A Case Study of Obsessive Impulsive Disorder

A part Study of Obsessive-Compulsive Disorder nearly Diagnostic Considerations INTRODUCTION Prior to 1984,obsessive- neurotic nausea (OCD)wasconsideredarargon derangement and unmatched difficultto treat (I). In 1984 the epidemiological CatchmentArea (ECA) initial survey resultsbecame operational for the first time, andOCDprevalence figuresshowed that2. 5%ofthepopulation metsymptomaticcriteriafor OCD (2,3). nettsurvey results publishedin 1988(4) support theseearlier reports. In sum, a 6-month blame prevalence of1. 6%was observed,anda purporttimeprevalenceof 3. 0% wasfound.OCD isan illness of secrecy, and a great deal the uncomplainingspresentto physicians inspecialties opposite than abnormal psychological science. Another factor contri provideding to confused diagnosing ofthis affectionis thatpsychiatrists ma y fail to ask concealment questionsthat would identifyOCD. The pursuit case submit wind isan exampleofa diligentwith middling severe OCDwhopresentedtoa occupie rpsychiatryclinicten long time prior to beingness diagnosedwith OCD. The diligent role role ofwascompliant with break long-suffering discourse for theentire time currentand was treatedfor nurturedepressivedisorderand inch line constitution disorder with practice of medicine s andsupportivepsychotherapy.The patient never discussedher OCD symbolswith her doctorsbut in retrospect had offered galore(postnominal) cluesthat mightiness stool al lowedaswifterdiagnosis and treatment. CASE account statement Simran Ahuja was a 29 yearold,divorced,indian female who workedas a file clerk. Shewas followed as anout patientat thesameresidentclinic since1971. Ifirst saw her 2012. other(prenominal) PSYCHIATRIC fib Simran had beenseen in theresidentout patientclinic since July of 1984. Priortothis shehad not beenin psychiatric treatment. Shehad never been hospitalized.Her initialcomplaints were clinical depression and concernand she had been placed onan phenelzineand responded wellsp ring. Herdepressionwasinitially eyeshotto be succor-string to amphetamine withdrawal, since shehad been using farepillsfor 10 geezerhood. She give tongue tothat at firstshetook them to suffer saddle,but stick aroundd forso presbyopic because people at work had storied that sheconcentratedbetterand that her job motion had improved. In addition,her past doctors hadallcommented on her limitedibility to spayand her neediness, insecurity,lowself-esteem,and poor boundaries. In addition,her past doctors had illustriousher promiscuity.All notedher poor attention scotch and limited capacityfor insight. Neurological interrogation during her initialevaluation had sh admit thepossibility of non-dominant parietallobe dearths. Testingwas recuredin 1989 andshowed problems in attention ,recent optical and oral memory(witha greater deficitin visual memory),abstract thought, cognitive flexibility, useof mathematical operations, and visual analysis. A possibility of right blase dysfunctio n issuggested. IQ testing showed acom bine d score of 77 on the with child(p) WeschlerIQ test ,whichindicated marginal intellectualretardation.Over the yearsthe patient had been holdon variousantidepressantsand antianxiety agents. These admitdphenelzine,trazadone, desipramine, alprazolam, clonazapam,and hydroxyzine. to bewilder with longshewas on fluoxetine20mgdaily and clonazaparn 0. 5 mg in two waysa day and 1. 0 mg at bedtime . The antidepressantshad been effective over the years in tr have her depression. Shehasnever usedmore clonazapam than prescribed and at that place was no explanation ofa run throughenger c beof intoxicant or highway drugs. Also, there was no archivesof apprehensivemanic episodes andshewasnever treated with neu personapics.PAST MEDI CAL HISTORY She suffered fromgastroesophageal reflux andwas holdsymptom free on a crewofranitidineandomeprazole. PSYCHOSOCIALHISTORY Simran wasbornand sharpen d ina thumping city. She had a pal who was3 years youn ger. Shedescribedher contractas sinister , withdrawn,and recalledthat he has depict, I dontlikemychildren. Her beget wasphysically andverbally abusive passim herchildhood. Shehad forever longedfor a wakeless relationshipwith him. Shedescribedher mother asthefamily martyr and theglue thatheldthefamily together.She stated thatshewas genuinelycloseto hermotherher mother forever listenedto her and was eternallyavailable to talk with her. Shewas a poor student,had bar all by means of school , and described herselfas everlastingly disruptingtheclass by talking or runningaround. Shehadabest jockstrap through grade school whomshestated deserted herin highschool. Shehad maintainedfew closefriends sincethen . She gradational high school with much difficulty andeffort. Shedated ongroup datesbut never alone. Her husbandleft her p smokeshe waspregnant with herson.The husbandwas abus driverand had not hadarole in theirlivessince thedivorce. Afte r thedivorce,she movedbackto her paren ts spotwith her sonandremained there until getting herown apartment3 years ago. FAMILY HISTORY Simransmotherhad two monstroussuicide attempts atage 72 and wasdiagnosed with majordepressivedisorder with psychotic featuresand OCD. She as well had non-insulin dependentdiabetesmellitus and irritablebowelsyndrome. Herbrother was treatedfor OCDas an outpatientfor thepast20 years and in addition has Hodgkins Disease, currently in remission.The brothers diagnosis ofOCD was kept secret fromherand did not becomeavailableto her until her mother died. Her fatherisalive and well. MENTAL STATUS test Shewas athin,bleached blonde womanwho appeared herstatedage. Shewas dressed inskintight,provocativeclothing, fig out jewelry earringsthat eclipsed her earsand hung to hershoulders, heavymake-up and elaboratelystyled hair. Shehad difficultysittingstilland fidgeted everinherchair. Her tree trunk language through outthe interviewwassexually provocative. Her linguistic communication wasrapid,mildly p ressured,andsherarely finisheda sentence.Shedescribedhermoodas anxious. Her doctor appeared anxious. Herthoughtprocesses showed mildcircumstantiality and tangentiality. More evidentialwas her inability to finish athoughtas exhibited by her in have a go at itsentences. COURSEOF TREATMENT Initialsessions with thepatient werespentgathering fabricationand geting a workingalliance. Althoughsheshowed agood receptionbyslowingdown sufficient to finishsentences and focus onconversations,shecould not toleratethe side effects andrefusedtocontinue taking the medication. Thewinterof1993-94was peculiarlyharsh.Thepatientmissed many a(prenominal) sessions because of atrocious weather. A patternbegantoemergeofa pursuant(predicate)increasein the figure of speechof phonecalls thatshemadeto the office partingmail to hindquarterscela session. Whenshe was questioned virtually her phonemessages she stated,I always repeatcalls to make sure mymessageis received. Sincethe to the highest degree rec ent cancellation generatedno less than sixer phone calls ,shewas asked why asecond call wouldntbeenough to besure . She put-onednervously andsaid,Ialways repeatthings. With careful questioningthe followingbehaviorswere uncovered.The patient checkedall haspsand windows repeatedlybeforeretiring. Shechecked theiron a dozen timesbefore difference the house . Shecheckedher doorlockahundredtimes beforeshewas able toget in hercar. The patientwashed her hands frequently. She carried disposablewashcloths inher pocket defend so Ican wash asoftenas I need too. Shesaid peopleat work laughat herfor washingsomuch. unless shestated,Ican t attention it. Ive been this waysinceI wasa bitty girl. Whenquestioned or so telling formerdoctors nigh this,thepatientstated that shehad nevertalked to the highest degree it with her doctors.Shestatedthate genuinelyone that knewhersimply knewthatthiswasthewayshewasIts onlyme . Infact , shestated, I didnt believe my doctorswouldcare .Ive alwaysbeen thisw aysoitsnot nighthingyou canchange . Over the nextfew sessions, it became uninfectedthat her argumentswith her boyfriend c submitedonhis fuss with her needtoconstantly repeatthings. This waswhat shealways referred toas talking too much. Insessions itwasobserved thatheranxiety,neediness and poor boundariesarose over issues of misplacing things in her purse and insurance forms that were incorrectlyfilledout.Infact,when Iattempted to correct theinsurance forms for her, I had difficulty because of her need to repeat the instruction manual to meover and over. The Introduction Obsessive arbitrary disorder (OCD) is an anxiety disorder characterised by persistent fixingal thoughts and/or compulsive acts. Obsessions are recurrent ideas, images or impulses, which enter the individuals mind in a unimaginative manner and against his will. Often such thoughts are absurd, obscene or violent in nature, or else senseless. Though the patient recognises them as his own, he witnesss powerless ov er them.Similarly,compulsive acts or rituals are stereotyped behaviours, performed repetitively without the closure of any inherently useful task. The commonest obsession involved is fear of contamination by dirt, germs or grease, leading to compulsive cleanup spot rituals. other insolent themes of obsessions include aggression, orderliness, illness, sex, symmetry and religion. Other compulsive behaviors include checking and counting, often in a ritualistic manner, and over a magical number of times. About 70% of OCD patients suffer from both bsessions and compulsions obsessions alone total in 25%, whilst compulsions alone are rare. 1nshe spentten minutes checking and recheckingtheformagainst the receipts. Shebecame convinced that sheddone it wrong, her anxiety would increase, andshewouldgetthe forms outand checkthem again. Herneed to includeme in thischeckingwasso greatthat shewas al almost physically ontopofmychair. In thefollowingweeks,session s concentrateoneducating thepat ient roundOCD. Her dose of fluoxetinewas increasedto 40 mgaday but stop becauseof severe restlessness and insomnia.She continued to put in 20mg offluoxetine a day. Startinganother medication inaddition to fluoxetinewas difficult because of the patientsobsessivethoughtsaboutweight gain, thenumberofpillsshewastaking, and thepossible side effects . Finally,thepatient agreed to try addingclomipramine to her medications. Theresults weredramatic. She entanglemore relaxed and had less anxiety. Shebegan to talk, forthefirsttime, about herabusivefather. She said,His behavior was always supposeto be the familysecret. I feltso afraidandanxious I didnt hardiness tellanyone.But nowIfeel better. I dont care whoknows. Its woo mymothertoomuchto occlusionsilent. Atthis timetheplan is to begin behavioral therapy withthepatientinaddition to medication sandsupportive therapy to bonk with herdifficulties with relationships. DISCUSSION This isa complicatedcasewith multiple diagnoses edgementalretar dation,attention deficit disorder, metepersonalitydisorder,ahistoryofmajor depressive disorder andobsessive compulsive disorder. wedded thelevelofcomplexity ofthiscase and thepatient sown silenceabout hersymptoms,itisnot urprisingthat thispatients OCD remainedundiagnosedforsolong. However,inreviewingthe literatureand the case,it is instructive tolookat the enjoin thatmighthaveledto an earlier diagnosis. First ofall,therewas thefindingof soft neurological deficits. The patients Neuropsychological testing suggestedproblemswithvisuospacial surgical proceduren visual memory,as well asattentional difficultiesandalow IQ. In thepast,her doctors were so impressedwith her history ofcognitive difficultiesthatneuropsychological testing was enjoinon two separate occasions.Fourstudies in therecent literature haveshown consistent findings ofright hemispheric dysfunction, preciseallydifficultiesin visuospatialtasks, associatedwith OCD(6,7,8,9). The patient also had a historyof chronic dieting,and althoughextremelythin, she continue d to beobsessed with notgaininga single pound. This wasapatient who took dietpills for 10years and whosee earliest memoriesinvolvedher fathers disapproval ofher bodyhabitus. Eatingdisorders areviewed bysomecliniciansasa formofO C D. OC D.Swedo and Rapoport (II)also notean increased incidenceofeating disorders in childrenandadolescentswithOCD. seasonthis wasno dubiety true,the downstairslyingobsessionalcontent pointed right awayto OCD and should havegenerated a list of concealment questionsfor OCD. This underscorestheneed to bevigilant for symptomatic clues and to perform onesown diagnostic judgment whenassuming the treatmentof anypatient. While theliteraturemakesit clear that OCDruns in families,thepatient was unaware of theillnessin her familyuntil later onher diagnosiswas made.Itwould have beenhelpful to know this developmentfrom thebeginningas it shouldimmediately swot up a suspicion of OCD in a patientpresentingwith complaintsofdepress ion and anxiety. Finally,her diagnosis of borderlinepersonalitydisordermadeiteasier to passoff her observablebehaviorin the office asfurtherevidenceofhercharacter structure. The diagnosis of borderlinepersonalitydisorder wasclear. Sheused thedefense of change integrityas evidence d by her descriptionsof her fightswith her boyfriend . He was bothwonderful or a fill in bastard. Herrelationships werechaoticand unstable.She had no close friends afterwards-school(prenominal)of her family. Sheexhibitedaffective instability, markeddisturbance of bodyimageand impulsive behaviors. However, it was difficult to sleep together whether hersymptoms were trulycharacter logicalordueinsteadto her underlyingOCD and associateanxiety. For instance,theinstabilityin her relationships was,inpart,the resultofher OCD, sinceonce shebegan to obsessonsomething,sherepeatedherself so muchthatshefrequentlydrove others intoarage. A engage by Ricciardi,investigatedDSM-III-R Axis II diagnoses following treatm ent for OCD.Overhalfofthepatients in the studyno longer met DSM-III-Rcriteria for personality disorders afterbehavioraland/or pharmacological treatmentoftheirOCD. Theauthorsconclude thatthisraises questionsaboutthe validityof an AxisII diagnosisin thefaceofOCD. One might also beginto wonder how manypatientswith personalitydisordershave undiagnosedOCD? Rasmussenand Eisenfound a very high comorbidity ofother Axis I diagnoses in patientswith OCD. Thirty-onepercent of patients canvasswerealso diagnosed with majordepression, andanxiety disorders accounted for xxiv percent.Other coexisting disordersincluded eating disorders, alcoholabuseand dependence, and Tourettes syndrome. Baer,investigatedthe comorbidityof AxisII disordersin patientswith OCDand found that 52percentmetthe criteria forat least onepersonalitydisorderwith mixed,dependentand histrionic beingthemost common disorders diagnosed. Giventhefrequency of comorbidity in patientswith OCD,it wouldbe wise to includescreening questio nsin allpsychiatricevaluation. Theseneednotbe elaborate. Questions aboutchecking,washing,and ntrusive,unwanted thoughts can besimpleand direct. Ineliciting afamily history,specificquestions aboutfamily fractionswho checkrepeatedlyorwashfrequentlyshouldbe included. exactly asking ifanyfamily memberhasOCDmaynotelicitthe culture, sincefamily members mayalso be undiagnosed. Insummary, thiscaserepresents a complicateddiagnosticpuzzle. Herpast physiciansdid not have the trainingwe dotodayto plythetangled skeinsof symptoms. Itisimportant to be spryforthepossibilitythat thispatient s story is not anuncommon one.BIBLIOGRAPHY * Psychology book (NCERT) * Identical * Suicidal notes * A psychopath test journey through the earth of madness * Disorder of impulse influence by Hucker INDEX * Introduction * causal agent study * Course of treatment * news * Bibliography ACKNOWLEDGEMENT I would like to express my special thanks and gratitude to my teacher Mrs. Girija Singh who gave me the boomi ng opportunity to do this wonderful look on the topic obsessive-compulsive disorder, which also helped me in doing a lot of research and I came to know about so many new things.Secondly I would also like to thank my family and my friends who helped me a lot in finishing this visit. documentation This is to certify that Jailaxmi Rathore of class 12 has successfully completed the project on psychology titled obsessive-compulsive disorder under the guidance of Mrs. Girija Singh. Also this project project is as per cbse guidelines 2012-2013. Teachers sense of touch (Mrs. Girija Singh) (Head of psychology department) 2012-2013 PSYCHOLOGY PROJECT wee OF THE CANDIDATE JAILAXMI RATHORE CLASS XII humanities B SCHOOL MGD GIRLS SCHOOL