strict about discipline and

cleanliness.

There are environmental factors that can trigger the disorder in individuals

psychologically prone for OCD. Some of these symptoms include: abuse; changes in living

situations; illness; death of a loved person; relationship concerns. Here the client’s symptoms

were triggered when he spent time with the religious people and they blamed him that he had

blown up a mosque which he knew was a great sin. The predisposing factors were the death of

his brother and then the demise of his father.

It is now clear that OCD is characterized by a number of errors in thinking or so-called

cognitive distortions that can potentially lead to obsessions and compulsions. Although OCD is

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complex illness with many causes and risk-factors, understanding the psychological factors that

cause and maintain OCD symptoms such as cognitive distortions is essential. The client was on

the road to recovery.

MANAGEMENT PLAN

To eliminate obsessions and compulsions these therapies will be used:

7. Psycho-education

8. Behavioral Therapy

 Deep Breathing

 Activity Scheduling

 Thought Stopping and Covert Assertion

 Exposure and Response Prevention (ERP)

 Distraction Technique

9. Cognitive Therapy

10. Rational Emotive Behavior Therapy

 ABC Model

 Disputing

11. Cognitive Homework

12. Cognitive Behavioral Therapy (CBT)

SHORT TERM GOALS

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 Psycho-education will be used to give awareness about the illness, its causes, course

mode of treatment and role in the treatment to client and his family.

 Thought stopping technique will be implemented that will cognitively interferes with

obsessions by thinking of a stop sign and then a pleasant scene to interrupt obsessions.

 After thought stopping will be completed, covert assertion will be helpful to control the

behavior and maintain the effect and to strengthen the behavior.

 The client will be assisted in adopting coping strategies through involving him in

domestic affairs and social gatherings. Activity scheduling pleasure and mastery chart

will be organized for this purpose.

 Techniques of complete exposure will be introduced for reducing anxiety and giving

awareness how it falls down. He will be engaged in activities like watching T.V.,

calling a friend, walk etc.

 Relaxation methods will be used that are deep breathing, muscle tension and positive

imagery to counter-act high anxiety.

 REBT will be used to identify the irrational beliefs.

 Therapist will help the client in identifying his life goals, with his consent, an activity

schedule will be developed, which he has to follow at the best of his capabilities.

 ABC Model will be used to help the client to understand the healthy and unhealthy

ways of thinking and importance of healthy ways of thinking.

 Distorted thinking and belief errors will be identified and replaced. For reducing their

impact the client will be asked to complete exercises in daily functioning that focus on

cost benefit analysis and distorted thinking.

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LONG TERM GOALS

 Therapist will motivate the client to resolve key life conflicts and the emotional stress

that fuels obsessive compulsive patterns.

 The client will be asked to function daily at a consistent level with minimal interference

from obsessions and compulsions.

 The client will be helped in achieving controlled behavior, moderated mood, and more

deliberative speech and thought process through psychotherapy.

LIMITATIONS AND SUGGESTIONS

The limitations are as following:

 This case study is only for academic purposes, so time was very short for gathering all

information.

 Time period for building rapport with the client was very short.

 There was a little bit distraction in the room.

The suggestions are as follows:

 Time period for case study should be extended.

 Environment should be peaceful for good case study.

 Family should be educated to treat the patient in good manner.

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