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Case Report 1

Sana Hussain

Department of Psychology, Forman Christian College University

PSYC: Adult Placement

21st December, 2022

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Summary

A 20 year old male approached out patient department of Jinnah Hospital to seek

treatment of his presenting complaints about having excessive distressing thoughts about

sexually abusing females that he saw in a movie or in reality. The client was prescribed

medication first by the consultant psychiatrist, then he was seen by senior clinical psychologist

for the presenting complaints and referred to trainee clinical psychologist for assessment and

management of the symptoms. The client was diagnosed with OCD as revealed by the

comprehensive assessment carried out. Assessment revealed that the client suffered from two

types of obsessions, intrusive thoughts with sexual content and that of harm or killing another

person while compulsion was self-reassurance. With respect to severity, Y-BOCS revealed a

total score of 21 which falls within the range of 19-23 specified for moderate level ocd.

Moreover, a number of techniques were used across 8 sessions where the client was psycho

educated about ocd, normalization techniques was used. Core beliefs were elicited using the

vertical descent technique. Furthermore, suppression experiment, detached mindfulness,

restructuring and exposure and response prevention were used.

Demographic data

Name: WQ

Gender: M

Age: 20

No of siblings: 4

Birth order: 2nd

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Marital Status: Single

Education: MBBS 1st year

Religion: Islam

Reasons for Referral

WQ was referred to trainee clinical psychologist at Jinnah Hospital for psychological

assessment and management for presenting complaints of having thoughts about sexually

abusing other, and harming or killing other with a knife or gun.

Presenting Complaints

Symptoms Duration

When I look at a girl by mistake I have 1 year

thoughts about sexually abusing her

When I watch somebody being killed in a movie 1 year

, I feel I have also killed someone.

History of present illness:

Clients problem began in 2019. WQ reported that towards the beginning of fsc while

taking class one day, suddenly a thought came to his mind that how do people understand urdu

language and how do we communicate. Also the client reported that he realized the thought was

not relevant but it began to cause distress and extreme fear which was exhibited by increased

heart rate and confusion. The intense fear persisted for the entire class which lasted for one and a
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half hour. The distress was slightly reduced when next class started but it was causing anxiety off

and on that day. However, the next day, there was no distress experienced due to similar thought.

Moreover, WQ reported that through out his fsc, he experienced sudden thoughts which caused

anxiety for instance, while studying chemistry thoughts about different chemicals reacting and

causing explosions would come to his mind which would intensify as he would think about those

thoughts and his fear would aggravate gradually. Also WQ reported that in order to subside the

fear and anxiety resulting from this thought, he would repeatedly convince himself that the

chemicals will not cause explosion because they are frequently used together in a number of

products and medicines. The medicines don’t explode so thinking about these thoughts is not

important. At this stage, the obsessions client had were controllable reportedly and the content of

obsessions was mostly related to study. However, a progression in the symptoms was

experienced when WQ was in second year of Fsc and a male servant at home tried to convince

WQ to have sexual relationship with him while offering him a specific amount of money upon

which WQ was afraid feeling worried and refused saying that he will inform his parents. This

was the first time that WQ began to have persistent thoughts about sexually assaulting females

that he watched on television or around himself for instance, in university. Also, bodily changes

were experienced when these thoughts occurred for instance, erection in the male reproductive

organ. Moreover, these thoughts were experienced as anxiety arousing. Also, WQ learnt a

mechanism to subside his anxiety by convincing himself that he had not sexually assaulted any

female.

Furthermore, upon completion of fsc, one day WQ was out with his friends for swimming

where one of his friends tried to sexually abuse him after rest of the friends were gone. WQ was

afraid and expressed his anger over advancements made by his friend. However, his friend got
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aggressive and got hold of WQ but he escaped by physically attacking his friend, beating him up

and verbally abusing him. This event further added to the distress and preoccupation with

intrusive thoughts which persisted for hours and sometimes most of the day. Further, WQ

reported that eventually, he experienced persistent thoughts about harming others with a knife or

gun each time he watched a movie which included serial killing. Thoughts about harming others

caused anxiety as well. WQ used similar mechanism of convincing himself that he has harmed

no one. Other mechanisms he used in order to relief his anxiety was to avoid watching movies so

that he does not experience thoughts about harming others or sexually abusing others. Also

maintaining eye contact with females was avoided according to client’s report.

By this time, most of the recurrent distressing thoughts which WQ experienced were

sexual in nature and related to harm only. WQ lived with this condition without any treatment for

almost two and a half years. It was recently that WQ realized that he should seek therapy because

his thoughts were becoming out of control and excessive due to which he visited the hospital.

Past Psychiatric History

Past psychiatric history was unremarkable

Past Medical History

The client had no past or current medical illness

Current Medication

The client was prescribed two medicines Olan and Galaxy by consultant psychiatrist

Family History
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Father

Father was 44, educated till masters in political science and was owning a school.

Temperamentally father was very strict about rules regulations and academics. He wanted his

children to be perfect and competent. Furthermore, he could not tolerate mistakes his children

made in academics even if the mistakes were minor. He would punish WQ physically for not

earning desired grades. Generally, father’s relationship with WQ was not congenial. Reportedly

WQ would suffer humiliation at the hands of his father in front of outsiders as well. Moreover,

presence of father at home threatened WQ. He would stay most of the time in his room so that he

does not interact with him much. As his father, reportedly induced guilt in WQ regarding studies.

Mother

Mother was 46, educated till matric and currently a house maker. Temperamentally she

was a calm person and never scolded WQ for his academic performance. She used to correct his

mistakes by being very polite with him. WQ reported that he felt very secure in his mother’s

presence. He had congenial relationship with her and in case of any suggestion, he preferred

approaching his mother for instance, if he needed money, he asked his mother to fulfill his need

instead of directly consulting his father.

Siblings

WQ had two brothers and one sister. The eldest of all siblings was a 21-year-old brother

who was studying BS biochemistry. Temperamentally eldest brother was very supportive and

caring. His relationship with WQ was congenial. Younger brother was 17 years and was student

of first year ICS. Younger brother was the favourite child of his father. Also relationship of WQ

was not congenial with younger brother because he thought WQ was good for nothing and that
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he would not be a successful person in life. The youngest of all was 12 years old sister who was

in grade six. She was very loving and nice to everybody else at home. WQ shared congenial

relationship with her.

General Home Environment

The client lived in a nuclear family system. The general home environment was

experienced by the client as calm but in father’s presence WQ experienced fear that he might get

scolded any time. As client’s relationship with father was distant, home environment threatened

WQ only in father’s presence. Otherwise, support and nurturance from others at home was

sufficient making home environment favorable.

Birth and early childhood history

WQ was born through normal delivery and no birth complications infections or illnesses

were experienced by the client or his mother. Moreover, WQ achieved all milestones age

appropriately.

Educational History

The client started going to school at the age of 5. He was a hardworking student but he

did not have aptitude for technical subjects like maths, physics due to which he would easily lose

marks in these courses. Moreover, with respect to relationships with friends, WQ had many

friends at school and had congenial relationship with them. Furthermore, relationship with

teachers was reportedly congenial except for maths teacher as she was very strict and punished

WQ in almost every class for having weak mathematical skills. At college, WQ also had many

friends with whom he shared congenial relationship. This time his relations with teachers were
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also congenial. However, towards the end of Fsc, his relationship with one friend was ended

since he tried to disgrace WQ.

Sexual History

The client entered puberty at the age of 14. First hand information about puberty was

achieved through friend circle. Further, client reported that information regarding sexual

relationships was also obtained through friends when WQ was 12 years old. Furthermore, one of

his friends also tried to sexually abuse WQ but his attempt was not successful reportedly. Also, a

male servant tried to sexually abuse WQ who was not successful in his attempt either. Moreover,

with respect to masturbation, WQ reported to have heard benefits of masturbating for males from

his fellows at the age of 14 due to which he attempted it. The client reported to continue

masturbating occasionally to relieve stress.

Pre-morbid Personality

According to client’s report, the client was sensitive person who got offended quickly. He could

not handle jokes from fellows and friends which were considered humorous by others.

Moreover, he was hardworking and put effort in almost everything he did because his father was

strict and expected hard work from WQ. Also, the client reported to be secretive meaning he

would not open up very quickly with others. He was cautious and always observed other person

before choosing to share secrets with that person. Furthermore, WQ reported himself to be

introverted. Although he had friends, but he did not engage with them actively all the time, for

instance, if his friends would go somewhere WQ would not always join them in their gatherings.

He enjoyed his personal space at times more than engaging with others. WQ also reported to

have low confidence due to which he would avoid class participation because he feared being
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evaluated by others and that he might make mistakes. Moreover, WQ enjoyed watching south

Indian movies in leisure time but after his illness he gave up watching movies.

Psychological Assessment

Both informal and formal assessment was conducted

Table 1.2 Informal and Formal Assessment

Informal Assessment Formal Assessment

Clinical Interview Yale Brown obsessive compulsive scale

(Y-BOCS; Godman, Price, Rasmussen, Mazure, Delgado, et

al., 1989)

:Mental Status Examination

Subjective Rating

Dysfunctional Thought Record

1. Clinical interview

In depth clinical interview was conducted with the client which helped identify

the logical errors in thinking for instance, WQ made a cognitive error of thought action

fusion. Similarly, exploring different areas of life related to daily functioning of a client

help give a clearer picture of client’s symptom which assist in accuracy of diagnosis.

2. Mental Status Examination

Mental Status was done to assess current level of cognitive and behavioural

functioning of the client. The physical stature of the client was consistent with his age. He

neither looked too young nor too old from his age. He was dressed properly but could not
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maintain eye contact. He would look up for a second and shift his eyes to other side. His

speech was appropriate but seemed confused sometimes. He became anxious while

sharing his history. He seemed restless most of the times. However, his perception,

attention and concentration was appropriate his recent and remote memory was intact.

Client was alert during the session. He was fully oriented to time, place and person. No

delusions or hallucinations were reported by the client. There was no depersonalization

and derealization present in the client. Insight was present.

3. Subjective rating

Severity of presenting complaints was assessed on 10 point scale according to

intensity by the client to have pre treatment ratings so that comparison can be made with

post treatment ratings which ensures effectiveness of therapy

Table 1.3

Pre treatment Rating of Presenting Complaints on a 10 point Scale by the Client

Problem Area Pre Treatment Rating

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Recurrent thoughts of sexually assaulting 7

female watched on tv or in person

8
Recurrent thoughts of harming others with
with a gun or knife

Anxiety/ Distress 10
Self reassurance 10

Formal Assessment

Yale Brown Obsessive Compulsive Scale

Table 2

Results of Y-Bocs Symptoms Checklist and Severity

Rating
Level Obsessions Compulsions Y-BOCS Total Category

Sub total Sub total

Pre- Assessment 9 12 21 moderate

Diagnosis

300.3(F42) Obsessive Compulsive Disorder with fair Insight

Management Plan

Short Term Goals Therapeutic Intervention

To educate the client about the illness and its Psychoeducation

possible outcome
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Idiosyncratic case conceptualization

to introduce cognitive behavioural (Wells,2009)

conceptualization of OCD to the client To
elicit dysfunctional thoughts and identify Vertical descent (Leahy, 2017)
core beliefs

Suppression Experiment (Leahy, 2017)

To make client aware that suppressing thoughts
result in increasing ocd thoughts

Dysfunctional Thought Record DTR (Wells,

To increase clients ability to differentiate 2009)

between types of thoughts and provide
awareness to focus on worry about thought
rather that thought itself

Detached Mindfulness (Wells, 2009)

To reduce distress by passively let go of
intrusions and without engaging in the
intrusions

Verbal Reattribution (Wells, 2009)

To challenge specific beliefs about intrusions
and replace them with more adaptive ones

To reduce rituals and challenge clients beliefs Restructuring

for not doing rituals
Exposure and Response Prevention ERP

(Wells,1997)

Case Conceptualization (Wells,2009)

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Situation

a. Saw a girl

b. watching someone harming or killing other person in movie

Intrusion

a. Thinking about sexually abusing girl

b. Thinking about harming other person with knife

Metacognitive Beliefs

a. Am I a rapist?

If I don’t look at girls I will be okay

b. Am I bad person that I have thoughts about stabbing other person?

If I don’t watch movies I will not have thoughts of harming others

Safety Behaviour Emotions

Self reassurance Anxiety

Not making eye contact with females Worry

Not watching movies

Sessions Report
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1st session

Clinical interview was conducted with the client. The therapist adopted active listening

and positive regard so that the client feels comfortable when providing information. Moreover,

presenting complaints and history of present illness was obtained.

2nd session

Yale brown obsessive compulsive scale was administered. Both categories and severity of

obsessions and compulsions were identified. A list of situations was generated by the client

which resulted in obsessions and compulsions. Client also rated distress level for each situation.

Dysfunctional thought record was given for homework

3rd session

DTR was reviewed with client also vertical descent technique was used to elicit core

beliefs. Client was also given information about obsessions and compulsions through case

conceptualization. He was explained how ocd symptoms were interacting and causing distress

and dysfunction. Moreover, client was told that research findings have proved that 90 to 95

percent of non symptomatic people can experience intrusive thoughts at some point of time in

life. This was done to normalize the client. Also client was given a short assignment to ask few

people if they have ever had thoughts about killing someone or other ocd thoughts. The mini

survey was conducted to invalidate client’s claim that intrusive thoughts is an unusual

phenomenon occurring to few people only. Also client was told about the reason why not all

people having intrusions are affected by it. Further more, suppression experiment was conducted

by asking the client to not think about pink elephant and raise his hand each time thought about
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pink elephant came to his mind. The experiment was helpful in that it taught the client that

suppressing thoughts led to progression in thoughts

4th session

Detached mindfulness was taught to the client to make obsessions meaningless so that

there is no need to perform compulsions. Client was taught to become an outside observer of

thoughts arising in his mind. The client was told to think about ocd thought like a train waiting

on the station and the client is also standing near that train. Unless he chooses to sit in that train,

he cannot be forced to sit in it and after sometime, the train will eventually pass the station.

Another technique taught to the client was to listen to ocd thoughts in voice of his favourite

cartoon character.

Client enjoyed the cartoon character voice technique and learnt the techniques for practicing at

home.

5th session

Feedback on homework was taken. Detached mindfulness helped somewhat according to

client’s report. Further self-coping statement was taught to the client to use in conjunction with

detached mindfulness. “This ocd thought cannot cause harm, just let it go” was the statement

learnt by the client. Moreover, another technique for delaying worry was taught to the client.

Client was asked to set a time in 24 hours for thinking about ocd thoughts for instance 7 o clock

in evening for 15 min. Each time ocd thought came in his mind, WQ recalled himself to think
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about it at 7. Eventually when time reached 7, WQ reported that he never felt the need to recall

ocd thought and think about it for 15 minutes.

6th session

Feedback on homework was taken. Client reported that delaying worry was effective as it

prevented worrying about intrusions. Restructuring was done for ritual self reassurance

behaviour. Cost and benefit analysis was done and the benefit that client wrote about the ritual

was challenged which helped the client recognize that rituals don’t prevent harm. No harm will

occur if ritual is not performed.

7th session

Feedback on homework was given. Client reported that he watched one movie without

having intrusions about sexually assaulting the female in the movie.To bring about maximum

improvement, written exposure was conducted for which consent of the client was obtained first.

In written exposure the client was asked to write down ocd thought repeatedly while saying it

aloud in order to prevent self reassurance behaviour of the client which served as a compulsion.

Also the client mentioned distress level for every 10th time he wrote the compulsion.repetition

was aimed at habituating the client with that thought so that it begins to seem less significant.

Client reported it to be very helpful.

8th session

Post assessment was conducted to compare improvement achieved. Relapse prevention

was discussed with client

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9th session

Therapy blueprint was provided.

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References

Leahy, R. L. (2017). Cognitive therapy techniques: A practitioner's guide. Guilford Publications.

Fisher, P., & Wells, A. (2009). Metacognitive therapy: Distinctive features. Routledge.

Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., ...

& Charney, D. S. (1989). The Yale-Brown obsessive compulsive scale: I. Development,

use, and reliability. Archives of general psychiatry, 46(11), 1006-1011.

doi:10.1001/archpsyc.1989.01810110048007