case study of ocd

• Presidential Message
• Nominations/Elections
• Past Presidents
• Member Spotlight
• Fellow List
• Fellowship Nominations
• Current Awardees
• Award Nominations
• SCP Mentoring Program
• SCP Book Club
• Pub Fee & Certificate Purchases
• LEAD Program
• Introduction
• Find a Treatment
• Submit Proposal
• Dissemination and Implementation
• Diversity Resources
• Graduate School Applicants
• Student Resources
• Early Career Resources
• Principles for Training in Evidence-Based Psychology
• Advances in Psychotherapy
• Announcements
• Submit Blog
• Student Blog
• The Clinical Psychologist
• CP:SP Journal
• APA Convention
• SCP Conference

CASE STUDY John (obsessive-compulsive disorder)

Case study details.

John is a 56-year-old man who presents to you for treatment. His symptoms started slowly; he tells you that he was always described as an anxious person and remembers being worried about a lot of things throughout his life. For instance, he reported he was very afraid he’d contract HIV by touching doorknobs, even though he tells you he knew this was “irrational.” He tells you that about 10 years ago, following a few life stressors, his anxiety and intrusive thoughts worsened significantly. He tells you he began washing his hands excessively. He reports he developed an intense fear that someone would break into the house and it would be his fault because he left something unlocked. He states that this fear led him to repeatedly check doors and windows before sleep in a specific order, which was a source of contention with his wife. He says that his fear of making a mistake also leads him to be slow to turn in work for his job, checking many times to make sure there are no mistakes, for which he gets reprimanded on occasion.

John reports that his symptoms are getting worse, which is why he has sought treatment. For example, currently he washes his hands until he finishes the whole soap bar, and his hands are cracked because they are so dry. He says he continues to check the doors and windows of his house numerous times throughout the day, not just at night, and has on occasion driven home from work to be sure everything truly was locked. If he notices even a speck of dust on the floor, he states he has the urge to clean the whole house and he often complies with that urge.

John expresses significant distress over these symptoms, as they are taking up more of his time and robbing him of his confidence, as he is increasingly distracted at work and in his family life.

• Compulsions
• Concentration Difficulties
• Intrusive Thoughts
• Ruminations

Diagnoses and Related Treatments

1. obsessive-compulsive disorder.

Thank you for supporting the Society of Clinical Psychology. To enhance our membership benefits, we are requesting that members fill out their profile in full. This will help the Division to gather appropriate data to provide you with the best benefits. You will be able to access all other areas of the website, once your profile is submitted. Thank you and please feel free to email the Central Office at  [email protected] if you have any questions

• Case report
• Open access
• Published: 11 July 2020

Obsessive compulsive disorder in very young children – a case series from a specialized outpatient clinic

• Veronika Brezinka   ORCID: orcid.org/0000-0003-2192-3093 1 ,
• Veronika Mailänder 1 &
• Susanne Walitza 1  

BMC Psychiatry volume  20 , Article number:  366 ( 2020 ) Cite this article

24k Accesses

5 Citations

1 Altmetric

Metrics details

Paediatric obsessive-compulsive disorder (OCD) is a chronic condition often associated with severe disruptions of family functioning, impairment of peer relationships and academic performance. Mean age of onset of juvenile OCD is 10.3 years; however, reports on young children with OCD show that the disorder can manifest itself at an earlier age. Both an earlier age of onset and a longer duration of illness have been associated with increased persistence of OCD. There seems to be difficulty for health professionals to recognize and diagnose OCD in young children appropriately, which in turn may prolong the interval between help seeking and receiving an adequate diagnosis and treatment. The objective of this study is to enhance knowledge about the clinical presentation, diagnosis and possible treatment of OCD in very young children.

Case presentation

We describe a prospective 6 month follow-up of five cases of OCD in very young children (between 4 and 5 years old). At the moment of first presentation, all children were so severely impaired that attendance of compulsory Kindergarten was uncertain. Parents were deeply involved in accommodating their child’s rituals. Because of the children’s young age, medication was not indicated. Therefore, a minimal CBT intervention for parents was offered, mainly focusing on reducing family accommodation. Parents were asked to bring video tapes of critical situations that were watched together. They were coached to reduce family accommodation for OCD, while enhancing praise and reward for adequate behaviors of the child. CY-BOCS scores at the beginning and after 3 months show an impressive decline in OCD severity that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child was admitted to the next level / class.

Conclusions

Disseminating knowledge about the clinical presentation, diagnosis and treatment of early OCD may shorten the long delay between first OCD symptoms and disease-specific treatment that is reported as main predictor for persistent OCD.

Peer Review reports

Paediatric obsessive compulsive disorder [ 1 ] is a chronic condition with lifetime prevalence estimates ranging from 0.25 [ 2 ] to 2–3% [ 3 ]. OCD is often associated with severe disruptions of family functioning [ 4 ] and impairment of peer relationships as well as academic performance [ 5 ]. Mean age of onset of early onset OCD is 10.3 years, with a range from 7.5 to 12.5 years [ 6 ] or at an average of 11 years [ 7 ]. However, OCD can manifest itself also at a very early age - in a sample of 58 children, mean age of onset was 4.95 years [ 8 ], and in a study from Turkey, OCD is described in children as young as two and a half years [ 9 ]. According to different epidemiological surveys the prevalence of subclinical OC syndromes was estimated between 7 and 25%, and already very common at the age of 11 years [ 10 ].

Understanding the phenomenology of OCD in young children is important because both an earlier age of onset and a longer duration of illness have been associated with increased persistence of OCD [ 11 , 12 , 13 ]. One of the main predictors for persistent OCD is duration of illness at assessment, which underlines that early recognition and treatment of the disorder are crucial to prevent chronicity [ 10 , 14 , 15 ]. OCD in very young children can be so severe that it has to be treated in an inpatient-clinic [ 16 ]. This might be prevented if the disorder were diagnosed and treated earlier.

In order to disseminate knowledge about early childhood OCD, detailed descriptions of its phenomenology are necessary to enable clinicians to recognize and assess the disorder in time. Yet, studies on this young population are scarce and differ in the definition of what is described as ‘very young’. For example, 292 treatment seeking youth with OCD were divided into a younger group (3–9 years old) and an older group (10–18 years old) [ 17 ]. While overall OCD severity did not differ between groups, younger children exhibited poorer insight, increased incidence of hoarding compulsions, and higher rates of separation anxiety and social fears than older youth. It is not clear how many very young children (between 3 and 5 years old) were included in this study. Skriner et al. [ 18 ] investigated characteristics of 127 young children (from 5 to 8) enrolled in a pilot sample of the POTS Jr. Study. These young children revealed moderate to severe OCD symptoms, high levels of impairment and significant comorbidity, providing further evidence that symptom severity in young children with OCD is similar to that observed in older samples. To our knowledge, the only European studies describing OCD in very young children on a detailed, phenotypic level are a single-case study of a 4 year old girl [ 16 ] and a report from Turkey on 25 children under 6 years with OCD [ 9 ]. Subjects were fifteen boys and ten girls between 2 and 5 years old. Mean age of onset of OCD symptoms was 3 years, with some OCD symptoms appearing as early as 18 months of age. All subjects had at least one comorbid disorder; the most frequent comorbidity was an anxiety disorder, and boys exhibited more comorbid diagnoses than girls. In 68% of the subjects, at least one parent received a lifetime OCD diagnosis. The study reports no further information on follow-up or treatment of these young patients.

In comparison to other mental disorders, duration of untreated illness in obsessive compulsive disorder is one of the longest [ 19 ]. One reason may be that obsessive-compulsive symptoms in young children are mistaken as a normal developmental phase [ 20 ]. Parents as well as professionals not experienced with OCD may tend to ‘watch and wait’ instead of asking for referral to a specialist, thus contributing to the long delay between symptom onset and assessment / treatment [ 10 ]. This might ameliorate if health professionals become more familiar with the clinical presentation, diagnosis and treatment of the disorder in the very young. The purpose of this study is to provide a detailed description of the clinical presentation, diagnosis and treatment of OCD in five very young children.

We describe a prospective 6 month follow-up of five cases of OCD in very young children (between 4 and 5 years old) who were referred to the OCD Outpatient Treatment Unit of a Psychiatric University Hospital. Three patients were directly referred by their parents, one by the paediatrician and one by another specialist. Parents and child were offered a first session within 1 week of referral. An experienced clinician (V.B.) globally assessed comorbidity, intelligence and functioning, and a CY-BOCS was administered with the parents.

Instruments

To assess OCD severity in youth, the Children Yale-Brown Obsessive Compulsive Scale CY-BOCS [ 21 ] is regarded as the gold standard, with excellent inter-rater and test-retest reliability as well as construct validity [ 21 , 22 ]. The CY-BOCS has been validated in very young children by obtaining information from the parent. As in the clinical interview Y-BOCS for adults, severity of obsessions and compulsions are assessed separately. If both obsessions and compulsions are reported, a score of 16 is regarded as the cut-off for clinically meaningful OCD. If only compulsions are reported, Lewin et al. [ 23 ] suggest a cut-off score of 8. In their CY-BOCS classification, a score between 5 and 13 corresponds to mild symptoms / little functional impairment or a Clinical Global Impression Severity (CGI-S) of 2. A score between 14 and 24 corresponds to moderate symptoms / functioning with effort or a CGI-S of 3. Generally, it is recommended to obtain information from both child and parents. However, in case of the very young patients presented here, CY-BOCS scores were exclusively obtained from the parents. The parents of all five children reported not being familiar with any obsessions their child might have. In accordance with previous recommendations [ 23 ], a cut-off point of 8 for clinically meaningful OCD was used.

Patient vignettes

Patient 1 is a 4 year old girl, a single child living with both parents. She had never been separated an entire day from her mother. At the nursery, she suffered from separation anxiety for months. Parents reported that the girl had insisted on rituals already at the age of two. In the evening, she ‚had‘ to take her toys into bed and had got up several times crying because she ‚had to‘ pick up more toys. In the morning, only she ‚had the right‘ to open the apartment door. When dressing in the morning, she ‚had‘ to be ready before the parents. Only she was allowed to flush the toilet, even if it concerned toilet use of the parents. Moreover, only she ‘had the right’ to switch on the light, and this had to be with ten fingers at the same time. If she did not succeed, she got extremely upset and pressed the light button again and again until she was satisfied. The girl was not able to throw away garbage and kept packaging waste in a separate box. In the evening, she had to tidy her room for a long time until everything was ‚right‘. Whenever her routine was changed, she protested by crying, shouting and yelling at her parents. Moreover, she insisted on repeating routines if there had been a ‚mistake‘. In order to avoid conflict, both parents adapted their behavior to their daughter’s desires. In the first assessment with the parents, her score on the CY-BOCS was 15, implying clinically meaningful OCD. Psychiatric family history revealed that the mother had suffered from severe separation anxiety as a child and the father from severe night mares. Both parents described themselves as healthy adults.

Patient 2 is a four and a half year old boy, the younger of two brothers. He was reported to have been very oppositional since the age of two. Since the age of three, he insisted on a specific ritual when flushing the toilet – he had to pronounce several distinct sentences and then to run away quickly. Some months later he developed a complicated fare-well ritual and insisted on every family member using exactly the sentences he wanted to hear. If one of these words changed, he started to shout and threw himself on the floor. After a short time, he insisted on unknown people like the cashier at the supermarket to use the same words when saying good-bye.Moreover, he insisted that objects and meals had to be put back to the same place as before in case they had been moved. When walking outside, he had to count his steps and had to start this over and over again. In the morning, he determined where his mother had to stand and how her face had to look when saying good-bye. In order to avoid conflict, parents and brother had deeply accommodated their behavior to his whims. On the CY-BOCS, patient 2 reached a score of 15, which is equivalent to clinically meaningful OCD. Neither his father nor his mother reported any psychiatric disorder in past or present.

Patient 3 is a 4 year old boy referred because of possible OCD. Since the age of three, he had insisted on things going his way. When this was not the case, he threw a temper tantrum and demanded that time should be turned back. If, for example, he had cut a piece of bread from the loaf and was not satisfied with its form, he insisted that the piece should be ‘glued’ to the loaf again. Since he entered Kindergarten at the age of four, his behavior became more severe. If he was not satisfied with a certain routine like, for example, dressing in the morning, he demanded that the entire family had to undress and go to bed again, that objects had to lie at the same place as before or that the clock had to be turned back. In order to avoid conflict, the parents had repeatedly consented to his wishes. His behavior was judged as problematic at Kindergarten, because he demanded certain situations to be repeated or ‚played back‘. When the teacher refused to do that, the boy once run away furiously. On the CY-BOCS, patient 3 reached a score of 15. The mother described herself as being rather anxious (but not in treatment), the father himself as not suffering from any psychiatric symptoms. However, his mother had suffered from such severe OCD when he was a child that she had undergone inpatient treatment several times. This was also the reason why the parents had asked for referral to a specialist for the symptoms of their son.

Patient 4 is a 5 year old girl, the eldest of three siblings. Since the age of two, she was only able to wear certain clothes. For months, she refused to wear any shoes besides Espadrilles; she was unable to wear jeans and could only wear one certain pair of leggings. Wearing warm or thicker garments was extremely difficult, leading to numerous conflicts with her mother in winter. Socks had to have the same height, stockings had to be thin, and slips slack. When dressing in the morning, she regularly got angry and despaired and engaged in severe conflicts with her mother; dressing took a long time, whereas she had to be in Kindergarten on time. Her compulsions with clothes seemed to influence her social behavior as well; she had been watching other children at the playground for 40 min and did not participate because her winter coat did not ‚feel right‘. She started to join peers only when she was allowed to pull the coat off. She also had to dry herself excessively after peeing and was reported to be perfectionist in drawing, cleaning or tidying. Her CY-BOCS score was 15, equivalent to clinically meaningful OCD. Both parents described themselves as not suffering from any psychiatric problem in past or present. However, the grandmother on the mother’s side was reported to have had similar compulsions when she was a child.

Patient 5 was a four and a half year old girl referred because of early OCD. She had one elder brother and lived with both parents. At the age of 1 year, patient 5 was diagnosed with a benign brain tumor (astrocytoma). The tumor had been removed for 90% by surgery; the remaining tumor was treated with chemotherapy. The first chemotherapy at the age of 3 years was reasonably well tolerated. Shortly thereafter, the girl developed just-right-compulsions concerning her shoes. When the second chemotherapy (with a different drug) was started at the age of four, compulsions increased so dramatically that she was referred to our outpatient clinic by the treating oncologist. She insisted on her shoes being closed very tightly, her socks and underwear being put on according to a certain ritual, and her belt being closed so tightly that her father had to punch an additional hole. She refused to wear slack or new clothes and was not able to leave the toilet after peeing because ‘something might still come’; she used large amounts of toilet paper and complained that she wasn’t dry yet. She also insisted on straightening the blanket of her bed many times. She was described by her mother as extremely stressed, impatient and irritable; she woke up every night and insisted to go to the toilet, from where she would come back only after intense cleaning rituals. In the morning, she frequently threw a severe temper tantrum, including hitting and scratching the mother, staying naked in the bathroom and refusing to get dressed because clothes were not fitting ‚just right‘or were not tight enough. Shortly after the start of the second chemotherapy, the girl had entered Kindergarten which was in a different language than the family language. Moreover, her mother had just taken up a new job and had to make a trip of several days during the first month. Although the mother gave up her job after the dramatic increase in OCD severity, the girl’s symptoms did not change. As an association between chemotherapy and the increase in OCD symptoms could not be excluded, the treating oncologist decided to stop chemotherapy 2 weeks after patient 5 was presented with OCD at our department. At the moment of presentation, she arrived at Kindergarten too late daily, after long scenes of crying and shouting, or refused to go altogether. She reached a score of 20 on the CY-BOCS, the highest score of the five children presented here. Her father described himself as free of any psychiatric symptoms in past or present. Her mother had been extremely socially anxious as a child.

None of the siblings of the children described above was reported to show any psychiatric symptoms in past or present (Table  1 ).

The five cases described above show a broad range of OCD symptomatology in young children. Besides Just-Right compulsions concerning clothes, compulsive behavior on the toilet was reported such as having to pee frequently, having to dry oneself over and over again as well as rituals concerning flushing. Other symptoms were pronouncing certain words or phrases compulsively, insisting on a ‘perfect’ action and claiming that time or situations must be played back like a video or DVD if the action or situation were not ‘perfect enough’. The patients described here have in common that parents were already much involved in the process of family accommodation. For example, the parents of patient 3 had consented several times to undress and go to bed again in order to ‘play back’ certain situations; they had also consented turning back the clock in the house. The parents of patient 2 had accommodated his complicated fare-well ritual, thus having to rush to work in the morning themselves. However, all parents were smart enough not just to indulge their child’s behavior, but to seek professional advice.

Treatment recommendations

Practice Parameters and guidelines for the assessment and treatment of OCD in older children and adolescents recommend cognitive behavior therapy (CBT) as first line treatment for mild to moderate cases, and medication in addition to CBT for moderate to severe OCD [ 24 , 25 ]. However, there is a lack of treatment studies including young children with OCD [ 26 ]. A case series with seven children between the age of 3 and 8 years diagnosed with OCD describes an intervention adapted to this young age group. Treatment emphasized reducing family accommodation and anxiety-enhancing parenting behaviors while enhancing problem solving skills of the parents [ 27 ]. A much larger randomized clinical trial for 127 young children (5 to 8 years of age) with OCD showed family-based CBT superior to a relaxation protocol for this age group [ 14 ]. Despite these advances in treatment for early childhood OCD, availability of CBT for paediatric OCD in the community is scarce due to workforce limitations and regional limitations in paediatric OCD expertise [ 28 ]. This is certainly not only true for the US, but for most European countries as well.

When discussing treatment of OCD in young children, the topic of family accommodation is of utmost importance. Family accommodation, also referred to as a ‘hallmark of early childhood OCD’ [ 15 ] means that parents of children with OCD tend to accommodate and even participate in rituals of the affected child. In order to avoid temper tantrums and aggressive behavior of the child, parents often adapt daily routines by engaging in child rituals or facilitating OCD by allowing extra time, purchasing special products or adapting family rules and organisation to OCD [ 29 , 30 , 31 ]. Although driven by empathy for and compassion with the child, family accommodation is reported to be detrimental because it further reinforces OCD symptoms and avoidance behavior, thus enhancing stress and anxiety [ 4 , 32 ].

Parent-oriented CBT intervention

At the moment of first presentation, the five children were so severely impaired by their OCD that attendance of (compulsory) Kindergarten was uncertain. All parents reported being utterly worried and stressed by their child’s symptoms and the associated conflicts in the family. However, no single family wanted an in-patient treatment of their child, and because of the children’s young age, medication was not indicated. Some families lived far away from our clinic and / or had to take care of young siblings.

Therefore, a CBT-intervention was offered to the parents, mainly focusing on reducing family accommodation. This approach is in line with current treatment recommendations to aggressively target family accommodation in children with OCD [ 15 ]. Parents and child were seen together in a first session. The following sessions were done with the parents only, who were encouraged to bring video tapes of critical situations. The scenes were watched together and parents were coached to reduce family accommodation for OCD, while enhancing praise and reward for adequate behaviors of the child. Parents were also encouraged to use ignoring and time-out for problematic behaviors. As some families lived far away and had to take care of young siblings as well, telephone sessions were offered as an alternative whenever parents felt the need for it. Moreover, parents were prompted to facilitate developmental tasks of their child such as attending Kindergarten regularly, or building friendships with peers. The minimal number of treatment sessions was four and the maximal number ten, with a median of six sessions.

Three of the five children (patients 3, 4 and 5) were raised in a different language at home than the one spoken at Kindergarten. This can be interpreted as an additional stressor for the child, possibly enhancing OCD symptoms. Instead of expecting their child to learn the foreign language mainly by ‚trial and error‘, parents were encouraged to speak this language at home themselves, to praise their child for progress in language skills and to facilitate playdates with children native in the foreign language.

Three and six months after intake, assessment of OCD-severity by means of the CY-BOCS was repeated. Table  2 shows an impressive decline in OCD-severity after 3 months that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child was admitted to the next level of Kindergarten or, in the case of patient 4, to school.

We report on five children of 4 and 5 years with very early onset OCD who were presented at a University Department of Child and Adolescent Psychiatry. These children are ‚early starters‘with regard to OCD. As underlined in a recent consensus statement [ 10 ], delayed initiation of treatment is seen as an important aspect of the overall burden of OCD (see also [ 19 ]). In our small sample, a CBT-based parent-oriented intervention targeting mainly family accommodation led to a significant decline in CY-BOCS scores after 3 months that was maintained at 6 months. At 3 months, all children were able to attend Kindergarten daily, and at 6 months, every child was admitted to the next grade. This can be seen as an encouraging result, as it allowed the children to continue their developmental milestones without disruptions, like staying at home for a long period or following an inpatient treatment that would have demanded high expenses and probably led to separation problems at this young age. Moreover, the reduction on CY-BOCS scores was reached without medication. The number of sessions of the CBT-based intervention with the parents varied between four and ten sessions, depending on the need of the family. Families stayed in touch with the therapist during the 6 month period and knew they could get an appointment quickly when needed.

A possible objection to these results might be the question of differential diagnosis. Couldn’t the problematic behaviors described merely be classified as benign childhood rituals that would change automatically with time? As described in the patient vignettes, the five children were so severely impaired by their OCD that attendance of Kindergarten – a developmental milestone – was uncertain. Moreover, parents were extremely worried and stressed by their child’s symptoms and associated family conflicts. In our view, it would have been a professional mistake to judge these symptoms as benign rituals not worthy of diagnosis or disorder-specific treatment. One possible, but rare and debated cause of OCD are streptococcal infections, often referred to as PANS [ 33 ]. However, in none of the cases parents reported an abrupt and sudden onset of OCD symptoms after an infection. Instead, symptoms seem to have developed gradually over a period of several months or even years. In the case of patient 5 with the astrocytoma, first just-right compulsions appeared at the age of three (after the first chemotherapy), and were followed by more severe compulsions at the age of four, when – within a period of 6 weeks – a new chemotherapy was started, the mother took up a new job and the patient entered Kindergarten. Diagnosing the severe compulsions of patient 5 as, for example, adjustment disorder due to her medical condition would not have delivered a disorder-specific treatment encouraging parents to reduce their accommodation. This might have led to even more family accommodation and to more severe OCD symptoms in the young girl. Last but not least, a possible objection might be that the behaviors described were stereotypies. However, stereotypies are defined as repetitive or ritualistic movements, postures or utterances and are often associated with an autism spectrum disorder or intellectual disability. The careful intake with the children revealed no indication for any of these disorders.

Data reported here have several limitations. The children did not undergo intelligence testing; their reactions and behavior during the first session, as well as their acceptance and graduation at Kindergarten were assumed as sufficient to judge them as average intelligent. Comorbidities were assessed according to clinical impression and parents’ reports. The CBT treatment was based on our clinical expertise as a specialized OCD outpatient clinic. It included parent-oriented CBT elements, but did not have a fixed protocol and was adjusted individually to the needs of every family. Last but not least, no control group of young patients without an intervention was included.

Conclusions and clinical implications

We described a prospective 6 month follow-up of five cases of OCD in very young children. At the moment of first presentation, all children were so severely impaired that attendance of Kindergarten was uncertain. Parents were deeply involved in accommodating their child’s rituals. Because of the children’s young age, medication was not indicated. Therefore, a minimal CBT intervention for parents was offered, mainly focusing on reducing family accommodation. CY-BOCS scores at the beginning and after 3 months show an impressive decline in OCD severity that remained stable after 6 months. At 3 months follow-up, all children were able to attend Kindergarten daily, and at 6 months follow-up, every child had been admitted to the next grade. OCD is known to be a chronic condition. Therefore, in spite of treatment success, relapse might occur. However, as our treatment approach mainly targeted family accommodation, parents will hopefully react with less accommodation, should a new episode of OCD occur. Moreover, parents stay in touch with the outpatient clinic and can call when needed.

The clinical implications of our findings are that clinicians should not hesitate to think of OCD in a young child when obsessive-compulsive symptoms are reported. The assessment of the disorder should include the CY-BOCS, which has been validated in very young children by obtaining information from the parent. If CY-BOCS scores are clinically meaningful (for young children, a score above 8), a parent-based treatment targeting family accommodation should be offered.

By disseminating knowledge about the clinical presentation, assessment and treatment of early childhood OCD, it should be possible to shorten the long delay between first symptoms of OCD and disease-specific treatment that is reported as main predictor for persistent OCD. Early recognition and treatment of OCD are crucial to prevent chronicity [ 14 , 15 ]. As children and adolescents with OCD have a heightened risk for clinically significant psychiatric and psychosocial problems as adults, intervening early offers an important opportunity to prevent the development of long-standing problem behaviors [ 10 , 19 ].

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Abbreviations

Obsessive compulsive behavior

Child Yale-Brown Obsessive Compulsive Scale

Cognitive Behavior Therapy

Pediatric OCD Treatment Study PT. Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder. The Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA. 2004;292(16):1969–76.

Article   Google Scholar  

Heyman I, Fombonne E, Simmons H, Ford T, Meltzer H, Goodman R. Prevalence of obsessive-compulsive disorder in the British nationwide survey of child mental health. Int Rev Psychiatry. 2003;15:178–84.

Article   CAS   PubMed   Google Scholar  

Zohar AH. The epidemiology of obsessive-compulsive disorder in children and adolescents. Child & Adolescent Psychiatric Clinics of North America. 1999;8:445–60.

Article   CAS   Google Scholar  

Renshaw KD, Steketee GS, Chambless DL. Involving family members in the treatment of OCD. Cogn Behav Ther. 2005;34(3):164–75.

Article   PubMed   Google Scholar  

Barrett P, Farrell L, Dadds M, Boulter N. Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: long-term follow-up and predictors of outcome. J Am Acad Child Adolesc Psychiatry. 2005;44(10):1005–14.

Geller DA. Obsessive-compulsive and spectrum disorders in children and adolescents. Psychiatr Clin N Am. 2006;29:353–70.

Taylor S. Early versus late onset obsessive-compulsive disorder: evidence for distinct subtypes. Clin Psychol Review. 2011;31:1083–100.

Garcia A, Freeman J, Himle M, Berman N, Ogata AK, Ng J, et al. Phenomenology of early childhood onset obsessive compulsive disorder. J Psychopathol Behav Assess. 2009;31:104–11.

Article   PubMed   PubMed Central   Google Scholar  

Coskun M, Zoroglu S, Ozturk M. Phenomenology, psychiatric comorbidity and family history in referred preschool children with obsessive-compulsive disorder. Child Adolesc Psychiatry Ment Health. 2012;6(1):36.

Fineberg NA, Dell'Osso B, Albert U, Maina G, Geller DA, Carmi L, et al. Early intervention for obsessive compulsive disorder: an expert consensus statement. Eur Neuropsychopharmacol. 2019. https://doi.org/10.1016/j.euroneuro.2019.02.002 .

Micali N, Heyman I, Perez M, Hilton K, Nakatani E, Turner C, et al. Long-term outcomes of obsessive-compulsive disorder: follow-up of 142 children and adolescents. Br J Psychiatry. 2010;197:128–34.

Zellmann H, Jans T, Irblich B, Hemminger U, Reinecker H, Sauer C, et al. Children and adolescents with obsessive-compulsive disorders. Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie. 2009;37(3):173–82.

Stewart SE, Geller DA, Jenike M, Pauls D, Shaw D, Mullin B, et al. Long-term outcome of pediatric obsessive-compulsive disorder: a meta-analysis and qualitative review of the literature. Acta Psychiatr Scand. 2004;110(1):4–13.

Freeman J, Sapyta JJ, Garcia A, Compton S, Khanna M, Flessner C, et al. Family-based Treatment of early childhood obsessive-compulsive disorder: the Pediatric obsessive-compulsive disorder Treatment Study for young children (POTS Jr) - a randomized clinical trial. JAMA Psychiatry. 2014;71(6):689–98.

Lewin AB, Park JM, Jones AM, Crawford EA, De Nadai AS, Menzel J, et al. Family-based exposure and response prevention therapy for preschool-aged children with obsessive-compulsive disorder: a pilot randomized controlled trial. Behav Res Ther. 2014;56:30–8.

Renner T, Walitza S. Schwere frühkindliche Zwangsstörung - Kasuistik eines 4-jährigen Mädchens. Zeitschrift für Kinder- und Jugendpsychiatrie und Psychotherapie. 2006;34:287–93.

Selles RR, Storch EA, Lewin AB. Variations in symptom prevalence and clinical correlates in younger versus older youth with obsessive–compulsive disorder. Child Psychiatry Hum Dev. 2014;45:666–74.

Skriner LC, Freeman J, Garcia A, Benito K, Sapyta J, Franklin M. Characteristics of young children with obsessive–compulsive disorder: baseline features from the POTS Jr. Sample Child Psychiatry and Human Development. 2016;47:83–93.

Walitza S, van Ameringen M, Geller D. Early detection and intervention for obsessive-compulsive disorder in childhood and adolescence. Lancet Child Adolesc Health. 2019. https://doi.org/10.1016/S2352-4642(19)30376-1 .

Nakatani E, Krebs G, Micali N, Turner C, Heyman I, Mataix-Cols D. Children with very early onset obsessive-compulsive disorder: clinical features and treatment outcome. J Child Psychol Psychiatry. 2011;52(12):1261–8.

Scahill L, Riddle MA, McSwiggin-Hardin M. Children's Yale-Brown obsessive-compulsive scale: reliability and validity. J Am Acad Child Adolesc Psychiatry. 1997;36:844–52.

Freeman J, Flessner C, Garcia A. The Children’s Yale-Brown obsessive compulsive scale: reliability and validity for use among 5 to 8 year olds with obsessive-compulsive disorder. J Abnorm Child Psychol. 2011;39:877–83.

Lewin AB, Piacentini J, De Nadai AS, Jones AM, Peris TS, Geffken GR, et al. Defining clinical severity in pediatric obsessive-compulsive disorder. Psychol Assess. 2014;26(2):679–84.

AACAP. Practice parameter for the assessment and Treatment of children and adolescents with obsessive-compulsive disorder. J Am Acad Child Adolesc Psychiatry. 2012;51(1):98–113.

NICE. Treatment options for children and young people with obsessive-compulsive disorder or body dysmorphic disorder. In: Excellence NIfHaC, 2019.

Google Scholar  

Freeman J, Choate-Summers ML, Moore PS, Garcia AM, Sapyta JJ, Leonard HL, et al. Cognitive behavioral Treatment for young children with obsessive-compulsive disorder. Biol Psychiatry. 2007;61(3):337–43.

Ginsburg GS, Burstein M, Becker KD, Drake KL. Treatment of obsessive compulsive disorder in young children: an intervention model and case series. Child Family Behav Ther. 2011;33(2):97–122.

Comer JS, Furr JM, Kerns CE, Miguel E, Coxe S, Elkins RM, et al. Internet-delivered, family-based treatment for early-onset OCD: a pilot randomized trial. J Consult Clin Psychol. 2017;85(2):178–86.

Storch EA, Geffken GR, Merlo LJ, Jacob ML, Murphy TK, Goodman WK, et al. Family accommodation in Pediatric obsessive-compulsive disorder. J Clin Child Adolesc Psychol. 2007;36(2):207–16.

Brezinka V. Zwangsstörungen bei Kindern. Die Rolle der Angehörigen. Schweizer Zeitschrift für Psychiatrie & Neurologie. 2015;15(4):4–6.

Lebowitz ER. Treatment of extreme family accommodation in a youth with obsessive-compulsive disorder. In: Storch EA, Lewin AB, editors. Clinical handbook of obsessive-compulsive and related disorders. New York: Springer; 2016. p. 321–35.

Chapter   Google Scholar  

Lebowitz ER. Parent-based treatment for childhood and adolescent OCD. J Obsessive-Compulsive Related Dis. 2013;2(4):425–31.

Chang K, Frankovich J, Cooperstock M, Cunningham M, Latimer ME, Murphy TK, et al. Clinical evaluation of youth with Pediatric acute onset neuropsychiatric syndrome (PANS). Recommendations from the 2013 PANS consensus conference. J Child Adolesc Psychopharmacol. 2015;25:3–13.

Download references

Acknowledgements

Not applicable.

no funding was obtained for this study.

Author information

Authors and affiliations.

Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich, Neumünsterallee 3, 8032, Zurich, Switzerland

Veronika Brezinka, Veronika Mailänder & Susanne Walitza

You can also search for this author in PubMed   Google Scholar

Contributions

V.B. conducted the diagnostic and therapeutic sessions and wrote the manuscript. V.M. was responsible for medical supervision and revised the manuscript. S.W. supervised the OCD treatment and research overall, applied for ethics approval and revised the manuscript. All authors have read and approved the manuscript.

Corresponding author

Correspondence to Veronika Brezinka .

Ethics declarations

Ethics approval and consent to participate.

the study was approved by the Kantonale Ethikkommission Zürich, July 22nd, 2019.

Consent for publication

Written informed consent was obtained from the parents for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.

Competing interests

V.B. and V.M. declare that they have no competing interests. S.W. has received royalties from Thieme, Hogrefe, Kohlhammer, Springer, Beltz in the last 5 years. Her work was supported in the last 5 years by the Swiss National Science Foundation (SNF), diff. EU FP7s, HSM Hochspezialisierte Medizin of the Kanton Zurich, Switzerland, Bfarm Germany, ZInEP, Hartmann Müller Stiftung, Olga Mayenfisch, Gertrud Thalmann, Vontobel-, Unisciencia and Erika Schwarz Fonds. Outside professional activities and interests are declared under the link of the University of Zurich www.uzh.ch/prof/ssl-dir/interessenbindungen/client/web/

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Brezinka, V., Mailänder, V. & Walitza, S. Obsessive compulsive disorder in very young children – a case series from a specialized outpatient clinic. BMC Psychiatry 20 , 366 (2020). https://doi.org/10.1186/s12888-020-02780-0

Download citation

Received : 02 March 2020

Accepted : 05 July 2020

Published : 11 July 2020

DOI : https://doi.org/10.1186/s12888-020-02780-0

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Obsessive compulsive disorder
• Early childhood
• Family accommodation

BMC Psychiatry

ISSN: 1471-244X

• Submission enquiries: [email protected]
• General enquiries: [email protected]

A True Story of Living With Obsessive-Compulsive Disorder

An authentic and personal perspective of the internal battles within the mind..

Posted April 3, 2017

• What Is Obsessive-Compulsive Disorder?
• Find a therapist to treat OCD

Contributed by Tiffany Dawn Hasse in collaboration with Kristen Fuller, M.D.

The underlying reasons why I have to repeatedly re-zip things, blink a certain way, count to an odd number, check behind my shower curtain to ensure no one is hiding to plot my abduction, make sure that computer cords are not rat tails, etc., will never be clear to me. Is it the result of a poor reaction to the anesthesiology that was administered during my wisdom teeth extraction? These aggravating thoughts and compulsions began immediately after the procedure. Or is it related to PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infection) which is a proposed theory connoting a strange relationship between group A beta-hemolytic streptococcal infection with rapidly developing symptoms of obsessive-compulsive disorder in the basal ganglia? Is it simply a hereditary byproduct of my genetic makeup associated with my nervous personality ? Or is it a defense tactic I developed through having an overly concerned mother?

The consequences associated with my OCD

Growing up with mild, in fact dormant, obsessive-compulsive disorder, I would have never proposed such bizarre questions until 2002, when an exacerbated overnight onset of severe OCD mentally paralyzed me. I'd just had my wisdom teeth removed and was immediately bombarded with incessant and intrusive unwanted thoughts, ranging from a fear of being gay to questioning if I was truly seeing the sky as blue. I'm sure similar thoughts had passed through my mind before; however, they must have been filtered out of my conscious, as I never had such incapacitating ideas enter my train of thought before. During the summer of 2002, not one thought was left unfiltered from my conscious. Thoughts that didn't even matter and held no significance were debilitating; they prevented me from accomplishing the simplest, most mundane tasks. Tying my shoe only to untie it repetitively, continuously being tardy for work and school, spending long hours in a bathroom engaging in compulsive rituals such as tapping inanimate objects endlessly with no resolution, and finally medically withdrawing from college, eventually to drop out completely not once but twice, were just a few of the consequences I endured.

Seeking help

After seeing a medical specialist for OCD, I had tried a mixed cocktail of medications over a 10-year span, including escitalopram (Lexapro), fluoxetine (Prozac), risperidone (Risperdal), aripiprazole (Abilify), sertraline (Zoloft), clomipramine (Anafranil), lamotrigine (Lamictal), and finally, after a recent bipolar disorder II diagnosis, lurasidone (Latuda). The only medication that has remotely curbed my intrusive thoughts and repetitive compulsions is lurasidone, giving me approximately 60 to 70 percent relief from my symptoms.

Many psychologists and psychiatrists would argue that a combination of cognitive behavioral therapy (CBT) and pharmacological management might be the only successful treatment approach for an individual plagued with OCD. If an individual is brave enough to undergo exposure and response prevention therapy (ERP), a type of CBT that has been shown to relieve symptoms of OCD and anxiety through desensitization and habituation, then my hat is off to them; however, I may have an alternative perspective. It's not a perspective that has been researched or proven in clinical trials — just a coping mechanism I have learned through years of suffering and endless hours of therapy that has allowed me to see light at the end of the tunnel.

In my experience with cognitive behavioral therapy, it may be semi-helpful by deconstructing or cognitively restructuring the importance of obsessive thoughts in a hierarchical order; however, I still encounter many problems with this type of technique, especially because each and every OCD thought that gets stuck in my mind, big or small, tends to hold great importance. Thoughts associated with becoming pregnant , seeing my family suffer, or living with rats are deeply rooted within me, and simply deconstructing them to meaningless underlying triggers was not a successful approach for me.

In the majority of cases of severe OCD, I believe pharmacological management is a must. A neurological malfunction of transitioning from gear to gear, or fight-or-flight, is surely out of whack and often falsely fired, and therefore, medication works to help balance this misfiring of certain neurotransmitters.

Exposure and response prevention therapy (ERP) is an aggressive and abrasive approach that did not work for me, although it may be helpful for militant-minded souls that seek direct structure. When I was enrolled in the OCD treatment program at UCLA, I had an intense fear of gaining weight, to the point that I thought my body could morph into something unsightly. I remember being encouraged to literally pour chocolate on my thighs when the repetitive fear occurred that chocolate, if touching my skin, could seep through the epidermal layers, and thus make my thighs bigger. While I boldly mustered up the courage to go through with this ERP technique recommended by my specialist, the intrusive thoughts and compulsive behaviors associated with my OCD still and often abstain these techniques. Yes, the idea of initially provoking my anxiety in the hope of habituating and desensitizing its triggers sounds great in theory, and even in a technical scientific sense; but as a human with real emotions and feelings, I find this therapy aggressive and infringing upon my comfort level.

How I conquered my OCD

So, what does a person incapacitated with OCD do? If, as a person with severe OCD, I truly had an answer, I would probably leave my house more often, take a risk once in a while, and live freely without fearing the mundane nuances associated with public places. It's been my experience with OCD to take everything one second at a time and remain grateful for those good seconds. If I were to take OCD one day at a time, well, too many millions of internal battles would be lost in this 24-hour period. I have learned to live with my OCD through writing and performing as a spoken word artist. I have taken the time to explore my pain and transmute it into an art form which has allowed me to explore the topic of pain as an interesting and beneficial subject matter. I am the last person to attempt to tell any individuals with OCD what the best therapy approach is for them, but I will encourage each and every individual to explore their own pain, and believe that manageability can come in many forms, from classic techniques to intricate art forms, in order for healing to begin.

Tiffany Dawn Hasse is a performance poet, a TED talk speaker , and an individual successfully living with OCD who strives to share about her disorder through her art of written and spoken word.

Kristen Fuller M.D. is a clinical writer for Center For Discovery.

Facebook image: pathdoc/Shutterstock

Kristen Fuller, M.D., is a physician and a clinical mental health writer for Center For Discovery.

• Find a Therapist
• Find a Treatment Center
• Find a Psychiatrist
• Find a Support Group
• Find Online Therapy
• United States
• Brooklyn, NY
• Chicago, IL
• Houston, TX
• Los Angeles, CA
• New York, NY
• Portland, OR
• San Diego, CA
• San Francisco, CA
• Seattle, WA
• Washington, DC
• Asperger's
• Bipolar Disorder
• Chronic Pain
• Eating Disorders
• Passive Aggression
• Personality
• Goal Setting
• Positive Psychology
• Stopping Smoking
• Low Sexual Desire
• Relationships
• Child Development
• Self Tests NEW
• Therapy Center
• Diagnosis Dictionary
• Types of Therapy

At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that could derail our entire day. Here’s how we can face triggers with less reactivity and get on with our lives.

• Emotional Intelligence
• Gaslighting
• Affective Forecasting
• Neuroscience

Change Password

Your password must have 6 characters or more:.

• a lower case character, 
• an upper case character, 
• a special character 

Password Changed Successfully

Your password has been changed

Create your account

Forget yout password.

Enter your email address below and we will send you the reset instructions

If the address matches an existing account you will receive an email with instructions to reset your password

Forgot your Username?

Enter your email address below and we will send you your username

If the address matches an existing account you will receive an email with instructions to retrieve your username

• June 15, 2024 | VOL. 77, NO. 2 CURRENT ISSUE pp.43-100
• March 15, 2024 | VOL. 77, NO. 1 pp.1-42

The American Psychiatric Association (APA) has updated its Privacy Policy and Terms of Use , including with new information specifically addressed to individuals in the European Economic Area. As described in the Privacy Policy and Terms of Use, this website utilizes cookies, including for the purpose of offering an optimal online experience and services tailored to your preferences.

Please read the entire Privacy Policy and Terms of Use. By closing this message, browsing this website, continuing the navigation, or otherwise continuing to use the APA's websites, you confirm that you understand and accept the terms of the Privacy Policy and Terms of Use, including the utilization of cookies.

“The Ickiness Factor:” Case Study of an Unconventional Psychotherapeutic Approach to Pediatric OCD

• Justine S. Dembo , MD, FRCP(C)

Department of Psychiatry, University of Toronto, Ontario, Canada.

Search for more papers by this author

Obsessive-compulsive disorder (OCD) is a complex condition with biological, genetic, and psychosocial causes. Traditional evidence-based treatments include cognitive-behavioural therapy, either alone or in combination with serotonin-specific reuptake inhibitors (SSRI’s), other serotonergic agents, or atypical antipsychotics. These treatments, however, often do not lead to remission, and therefore, it is crucial to explore other less conventional therapeutic approaches. This paper describes a case study in which psychodynamic, narrative, existential, and metaphor therapy in combination with more conventional treatments led to a dramatic remission of severe OCD in a 12 year old hospitalized on a psychiatric inpatient unit. The paper, which is written partly in the form of a story to demonstrate on a meta-level the power of narrative, is also intended to illustrate the challenges of countertransference in the treatment of patients with severe OCD, and the ways in which a reparative therapeutic alliance can lead to unexpected and vital change.

Introduction

Obsessive-compulsive disorder (OCD) is defined for both children and adults in the DSM-IV-TR as follows: ( APA, 2000 , p. 462) “Either obsessions or compulsions,” with obsessions consisting of recurrent and intrusive thoughts, images or impulses experienced as unwanted or distressing, and compulsions being repetitive behaviours that the person feels driven to do, usually with the aim of reducing distress. The symptoms must either occupy more than one hour per day or cause significant distress or social or occupational impairment. The DSM-IV-TR specifies that children do not need to recognize that the obsessions or compulsions are excessive or unreasonable, whereas adults do. Population-based studies indicate a prevalence of OCD in 2% to 4% of children and adolescents, with a mean age of onset between ages 7.5 years and 12.5 years (AACAP, 2012; Boileau, 2011 ). Some studies indicate that in OCD affecting children it is more common in boys (3:2), while in adults it is equally common in men and women (AACAP, 2012; Boileau, 2011 ). The etiology of OCD at all ages is multifactorial, involving a combination of genetic, neurobiological, neurochemical, biological, personality/trait, psychological and social factors. In some cases, infection with group A beta-hemolytic streptococcus can create a syndrome that is indistinguishable from OCD; this is part of a larger group of syndromes known as PANDAS: pediatric autoimmune neurological disorders associated with streptococci ( Shulman, 2009 ). A full review of the etiology is beyond the scope of this paper.

In pediatric and adolescent OCD, the most common obsessions involve religion, sexuality, death or illness, contamination, and over-responsibility for feared harm to self or others or for catastrophic events ( Boileau, 2011 ; Butwicka & Gmitrowics, 2010 ); the most common compulsions, mean-while, involve cleaning and hoarding ( Boileau, 2011 ). Some research indicates that young children with OCD have associated features of severe indecisiveness, extreme slowness, and excessive doubt about trivial matters ( Boileau, 2011 ). There is some evidence to suggest a higher rate of comorbid obsessive-compulsive personality disorder (OCPD) traits in these children (AACAP, 2012), including a tendency toward rigidity, perfectionism, orderliness, and control. Compared to patients with adult-onset OCD, those who experience onset in childhood are more likely to have comorbid disruptive behaviour, tic disorders, mood disorders, other anxiety disorders, or attention deficit hyperactivity disorder (ADHD) ( Boileau, 2011 ). Significant to the case featured in this article are several studies that indicate children who have OCD and comorbid major depressive disorder have greater OCD severity, and tend to have higher levels of family conflict ( Boileau, 2011 ). Also relevant to the current case, children with comorbid disruptive behaviour disorders tend to have greater severity of symptoms, greater levels of family accommodation, more treatment resistance, and are 3.6 times more likely to be prescribed atypical antipsychotics than those without concomitant behavior dysfunction ( Storch, Lewin, Geffken, Morgan, & Murphy, 2010 ).

Obsessive-compulsive disorder can have a significant impact on functioning, both at home and at school. The 2012 American Academy of Child and Adolescent Psychiatry (AACAP) OCD treatment guidelines cites peer problems in 55% to 100% of patients, and isolation and current or future unemployment at 45% (AACAP, 2012). The World Health Organization recently stated that OCD (regardless of age group) is the tenth leading cause of disability worldwide ( Gilbert & Maalouf, 2008 ). In addition, OCD in childhood tends to be chronic, with 41% to 60% of children remaining symptomatic into adulthood ( Boileau, 2011 ). Predictors of chronicity include the presence of other psychiatric comorbidities and poor initial treatment response (AACAP, 2012), and also possibly the need for hospitalization ( Boileau, 2011 ). The most commonly studied treatment modalities include cognitive-behavioural therapy (CBT), medication management (primarily with serotonin-specific reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and atypical antipsychotic augmentation), or combined medication and CBT.

However, CBT, medication, or combinations therein often do not result in full remission ( Boileau, 2011 ; Leib, 2001 ). Given this, and the high side-effect burden of the medications used to treat OCD, it is crucial that we continue to explore the potential of broader and more integrated treatments for children as well as adults. The vast majority of contemporary evidence-based research on psychotherapy in children and adolescents with OCD involves cognitive-behavioural therapy exclusively ( In-Albon & Schneider, 2007 ; McGehee, 2005 ; Storch, Mariaskin, & Murphy, 2009 ), and the majority of nonbiological theories about the etiology of OCD, such as learning theory, are related to the cognitive-behavioural model ( Kempke & Luyton, 2007 ). Of great concern is that many CBT experts bluntly dismiss psychodynamic theory with regards to OCD, and state that psychoanalytic techniques have no place in its treatment ( Foa, 2010 ; British Psychological Society/NICE, 2006 ). Furthermore, there is disappointingly little contemporary published research on psychoanalytic approaches to pediatric and adolescent OCD ( Cohen, 2011 ), although authors allude to the fact that therapists use these approaches quite commonly in this population ( Fonagy, 1999 ; Quinn, 2010 ). Some authors argue that there is significant overlap between cognitive-behavioural and psychodynamic theories of OCD, and that the techniques, at least for adults, can be merged successfully in treatment ( Kempke & Luyten, 2007 ).

My intention in this paper is to add support to the evidence base for the integration of psychodynamic and other therapeutic modalities in the contemporary treatment of children, adolescents, and even adults, with OCD. In a society that increasingly favours short-term and psychopharmacological treatment strategies, the richness that these other modalities contribute to treatment may well be lost; furthermore, adolescents like the one described in this paper may all too often be deemed treatment refractory and may be heavily medicated or institutionalized when CBT and first-line medications do not lead to remission. The case study described in this paper illustrates the ways in which psychodynamic, narrative, existential, and metaphor therapy enhance the use of CBT and medication management. It also demonstrates the necessity of complex interventions in the case of an illness as multifaceted as OCD, and the indisputable fact that even young children and adolescents can struggle with sophisticated psychodynamic conflicts. The paper begins with a summary of the patient’s history, followed by a description of the use of conventional therapies. Following this is a discussion of key aspects of different theoretical frameworks, and the ways in which incorporating these frameworks enriched and enhanced the clinical outcome in this particular case. I will argue that had we not employed psychodynamic and other approaches, this patient would likely not have engaged in CBT at all, nor would she have achieved such a meaningful recovery.

Introduction to the Case

I will refer to the patient as “Cassandra,” the name of the fictional character she created during the narrative component of psychotherapy. Cassandra was a 12-year-old in middle school, living in a suburban house with her two parents and one younger sister. Her parents, European in origin, described a generally happy marriage, and were supportive and loving. They were financially stable, with extended family living nearby. Her father worked, and her mother was a homemaker. Although there was no family history of OCD, Cassandra had a paternal grandmother with severe major depressive disorder who had attempted suicide and survived. Cassandra’s medical history was unremarkable, except for pneumonia at age 10 years. She had recently begun menstruating, with regular cycles. She had no known history of streptococcal infection. She also had no history of tics, ADHD, or other diagnosed psychiatric or medical comorbidities. Although she did not meet criteria for a disruptive behaviour disorder, she was described by her parents at baseline as quite “oppositional,” controlling, and perfectionistic.

Cassandra developed OCD six months prior to her hospital admission, when the family had moved to her maternal grandmother’s house while their own home was renovated. Her first symptoms included prolonged and repetitive ordering and re-ordering of shoes by the front door, refusal to empty her backpack or to discard numerous useless items, such as store tags and shopping bags, and a gradual decreasing attention to her own hygiene. Furthermore, she had become increasingly angry with her grandmother, with whom she eventually refused to associate altogether. She developed contamination obsessions and compulsions about her grandmother, and began also to avoid food, clothing, toys, furniture, and other items that her grandmother may have touched. She began to refuse any food that was even remotely associated with her grandmother, and then with her other family members, and her parents had to take her out to restaurants or buy prepackaged food in her presence, in order to get her to eat. She began losing weight. She developed elaborate rituals around the staircase at home, taking up to two hours to get up the stairs, and completing a number of rituals on each step. If her parents so much as moved or breathed audibly during her ascent, she would have to start again at the beginning. Her parents and sister, uncertain of how to cope with this, accommodated and tried to be as quiet as possible during the staircase rituals; each time they accommodated further, however, Cassandra’s symptoms worsened. She developed compulsions in the car as well, requiring that the radio be on at all times and that the windows remain open even in mid-winter. She was afraid to inhale the car air, which she believed was tainted by her parents’ association with her grandmother. She became increasingly (and constantly) distressed and her hygiene deteriorated further, as she refused to shower or change her clothes. She became unable to hide her rituals from her friends, and she was eventually unable to attend school.

By the mid-winter, her illness was so severe her parents brought her to a community hospital, and though she had a three-week admission, she did not receive any specific treatment for OCD. The inpatient psychiatrist suggested aripiprazole, but Cassandra and her parents refused because they were concerned about side effects. Following the admission, Cassandra saw a psychologist for three CBT sessions, but the therapeutic alliance was quite poor. Within the next month, Cassandra further deteriorated, and began refusing to enter the front door of her house. On a particularly cold night, she was unable to enter the house at all, and resisted her parents’ desperate attempts to carry her in, until she urinated in her clothes on the doorstep. Once in the house she begged her mother to kill her with a kitchen knife; her parents managed to force her into the car, and drove her to a downtown hospital. On the way there, Cassandra attempted to exit the moving car on a busy street, and her parents restrained her. She was assessed in the emergency room and then rerouted to our community hospital, where we admitted her to our child and adolescent inpatient unit. Of note is that during the initial interview, Cassandra and her parents denied any significant history of other anxiety disorders, depression, or other psychiatric comorbidities; however, given that she presented with suicidal ideation and a history of social withdrawal, irritability, mood lability, anhedonia, weight loss and insomnia, we suspected that she was suffering from a major depressive episode of several months’ duration. On initial presentation, she was very thin, pale, and significantly malodourous, and she appeared older than her stated age. She was furious with her parents and highly guarded, hostile, and reluctant to engage on interview, often refusing to speak. When she did speak, everyone was struck by her adult vocabulary, her tenacious and complex arguments, and her lack of warmth.

Stabilization, Treatment Structure, and Medication Management

Our primary goal was to ensure that Cassandra was medically stable. A physical exam, a full blood-work panel, titres for streptococcal antigens, and a CT head scan were all normal. Fortunately, Cassandra ate well because the food we provided had not come into contact with her family. As per the AACAP OCD treatment guidelines, we proposed a combination of medication management and CBT. Cassandra adamantly refused medication and became hostile toward my supervisor for insisting upon it. She was willing to begin CBT, however, and so we began CBT prior to the initiation of an SSRI. She was well-versed on the side effects and risks of the different medications, and argued her case with the manner and understanding of a much older adolescent. There were many painfully lengthy negotiations with her, regarding the type of medication (SSRI versus atypical antipsychotic), dosing, and dosage form (liquid versus capsule versus pill), all of which she refused. My supervisor believed Cassandra was incapable of making decisions with respect to treatment, and as per provincial law for adolescents age 12 and older, Cassandra was allowed to contest this finding with the help of a lawyer. At this point my supervisor and I discussed which of us would be involved in the legal review board hearing, as thus far Cassandra had clearly employed the defense mechanism of splitting, such that my supervisor was “all bad” and I was “all good.” My supervisor proposed that we use the splitting to our advantage, and she advocated for a finding of incapacity during the review board, whereas I was completely uninvolved in the hearing and continued treating Cassandra with daily CBT. Cassandra was found incapable with respect to antidepressant but not antipsychotic treatment, and therefore we ordered fluoxetine, beginning at 10 mg daily. Only when we had security officers accompany us to unit with the threat of holding her down while we inserted a nasogastric tube did Cassandra agree to swallow the fluoxetine. Security officers were required to be present for the first few days. Over several weeks the dosage was titrated upward to 30 mg daily. Cassandra’s mood gradually improved, as did her self-care, appetite, and willingness to attend to hygiene, and she began coming to the nursing station to request her medication, saying she felt it was helping. She denied any side effects. The psychotherapies described below occurred in parallel with the medication management.

As Cassandra herself often pointed out, she was a “complicated person” with a complicated illness, whose treatment was, in parallel, complicated. Although I will describe different aspects of her treatment under separate headings, it is important to note that these facets of treatment occurred simultaneously.

Psychotherapy for OCD: CBT Component

Although this paper intends to demonstrate the importance of an eclectic and unconventional approach to OCD, we will still begin with a discussion of CBT and the ways in which it was applied to Cassandra, because CBT was a constant part of her treatment. I would like to emphasise that many of the gains Cassandra made in CBT occurred after interventions that were more psychodynamic in nature, and this will be made apparent below. Numerous sources suggest that the effects of CBT are longer-lasting than those of medication alone ( Jenike, 2004 ; Storch et al., 2007 ). Cognitive-behavioural therapy is the first-line treatment in children or adolescents with mild to moderate OCD, whereas combined CBT and medication is recommended for those with moderate to severe OCD, or for those with poor insight or cognitive deficits that would interfere with CBT (AACAP). A review of the National Institute for Mental Health data on CBT for OCD describes several meta-analyses that clearly support the use of CBT in children and adolescents ( Munoz-Solomando, Kendall, & Whittington, 2008 ). The most effective form of CBT for OCD is known as exposure and response prevention (ERP) ( Foa, 2010 ; Jenike, 2004 ), which involves gradual and systematic exposures, along a hierarchy of increasing subjective units of distress (SUDS), to the feared objects or situations. The patient’s usual response (compulsion, ritual, or avoidance) is prevented during exposures. Each exposure must be continued until the SUDS score drops by 50% to facilitate habituation, so that anxiety-provoking stimuli are eventually perceived as neutral. Often relaxation techniques are taught in conjunction with ERP. Exposure and response prevention is primarily a behavioural therapy, but can be combined with CBT when there is a significant cognitive component to the OCD, so that distorted thoughts are targeted along with maladaptive behaviours. There is also some evidence that intensive inpatient CBT involving 15 90-minute sessions spread over three weeks and including a family component, may confer a shorter time to treatment response than once-weekly outpatient CBT in children and adolescents ( Storch et al., 2007 ).

The Ickiness Hierarchy

We began CBT with Cassandra by providing psychoeducation about the etiology, diagnosis, and treatment of OCD, and about the process of CBT. Given Cassandra’s frustration at being referred to as “only a 12-year-old” by many adults, when she clearly was unusually intelligent, I felt it crucial to deliver this psychoeducation in adult terms. She was receptive and easily able to develop a sophisticated understanding of her disorder. She was also able to understand the concept of negative reinforcement as it applied to her OCD: namely, that when avoiding a “contaminated” object or place, she would feel relief, which would then perpetuate avoidant behaviours. She began to understand how her family’s accommodation to her rituals had contributed to her deterioration. We then developed an “ickiness” hierarchy, which was to be the first of many. A brief note on the term “icky:” Cassandra and I brainstormed to describe her feelings associated with contamination, and she felt “icky” was the most fitting. Other words and terms included “disgusting,” “repulsive,” “worse-than-gross,” and “slippery green slime and slugs, and snails, all over everything.” Cassandra greatly enjoyed the process of creating hierarchies, and especially the process of rating “ickiness” scores for SUDS; she had a quirky sense of humour, and would often rate extremely specific scores, such as 92.56%, on the hierarchies. Please see Figure 1 for an example of her first hierarchy. In the end we developed three hierarchies: one for general “ickiness,” one for “repulsiveness” associated with her family, and another for her home and car. The angrier Cassandra was at a person, the higher up that individual appeared on her hierarchies. Although we expected her grandmother to be ranked at 100%, her father was, in fact, equally distressing to her.

Figure 1. “ICKINESS” HIERARCHY

The first exposure involved Cassandra’s grey shirt, which had been brought from home after undergoing five rounds in the laundry, but which was associated with her grandmother. Cassandra wanted to do this exposure alone, and so after rating her SUDS score, I left her, with an expression on her face that demonstrated her aversion to the “icky” item, in her hospital room with the shirt on her lap. By the time I had returned 20 minutes later, Cassandra’s SUDS score had dropped significantly. We worked with this shirt for two days, and then progressed to exposure to her yellow teddy bear, and treatment proceeded stepwise up the hierarchy for weeks. On the days I was not there, the nursing staff conducted exposures with her, though she often refused to cooperate, side-stepped the exposures, or added an unexpected complication. One such complication was that at times Cassandra’s SUDS score would drop dramatically within seconds, and none of us understood whether or not she was being truthful. In the hopes of improving consistency in exposure exercises across staff members, the unit psychologist provided the team with an educational session about OCD and the use of ERP, which proved to be quite useful. The unusual nature of Cassandra’s response patterns to certain exposures may have been attributable to some of the psychodynamic factors described below.

As we progressed up the hierarchies, some creativity was required. After Cassandra began to look at photographs of her family, then of her father, we wanted to start preparing her to return home. She had not been home at this point for nearly three months. Given that the house and car were near the top of her “icky” hierarchy, we decided on a car visit, and then home visit. The goal of this exposure was to arrive in her driveway, with the idea that we would conduct a second visit in which she would then exit the car and hopefully enter the house. During the 40-minute drive, I sat with Cassandra in the back seat and we conducted extensive car-related ERP. Upon arrival in the driveway to her home, she refused to look out the car windows at her mother and sister who were waiting for her. Her mother and sister went into the house, and Cassandra eventually opened the car door and gingerly placed her foot on the ground. Suddenly, as per her usual unpredictable nature, Cassandra jumped out of the car and ran onto the lawn. Without hesitation she continued through the front door and into the kitchen, where she proceeded to open the refrigerator and drink juice. She climbed up the stairs to her room, again unhesitatingly. It was a very powerful moment for her mother, who tearfully watched from the kitchen. We were all surprised that Cassandra had not ritualized at all in the doorway, on the stairs, or elsewhere. When it was time to return to the hospital, Cassandra was actually reluctant to leave.

On her first pass home, she asked to stay overnight. I later discovered the reason for this stemmed from my challenging her by saying “I don’t believe you,” when she had told me that spending time at home would be easy. Following this overnight stay, she progressed to a few weekend passes, after which she was ready to be discharged. Ironically, she resisted discharge, but the timing of her discharge with the end of my rotation at the hospital provided her with an incentive to follow through, which she did. I conducted a telephone interview two months later, and for the first time in our work together, she sounded (as best I can describe) like a “normal” 12-year-old. No more sophisticated arguments or existential turmoil; instead she told me about her plans for the day, her schoolwork, a recent donation she had made, and some extracurricular activities.

In her last few weeks of treatment, Cassandra confessed to an obsession that she had kept secret all along. After one of our discussions about mortality, she told me: “If I don’t pay attention to the sun setting, it won’t rise the next morning.” She and I grappled with the gravity of this idea, and the immense weight of responsibility on her shoulders; indeed, no one would survive, if Cassandra did not pay attention to the sun setting! After considering this belief very seriously, I paused, and said rather lightly, “But that’s not logical,” and she agreed. After this, her insomnia slowly resolved, and when I followed up with her about this obsession, she dismissed it, and waving her hand, playfully said: “Whatevs.”

When CBT Alone Does Not Suffice: Psychodynamic Component

Although Cassandra’s progress with CBT was remarkable, it would not have been possible without the other integrated components of treatment. Following a summary of key psychoanalytic theories about OCD, I will describe some crucial turning points in the therapy that were clearly attributable to psychodynamic and other interventions.

Numerous psychodynamic theories exist about the etiology of OCD, ranging from Freud’s hypothesis that the symptoms constitute a defense against unacceptable aggressive or sexual drives or fantasies ( Freud, 1909 ; Freud, 1966 ; Gabbard, 2005 ; Moritz, Kempke, Luyten, Randjbar, & Jelinek, 2011 ; Sadock, 2007 ), to later theories about complex family dynamics, developmental trauma ( Gabbard, 2005 ), and maladaptive attachment styles ( Doron et al., 2012 ). The defense mechanisms found most commonly in OCD include denial, indecision, regression, magical thinking, intellectualization, rationalization, isolation, reaction formation, repression, and undoing ( Chlebowski & Gregory, 2009 ; Freud, 1966 ). Some theorize that in OCD a particularly severe superego, in combination with strong aggressive impulses, results in extreme repression of the impulses ( Freud, 1966 ) that are channeled into obsessions and compulsive symptoms ( Kempke & Luyten, 2007 ). Anna Freud (1966) also posited that in OCD, the ego matures faster than the drives, and that the ego and superego are too advanced at too early a stage, such that they cannot adapt to the drives in a healthy way. This theory may well apply to Cassandra, given her unusual intelligence and the early development of her verbal, moral, and analytical skills. Other psychodynamic factors discussed in the literature on pediatric and adult OCD include: hyperresponsibility, control, shame, loss, relational discord ( Gabbard, 2005 ), anger, and disgust ( Allen, Abbott, & Rapee, 2006 ; Radomsky, Ashbaugh, & Gelfand, 2007 ). In his famous case of the Rat Man , Freud (1909) hypothesized that the fears in obsessional neurosis correspond to repressed unacceptable wishes, and that obsessional patients intellectualize as a means of consciously accounting for unconscious processes, such as the coexistence of intense love and hate toward the same individual. Interestingly, and highly pertinent to the case of Cassandra, Freud also pointed out that patients with severe obsessions cannot be treated in a simplistic manner.

Further evidence of the role psychodynamic factors play in OCD appears in the form of case reports: Chlebowski and Gregory (2009) describe a series of adult cases in which certain psychodynamic interpretations, mainly about displacement of affect, led to a significant reduction in obsessions and compulsions. McGehee (2005) illustrates the successful purely psychoanalytic treatment of a ten-year-old boy with OCD: in four sessions per week, over the span of two years, an intensive focus on transference allowed the patient to work through numerous obsessional symptoms and achieve long-lasting remission. The author passionately argues for the reintroduction of psychoanalytic thought into contemporary treatment of OCD. Dr. Peter Fonagy presents a compelling case study of a young man named Glen, with severe OCD ( Fonagy, 1999 ). Glen, age 15, acted on compulsions during every waking hour, and after three years of psychoanalytic treatment, his symptoms remitted. Dr. Prudence Leib (2001) presents another fascinating case study, of a woman in her late twenties who refused to accept CBT until her therapist engaged with her in two years of psychoanalysis. Dr. Leib reports that it was only when this patient felt her distress and its origins to be adequately understood, that she was willing to consider changing her behaviours; then the CBT was highly effective, and most of her symptoms, like Glen’s, remitted. (A similar process occurred with Cassandra, as described below.) The authors of a series of cases specific to childhood OCD (Ierodiakonou & Ierodiakonou-Benou, 1997) also argue that a psychoanalytic approach is often essential. Although one larger study ( Maina, Rigardetto, Piat, & Borgetto, 2010 ) reported no additional benefit of adding brief dynamic therapy to SSRI treatment in children with OCD, this study was seriously limited, given the lack of other comparison groups, and because it did not examine the potential effects of adding brief dynamic therapy to CBT, or even to multimodal treatment.

Psychoanalysis and Cassandra

Many of Cassandra’s symptoms are best viewed through a psychoanalytic lens, and it is clear that the psychodynamic components of therapy fostered crucial turning points in Cassandra’s recovery. Certainly, Cassandra exemplified traits described above in the psychoanalytic literature on patients with OCD, such as a particularly powerful superego, and prominent defense mechanisms including intellectualization, rationalization, denial, magical thinking, and isolation. Early on in treatment, Cassandra confided that she believed she was a “terrible person,” which certainly corresponds to Chlebowski and Gregory’s (2009) formulation that “the patient feels threatened by thoughts that he or she is bad, imperfect, unreliable, uncontrollable, or immoral, and he or she is unable to integrate these attributions into a coherent self-image” (p. 9). Cassandra provided me with numerous examples of her “terrible-ness,” discussing how selfish and controlling she was at home, how she cheated when playing games with friends, and how she was mean to her sister and unaffectionate with her parents. This sense of herself as a bad person may have fuelled her attempts to be “perfect,” as well as to be “right” about everything. These compensatory strategies are in keeping with the psychoanalytic theory that perfectionism in OCD may be an attempt to counter unwanted hostile impulses ( Kempke & Luyten, 2007 ).

Cassandra and I talked at length about what it means to be a “good person.” Merging this discussion with a CBT technique, I suggested that she consider behaving as she would imagine a “good person” to behave, and she generated several ideas, including reducing her time in the shower, asking her mother how she was feeling, using recycled paper, and perhaps becoming a vegetarian. During the follow-up interview months after therapy, she told me that she had donated money to a charity, remembering these discussions on the unit. Viewed through a psychoanalytic lens, Cassandra’s lack of warmth, noted upon our initial evaluation, supports Freud’s (1909) hypothesis that resistance in obsessional patients takes the form of indifference toward loved ones. As Cassandra relaxed into the therapy, and as her defenses lowered, she displayed an increasing range of emotions in the presence of her family and staff; on her last day working with me I was both taken aback and touched by her request for a hug goodbye.

Midway through our work together, Cassandra revealed that she was furious with her father for allowing the renovation (and resultant move) and the destruction of her trees in the back yard. She also eventually confided that she was angry with her father for being, as she saw it, emotionally unfaithful to her mother. Although the verity of these claims cannot be confirmed, one remarkable change was that she only agreed to see her father and to conduct exposures around him and the rest of her family after expressing her outrage at him. Interestingly, Cassandra’s expressed hatred toward her father is congruent with Freud’s theory (1909) that in OCD there is aggression particularly directed at the father. Cassandra’s intense anger toward her father, whom she also loved, resonates with the psychodynamic formulations about the difficulties obsessional patients have in tolerating ambivalent emotions toward their loved ones. Her overwhelming anger at her parents resulted in particular compulsions (such as refusing to eat or repeating two-hour long staircase rituals each time they breathed or moved audibly) that controlled and distressed them, and that severely disrupted their lives. One may conjecture that the ultimate expression of this aggression was Cassandra’s plea to her mother to kill her own daughter with a kitchen knife; that said, I felt that Cassandra’s suicidal wish was more likely born of a genuine sense of hopelessness about her situation.

Existential and Metaphor Therapy

The literature on existential psychotherapy and metaphor therapy for OCD in children and adolescents is sparse. Nonetheless, glimpses of these approaches to therapy in children are apparent in many of the above studies, as well as in various textbooks on psychotherapy ( Luepnitz, 2002 ). One could argue that metaphors and existential themes are common to most therapies ( Yalom, 1980 ), but that their use is not generally made explicit. There is one paper that examines the use of existential psychotherapy with children, focusing on issues of freedom and personal choice ( Quinn, 2010 ). The author argues that an existential approach, which comprises working through concepts of freedom, responsibility, death, meaning and meaninglessness, and isolation, is highly relevant for children with mental illness. She points out that existential themes appear almost ubiquitously in the use of metaphor and play. She also posits that an existential therapeutic stance fosters a crucial “relatedness” between child and therapist, providing a safe space in which children can understand themselves more fully, and in which they can then come to terms with the world around them. She notes that this is especially important for children who are critical thinkers, and who are highly perceptive about existential realities, given that often adults disavow these perceptions. Cassandra certainly fit into this category. Quinn also highlights the essential role existential themes and metaphorical play have in consolidating a trusting therapeutic alliance; these factors were, again, essential in our work with Cassandra. Some theorists argue that it is in fact impossible to conduct therapy without metaphors ( Barker, 1985 ; Siegelman, 1990 ), and that the use of metaphors is linked to narrative and is especially crucial to psychotherapy in children ( DeSocio, 2005 ; Quinn, 2010 ). Like narrative, metaphors facilitate the creation of a mutual reality; furthermore, metaphors allow patients and therapists to communicate sophisticated ideas using accessible and simple language, which is invaluable when working with children.

Contemplating Existence and Metaphors with Cassandra

Woven through the CBT and dynamic therapy with Cassandra were many existential themes. She described a paralyzing fear that she was “wasting time,” both in terms of wasting her childhood and of wasting her life. She worried that it was “already too late to do something important with [her] life.” She also described her mother as becoming “unkempt,” and had begun to worry over the past few years about her mother aging and dying, and in turn, Cassandra worried about her own mortality. Cassandra reported a fear of aging beginning when she was eight, and as her 13 th birthday approached, this anxiety began to heighten. She had an intense ambivalence about attending her grandmother’s 102 nd birthday: she feared missing what could be her grandmother’s last birthday, but also feared witnessing her grandmother’s aging. After voicing her fears, she did attend and it was a success. When she had disclosed the above fears to others, she had been told not to be “silly,” and that she was only 12 years old and shouldn’t worry about such things; these responses had then increased her anxiety and sense of isolation. She seemed relieved to be able to discuss these fears with me, and in fact I used these existential discussions as a reward for doing her CBT homework. This was a very effective strategy.

Given Cassandra’s vivid imagination, and the importance of metaphors in creating a shared reality and envisioning a different future, it only made sense to play with metaphors during therapy. One of the first metaphors we used was regarding the process of CBT itself: Cassandra likened CBT to “putting on sunglasses” in order to control what one chooses to see, or think. Another useful metaphor arose when we discussed the benefits and risks of perfectionism. Cassandra recalled the story of Icarus and told me that “if you try to be perfect, you can be burned, your wings can melt.” Cassandra created several metaphors for herself, as well. She first said, “I am like Pandora’s box: all the evils of the world come out, and the only good thing is a tiny little bit of hope.” Also early on in the therapy, she said, “I am like the Arctic tundra: barren, freezing cold, not many can survive it.” When I asked her about this metaphor again several weeks later, after we had further grappled with her sense of herself as a terrible person, she said, “In the springtime, there are rabbits and a few beautiful flowers that grow.” It was inspirational to watch her inner landscape evolve, from one rife with evils, and from a state of barrenness, to one symbolic of greenness, life, and hope. When I asked her explicitly about metaphors for hope at the end of our work together, she said the following: “Just because you can’t see the sun doesn’t mean it’s not shining.” This beautiful metaphor remains with me, and I have shared it with many subsequent patients in times of hopelessness. Watching Cassandra’s metaphors change as the therapy progressed, and the mutuality of playing with the symbolism together, was an unforgettable experience.

Narrative Therapy

The literature on narrative therapy for any age group is also relatively sparse, and interestingly, better-developed in the field of nursing, rather than in general medicine or psychiatry. Narrative therapy is based on the philosophy that language reflects a social construction of reality, and that mentally ill children, adolescents, and adults hold within themselves life narratives that reinforce their painful beliefs about themselves, the world, and others ( DeSocio, 2005 ). Weaving together a new, more understanding, and more forgiving shared narrative in psychotherapy can lead to the creation of a more positive projection of the future ( Bennett, 2008 ). Relevant to the present case study, DeSocio (2005) points out that the upheavals of social and cognitive identity in adolescence provide a unique window of opportunity in which narrative therapy can positively influence the construction of an adolescent’s life story. Bennett (2008) argues that dominant narratives imposed by parents and institutions too often leave a child feeling powerless, whereas creating her own narrative provides a sense of agency. Bennett also capitalizes on the fact that children, whose imaginations remain relatively unfettered in comparison to adults, make ideal candidates for a narrative approach.

It may be no coincidence that our patient named her protagonist Cassandra. She was fascinated by Greek mythology, in which there was a priestess by the name of Cassandra to whom Apollo bestowed the gift of foreseeing the future. When the Greek Cassandra later refused Apollo’s love, he cursed her in anger, ensuring that though she would continue to see the future with stunning clarity (for example, some stories state that she warned her people against accepting the Trojan Horse), she would forevermore be disbelieved ( Hamilton, 1999 ). Various accounts of Greek mythology depict Cassandra as unusually beautiful, charming, astute, and intelligent; nonetheless, she was doomed to be perceived as insane no matter how many times her predictions came true ( Hamilton, 1999 ).

Since a primary goal of narrative therapy is to increase an individual’s awareness of the dominant narratives influencing her life, and to challenge those, it made sense to incorporate this approach into Cassandra’s therapy. Cassandra—our patient—faced a “curse” not unlike that of her Greek counterpart. As described previously, her intelligence and insight were so unusual for her age that she was more often than not disbelieved, and her family and the unit staff often disavowed many of her own theories about her illness as the fanciful notions of “just a 12-year-old.” Interestingly, Cassandra was reluctant to create a narrative about herself, saying, “it’s too personal.” This was further impetus to create a fictional character. Therefore, I will refer to our patient as Cassandra, and her character as “C.,” to avoid undue confusion.

Weaving the Narrative

With some encouragement, Cassandra began to weave C.’s story, which evolved over time as we incorporated it into most sessions. At first, C. was “a happy little girl from a happy family, who suddenly developed OCD.” Soon after, C. was “an anxious girl who had a great life, until some things changed, and everything spiralled out of control.” When Cassandra’s defenses lowered further after a few weeks of psychotherapy, she told a very different story: Here, C. was “a 12-year-old girl who always tried to follow the rules and who wanted to be perfect at everything she did.” When C. was three years old, her sister was born and “got away with” being much less rule-abiding, which made C. angry. C. always felt like a “bad person;” she felt she was selfish and unkind, and also that she had to prove she was good by exceeding everyone’s expectations. In grade three, as the story went, C. was given some tests at school, and no one told her what they were for. She was identified as gifted and reluctantly moved to a new school, where she began to worry about achieving “perfectly” academically. At the end of the day, to relieve stress, she would retreat to her favourite trees in the back yard and read for hours. Then, her house underwent renovation and she had to move to her grandmother’s house. No one told her that as part of the construction trees would be cut down. On a visit to the home one day she realized her trees were no longer there, and that was when she began to do other things to relieve her distress, such as organize her shoes in very specific ways, keep everything in her backpack, refuse to change her clothes, act angrily toward her family members, and refuse to talk to her grandmother. Cassandra said that C.’s mother bought a book about OCD, which C. read, and C. then began to “prove her mother right” by performing more of the rituals that the book said children with OCD do. At first C. felt that all these behaviours were “choices,” and were under her control. After some time, though, her “made-up” OCD behaviours worsened, and escalated uncontrollably.

I will highlight the major themes within this third version of the narrative, just as I did when working through it with Cassandra, as these themes illustrate her psychodynamic complexity. It was clear that Cassandra relaxed into the therapy quite markedly after we began working with narrative. She became more forthcoming and at times quite playful during this process, which is in keeping with the above case reports by Fonagy (1999) and Leib (2001) . Apparent in this fictional account is, again, Cassandra’s perfectionism. She experienced the very real academic pressures of a gifted program, which further amplified her prior need to exceed others’ expectations. Alongside this is the theme of sibling rivalry, with Cassandra’s frustration that her sister could get away with less “perfect” behaviour. Also apparent are themes of loss of control, in multiple domains: the birth of her sister, the initially unexplained educational tests leading to an identification as gifted, the move to a new school, the move to her grandmother’s house against her will, the construction that led to changes within her house, and the loss of her back-yard tree refuge, among other things. Themes of anger, frustration, self-hatred, and rage kept emerging in different versions of both her fictional and autobiographical accounts. Within this third story also exists an explanation for the breadth and variety of Cassandra’s OCD symptoms, which is in keeping also with Cassandra’s long-standing oppositionality: if we are to believe the story, it seems that she went to great lengths to prove her mother “right” that she had OCD by adopting symptoms that the OCD book described in other children. Furthermore, this story explains the surprising ease with which Cassandra was able to relinquish certain symptoms after exposures that sometimes lasted less than a few seconds, which as above stirred significant perplexity among the team members. Here Cassandra, like her Greek counterpart, struggled with others’ disbelief; through narrative, however, she was able to convey her internal reality, which increased our understanding, in turn strengthening her trust in our ability to help her. Here, then, is a powerful example of the ways in which narrative relates to psychodynamic therapy and the therapeutic alliance.

On the second-last day of our therapy and of her inpatient treatment, Cassandra told me the fourth and final version of C.’s tale. She said that C. was a “pretty average” 12-year-old who was “OK at a lot of things,” but wanted to do “a lot of non-average things in her life.” She was tired of being average. She ended up in hospital, and learned that she is not a “solid person” but is instead evolving. She learned that “feelings are just feelings,” and that she could control them. She learned how to be her “ideal self” by taking the best parts of herself with her and throwing the rest out.

A Note on Team Dynamics and Countertransference

Daily inpatient psychotherapy was not a standard treatment performed on the acute inpatient unit, and it was a challenge to persuade the team we should take this approach with Cassandra. There were concerns about bed availability and the cost effectiveness of a lengthier admission, and more important, about how challenging Cassandra was as a patient. She was quite oppositional and occasionally verbally tormented the unit staff. She often defied the rules; she spent hours arguing for a particular thing and then once it was done, she argued the opposite cause. Many staff members at times threw up their hands in frustration, saying that Cassandra’s OCD was all “behavioural,” meaning that her symptoms were not in fact the result of anxiety. She caused a great deal of strife among team members, and emotions often ran high during team meetings. Her behaviour, and its effect on team dynamics, was consistent with the clinical literature that addresses countertransference and team conflict in the treatment of adolescents and adults with severe OCD, eating disorders, and personality disorders ( Bland, Tudor, & Whitehouse, 2007 ; Whalley, 1994 ). This literature indicates high levels of miscommunication, distress, burnout, and anger on these multidisciplinary teams, as well as complex power dynamics and role-reversals among treatment providers. Suggestions for management include the following (to which we did try to adhere): frequent team meetings, debriefing, repeated clarification of treatment goals, and psychoeducation that includes having more than one team member present in each interaction to reduce splitting.

It is only fair that since I described the team’s countertransference, I also describe my own. My experience with Cassandra was very different from that of most of the other team members: I looked forward to working with her each day and left most sessions with a sense of progress and accomplishment. Our interactions were almost all positive. I sometimes felt allied with Cassandra, in the sense that I felt opposed and disbelieved by the rest of the team; I experienced powerful self-doubt and a fear that I was grandiose in thinking I could help her because far more experienced clinicians felt hopeless. When I reflect upon this unusual therapeutic alliance, and the ways in which my countertransference differed from that of the others, I can imagine numerous explanations. I was, firstly, fortunate that she developed a positive transference toward me; it was easier to be empathetic toward her, because she treated me with respect. Secondly, I can surmise that the differences were related to my identification with Cassandra in numerous domains. Lastly, as a psychiatric resident, I was an underling of sorts, and as such identified with not only Cassandra, but with other patients as well.

Follow-Up Interview

During the two-month follow-up interview, I was again struck by how much like a “normal” 12 year old Cassandra sounded, and what a contrast this was to her initial presentation. As we had discussed prior to ending therapy on the unit, I was preparing a case presentation about her and she had wanted me to convey certain messages to my colleagues about how to treat patients. I will, therefore, convey these same messages here. The first thing she told me was, “Burn the textbook!” She wanted me to stress that every patient is unique, and that following a textbook approach would not have worked for her. In her words: “… because [the textbook] is not going to cover everything, because every person is different…. people should put trust in the patient occasionally.” She also wanted therapists to know the following: “People are complicated and just that much more complex when they’re not yet sure who they are. So don’t try to figure a person out, but help them to figure out who they are.” Regarding patient-hood, she said: “… they’re not really a patient per se; it’s more like we’re people as well who are having some trouble. You shouldn’t put a label because it’s upsetting. They’re a person. You should say ‘person who’s having trouble.’”

Discussion and Conclusions

The current case study illustrates a highly integrated and multimodal treatment, with a combination of individual and family psychoeducation, and psychotherapy including CBT, ERP, psychodynamic, existential, metaphor, and narrative therapy. Furthermore, the patient benefited because there was a team of nurses, social workers, occupational therapists, psychologists, and psychiatrists, most of whom specialized in child and adolescent psychiatry. Their unique abilities were all incorporated at various points into the treatment. I hope that this case demonstrates the importance of complexity and flexibility in the therapeutic approach, as well as the importance of openness to using different types of psychotherapy when indicated, in a highly intelligent, resistant, and troubled young patient. Furthermore, I take seriously, in this report, the patient’s own belief that the less conventional parts of treatment were “the most important stuff.”

In many ways, the story of Cassandra and her treatment reads like a fairy-tale, and this fascinates me because the experience of working with her also felt quite magical. In treating her, the team as a whole shifted from a position of therapeutic nihilism to one of optimism; in parallel, Cassandra arrived in a state of suicidal despair and then left in one of hopefulness. We assessed Cassandra in a traditional way, and initially proposed a traditional treatment. We adhered to evidence-based treatment guidelines, while responding to her unique needs; however, we allowed for an unusual degree of creativity in treatment, from both a team-based and an individual therapy-based perspective. As a team, we concluded that the non-evidence-based components of the treatment were essential, and we could not imagine that this degree of profound change could have been achieved solely through medication and manualized CBT. That said it is important to recognize that as with all individual case studies, there was no control group, and so it is impossible to infer causality with complete confidence. Our conclusions are also limited because Cassandra and her family elected not to remain in treatment post-admission, and so long-term follow-up data are not available. Furthermore, it is possible that simply of being away from home, in a structured environment, would have led to remission; it is also possible that the CBT or fluoxetine would have been sufficient, or that the positive therapeutic alliance we forged was the main ingredient in her recovery.

The beauty of exploring a case in depth is that it allows for a full appreciation of a patient’s uniqueness, which is not possible in large randomized controlled trials. In this case the art of storytelling provided a valuable chance to consider alternative possibilities and to examine the subtle turning-points in therapy; it allowed us, the therapists, a chance to enter the particularities of an individual’s psyche, and in turn it allowed that individual to feel “seen” and understood as a person in her entirety. I am convinced that had Cassandra not felt recognized in her unique perspective on her illness, her family, and life itself, she would not have undergone this transformation.

The conclusions to this “story” are as follows: OCD is a complex and multifaceted illness, as are the patients it consumes; treatment needs to follow evidence-based guidelines while also remaining flexible and accommodating to each individual; 12-year-olds can be highly intelligent and can provide valuable insights regarding their illnesses and treatment; psychodynamic, narrative, metaphor, and existential therapy do have a role in conjunction with CBT, in treating children and adolescents with OCD, no matter how severe the illness. Finally, I wonder whether it was my inexperience that gave me the hubris to attempt such an unconventional treatment with a patient who was deemed treatment-refractory from the start. I would posit that medical and psychotherapy trainees can offer the particular kind of inquisitiveness and creativity that come with naiveté, and it is possible that these ingredients in part led Cassandra’s story to such a hopeful ending.

Acknowledgments:

I have no financial disclosures, nor have I received any funding for this paper. I am indebted to Cassandra, and also to Dr. Leigh Solomon, Dr. Shawna Lightbody, and the child and adolescent inpatient team at the community hospital where the treatment took place.

Allen, J.L., Abbott, M.J., Rapee, R.M., Coltheart, M. ( 2006 ). Ew Gross! Recognition of disgust by children with obsessive-compulsive disorder . Behaviour Change , 23 (4), 239–249. Crossref ,  Google Scholar

American Academy of Child and Adolescent Psychiatry (AACAP) ( 2005 ). Practice Parameter for the Assessment and Treatment of Children and Adolescents with Obsessive-Compulsive Disorder . Journal of the American Academy of Child and Adolescent Psychiatry , 51 (1), 98–113. Google Scholar

American Psychiatric Association ( 2000 ). Diagnostic and statistical manual of mental disorders. 4th ed. Text Revised. (DSM-IV-TR). Arlington, VA: American Psychiatric Publishing. Google Scholar

Barker, P. ( 1985 ). Using Metaphors in Psychotherapy. New York: Brunner/Mazel. Google Scholar

Bennett, L. ( 2008 ). Narrative methods and children . Journal of Child & Adolescent Psychiatric Nursing , 21 (1), 13–23. Crossref , Medline ,  Google Scholar

Bland, A.R., Tudor, G., & Whitehouse, D.M. ( 2007 ). Nursing care of inpatients with borderline personality disorder . Perspectives in Psychiatric Care , 43 (4), 204–212. Crossref , Medline ,  Google Scholar

Boileau, B. ( 2011 ). A review of obsessive-compulsive disorder in children and adolescents . Dialogues in Clinical Neuroscience , 13 (4), 401–411. Medline ,  Google Scholar

Butwicka, A., & Gmitrowics, A. ( 2011 ). Symptom clusters in obsessive-compulsive disorder: influence of age and onset . European Journal of Child and Adolescent Psychiatry , 19, 365–370. Crossref ,  Google Scholar

Chlebowski, S., & Gregory, R.J. ( 2009 ). Is a psychodynamic perspective relevant to the clinical management of obsessive-compulsive disorder? American Journal of Psychotherapy , 63 (3), 245–56. Link ,  Google Scholar

Cohen, D. ( 2011 ). Does experimental research support psychoanalysis? Journal of Physiology , 105 (4–6), 211–219. Google Scholar

DeSocio, J.E. ( 2005 ). Accessing self-development through narrative approaches in child and adolescent psychotherapy . Journal of Child & Adolescent Psychiatric Nursing , 18 (2), 53–61. Crossref , Medline ,  Google Scholar

Doron, G., Moulding, R., Nedeljkovik, N., Kyrios, M., Mikulincer, M., Sar-El, D. ( 2012 ). Adult attachment insecurities are associated with obsessive-compulsive disorder . Psychology and Psychotherapy: Theory, Research and Practice , 85, 163–78. Crossref , Medline ,  Google Scholar

Foa, E.B. ( 2010 ). Cognitive behavioral therapy of obsessive-compulsive disorder . Dialogues in Clinical Neuroscience , 12 (2), 199–207. Medline ,  Google Scholar

Fonagy, P. ( 1999 ). The transgenerational transmission of holocaust trauma . Attachment and Human Development , 1 (1), 92–114. Crossref , Medline ,  Google Scholar

Freud, A. ( 1966 ). Obsessional neurosis: a summary of psychoanalytical views presented at Congress . International Journal of Psychoanalysis , 37, 116–22. Google Scholar

Freud, S. ( 1909 ). Notes Upon a Case of Obsessional Neurosis . In Reiff, P. (Editor) (1963). Three Case Histories: Sigmund Freud. New York: Simon & Schuster. Google Scholar

Gabbard, G. ( 2005 ). Psychodynamic Psychiatry in Clinical Practice. Washington: American Psychiatric Publishing. (4th ed.). Google Scholar

Gilbert, A.R., & Maalouf, F.T. ( 2008 ). Pediatric obsessive-compulsive disorder: management in primary care . Current Opinion in Pediatrics , 20, 544–550. Crossref , Medline ,  Google Scholar

Hamilton, E. ( 1999 ). Mythology: Timeless Tales of Gods and Heroes. New York: Grand Central Publishing. Google Scholar

Ierodiakonou, C.S., & Ierodiakonou-Benou, I. Short-term psychoanalytic psychotherapy with obsessive preadolescents . American Journal of Psychotherapy , 51 (4), 569–579. Link ,  Google Scholar

In-Albon, T. & Schneider, S. ( 2007 ). Psychotherapy of childhood anxiety disorders . Psychotherapy & Psychosomatics , 76 (1), 15–24. Crossref , Medline ,  Google Scholar

Jenike, M.A. ( 2004 ). Obsessive-compulsive disorder . The New England Journal of Medicine , 350, 259–265. Crossref , Medline ,  Google Scholar

Kempke, S., & Luyten, P. ( 2007 ). Psychodynamc and cognitive-behavioral approaches of obsessive-compulsive disorder: is it time to work through our ambivalence? Bulletin of the Menninger Clinic , 71 (4), 291–311. Crossref , Medline ,  Google Scholar

Leib, P.T. ( 2001 ). Integrating behavior modification and pharmacotherapy with the psychoanalytic treatment of obsessive-compulsive disorder: a case study . Psychoanalytic Inquiry , 21 (2), 222–241. Crossref ,  Google Scholar

Leupnitz, D.A. ( 2002 ). Schopenhauer’s Porcupines: Intimacy and Its Dilemmas. (Ch. 2, pp. 66–102). New York: BasicBooks. Google Scholar

Maina, G., Rosso, G., Rigardetto, S., Piat, C., & Bogetto, F. ( 2010 ). No effect of adding brief dynamic therapy in the treatment of obsessive-compulsive disorder with concurrent major depression . Psychotherapy & Psychosomatics , 79 (5), 295–302. Crossref , Medline ,  Google Scholar

McGehee, R.H. ( 2005 ). Child psychoanalysis and obsessive-compulsive symptoms: the treatment of a ten-year-old boy . Journal of the American Psychoanalytic Association , 53 (1), 213–37. Crossref , Medline ,  Google Scholar

Moritz, S., Kempke, S., Luyten, P., Randjbar, S., & Jelinek, L. ( 2011 ). Was Freud partly right on obsessive-compulsive disorder (OCD)? Investigation of latent aggression in OCD . Psychiatry Research , 187, 180–184. Crossref , Medline ,  Google Scholar

Munoz-Solomando, A., Kendall, T., & Whittington, C.J. ( 2008 ). Cognitive behavioral therapy for children and adolescents . Current Opinion in Psychiatry , 21, 332–337. Crossref , Medline ,  Google Scholar

National Institute for Health and Clinical Excellence (NICE) : Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder . The British Psychological Society & the Royal College of Psychiatrists. 2006 . Available at www.nice.org.uk . Google Scholar

Quinn, F. ( 2010 ). The right to choose: existential phenomenological psychotherapy with primary school-aged children . Counselling Psychology Review , 25 (1), 41–48. Google Scholar

Radomsky, A.S., Ashbaugh, A.R., & Gelfand, L.A. ( 2007 ). Relationships between anger, symptoms, and cognitive factors in OCD checkers . Behaviour Research & Therapy , 45, 2712–2725. Crossref , Medline ,  Google Scholar

Sadock, B.J., Sadock, V.A. ( 2007 ). Synopsis of Psychiatry. Philadelphia: Lippincott Williams & Wilkins; 1270–1273. Google Scholar

Shulman, S.T. ( 2009 ). Pediatric autoimmune disorders associated with streptococci (PANDAS): update . Current Opinion in Pediatrics , 21, 127–130. Crossref , Medline ,  Google Scholar

Siegelman, E.Y. ( 1990 ). Metaphor & Meaning in Psychotherapy. New York: Guilford Press. Google Scholar

Storch, E.A., Geffken, G.R., Merlo L.J., Mann, G., Duke, D., … Goodman, W.K. ( 2007 ). Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: comparison of intensive and weekly approaches . Journal of the American Academy of Child & Adolescent Psychiatry , 46 (4), 469–478. Crossref , Medline ,  Google Scholar

Storch, E.A., Lewin, A.B., Geffken, G.R., Morgan, J.R., & Murphy, T.K. ( 2010 ). The role of comorbid disruptive behavior in the clinical expression of pediatric obsessive-compulsive disorder . Behaviour Research & Therapy , 48 (12), 1204–1210. Crossref , Medline ,  Google Scholar

Storch, E.A., Mariaskin, A., & Murphy, T.K. ( 2009 ). Psychotherapyfor obsessive-compulsive disorder . Current Psychiatry Reports , 11, 296–301. Crossref , Medline ,  Google Scholar

Whalley, P. ( 1994 ). Team approach to working with transference and countertransference in a pediatric/psychiatric milieu . Issues in Mental Health Nursing , 15 (5), 457–459. Crossref , Medline ,  Google Scholar

Yalom, I.D. ( 1980 ). Existential Psychotherapy. New York: BasicBooks. Google Scholar

• Öyküsel Terapinin Dışavurumcu Sanat Uygulamaları ile Bütünleşmesi 31 March 2021 | Psikiyatride Guncel Yaklasimlar - Current Approaches in Psychiatry, Vol. 13, No. 1
• Obsessive‐Compulsive and Related Disorders 15 December 2023

• pediatric obsessive-compulsive disorder
• psychodynamic psychotherapy
• cognitive-behavioural therapy
• narrative therapy
• countertransference

Information

• Author Services

Initiatives

You are accessing a machine-readable page. In order to be human-readable, please install an RSS reader.

All articles published by MDPI are made immediately available worldwide under an open access license. No special permission is required to reuse all or part of the article published by MDPI, including figures and tables. For articles published under an open access Creative Common CC BY license, any part of the article may be reused without permission provided that the original article is clearly cited. For more information, please refer to https://www.mdpi.com/openaccess .

Feature papers represent the most advanced research with significant potential for high impact in the field. A Feature Paper should be a substantial original Article that involves several techniques or approaches, provides an outlook for future research directions and describes possible research applications.

Feature papers are submitted upon individual invitation or recommendation by the scientific editors and must receive positive feedback from the reviewers.

Editor’s Choice articles are based on recommendations by the scientific editors of MDPI journals from around the world. Editors select a small number of articles recently published in the journal that they believe will be particularly interesting to readers, or important in the respective research area. The aim is to provide a snapshot of some of the most exciting work published in the various research areas of the journal.

Original Submission Date Received: .

• Active Journals
• Find a Journal
• Proceedings Series
• For Authors
• For Reviewers
• For Editors
• For Librarians
• For Publishers
• For Societies
• For Conference Organizers
• Open Access Policy
• Institutional Open Access Program
• Special Issues Guidelines
• Editorial Process
• Research and Publication Ethics
• Article Processing Charges
• Testimonials
• Preprints.org
• SciProfiles
• Encyclopedia

Article Menu

• Subscribe SciFeed
• Google Scholar
• on Google Scholar
• Table of Contents

Find support for a specific problem in the support section of our website.

Please let us know what you think of our products and services.

Visit our dedicated information section to learn more about MDPI.

JSmol Viewer

A case of obsessive-compulsive disorder triggered by the pandemic.

1. Introduction

2. case presentation, 3. discussion, 4. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest, abbreviations.

• CDC. Coronavirus Disease 2019 (COVID-19). 2020. Available online: https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/overview/index.html (accessed on 27 January 2021).
• Cunning, C.; Hodes, M. The COVID-19 pandemic and obsessive–compulsive disorder in young people: Systematic review. Clin. Child Psychol. Psychiatry 2021 , 0 , 1–17. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Abba-Aji, A.; Li, D.; Hrabok, M.; Shalaby, R.; Gusnowski, A.; Vuong, W.; Surood, S.; Nkire, N.; Li, X.-M.; Greenshaw, A.J.; et al. COVID-19 pandemic and mental health: Prevalence and correlates of new-onset obsessive-compulsive symptoms in a Canadian province. Int. J. Environ. Res. Public Health 2020 , 17 , 6986. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Fineberg, N.A.; Van Ameringen, M.; Drummond, L.; Hollander, E.; Stein, D.J.; Geller, D.; Walitza, S.; Pallanti, S.; Pellegrini, L.; Zohar, J.; et al. How to manage obsessive-compulsive disorder (OCD) under COVID-19: A clinician’s guide from the International College of Obsessive Compulsive Spectrum Disorders (ICOCS) and the Obsessive-Compulsive and Related Disorders Research Network (OCRN) of the European College of Neuropsychopharmacology. Compr. Psychiatry 2020 , 100 , 152174. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Murray, C.J.L.; Lopez, A.D. (Eds.) The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020: Summary ; World Health Organization: Geneva, Switzerland; World Bank: Washington, DC, USA; Harvard School of Public Health: Boston, MA, USA, 1996. [ Google Scholar ]
• Mertens, G.; Gerritsen, L.; Duijndam, S.; Salemink, E.; Engelhard, I.M. Fear of the coronavirus (COVID-19): Predictors in an online study conducted in March 2020. J. Anxiety Disord. 2020 , 74 , 102258. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Coelho, C.M.; Suttiwan, P.; Arato, N.; Zsido, A.N. On the Nature of Fear and Anxiety Triggered by COVID-19. Front. Psychol. 2020 , 11 , 581314. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Ahorsu, D.K.; Lin, C.Y.; Imani, V.; Saffari, M.; Griffiths, M.D.; Pakpour, A.H. The Fear of COVID-19 Scale: Development and Initial Validation. Int. J. Ment. Health Addict. 2020 . [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Banerjee, D. The other side of COVID-19: Impact on obsessive compulsive disorder (OCD) and hoarding. Psychiatry Res. 2020 , 288 , 112966. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Sheu, J.C.; Mckay, D.; Storch, E.A. COVID-19 and OCD: Potential impact of exposure and response prevention therapy. J. Anxiety Disord. 2020 , 76 , 102314. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Olatunji, B.O.; Sawchuk, C.N.; Lohr, J.M.; De Jong, P.J. Disgust domains in the prediction of contamination fear. Behav. Res. Ther. 2004 , 42 , 93–104. [ Google Scholar ] [ CrossRef ]
• Ng, Q.X.; Chee, K.T.; De Deyn, M.L.Z.Q.; Chua, Z. Staying connected during the COVID-19 pandemic. Int. J. Soc. Psychiatry 2020 , 66 , 519–520. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Rajkumar, R. Contamination and infection: What the coronavirus pandemic could reveal about the evolutionary origins of obsessive-compulsive disorder. Psychiatry Res. 2020 , 289 , 113062. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Goodman, W.K.; Price, L.H.; Rasmussen, S.A.; Mazure, C.; Fleischmann, R.L.; Hill, C.L.; Heninger, R.; Charney, D. The Yale-Brown Obsessive. Arch. Gen. Psychiatry 1989 , 46 , 1006–1011. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders , 5th ed.; American Psychiatric Publishing: Washington, DC, USA, 2013. [ Google Scholar ]
• Hamm, B.S.; Rosenthal, L.J. Psychiatric Aspects of Chloroquine and Hydroxychloroquine Treatment in the Wake of Coronavirus Disease-2019: Psychopharmacological Interactions and Neuropsychiatric Sequelae. Psychosomatics 2020 , 61 , 597–606. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Piccinelli, M.; Pini, S.; Bellantuono, C.; Wilkinson, G. Efficacy of drug treatment in obsessive-compulsive disorder. A meta-analytic review. Br. J. Psychiatry 1995 , 166 , 424–443. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Rivera, R.M.; Carballea, D. Coronavirus: A Trigger for OCD and Illness Anxiety Disorder? Psychol. Trauma Theory Res. Pract. Policy 2020 , 12 , 33324. [ Google Scholar ] [ CrossRef ] [ PubMed ]

Share and Cite

Costa, A.; Jesus, S.; Simões, L.; Almeida, M.; Alcafache, J. A Case of Obsessive-Compulsive Disorder Triggered by the Pandemic. Psych 2021 , 3 , 890-896. https://doi.org/10.3390/psych3040055

Costa A, Jesus S, Simões L, Almeida M, Alcafache J. A Case of Obsessive-Compulsive Disorder Triggered by the Pandemic. Psych . 2021; 3(4):890-896. https://doi.org/10.3390/psych3040055

Costa, Ana, Sabrina Jesus, Luís Simões, Mónica Almeida, and João Alcafache. 2021. "A Case of Obsessive-Compulsive Disorder Triggered by the Pandemic" Psych 3, no. 4: 890-896. https://doi.org/10.3390/psych3040055

Article Metrics

Article access statistics, further information, mdpi initiatives, follow mdpi.

Subscribe to receive issue release notifications and newsletters from MDPI journals

• Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a disorder in which people have recurring, unwanted thoughts, ideas or sensations (obsessions). To get rid of the thoughts, they feel driven to do something repetitively (compulsions). The repetitive behaviors, such as hand washing/cleaning, checking on things, mental acts (like counting), or other activities, can significantly interfere with a person’s daily activities and social interactions.

Many people without OCD have distressing thoughts or repetitive behaviors. However, these do not typically disrupt daily life. For people with OCD, thoughts are persistent and intrusive, and behaviors are rigid. Not performing the behaviors commonly causes great distress, often attached to a specific fear of dire consequences (to self or loved ones) if the behaviors are not completed. Many people with OCD know or suspect their obsessional thoughts are not realistic; others may think they could be true. Even if they know their obsessional thoughts are not realistic, people with OCD have difficulty disengaging from the obsessive thoughts or stopping the compulsive actions.

A diagnosis of OCD requires the presence of obsessional thoughts and/or compulsions that are time-consuming (more than one hour a day), cause significant distress, and impair work or social functioning. OCD affects 2-3% of people in the United States, and among adults, slightly more women than men are affected. OCD often begins in childhood, adolescence, or early adulthood. Some people may have some symptoms of OCD but not meet full criteria for this disorder.

• Expert Q&A: Obsessive-Compulsive Disorder

People casually talk about being “obsessed” or even use the term “OCD” in a casual context. What is the distinction between normal, or even “quirky,” behavior, such as liking a very clean house, and the disorder?

The often off-hand or casual way OCD is referred to in the media or in everyday conversion may make it seem that the obsessions or compulsions are just something annoying or amusing that a person could “get over.” But for people with OCD it’s not a simple annoyance, it is all-consuming anxiety associated with the obsessive thoughts.

Many people will at times have concerning thoughts or prefer a clear routine and structure. But for people with OCD, the thoughts become overwhelming and create a great deal of anxiety. Compulsions associated with OCD disrupt normal daily activities. A diagnosis of OCD requires that the obsession or compulsions take more than one hour a day and cause major distress or cause problems at home, work or other function.

I have OCD, any suggestions on how to talk to family and friends about it?

Talking about your ODC and deciding who to tell are personal decisions. Family and friends can be an important source of support and understanding. They may have noticed changes in your behavior and talking about it could provide them with a better understanding and the ability to be more supportive.

In addition to the basic information on this help page, suggestions for other sources of information include the National Institute on Mental Health – NIMH-OCD page , the International OCD Foundation and NAMI’s OCD page .

Personal stories of people living with OCD can also be very useful in helping someone understand what it is like. Some examples include:

• Why OCD Is 'Miserable': A Science Reporter's Obsession With Contracting HIV (interview on National Public Radio)
• Devil in the Details: Scenes from an Obsessive Girlhood by Jennifer Traig
• Rewind, Replay Repeat: A Memoir of Obsessive Compulsive Disorder by Jeff Bell

Will OCD symptoms typically get worse over time if a person does not get treated?

Some people with mild OCD improve without treatment. More moderate or severe OCD usually requires treatment. However, there are often periods of time when the symptoms get better. There may also be times when symptoms get worse, such as when a person is stressed or depressed.

I have a family member recently diagnosed with ODC, how can I best help and support her?

Try to learn as much as you can about OCD, what it’s like, and what options are available to treat and manage the disorder. Remember to view compulsive behaviors as part of a medical condition and not personality traits or a matter of simple choice. Recognize small accomplishments – what may seem like a small change may actually take significant effort. Be patient – remember progress may be slow and symptoms may increase or decrease at times. Be mindful of changes — any change, including positive change, can be stressful and increase OCD symptoms. Work together with your family member to develop a family plan with agreed upon actions for managing symptoms. For example, set limits on discussions relating to obsessions/compulsions. Assistance from a mental health professional may be useful.

Does OCD run in families?

Yes, OCD is more common among people who have a family member who has the disorder. People with an immediate relative (parent or sibling) with OCD are two to five times more likely to experience OCD than someone without a close relative with OCD.

Tristan Gorrindo, M.D.

Chief Medical Officer Optum Behavioral Care

Medical leadership for mind, brain and body.

Mobile menu.

• Psychiatrists
• Residents & Medical Students
• Patients and Families
• Advocacy & APAPAC
• Diversity & Health Equity
• Research & Registry
• Meetings & Events
• Search Directories & Databases
• International
• Medical Students
• What is Psychiatry?
• Find a Psychiatrist
• Addiction and Substance Use Disorders
• Dementia and Alzheimer's Disease
• Alcohol Use Disorder
• Anxiety Disorders
• Attention-Deficit/Hyperactivity Disorder (ADHD)
• Autism Spectrum Disorder
• Bipolar Disorders
• Climate Change and Mental Health Connections
• Coping After Disaster
• Disruptive, Impulse-Control and Conduct Disorders
• Dissociative Disorders
• Domestic Violence
• Eating Disorders
• E-Cigarettes and Vaping
• Gambling Disorder
• Gender Dysphoria
• Helping a Loved One Cope with Mental Illness
• Hoarding Disorder
• Integrated Behavioral Healthcare
• Intellectual Disability
• Internet Gaming
• Opioid Use Disorder
• Perinatal Depression (formerly Postpartum)
• Personality Disorders
• Posttraumatic Stress Disorder (PTSD)
• Prolonged Grief Disorder
• Schizophrenia
• Seasonal Affective Disorder (SAD)
• Sleep Disorders
• Somatic Symptom Disorder
• Specific Learning Disorders
• Stigma, Prejudice and Discrimination Against People with Mental Illness
• Suicide Prevention
• Technology Addictions: Social Media, Online Gaming, and More
• Warning Signs of Mental Illness
• Electroconvulsive Therapy (ECT)
• What is Mental Illness?
• What is Psychotherapy?
• What is Telepsychiatry?
• La Salud Mental
• Childhood Disorders: Medication Guides for Parents
• Lifestyle to Support Mental Health
• Member Benefits
• Honorary Fellowship (FAPA & DFAPA)
• Awards & Leadership Opportunities
• Get Involved
• Directories, Contact Info & FAQs
• District Branches
• APA's Vision, Mission, Values, and Goals
• Meet Our Organization
• Read APA Organization Documents and Policies
• Work At APA
• About APA's Headquarters
• Policy Finder
• News Releases
• Messages from the APA President
• Reporting on Mental Health Conditions
• Goldwater Rule
• Annual Meeting Press Registration + Guidelines
• APA Public Opinion Polls
• Reporter Toolkit: Recommendations on Covering the AAPI Community
• Comunicados de prensa en español
• APA Annual Meeting
• APA Communities
• APA Foundation
• APA Learning Center
• APA Publishing
• Center for Workplace Mental Health
• Melvin Sabshin, M.D. Library & Archives
• Psychiatric News
• Psychiatry Online
• SMI Adviser
• Annual Meeting
• APA On Demand
• At the APA Educational Series
• Books and Journals
• Certification and Licensure
• Diversity and Health Equity Education Resources
• Meeting Submission and Guidelines
• Mental Health Innovation Zone
• The Mental Health Services Conference
• The Virtual Immersive
• Virtual Paid Courses
• Clinical Practice Guidelines
• Covid-19 / Coronavirus
• Digital Mental Health
• Helping Patients Access Care
• Media and Communications
• Mental Health Apps
• Mental Health Parity
• Practice Management
• Professional Interests
• Quality Improvement
• Risk Management
• Social Media
• Sunshine Act
• Telepsychiatry
• The Clozapine Risk Evaluation and Mitigation Strategy (REMS) Program
• Transition to Practice and Early Career Resources
• Well-being and Burnout
• Mental Health and Faith Community Partnership
• Mental Health Equity Looking Beyond Series
• Minority and Underrepresented (M/UR) Caucuses
• Moore Equity in Mental Health Initiative
• News and Updates
• Striving for Excellence Series
• AMNet: Addiction Medicine Practice Based Research Network
• PsychPRO: APA's Mental Health Registry
• Research Colloquium for Junior Psychiatrist Investigators
• Perinatal Mental Health Toolkit
• Psychiatric Bed Crisis Report
• Advocacy Action Center
• Congressional Advocacy Network
• Federal Affairs
• State Affairs
• Implementing 9-8-8
• Advocacy Update Webinars
• 2025 Annual Meeting
• The 2024 Mental Health Services Conference
• Addressing Structural Racism Town Hall Series
• APA Meetings App
• Governance Meetings
• Mental Health Equity Fireside Chat Series
• Moore Equity in Mental Health 5K
• Policy & Practice Insights Series
• September Component Meetings
• Social Determinants of Mental Health Town Hall Series
• Amicus Briefs
• Assembly Directory
• Component Directory
• Conference Publications
• Library and Archive
• Member Directory
• Member Obituaries
• Practice Guidelines
• Resource Documents
• International Trainees
• International Humanitarian Opportunities
• Global Mental Health
• International Medical Graduates Resources
• Residents' Journal
• Featured Publications
• APA/APAF Fellowships
• External Fellowships and Awards
• Helping Residents Cope with a Patient Suicide
• Vacant Resident Positions
• Leadership Positions
• SET for Success
• Apply for Psychiatric Residency
• Choosing a Career in Psychiatry
• Building a Career in Psychiatry
• Medical Student Programs
• Resident-Fellow Census
• Transitioning to Residency During COVID-19
• What Is a Substance Use Disorder?
• Expert Q&A: Addiction and Substance Use Disorders
• What Are Dementia and Alzheimer’s Disease?
• Expert Q&A: Dementia and Alzheimer's Disease
• What are Anxiety Disorders?
• Expert Q&A: Anxiety Disorders
• What is ADHD?
• Expert Q&A: ADHD
• What Is Autism Spectrum Disorder?
• Expert Q&A: Autism Spectrum Disorder
• What Are Bipolar Disorders?
• Expert Q&A: Bipolar Disorder
• How Extreme Weather Events Affect Mental Health
• Who Is Affected by Climate Change?
• What Is Depression?
• Expert Q&A: Depression
• What are Disruptive, Impulse Control and Conduct Disorders?
• Expert Q&A: Disruptive, Impulse Control and Conduct Disorders
• What Are Dissociative Disorders?
• Expert Q&A: Dissociative Disorders
• What are Eating Disorders?
• Expert Q&A: Eating Disorders
• What is Gambling Disorder?
• Expert Q&A: Gambling Disorder
• What is Gender Dysphoria?
• Expert Q&A: Gender Dysphoria
• What is Hoarding Disorder?
• Expert Q&A: Hoarding Disorder
• What is Intellectual Disability?
• Expert Q&A: Intellectual Disability
• What Is Obsessive-Compulsive Disorder?
• What is Perinatal Depression (formerly Postpartum)?
• Expert Q&A: Perinatal Depression
• What are Personality Disorders?
• Expert Q&A: Personality Disorders
• What is Posttraumatic Stress Disorder (PTSD)?
• Expert Q&A: Posttraumatic Stress Disorder (PTSD)
• What is Schizophrenia?
• Expert Q&A: Schizophrenia
• What are Sleep Disorders?
• Expert Q&A: Sleep Disorders
• What is Somatic Symptom Disorder?
• Expert Q&A: Somatic Symptom Disorder
• What Are Specific Learning Disorders?
• Expert Q&A: Specific Learning Disorders
• What is Technology Addiction?
• Expert Q&A: Technology Addiction
• Cigarrillos electrónicos y vapeo
• Trastorno del espectro autista
• Trastorno por consumo de alcohol
• Trastorno por consumo de opioides
• Trastorno de estrés postraumático (TEPT)
• Adicción a la tecnología: redes sociales, juegos en línea, y más
• ¿Qué es la psiquiatría?
• Conexiones entre el cambio climático y la salud mental
• General Members
• Early Career Psychiatrists
• Residents and Fellows
• International Resident-Fellows
• Semi-Retired and Retired
• View Your Profile
• Resident-Fellow Members
• Fellow of the APA
• Distinguished Fellow of the APA
• International Fellow of the APA
• International Distinguished Fellow of the APA
• 2024 Class of Honorary Fellows
• 2025 APA National Elections
• Councils, Committees and Components
• Resident-Fellow Leadership Opportunities
• Advocacy and APAPAC
• APA Specialty Interest Caucuses, Listservs & Communities
• Leadership, Equity and Diversity Institute
• Mentorship Program for APA/APAF Fellows
• Research Colloquium
• Contact Your Membership Specialist
• Contact Your District Branch
• Membership FAQs
• Semi-Retired and Retired FAQs
• Lump Sum Dues
• District Branch Resources
• District Branch Dues for General Members
• District Branch Dues for Residents and Fellows

Module 5: Obsessive Compulsive Disorder and Stressor Related Disorders

Case studies: ocd and ptsd, learning objectives.

• Identify OCD and PTSD in case studies

Case Study: Mauricio

Case Study: Cho

Possible treatment considerations for Cho may include CBT or eye movement desensitization and reprocessing (EMDR). This could also be coupled with pharmaceutical treatment, such as anti-anxiety medication or anti-depressants to help alleviate symptoms. Cho will need a trauma therapist who is experienced in working with adolescents. Other treatment that may be helpful is starting family therapy as well to ensure everyone is learning to cope with the trauma and work together through the painful experience.

Link to Learning

To read more about the ongoing issues of PTSD in violent-prone communities, read this article about a mother and her seven-year-old with PTSD .

Think It Over

If you were a licensed counselor working in a community that experienced a high rate of violent crimes, how might you treat the patients that sought therapeutic help? What might be some of the challenges in assisting them?

• Case Studies. Authored by : Christina Hicks for Lumen Learning. Provided by : Lumen Learning. License : Public Domain: No Known Copyright
• Desk top. Located at : https://www.pickpik.com/desk-top-desk-notebook-keyboard-desktop-shallow-116155 . License : Public Domain: No Known Copyright
• Lightning strike. Authored by : John Fowler. Located at : https://www.flickr.com/photos/snowpeak/3761397491 . License : CC BY: Attribution

• 315 Montgomery Street, 10 th Floor, Suite #900, San Francisco, CA 94104, USA
• [email protected]
•   +1-628-201-9788
• NLM Catalog

• Crossmark Policy

For Authors

• Author Guidelines
• Plagiarism policy
• Peer review Process
• Manuscript Guidelines
• Online submission system
• Processing Fee

For Editors

• Editor Guidelines
• Associate Editor Guidelines
• Reviewer Guidelines

To Register as

• Associate Editor
• Submit Manuscript

NLM Catalog Journals

• Archives in biomedical engineering & biotechnology
• Online journal of complementary & alternative medicine
• Archives in Neurology & Neuroscience
• Global Journal of Pediatrics & Neonatal Care
• World Journal of Gynecology & Womens Health
• Anaesthesia & Surgery Open Access Journal
• Global Journal of Orthopedics Research
• Annals of urology & nephrology

Online Journal of Complementary & Alternative Medicine - OJCAM

• ISSN: 2644-2957

Managing Editor: Justin Allison

NLM ID: 101752366

Contact us at:

• [email protected]
• [email protected]

Case Report

Case study of obsessive-compulsive disorder (ocd).

Muhammad Zafar Iqbal*

Department of Hypnotherapist and Psychotherapist, Islamabad, Pakistan

Corresponding Author

Muhammad Zafar Iqbal, Department of Hypnotherapist and Psychotherapist, Islamabad, Pakistan.

Received Date: April 05, 2019;   Published Date: May 08, 2019

Background: This document pertains of idiographic research; the case study of Obsessive-compulsive disorder (OCD). The objective of this case study was to reaffirm the efficacy of Fear-Stimuli Identification Therapy (FSIT). FSIT was used to eliminate the symptoms of OCD in a client, a successful treatment for disorders in different cases [1-8].

Method: Initially seven sessions of semi-structured interviews were conducted with client to dig out the reasons/causes of the disorder. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) was consulted for diagnosis [9]. Fear Stimuli Identification Therapy (FSIT) was used as therapeutic tool.

Results: After diagnosis, five sessions per week, a total of eighty-three sessions were conducted of FSIT. Positive behavioral change observed in client which proved the efficacy of FSIT.

Conclusion: Clinical observations during treatment indicated a gradual positive change in client’s personality. The client and her husband reported positive behavioral changes in different domains of life. The difference between pre-assessment and post- assessment confirmed precision of hypotheses and efficacy of FSIT.

Keywords: Obsessive compulsive disorder; Symptoms; Assessment; Case study; Idiographic

• Introduction

The subject of the disorder was Mrs. S.H. (Initials of real name), age 38 years, a Housewife. The client was referred to therapist clinic by a fellow psychologist from a metropolitan southern city. She had been under treatment of various psychiatrists and psychologists in her city, but the client did not improve. She contacted therapist online. Client reported about her compulsively repeating some acts in her daily life as obsession. She supposed that her mind was persistently occupied by some specific thoughts and her act of repeating some actions is a result of these thoughts. Therapist contacted her husband for more details about the behavior of client. Aggressive behavior, Sleeplessness, weeping without any apparent reason, Breath shortness, Uncontrollable thoughts, Repetition of some of her daily life acts Symptoms are reported by Client and her husband.

• Participants

Mrs. S.H, Client, Client’s Husband and Therapist.

• Instrument

No instrument/ Material used in this case study.

As already mentioned, in the first seven sessions, semistructured interviews were conducted with Mrs. S.H. and her husband. In the subsequent eighty-three sessions Mrs. S.H. was asked to write about specific topics suggested by therapist. Crossquestioning was carried out over the ideas mentioned in the writings by client. After diagnosis of OCD, treatment was started in the light of FSIT method. Five sessions per week were conducted and total of eighty-three sessions were conducted. It may be noted that all these sessions were carried out online [4].

Following facts were explored through initial interviews which were ‘Semi-structured’. These interviews revealed that at the age of 11 years, one day she (client) returned back from school in the company of her close friend N.S. After reaching home she and her parents received the shocking news of death of N.S. They were told that N.S. had eaten something poisonous and had died instantly. S.H., the client was shocked deeply. The incident of her friend’s death became a stimulant for fear instinct.

At the day of her funeral, she feared to see the face of her deceased friend and couldn’t enter the room where the dead body was laid. After the death of her friend another death happened that provoke more fear about the death. Her grandmother died six months later after her friend’s death. She, for the first time watched her grandmother’s dead body wrapped in white clothes which leaves bad marks on her memory that she stopped wearing white cloth especially white scarf or shawl for rest of her life.

Another incident happened after one year of marriage. Her father-in-law died in ambulance due to sudden attack. The ambulance became a stimulus for her fear. After developing death phobia, each death intensified the sense of fear in her unconscious mind. In the course of time she became a religious orator orator of a specific type as she used to narrate rhetorically upon the miseries and sorrows which had emerged from the unfortunate events of wars of Islamic history. By performing so, she felt some sort of relief as this became a source of catharsis for her. She was strongly obsessed by the idea of death that her mind often used to get stuck at the thought of her friend’s death. While doing random stuff she often found herself motionless due to the flashback of her friend’s death and to get rid from this obsession she used to force her mind to think of other things. Similarly, she taps her mobile phone with her fingers frequently while obsessing about her brother’s death. During one of Skype sessions she informed the therapist that after marriage she finds it more difficult to cope with the obsessive ideas.

Therapist and treatment

It is single case experimental study which is handled by only one therapist and after taking history, it was diagnosed that client was suffering from OCD and the treatment was carried out accordingly: As per procedure of SFW (specific free writing; one of procedures of FSIT), in very first session of treatment, client was asked to pen down her ideas freely on the topic “death”. She was asked to put a cross mark for each time whenever she feels stuck or blank-minded during writing process. The piece of writing was received by E-mail. She told that during the process of writing she felt burden at the occipital region of head and pain and burden on her shoulders. In the view of writing, client was cross-questioned over the ideas mentioned in the writing. After fifteen minutes, client went through a deep spell of drowsiness. The session was ended at this point. This drowsiness continued in the next five sessions during questioning over her writing. The extreme hate for and fear of her own death which had previously gripped her unconscious level of mind was identified and brought out clearly as it had been suppressed by patient’s unconscious for a very long time in past. Next topics given to write about were: “White shawl” (considered as coffin), “Bathing place” for a dead person at holy shrine, the “couch” upon which dead body is laid down after bath, “Ambulance”, “Funeral Bus” and “Thoughts about dead persons”. During writing practice, same mental and physical response was reported each time as it was observed first time that was a result of unconscious resistance to express fears. The thoughts of “white shawl”, “coffin” and ambulance etc caused the fear of her own death and ultimately became reason for OCD. In last sessions of treatment, the mentioned above things were rooted out and recovered from OCD.

The symptoms of disorder gradually removed during therapy. Feedback obtained from husband & client was obtained regularly which indicated the positive changes in client behavior of. Result also proved the efficacy of FSIT method empirically.

Brief description of a client’s social and family environment was obtained in order to comprehend the main causes of Mrs. S.H.’s disorder and this procedure is adopted in most of the cases treated by therapist. In this particular case following information came into knowledge of therapist. Mrs. S.H. was 38 years old, housewife and a lecturer in college. However, due to lack of concentration, disturbed sleep and unreasonable repetition of different acts of routine, her daily routine was badly affected, and it made her much depressed and disappointed. Mrs. S.H. was not much social person since her childhood. She had always tried to avoid social gatherings and people. After starting the problem of OCD, her social life became more difficult. It made her more depressed, but interestingly and contrarily, she had managed to carry out routine life activities as above the level of an ordinary social individual. She had been performing as an orator at religious gatherings. But she always avoided elaborating over the topics of death and afterlife in her speeches. No family history of OCD or any other psychiatric disorder was found and she. had no special medical/psychiatric problems in her childhood [10].

Fear Stimuli Identification Therapy (FSIT): Fear-Stimuli Identification Therapy (FSIT) is based upon the perception that some of the incidents (mostly the sudden incidents) in the early age of a child become stimuli for fear instinct which cast negative effects over the personality of a child and become reason for one or the other type of disorder. FSIT investigates and digs out such events from a person’s unconscious, which play as stimuli for fear instinct. In a later stage of life, if a person happens to face a situation or pass through an event having resemblance to that which he/ she had already faced in her/his childhood or early age of life, the present event becomes a strong stimulant for fear instinct as the previous incident is recalled.

Feedback & Clinical observations during treatment also indicated a gradual positive change in her personality. The difference between pre-assessment and post- assessment confirmed precision of hypotheses and efficacy of FSIT. Feedback was obtained on weekly basis for a period of three was confirmed that there was no reoccurrence of the disorder’s symptoms anymore.

• Acknowledgement
• Conflict of Interest

No conflict of interest.

• Ejaz M, Iqbal MZ (2016) Case Study of Major Depressive Disorder. J Clin Case Rep 6: 698.
• Iqbal MZ, Awan SN (2016) Case Study of Genophobia and Anxiety. J Depress Anxiety S2: 013.
• qbal MZ, Bibi S (2017) Case Study of Panic Attacks. J Psychol Psychother 7: 306.
• Iqbal MZ, Bibi S (2016) Treatment of Psychosis through Fear-Stimuli Identification Therapy (FSIT): A Case Report. Brain Disorders & Therapy 5(3): 221-224.
• Iqbal MZ, Ejaz M (2016) Case Study of Schizophrenia (Paranoid). J Clin Case Rep 6: 779.
• Iqbal MZ, Ejaz M (2016) Case Study of Functional Neurological Disorder (Aphonic). J Psychol Psychother 6(1): 243.
• Iqbal MZ, un Awan SN (2016) Case Study of Major Depression. J Med Diagn Meth 5: 214.
• Iqbal Z (2015) Case of Anxiety. J Psychol Clin Psychiatry 2(4): 79.
• American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders (DSM-IV-TR). Washington DC, USA.
• Muhammad Zafar Iqbal (2017) Case study of Obsessive-Compulsive Disorder (OCD). Journal of Behavioral Health 6(2): 99-102.
• Download PDF
• DOI: 10.33552/OJCAM.2019.01.000509
• Volume 1 - Issue 2, 2019
• Open Access

Muhammad Zafar Iqbal. Case Study of Obsessive-Compulsive Disorder (OCD). On J Complement & Alt Med. 1(2): 2019. OJCAM. MS.ID.000509.

Obsessive Compulsive Disorder, Symptoms, Assessment, Case Study, Idiographic, Therapist, Spirituality, Preventive, Health care, Physical fitness, Spiritual exercises, Soul, Human values, Stress, Complementary Medicine, Holistic education, Phenomenological study, Holistically, Facilitate, Spiritual care, Trigger depression, Spiritual work

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License .

Track Your Article

Refer a friend, suggested by, referrer details, advertise with us.

Last updated 27/06/24: Online ordering is currently unavailable due to technical issues. We apologise for any delays responding to customers while we resolve this. For further updates please visit our website: https://www.cambridge.org/news-and-insights/technical-incident

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings .

Login Alert

• > Journals
• > the Cognitive Behaviour Therapist
• > Volume 16
• > Treating trauma-driven OCD with narrative exposure...

Article contents

• Key learning aims

Introduction

Client characteristics and presenting problems, key practice points, data availability, author contributions, financial support, conflicts of interest, ethical standards, treating trauma-driven ocd with narrative exposure therapy alongside cognitive behavioural therapy.

Published online by Cambridge University Press:  06 January 2023

When post-traumatic stress disorder (PTSD) co-occurs with obsessive compulsive disorder (OCD), symptoms of the former can interfere with evidence-based treatment of the latter. As a result, exposure-based treatments are recommended for both OCD and PTSD, potentially facilitating a concurrent treatment approach. This case study describes the application of concurrent cognitive behaviour therapy (CBT including exposure and response prevention; ERP) for OCD and narrative exposure therapy to treat a patient whose PTSD symptoms of intrusive images of memories and hyperarousal were interfering with standard CBT (including ERP) treatment for OCD. Following this concurrent approach, the patient’s symptoms of OCD reduced to non-clinical levels and showed reliable improvement in PTSD symptoms. Whilst further methodologically robust research is required, this case study highlights that this approach may be beneficial to the treatment of OCD where PTSD symptoms are impacting on treatment.

(1) To explore the literature considering explanations of the co-occurrence of OCD and PTSD symptomology.

(2) To consider how symptoms of two mental health conditions can maintain one another and attenuate the effectiveness of evidence-based treatment for the other mental health condition.

(3) Consider the use of concurrent therapeutic approaches to treat co-occurring mental health conditions.

Access options

Obsessive compulsive disorder (OCD) is characterised by recurrent obsessions (intrusive, persistent, unwanted thoughts or images) and/or compulsions accompanied by marked distress and impairment in daily living (American Psychiatric Association, 2013 ). Cognitive behavioural explanations of OCD (e.g. Salkovskis, Reference Salkovskis 1985 ) postulate that normal intrusive thoughts can become clinical obsessions when the thought is interpreted by an individual as having personal significance and are ego-dystonic (Salkovskis, Reference Salkovskis 1985 ). These thoughts bring with them significant distress, which results in the individual completing some action (compulsion) to reduce this, i.e. a neutralising behaviour. This reduction in distress is reinforcing, leading to an increase in occurrence of the neutralising behaviour. Central components of this model, such as unwanted intrusive thoughts and avoidance, are shared by a number of anxiety conditions, including post-traumatic stress disorder (PTSD; American Psychiatric Association, 2013 ).

PTSD consists of the co-existence of the re-experiencing of elements of previously experienced traumatic event(s), avoidance of stimuli associated with the event(s), hyperarousal and negative alterations in cognitions and mood persisting for at least one month (American Psychiatric Association, 2013 ). The cognitive model of PTSD (Ehlers and Clark, Reference Ehlers and Clark 2000 ) suggests individuals process a traumatic event in a way that leads to a sense of current threat. This arises due to negative appraisals of the trauma and/or its consequences which go beyond how the trauma might be generally appraised as horrific (e.g. the fact the trauma happened to them being significant) and due to the autobiographical memory lacking contextualisation. Instead, it is characterised by strong associative memory and perceptual (sensory) priming leading to the memory having a sense of ‘nowness’. This problem becomes enduring due to problematic behavioural and cognitive strategies (i.e. SSBs) preventing new interpretations and further memory (cognitive, sensory and affective) processing (Ehlers and Clark, Reference Ehlers and Clark 2000 ).

Clinicians have long documented the overlap between OCD and PTSD. Pitman ( Reference Pitman 1993 ) presented the case of a veteran who developed OCD following traumatic experiences during his service, leading the author to coin the term post-traumatic obsessive compulsive disorder. Other case studies have since reported on similar presentations (e.g. De Moraes et al ., Reference De Moraes, Torresan, Trench and Torres 2008 ; Sasson et al ., Reference Sasson, Dekel, Nacasch, Chopra, Zinger, Amital and Zohar 2005 ). Empirical studies highlight the disorders can co-occur, with the National Comorbidity Survey Replication showing those with a current diagnosis of PTSD were 3.62 times more likely to have OCD than those without PTSD (Brown et al ., Reference Brown, Campbell, Lehman, Grisham and Mancill 2001 ; albeit with a small sample n = 13); whilst Huppert et al . ( Reference Huppert, Moser, Gershuny, Riggs, Spokas, Filip and Foa 2005 ) reviewed studies reporting rates of this co-morbidity and found rates of PTSD between 6 and 22% in those with OCD.

With reference to Rachman ( Reference Rachman 1991 ), it is clear these disorders share ‘psychological connectedness’ (p. 461) with several authors highlighting this link (Dinn et al ., Reference Dinn, Harris and Raynard 1999 ; Gershuny et al ., Reference Gershuny, Baer, Jenike, Minichiello and Wilhelm 2002 ; Huppert et al ., Reference Huppert, Moser, Gershuny, Riggs, Spokas, Filip and Foa 2005 ; Riggs, Reference Riggs 2000 ). Examples of the logical and semantic relationship between certain traumatic experiences and subsequent OCD symptoms are evident in Pitman ( Reference Pitman 1993 ) and the case series of Sasson et al . ( Reference Sasson, Dekel, Nacasch, Chopra, Zinger, Amital and Zohar 2005 ), such as being covered by the blood and flesh of soldiers leading to excessive cleaning. Huppert et al . ( Reference Huppert, Moser, Gershuny, Riggs, Spokas, Filip and Foa 2005 ) suggest rituals and avoidance behaviours develop to avoid intrusive memories associated with trauma. Through negative reinforcement via compulsions alleviating distress, these symptoms become independently maintained (Fostick et al ., Reference Fostick, Nacasch and Zohar 2012 ). Once established, symptoms of PTSD and OCD have been shown to interact and exacerbate each other. In a case series, Gershuny et al . ( Reference Gershuny, Baer, Radomsky, Wilson and Jenike 2003 ) observed symptoms of OCD and PTSD were connected such that targeting OCD specific symptoms in treatment resulted in increases in PTSD symptoms, such as intrusive thoughts and flashbacks related to specific trauma memories.

Cognitive models of co-occurrence of these disorders (Dinn et al ., Reference Dinn, Harris and Raynard 1999 ; Riggs, Reference Riggs 2000 ) focus on the negative cognitive effects of exposure to trauma evoking anxiety. This leads to excessive labelling of stimuli as threatening which leads to compensatory mechanisms, such as compulsions or neutralising behaviours which reduce arousal and are therefore reinforced (Eysenck and Rachman, Reference Eysenck and Rachman 1965 ). Gershuny et al . ( Reference Gershuny, Baer, Radomsky, Wilson and Jenike 2003 ) proposed OCD symptoms, such as excessive checking or hyper-attention, facilitate avoidance of emotional discomfort generated by trauma cues, and therefore the authors’ conceptualised obsessive compulsive behaviours as serving a protective function against trauma-related memories and associated negative affect. Indeed, to paraphrase Riggs ( Reference Riggs 2000 ), it’s easier to worry about the dirt in your kitchen than the trauma of your combat experience.

Literature describing ‘mental contamination’ which can be apparent in OCD also has relevance here given that this can relate to traumatic experiences. Mental contamination is a current internal sense of dirtiness that occurs in the absence of physical contact with a contaminant (Rachman, Reference Rachman 2004 ) and is thought to develop following previous emotional or physical violations such as degradation, betrayal or abuse. Importantly, feelings of mental contamination can be evoked by memories and images, such as traumatic memories, and therefore such symptoms could be triggered by situations associated with such memories. As with cognitive theories of PTSD and OCD which contest that a misinterpretation of meaning can result in distressing symptoms, the cognitive theory of mental contamination postulates too that this arises due to a serious misinterpretation of the personal significance of a psychological or physical violation. This distress results in vigorous and repetitive washing to get rid of associated unpleasant feelings (Radomsky et al ., Reference Radomsky, Coughtry, Shafran and Rachman 2017 ). Coughtrey et al . ( Reference Coughtrey, Shafran, Lee and Rachman 2013 ) found that 46% of individuals with OCD experienced mental contamination and that increased severity of mental contamination was associated with more severe OCD.

There is strong evidence for treatment of OCD from a cognitive behavioural framework. Cognitive behavioural therapy (CBT) including exposure and response prevention (ERP) has been shown to be effective for the treatment of OCD and is recommended as the first line treatment by NICE (National Institute of Health and Care Excellence, 2005 ). CBT including ERP identifies and modifies dysfunctional appraisals of intrusions and symptom related beliefs. It also identifies avoided stimuli which evoke anxiety, and has individuals come into contact with these stimuli whilst refraining from engaging in compulsions or neutralising behaviours (ERP).

Trauma-focused therapies incorporating exposure such as CBT (Ehlers and Clark, Reference Ehlers and Clark 2008 ), eye movement desensitisation and reprocessing (EMDR; Shapiro, Reference Shapiro 2014 ) and narrative exposure therapy (NET; Lely et al ., Reference Lely, Smid, Jongedijk, Knipscheer and Kleber 2019 ; Robjant and Fazel, Reference Robjant and Fazel 2010 ) have been demonstrated to be effective in the treatment of PTSD (Bisson et al ., Reference Bisson, Roberts, Andrew, Cooper and Lewis 2013 ) and are recommended by NICE guidelines (although EMDR is only recommended if an individual has a preference for this and the trauma was not combat-related). The approaches being trauma-focused means that they directly focus on memories, thoughts and feelings related to the traumatic event (Watkins et al ., Reference Watkins, Sprang and Rothbaum 2018 ). NET was specifically developed for individuals who have experienced multiple traumatic events. It enables individuals to develop a coherent autobiographical narrative of their most significant experiences to help contextualise events that were highly arousing so that internal reminders and trauma related triggers have less dominance of the person’s life (Neuner et al ., Reference Neuner, Elbert, Schauer, Bufka, Wright and Halfond 2020 ).

Treatment of OCD has been found to be less efficacious when there is co-morbid PTSD. Gershuny et al . ( Reference Gershuny, Baer, Jenike, Minichiello and Wilhelm 2002 ) found those with OCD alone improved with ERP while those with co-occurring PTSD did not, with decreases in symptoms of OCD during ERP leading to intensification of PTSD symptoms. Furthermore, Gershuny et al . ( Reference Gershuny, Baer, Parker, Gentes, Infield and Jenike 2008 ) observed that for those with treatment-resistant OCD, 82% had a history of trauma while 39% met criteria for PTSD, suggesting its co-occurrence contributed to treatment resistance. Gershuny et al . ( Reference Gershuny, Baer, Radomsky, Wilson and Jenike 2003 ) suggested due to their dynamic connection, targeting either disorder in isolation may impede therapy effectiveness. Clinicians have therefore advocated for treatment strategies targeting symptoms of OCD and PTSD simultaneously (Gershuny et al ., Reference Gershuny, Baer, Jenike, Minichiello and Wilhelm 2002 ), or consecutively (de Silva and Marks, Reference de Silva and Marks 1999 ). A number of recent case studies have reported on the presentation and treatment of individuals with OCD and co-morbid PTSD. Nijdam et al . ( Reference Nijdam, van der Pol, Dekens, Olff and Denys 2013 ) reported the successful treatment of a male with PTSD and OCD with EMDR followed by ERP following sexual assault. It was documented that during treatment, remission of PTSD symptoms preceded that of OCD symptoms and the authors highlighted that applying EMDR first made it easier for the patient to reduce OCD symptoms because of decreased anxiety and trauma reminders. Stobie ( Reference Stobie and Grey 2009 ) also reported on the case of women with PTSD and OCD which occurred following a physical assault. They used trauma-focused CBT initially to treat PTSD followed by CBT for OCD. They reported that helping the patient understand the link between the context of previous trauma (i.e. the location in which it happened) and current OCD related intrusions (triggered by a similar location to where the trauma occurred) helped change the symptom’s meaning, and in combination with CBT/ERP, reduced the compulsions associated with this intrusion.

The current case study seeks to add to the literature on the treatment of those presenting with PTSD and OCD by presenting a case of a male in his late-20s with OCD and PTSD symptoms which emerged following a series of traumatic and highly aversive experiences. The case was initially conceptualised as OCD; however, PTSD symptoms related to trauma became more prominent upon certain exposures and interfered with OCD treatment. The case study is novel in that it presents the use of concurrent NET and CBT with ERP as a treatment approach for co-morbid OCD and PTSD symptoms.

This study reports the case of Arwyn (anonymised), a Caucasian male referred to a Psychological Therapies Team who had recently stopped working and become housebound due to exacerbation of OCD symptoms. Arwyn reported he had been struggling with OCD for around 10 years. His symptoms centred on rituals to ensure cleanliness and decontamination. He reported spending 6 hours a day on rituals. He used anti-bacterial spray on his clothes, bed and furnishings, and washed excessively. He had quarantined all items he perceived were contaminated to his utility room, which he described as representing all the unpleasant things that occurred during his life. He refrained from eating in his family home due to fears of contamination. This resulted in him losing 10 kg of body weight.

History of traumatic and aversive events

Arwyn described four significant events he perceived as contributing to his eventual presentation. Arwyn did not initially disclose all these events but reported that intrusive memories of these events were triggered during the course of ERP. Initially when recalling these events, he was highly avoidant of discussing them and his recall was fragmented. The details below became clearer following the completion of NET itself. Certain events meet criteria for a traumatic event according to the DSM-V definition (American Psychiatric Association, 2013 ) in order to qualify for a diagnosis of PTSD (i.e. serious injury in this case). For others this may be less clear and might be more appropriately termed an aversive event (however, see Brewin et al ., Reference Brewin, Lanius, Novac, Schnyder and Galea 2009 and Anders et al ., Reference Anders, Frazier and Frankfurt 2011 for a discussion around the usefulness of Criterion A).

Arwyn was physically assaulted whilst visiting friends at a university he was planning to attend (1); this assault resulted in serious physical injury that required significant cosmetic treatment. As a result of this incident he stopped seeing this group of friends. He also decided not to go to university and instead started an apprenticeship in the local area which he saw as an opportunity to ‘toughen up’. During this he was subjected to significant verbal and physical bullying which occurred over a prolonged period of time and was perpetrated by individuals in a position of power over him (i.e. his supervisors). A number of bullying incidents resulted in Arwyn being put in a position of helplessness (2). He eventually dropped out of this apprenticeship and completed a university degree. By this time, he reported displaying symptoms of OCD such as excessive cleaning. Following his degree, he went travelling. Due to perceived differing hygiene norms in the country he visited and with OCD symptoms already present in the form of concerns about contamination with germs leading to illness or death, Arwyn was in a high state of stress throughout this time. It was in this context he believed he was cursed by a native of the country following a difficult interaction (3) and therefore engaged in neutralising rituals in line with the religions of that country to rid himself from the curse. Following his return, his OCD symptoms became more severe with large amounts of anxiety and SSBs. Arwyn experienced significant anxiety when confronted with people he perceived as originating from a country he had visited during his travels, or people from his workplace, leading him to take measures to avoid contact with them. This culminated in the final difficult event in which Arwyn became overwhelmed by anxiety in work whilst trying to avoid contact with contaminants (proximity to individuals perceived to be from the country in which he went travelling or objects that could have come into contact with such individuals) and subsequently became trapped in his utility room, unable to leave due to the fear of spreading perceived contamination (4).

Previous treatment

Arwyn received 12 private CBT sessions before entering the current service. Following these sessions, he had reduced his spraying of disinfectant and delayed washing his hands after touching doors. However, he still presented with avoidant and compulsive behaviours, such as not eating, which presented concerns about his health and therefore motivated a referral to secondary care. The exact nature of the CBT Arwyn received was unclear but his previous therapist (with Arwyn’s consent) reported he had a good understanding of the CBT model of OCD and his formulation. They also highlighted that Arwyn was extremely avoidant of difficult emotions.

Symptom measures

The Obsessive Compulsive Inventory revised (OCI-R; Foa et al ., Reference Foa, Huppert, Leiberg, Langner, Kichic, Hajcak and Salkovskis 2002 ) was used to measure OCD symptoms. It consists of 18 items assessing six symptoms of OCD (washing, checking, ordering, obsessing, hoarding and neutralising). The OCI-R has excellent internal consistency, test–retest reliability, and convergent and discriminant validity (Foa et al ., Reference Foa, Huppert, Leiberg, Langner, Kichic, Hajcak and Salkovskis 2002 ). A score of 21 or above is used as a cut-off to indicate the likely presence of OCD. The mean score on the OCI-R in a large sample of individuals with OCD is 28 ( SD = 13.53), while those without a diagnosis of OCD scored 18.82 ( SD = 11.10; Foa et al ., Reference Foa, Huppert, Leiberg, Langner, Kichic, Hajcak and Salkovskis 2002 ).

The Impact of Events Scale-Revised (IES-R; Weiss, Reference Weiss, Wilson and Keane 2007 ), a 22-item self-report measure that assesses subjective distress caused by traumatic events, was used on two occasions during Arwyn’s treatment, once before starting NET and once at his final session. A score of 33 and above represents best cut-off for probable PTSD (Creamer et al ., Reference Creamer, Bell and Failla 2003 ).

Informed consent

The rationale and process for each aspect of treatment was provided to Arwyn, who consented to proceed with treatment and for his assessment and treatment to be written as a case study.

Treatment initially used CBT (including ERP) for OCD (Salkovskis, Reference Salkovskis 1985 ) without any focus on traumatic memories (Phase A) and later progressed to combine NET with CBT including ERP (Phase B). The choice to add NET to the treatment approach was a pragmatic one which was influenced by a plateau in symptom reduction and evidence of re-experiencing symptoms of PTSD (intrusive unwanted memories and arousal) upon exposure to certain OCD triggers. When questioned about these during exposure there was also a reluctance (avoidance) to discuss these events. Phase A was completed by a qualified clinical psychologist. For Phase B, NET was facilitated by the same qualified clinical psychologist, while CBT with ERP was carried out by a trainee clinical psychologist.

Initial formulation

A formulation of Arwyn’s difficulties was collaboratively developed (see Fig.  1 ), based on a vicious flower maintenance cycle of OCD (Salkovskis, Reference Salkovskis, Tarrier, Wells and Haddock 1998 ). A longitudinal component was added to make sense of how the OCD developed, and a critical incident to account for the why now? question. It was hypothesised a combination of pre-disposing factors, such as perfectionist tendencies (which included high standards of cleanliness) and significant life events interactively combined to lead to an overwhelming experience of anxiety during the critical incident. During this incident, Arwyn described that he became overwhelmed by anxiety at work due to beliefs that it was contaminated as a result of coming into contact with individuals who he perceived were from the country in which he was ‘cursed’ during his travels. He believed that ‘germs’ associated with people originating from the country in which he went travelling would result in illness and himself and his family dying. He perceived he lost control and ‘escaped’ to his utility room at home and became ‘trapped’ due to not wanting to spread contamination. On Fig.  1 the connection between the critical incident and maintenance factors is reciprocal due to the fact that this belief and anxiety around contamination were already present to a lesser extent and influenced his experience of this incident.

Figure 1. Arwyn’s formulation. The dashed lines were added at Phase B (revised formulation).

Arwyn developed SSBs in relation to both anticipatory and consequent anxiety (Salkovskis, Reference Salkovskis 1991 ) in order to stop the feared outcome occurring. These avoidance and escape behaviours had the effect of preventing Arwyn discovering his beliefs were inaccurate (in line with Salkovskis, Reference Salkovskis 1991 ), and prevented the extinction of the anxiety when exposed to the feared situations (de Silva and Rachman, Reference de Silva and Rachman 1984 ).

Intervention directed by initial formulation

Arwyn was initially treated using CBT (including ERP) which is the first line treatment recommended for OCD by NICE guidelines (the National Institute of Health and Care Excellence, 2005 ). It was hypothesised Arwyn exposing himself to feared situations via ERP (following an exposure hierarchy) and challenging his beliefs about the consequence of this would lead him to learn his predictions were untrue and to a reduction in anxiety.

Sessions 1 to 20 involved the collaborative development of a formulation. Arwyn was introduced to the idea of Theory A  (‘contact with contaminants (‘germs’) associated with country I went travelling in will lead to illness and possible death as well as intolerable levels of anxiety causing me to lose control’) and Theory B (‘I am worried that contact with contaminants will lead to illness and possible death, anxiety is normal and will come down on its own accord’) (Challacombe et al ., Reference Challacombe, Oldfield and Salkovskis 2011 ) and evidence for these were discussed using cognitive restructuring. Arwyn completed homework tasks of exposure work to explore which theory fitted best with his experience. While ERP was conducted on two occasions with the psychologist, these were on items lower down Arwyn’s hierarchy. Most of the exposure homework was done by Arwyn alone or with help of a support worker or family members. The ERP tasks included not using his anti-bacterial spray and eating food prepared in the kitchen adjacent to the utility room.

Arwyn made progress on increasing his exposure to things lower down the hierarchy and reduced his ritualistic behaviour significantly. However, by session 20 Arwyn’s OCI-R scores had plateaued, remaining within the clinical range and both he and his family were frustrated at his rate of progress. Arwyn reported that exposure to items more directly associated with traumatic events (e.g. items or people associated with travelling, his old workplace or local areas where he was placed for his apprenticeship) he had experienced evoked intrusive memories and high levels of arousal he was unable to tolerate, and therefore would quickly discontinue the exposure. When initially questioned about these events Arwyn was visibly distressed and reluctant to discuss them and reported that he had never spoken to anyone about them before. The account of what he was able to initially share about his memory was also very fragmented.

Revised formulation

Arwyn’s formulation was revised to highlight how intrusive memories and thoughts with negative interpretation about traumatic events brought about a sense of current threat and high levels of arousal. This further added to Arwyn’s belief he would experience intolerable anxiety. The dashed arrows in Fig.  1 represent aspects added to the revised formulation, whilst asterisks represent aspects directly associated with traumatic events Arwyn experienced. Arwyn reported voluntary suppression of the memories related to his past experiences and was not prepared to discuss these in depth at the start of therapy, a characteristic also shared with PTSD (Ehlers and Clark, Reference Ehlers and Clark 2000 ). According to the cognitive model of PTSD, traumatic memories fail to become encoded in autobiographical memory and hence are experienced with a sense of current threat resulting in intrusions and physiological arousal. Due to the symptoms’ aversive nature, strategies emerge to control them (e.g. avoidance of reminders of trauma) further preventing processing and encoding into autobiographical memory (Ehlers and Clark, Reference Ehlers and Clark 2000 ). Arwyn’s symptoms could fit such a profile, as he experienced high levels of distress when placed in situations associated with trauma (i.e. sense of current threat) and developed strategies to control these symptoms such as avoiding his workplace and items and memories associated with travelling. Whilst these avoidance symptoms were related to his OCD, Arwyn also reported avoidance symptoms that were pre-morbid to his OCD in that he decided not to go university (where he was assaulted) and isolated himself from his friends as a result of them reminding him of the first traumatic event (assault). Due to avoidance, Arwyn’s sense of current threat (Ehlers and Clark, Reference Ehlers and Clark 2000 ) when exposed to situations associated with traumatic events remained high, making it difficult to complete ERPs.

It was hypothesised applying NET to allow further processing of the traumatic memories and therefore elaboration and contextualisation (Ehlers and Clark, Reference Ehlers and Clark 2000 ) would lead to autobiographical storage of the memories, reducing sense of current threat and therefore arousal. This would increase the likelihood that Arwyn could tolerate exposures. NET was chosen primarily pragmatically above approaches such as TF-CBT or EMDR due to Arwyn having experienced a series of traumatic and aversive events throughout his early adulthood which meant that there were significant periods of Arwyn’s history that he found difficult to talk about. His traumatic experiences also shared some relationship with one another, such that his experience of a serious assault led to a decision not to go to university and to start an apprenticeship. It was during this subsequent apprenticeship he experienced prolonged and significant physical and psychological bullying by individuals in a higher position of power than himself (supervisors). NET assists an individual to realign their traumatic experiences within the larger context of their life and their place in the world (Schauer et al ., Reference Schauer, Schauer, Neuner and Elbert 2011 ) and is specifically designed for individuals who have experienced multiple traumatic events (Robjant and Fazel, Reference Robjant and Fazel 2010 ) and therefore this was seen as a potential helpful approach for Arwyn. NET involves constructing a chronological account of someone’s traumatic experiences allowing conversion of the disjointed recollection of traumatic experiences to a coherent narrative, providing contextualisation (Schauer et al., Reference Schauer, Schauer, Neuner and Elbert 2011 ). The aim of NET was to reduce Arwyn’s current sense of threat and arousal levels experienced when exposed to avoided situations to help tolerate ERPs. The aim of CBT with ERP was to further challenge his beliefs and allow further anxiety response extinction (Rachman et al ., Reference Rachman, Rachman and Hodgson 1980 ) and therefore reduce compulsive behaviour.

NET for trauma memories

Sessions 22, 25, 27, 28 and 31 used NET to allow increased processing of Arwyn’s trauma memories of the assault at a university open day, his experience of bullying at his apprenticeship, his experience travelling, and his perception he was overwhelmed by anxiety whilst in work. Arwyn described his experiences to the clinical psychologist who wrote them out as a script. The psychologist asked questions of clarification around particular hotspots including around cognitions and affect that was experienced at the time with the aim of trying to re-connect ‘hot’ (cognitive, emotional and physiological representations) and ‘cold’ (context) memories (Neuner et al., Reference Neuner, Elbert, Schauer, Bufka, Wright and Halfond 2020 ). The writing of the script slowed down the pace to help processing of the sensory and emotional aspects of the memories. Arwyn was set between-session homework of reading through the script.

CBT with ERP

Sessions 24, 26, 29, 30 and 32 used CBT with ERP on items of his hierarchy which shared a relationship with Arwyn’s traumatic history (see Table  1 ). It was hypothesised that Arwyn exposing himself to avoided stimuli without engaging in neutralising behaviours would lead to a reduction in his obsessive beliefs, anxiety levels and compulsive behaviours when re-exposed to the same stimuli. During the first session, time was allocated to discuss the rationale for exposure with reference to his formulation (psychoeducation) and to update his exposure hierarchy (it should be emphasised all items were perceived as high up the hierarchy relative to previous ERPs he successfully managed during his previous 20 CBT sessions). The final hierarchy is depicted in Table  1 .

Table 1. Arwyn’s exposure hierarchy

An example session of exposure to the utility room is given below which was conducted according to the protocol outlined in Salkovskis ( Reference Salkovskis 2007 ). Each ERP session followed a similar structure and due to the prolonged and field-based nature lasted 3 hours on average. An exposure practice form was used to identify Arwyn’s predictions while also providing the opportunity to track his subjective units of distress (SUDs). Outlining predictions was important to address the cognitive aspect of OCD (e.g. Meyer, Reference Meyer 1966 ). Arwyn predicted he would become so anxious he would lose control (100% prediction). Prior to entering the utility room Arwyn was reminded to refrain from engaging in SSBs and the importance of not neutralising the exposure once he left the room was highlighted, as cognitively, going into a feared situation with the intention of undoing it can be considered as an avoidance strategy (Salkovskis, Reference Salkovskis 1985 ). While exposure began with the trainee psychologist suggesting items to be touched, a shift was made to Arwyn independently selecting the items of exposure. Arwyn touched various items associated with his place of work and apprenticeship while his attempts to prevent spreading of the perceived contamination (known as ‘tracking’) was also brought to his attention. It was important to ensure Arwyn was fully engaged with the stimuli (he had a tendency to use conversation as a distraction method), as Borkovec and Boulougouris ( Reference Borkovec and Boulougouris 1982 ) suggest active engagement with the stimuli is crucial for extinction. Discussion followed the conclusion of the exposure in order to consolidate Arwyn’s belief the prediction will not come true on subsequent occasions (Salkovskis, Reference Salkovskis 2007 ). Arwyn stated he learnt his anxiety reduced and he did not lose control. He re-rated the belief that he’d lose control if exposed to the same situation again at 20%. Arwyn’s SUDs also reduced from 95 to 40. A contract was collaboratively created listing the compulsions Arwyn would refrain from and the next natural time he would wash. Arwyn’s homework was to expose himself to the utility room every morning for half an hour without engaging in compulsions afterwards.

By the end of Phase B Arwyn had completed all exposures listed in his hierarchy.

On his entry to the service, Arwyn’s OCI-R score was 57, 2.14 SD s above the average of an OCD sample (Foa et al ., Reference Foa, Huppert, Leiberg, Langner, Kichic, Hajcak and Salkovskis 2002 ). As shown in Fig.  2 , following CBT (including ERP) treatment for OCD (Phase A), Arwyn’s symptoms reduced to 28 indicating reliable improvement (Abramowitz et al ., Reference Abramowitz, Tolin and Diefenbach 2005 ) but was still above clinical cut-off. The addition of concurrent NET and CBT with ERP to the items at the top of Arwyn’s hierarchy (Phase B) led to a further reduction in OCI-R score to 9 (further reliable improvement) and well below the clinical cut-off and therefore indicating reliable recovery (Clark and Oates, Reference Clark and Oates 2014 ). Arwyn first completed the IES-R prior to beginning Phase B, scoring 24 specifically related to his experiences in his last job (this was chosen as this was the memory he reported as currently the most traumatic). This score represents ‘clinical concern’ (Asukai et al ., Reference Asukai, Kato, Kawamura and Nishizono-Maher 2002 ) but is below the clinical cut-off of 33. By the end of Phase B Arwyn’s IES-R score reduced to 15, indicating reliable improvement (Clark and Oates, Reference Clark and Oates 2014 ).

Figure 2. Arwyn’s OCI-R and IES scores.

From a qualitative perspective, Arwyn’s functioning significantly improved by the end of therapy in that he was actively communicating with his workplace with a view to start work again, had holidayed with friends from work and had moved in with his girlfriend (something he had previously avoided due to fears of contamination). Arwyn had also managed to return to a healthy weight and was actively discussing his memories with others.

We presented the use of CBT including ERP (Phase A) followed by concurrent NET and CBT with ERP (Phase B) to treat an individual with OCD whose PTSD symptoms were interfering with first line OCD treatment.

Despite Arwyn’s 12 sessions of private CBT, his OCI-R remained within the clinical range and his compulsive behaviours were presenting a risk to his health. Phase A of CBT with ERP led to reliable improvement in Arwyn’s OCD symptoms and in particular in relation to SSBs and compulsions related to items lower down his exposure hierarchy. Despite this, his reduction in symptoms plateaued and remained within the clinical range and frustration emerged in response to a lack of progress on exposures higher up the hierarchy. Exposure to items at the top of his hierarchy resulted in involuntary intrusive memories and significant levels of distress which prevented Arwyn from engaging in ERP. While Arwyn’s scores on the IES-R did not meet the threshold indicating clinically significant PTSD symptoms, Arwyn presented with high levels of distress upon being asked about these memories, he was evidencing avoidance symptoms in the form of an unwillingness to discuss the memories, and reported historical avoidance symptoms that were pre-morbid to his OCD. When he did begin to try to share his memories of these events with the therapist his recall was very fragmented. Together, this suggested processing of these memories could be important to further progress. When NET and CBT with ERP were applied concurrently, Arwyn was able to complete exposure tasks to stimuli that shared a strong association with his trauma memories, something he was not able to do during Phase A. By the end of treatment Arwyn had achieved reliable recovery from OCD and reliable improvement in PTSD symptoms and he had returned to a level of functioning he was content with.

Clinical implications

Our approach involved adding NET to CBT with ERP which was already underway. This is as opposed to using a staggered approach of switching to NET alone first, before continuing with CBT with ERP. Therefore, it is difficult to separate out the individual contribution of NET and CBT with ERP to the reduction in symptoms evidenced above. However, we did show that following their concurrent application there was a reduction in Arwyn’s OCD symptoms to non-clinical levels. If OCD thoughts and behaviours developed to help avoid the distress related to trauma related memories (Gershuny et al ., Reference Gershuny, Baer, Radomsky, Wilson and Jenike 2003 ; Huppert et al ., Reference Huppert, Moser, Gershuny, Riggs, Spokas, Filip and Foa 2005 ), it is possible increased processing of the memories provided opportunity for Arwyn to consider their contribution to his life choices and this may have helped integrate it with his life story and lowered the level of arousal experienced when confronted with triggers to the memories. This may have contributed to his ability to participate in exposures to items at the top of his hierarchy whilst dropping previous compulsive behaviours. At the earlier stages of therapy, even following ERP on items lower down his hierarchy, Arwyn was not willing to do this. This appears consistent with research suggesting the experience of trauma makes the anxiety more severe and therefore more difficult to engage with ERP (Riggs, Reference Riggs 2000 ).

As described earlier, the co-occurrence of PTSD in those with OCD has been thought to contribute to its treatment resistance (Gershuny et al ., Reference Gershuny, Baer, Jenike, Minichiello and Wilhelm 2002 ). In the current case study we provide some evidence the combination of NET for trauma memories and CBT with ERP for OCD could be beneficial for the treatment of OCD with origins in traumatic events and first line treatment for OCD has not resulted in reliable improvement of symptoms.

Alternative approaches

In the current study, the choice to use NET was partly pragmatic due to Arwyn experiencing multiple connected traumatic or aversive experiences over a number of years. In light of the aim of NET in the current study, i.e. to reduce sense of current threat and arousal in response to trauma-related triggers, it is possible (and likely, given the evidence base) that other trauma-focused therapies such as TF-CBT, EMDR or cognitive processing therapy could have resulted in a similar outcome to NET (particularly in cases where there is a single trauma). Indeed, other case studies have described combining TF-CBT (Stobie, Reference Stobie and Grey 2009 ) or EMDR (Nijdam et al ., Reference Nijdam, van der Pol, Dekens, Olff and Denys 2013 ) with CBT and ERP (albeit consecutively rather than concurrently) as an approach to treating individuals with co-morbid OCD and PTSD.

It is also important to highlight that other studies have highlighted the role of ‘aversive’ memories in the development and maintenance of OCD (e.g. Coughtrey et al ., Reference Coughtrey, Shafran, Lee and Rachman 2013 ) and have used imagery re-scripting as a treatment approach in such cases. Imagery re-scripting can be used to relive and restructure the meaning or course of events in a memory to something less catastrophic and this is thought to be particularly helpful when the predominant emotions associated with a memory relate to anger, shame or guilt as opposed to fear (Arntz, Reference Arntz 2012 ). In a case series, Veale et al . ( Reference Veale, Page, Woodward and Salkovskis 2015 ) applied imagery re-scripting to a series of 12 cases with OCD with intrusive distressing images emotionally linked to a past aversive memory and found reliable improvement in nine out of 12 cases and clinically significant change in seven out of 12. Given the above, it is possible that using imagery re-scripting rather than NET in the current case could also have led to similar outcomes.

A further alternative treatment approach could have been to use a trauma-focused treatment alone, without concurrent CBT with ERP. If Arwyn’s OCD developed to avoid memories and associated distress, reducing the levels of arousal associated with exposure to certain triggers with NET alone could have been sufficient to absolve the need to engage in compulsive behaviours. Therefore it is possible that Arwyn could have reduced compulsive behaviours spontaneously without the need for further CBT with ERP. Future studies could explore this hypothesis by delivering a phase of NET (or other trauma-focused therapy) first and measuring symptom change, before moving onto a phase of CBT with ERP.

Limitations

There are a number of limitations to this case study which makes it difficult to draw strong conclusions about the combined use of NET and CBT with ERP for OCD and PTSD symptom reduction.

First, throughout Arwyn’s treatment there was a consistent downward trend in symptoms, despite a plateau around 20 weeks. Arwyn’s OCI-R scores may have continued to reduce had Phase A continued, given enough time. Second whilst Arwyn had the support of his family members or support workers during exposures during Phase A, it is possible the change in Phase B to prolonged (3 hour) in vivo ERP which was facilitated by the clinician led to Arwyn’s increased willingness to complete the ERPs and therefore the improvements observed. It is possible that the quality of ERP was higher when clinician-supported rather than self-directed (although an RCT has found no differences in outcome between self-directed and therapist-directed ERP; van Oppen et al ., Reference van Oppen, van Balkom, Smit, Schuurmans, van Dyck and Emmelkamp 2010 ), whilst the presence of the therapist may have improved trust in the approach and helped with emotional containment. In order to obtain a more accurate picture of the contribution of NET to Arwyn’s willingness to complete ERPs during Phase B, it may have been preferable to keep the support he had in completing the exposures the same as Phase A (i.e. self-directed with the support of family). Third, long-term follow-up measures were not collected due to this not being routine practice in the service, therefore it is not clear if the reliable recovery was maintained. It is possible the pattern of symptom reduction illustrated in Fig.  2 was not a stable pattern. Nonetheless, it is important to emphasise the positive functional changes Arwyn had made to his life in this time. Lastly, this study described the single case of an individual whose sub-threshold PTSD symptoms were thought to be impacting on OCD treatment and therefore the approach described may not be relevant to other cases of co-morbid OCD and PTSD. Since the completion of this case study, Pinicotti et al . ( Reference Pinciotti, Fontenelle, Van Kirk and Riemann in press ) have reviewed the co-morbid presentation of OCD and PTSD and have made a number of recommendations for its conceptualisation, assessment and treatment. The interested reader is directed to this.

(1) Clinicians treating OCD should consider how unprocessed trauma could impact on standard treatment for OCD.

(2) Combining NET to process trauma memories interspersed with CBT including ERP to treat OCD symptomology may be helpful in reducing symptoms of both OCD and PTSD.

(3) Further research in robust and controlled studies is required prior to conclusions about the effectiveness of this approach.

All data generated as part of this study are presented in this case study manuscript.

Acknowledgements

The authors would like to thank Arwyn (pseudonym) for his consent to share his case study.

Jac Airdrie: Conceptualization (equal), Formal analysis (lead), Investigation (equal), Methodology (equal), Writing – original draft (lead), Writing – review & editing (equal); Sinead Lambe: Conceptualization (supporting), Investigation (supporting), Methodology (supporting), Supervision (equal), Writing – review & editing (equal); Kate Cooper: Conceptualization (equal), Investigation (equal), Methodology (equal), Supervision (equal), Writing – review & editing (equal).

J.A., S.L. and K.C. were all employed by local NHS trusts during the completion of this case study. No additional funding was provided.

The authors declare no conflicts of interest.

All authors abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the BABCP and BPS. Written informed consent was provided by the subject of his case study, who saw the case study in full and agreed to it going forward to publication. No ethical approval was required for the study as only routine clinical data were used. The NHS trust which Arwyn was under approved its publication conditional on Arwyn providing his written informed consent.

Further reading

No CrossRef data available.

View all Google Scholar citations for this article.

Save article to Kindle

To save this article to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle .

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

• J.N. Airdrie (a1) (a2) , S. Lambe (a3) and K. Cooper (a4) (a5)
• DOI: https://doi.org/10.1017/S1754470X22000605

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox .

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive .

Reply to: Submit a response

- No HTML tags allowed - Web page URLs will display as text only - Lines and paragraphs break automatically - Attachments, images or tables are not permitted

Your details

Your email address will be used in order to notify you when your comment has been reviewed by the moderator and in case the author(s) of the article or the moderator need to contact you directly.

You have entered the maximum number of contributors

Conflicting interests.

Please list any fees and grants from, employment by, consultancy for, shared ownership in or any close relationship with, at any time over the preceding 36 months, any organisation whose interests may be affected by the publication of the response. Please also list any non-financial associations or interests (personal, professional, political, institutional, religious or other) that a reasonable reader would want to know about in relation to the submitted work. This pertains to all the authors of the piece, their spouses or partners.

• {{subColumn.name}}

AIMS Neuroscience

• {{newsColumn.name}}
• Share facebook twitter google linkedin

Drug repurposing for obsessive-compulsive disorder using deep learning-based binding affinity prediction models

• Thomas Papikinos ,  , 
• Marios Krokidis , 
• Aris Vrahatis , 
• Panagiotis Vlamos , 
• Themis P. Exarchos
• Bioinformatics and Human Electrophysiology Laboratory, Department of Informatics, Ionian University, Corfu, Greece
• Received: 28 December 2023 Revised: 29 May 2024 Accepted: 04 June 2024 Published: 26 June 2024
• Full Text(HTML)
• Download PDF
• drug repurposing ,
• drug repositioning ,
• obsessive-compulsive disorder ,
• deep learning ,
• drug-target interaction prediction ,
• binding affinity prediction

Citation: Thomas Papikinos, Marios Krokidis, Aris Vrahatis, Panagiotis Vlamos, Themis P. Exarchos. Drug repurposing for obsessive-compulsive disorder using deep learning-based binding affinity prediction models[J]. AIMS Neuroscience, 2024, 11(2): 203-211. doi: 10.3934/Neuroscience.2024013

Related Papers:

• This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0 ) -->

Supplements

Access History

• Corresponding author: * Correspondence: Email: [email protected] .; 

Reader Comments

• © 2024 the Author(s), licensee AIMS Press. This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0 )

通讯作者: 陈斌, [email protected]

沈阳化工大学材料科学与工程学院 沈阳 110142

Article views( 26 ) PDF downloads( 2 ) Cited by( 0 )

Figures and Tables

Figures( 1 )  /  Tables( 2 )

Associated material

Other articles by authors.

• Thomas Papikinos
• Marios Krokidis
• Aris Vrahatis
• Panagiotis Vlamos

Related pages

• on Google Scholar
• Email to a friend
• Order reprints

Export File

• Figure 1.  The workflow of the model from dataset creation to finish

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Br J Gen Pract
• v.40(334); May 1990

Obsessive-compulsive disorder: case study and discussion of treatment.

A patient's own account of her obsessive-compulsive disorder is presented. She describes her distressing experiences, the impact of the disturbance on her and her family's life and her subsequent improvement using the technique of exposure and response prevention. The treatments available are discussed and the benefits of self-directed behavioural psychotherapy are reviewed. A comment from a general practitioner is appended.

Full text is available as a scanned copy of the original print version. Get a printable copy (PDF file) of the complete article (789K), or click on a page image below to browse page by page. Links to PubMed are also available for Selected References .

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

• Kettl PA, Marks IM. Neurological factors in obsessive compulsive disorder. Two case reports and a review of the literature. Br J Psychiatry. 1986 Sep; 149 :315–319. [ PubMed ] [ Google Scholar ]
• Marks I, O'Sullivan G. Drugs and psychological treatments for agoraphobia/panic and obsessive-compulsive disorders: a review. Br J Psychiatry. 1988 Nov; 153 :650–658. [ PubMed ] [ Google Scholar ]
• Marks I. Behavioural psychotherapy in general psychiatry. Helping patients to help themselves. Br J Psychiatry. 1987 May; 150 :593–597. [ PubMed ] [ Google Scholar ]
• Meyer V. Modification of expectations in cases with obsessional rituals. Behav Res Ther. 1966 Nov; 4 (4):273–280. [ PubMed ] [ Google Scholar ]
• Rachman S, Marks IM, Hodgson R. The treatment of obsessive-compulsive neurotics by modelling and flooding in vivo. Behav Res Ther. 1973 Nov; 11 (4):463–471. [ PubMed ] [ Google Scholar ]
• Marks IM, Lelliott P, Basoglu M, Noshirvani H, Monteiro W, Cohen D, Kasvikis Y. Clomipramine, self-exposure and therapist-aided exposure for obsessive-compulsive rituals. Br J Psychiatry. 1988 Apr; 152 :522–534. [ PubMed ] [ Google Scholar ]