Case Study

 

Introduction

Many contemporary treatment approaches for obsessive compulsive disorder (OCD) combine behavioural and cognitive approaches. Researches have strongly suggested behaviour therapy as an effective and time-limited treatment over the last 3 decades (Greist, 2002) while psychoanalytic therapy gradually being the less frequent choice (Gabbard, 2001, Connolly Gibbons et al., 2008).

Current accounts of cognitive therapies generally agree that the thought content as such is less important than the meaning that the patient ascribes to it. Cognitive behaviour therapy (CBT) focuses on relieving the associated threat and anxiety and making the appraisal meaningless event that curbs the further cognitive processing (Freeston et al., 1996; Salkovskis, 1999). Cognitive drill (Kumar et al., 2012) is a novel technique for OCD management that also utilizes some of these principles along with cognitive exposure, Pavlovian conditioning and a change in linguistic pattern. However, psychodynamic approaches advocate the interpretation of symbolic meaning of the overt symptoms and the resolution of intra-psychic conflicts in the management of psychopathology and subsequent mental health gain.

Literature has also suggested that often in most patients, symptoms tends to persist to a mild to moderate degree following a course of cognitive behaviour therapy (Eddy et al., 2004). Besides, the phenomenology of OCD revealed wide age and socio-culture bound variations (Khanna & Srinath, 1988; Akhtar et al., 1978; Dutta, 1964) as well as heterogeneity in pathophysiology. This explores the need for some alternative conceptualizations and treatments that can be beneficial in a distinct group with OCD. Also, sometimes with the course of therapy new goals emerge that further makes it difficult to adhere to a particular regime and eventually leads to a demand for an eclectic approach. Furthermore, application of therapy becomes more challenging when there are comorbid psychiatric conditions like depression, anxiety, psychosis or suicidal tendency associated.

This study presents a successful demonstration of an eclectic approach where dissociation emerged as impediment for the continuation of cognitive and behaviour models. As non-pharmacological treatment proceeded, enriched understanding of psychodynamic explanations following cognitive drill therapy seemed more substantial over the continuous pharmacological treatment alone. It potentially throws the light on pathogenesis of OCD. This study also questions the relevance of psychodynamic principles among the contemporary treatment approaches.

 

Case report
Mrs. M.S., 35 years old well educated married female, hailing from urban background presented with 5 years fluctuating course of OCD on medication with history of suicidal attempt by consuming sleeping pills visited Institute of mental health and hospital for her first consultation with a clinical psychologist. The obsessions included names and images of some specific persons and theme of contamination of dead bodies. Patient was using overt and covert compulsions with some ritual. She had to replace the images by seeing her husband’s or child’s face because of that husband had to miss his job hours for days on several occasions. Whenever a name or image that came in her mind was interfered or followed by some sounds, like horn, sneeze or nearby on going conversations, she would make her husband and child to repeat the sounds, even whole conversations and other names to get relieved from anxiety. Till the repetition, she would wait for them, escape meals and avoid doing any house-hold duties. She would also avoid touching dead bodies, discussing about death and would wash the cloths and accessories of her husband and children. If she was touched by any stranger, she would touch her husband. Through the clinical interview it was later found that patient would also have one or two episodes of dissociative stupor per month. She also reported some paranormal experiences, nightmares and sleep paralysis.

 

Assessment
OCD was diagnosed as per ICD-10 with fluctuating course on medication (SSRIs with anxiolytics) persisting for the last 5 years. Severity had increased for past 5-6 months. Rating on Yales Brown Obsessive-compulsive Scale (YBOCS), Beck Depression Inventory (BDI-II) and Hamilton Rating Scale of Depression (HAMD) revealed severe level of OCD with major depression. However, Dissociative experience scale revealed lower scores as compared to experiences by general population.

 

Treatment procedure
The therapy was started with psychoeducation and normalization about nature, course and outcome of OCD that aided in reduction of her and her husband’s anxiety and hopelessness about illness.

 

Behavioural explanation (cognitive drill)	Psychoeducation of model of drill.Drill using one selected name as anxiety cue.
DISSOCIATIVE  STUPOR
Cognitive explanation	Cognitive model of OCD.Psychoeducation of dissociative disorders. Emergence of sexual aggression themes.
Psychodynamic explanation	Reflecting freud conceptualization.Association of common cognitive and psychodynamic concepts.
Behavioural explanation (cognitive drill)	Drill for other obsessions and compulsions sequentially.

 

Exposure and response prevention therapy could not be utilized as her anxiety would maintain for two to three days until she made her husband or child do the compulsive rituals. Hence, cognitive drill therapy was planned. The application of cognitive drill has yielded promising results in patients with OCD (Kumar et al, 2012).

 

Cognitive drill (behavioural explanation)
Cognitive drill uses principles of exposure therapy and Pavlovian conditioning to deal with stimulus bond anxiety. Patient was explained how repeated exposure of anxiety provoking cues at cognitive and verbal level, causes extinction and habituation of acquired anxiety response. This exposure would initially boost the anxiety response and in the process would get reduced. Names and images were identified as anxiety cues and drill was prescribed. Patient was first required to verbally repeat one name in bulk until anxiety reduction on a visual analogue scale. However, in the very first session, patient developed the dissociative stupor episode and drill was stopped. Dissociative episodes occurred sometimes when husband would try not to follow her imposed compulsions. Husband also reported that patient often tended to indulge in self-injurious behaviours like screaming, head banging, pulling hair and scratching self when the compulsions are curbed.

 

Cognitive explanations
Patient was unable to handle the exposure leaded anxiety thus it seemed difficult to adhere to drill or other behaviour therapies. Modification in therapy was indispensible. It seemed dubious whether at this stage to what extent the therapeutic model for dissociation with patient would work apart from supportive psychotherapy and how much it would be beneficial to manage it first over OCD that was proving to be more perilous to the patient. Transition from cognitive drill to a traditional cognitive approach for OCD considered appropriate at this phase. It was started with discussing the cognitive model. Patient was taught the role of appraisal, exaggerated sense of responsibility, perception of threat and mood context in the origin and maintenance of obsession and compulsions. Patient seemed cognitively sophisticated and this session, however, highlighted some sexual themes too.

Simultaneously it seemed requisite to psychoeducate the husband about dissociation as he was worried. This, however, proved to be the pivot point for the successful management of OCD as symptoms appeared to have symbolic meanings. Many strong sexual and aggression themes and interpersonal issues were derived in the session that shaped the further course of therapy. Discussion around these themes with the patient then assumed to be beneficial.

 

Premises for psychodynamic explanation
Patient reported non-congenial childhood atmosphere when interviewed further. She had constrained relationship with father. Father was authoritative with less emotional involvement in the family. He was also comparatively more concerned about the needs of patient’s other male siblings. She always sought for his affection and assurance. She stayed with her grandparents till 5th standard and when she got back her parents’ home, she would disclose and share less with them. Her pre-morbid history revealed inability to handle criticism and inclination towards cleanliness, symmetry and preference for perfection. When got married she faced significant conflicts with her mother-in-law. Adjustment problems and nil ventilation had led to first episode of dissociative stupor. Her obsessions were also found to have sexual and aggressive themes. The names and images belonged either to her adolescence emotional and physical attractions or alleged childhood molestation experiences. One such crush she had for her father’s friend.

 

Psychodynamic explanation
In the view of strong psychodynamic aspects that maybe contributing to her OCD and dissociation, psychodynamic understanding and explanations appeared essential for optimizing outcome. Oedipal unresolved conflicts in relation to her father and the search for fatherly affection in males and father figures during her initial adulthood was analysed with the help of patient. She was made aware of the links between emotions in past and present. She lacked her father’s support that she found finally in her husband. Her obsessions of names, touching strangers and contamination suggested emergence of strong morality, inhibition of sexual id impulses and ambivalent self. An overview of the psychodynamic and developmental psychological theories of OCD facilitated the appraisal. Repressed hostility for mother-in-law was conferred and following significant post marital and familial stress, ego seemed to regress to anal phase ego functioning. For fear of dead bodies and injuries since childhood, concept of thanatos and aggressive impulses was provided. Patient had tendency to analyse and incorporate the provided reflections congruent to her understanding that specifically was helpful with this approach. Eventually patient was herself able to identify her secondary reinforcements and coping deficits that were purported to maintain the dissociative episodes.

As she was already given cognitive psychoeducation, cognitive concepts like enhanced responsibility for risk behaviours towards self and others, guilt towards her husband were associated with psychodynamic concepts like domineering superego for an eclectic understanding. Later, cognitive drill sessions were reformulated for other obsessions but revealed no anxiety response. Husband was however conceptualized as a safety zone initially during drill that was gradually removed within second session of drill.

 

Homework
In addition, patient was prescribed deep breathing exercise for dissociation, letter and diary writing to release oedipal conflicts and id impulses along with other ego strengthening tasks.

 

Result
Within two sessions following psychodynamic understanding, there was significant improvement in OCD and depression. A decrease in YBOCS, BDI and HAMD scores from severe to mild severity was noticed during this period. She reported a greater sense of control over her obsessions and compulsions. However, she faced problems in controlling compulsions under time pressure which gradually resolved over time with the use of drill and explanation of role of mood context. Changes were maintained over two months. However, further follow up assessment could not be done.

 

Discussion
CBT and behaviour therapy are widely accepted treatment approaches for reducing obsessive-compulsive symptoms (Vogel et al., 2004) and has provided a range of treatment options with strong evidence base. Exposure and relapse prevention is the most prescribed therapy which was difficult to apply in this case as the patient would maintain the anxiety for days. This highlights the requirement of other regimes also essential for some distinct group that view the pathophysiology and management of OCD with a different conceptualization.

Present case was on pharmacological treatment for continuous five years showing no significant improvement but depressive symptoms, caregiver burden and a suicidal attempt two years back because of the distress associated with OCD. This case study supports the non-pharmacological approaches that have emphasized the importance of meaning, than the content itself, which the patient ascribes to it in the successful management of symptoms. In this view, it can be, however, hypothesized that biologically determined symptoms may acquire subjective or unconscious meanings to the patient or the other way round may tend to express that meaning. The interpretation of this meaning has variability with the schools of therapy but it seemed necessary for the prevention of relapse despite the pharmacological treatment alone. The analysis of continuation of illness for long, relapses, refusal to comply with medication or therapy regimes may underline the need for help that there are some conflicts that need to be dealt with.

The therapy was initiated with drill and eventually proceeded into cognitive and then into psychodynamic understanding. In this process we also tried to merge some of cognitive and psychodynamic concepts. Studies suggest that resolution of self-ambivalence predicts positive treatment outcomes in the cognitive-behavioural treatment of OCD (Bhar & Kyrios, 2015). Moreover, some evidence suggests that psychoanalytic formulation overlaps with recent CBT formulation and models of OCD (Bhar & Kyrios, 2007). Some attributions of psychodynamic models like lack of synthesis between good and bad attributions of self and other (Kempke & Luyten, 2007) are postulated in CBT also that was well utilized in this case with the demand of easy transitions required in an eclectic approach. Usually traditional psychoanalytic approach of ‘interpreting the unconscious’ behind the symptoms has not generally been effective (Gabbard, 2001), and has been used to help people with OCD to undertake other forms of treatment such as CBT (McCarter, 1997), and in conjunction with pharmacotherapy and behavioural treatments in adults (Leib, 2001). The present case finding however argues about the selection of independent psychodynamic approach over CBT if treatment had not been eclectic, simultaneously elaborating the successful integration of two.

This case also highlights the efficacy eclectic therapy in short management of OCD where dissociative disorder was obstructing the application of cognitive and behaviour principles alone. Despite the understanding of cognitive model behind the maintenance of OC symptoms, patient was unable to prevent her compulsions and leading into dissociation. ‘Dissociation’ as an ego defence seemed either to protect another defence ‘undoing’, making husband compel of following her imposed compulsions, or ultimately to find the secondary gain in form of his support and attention. It became difficult to treat undoing first which further signifies the presence of extremely punitive superego and repressed sexual-aggressive impulses. This further contributed to secondary depression and suicidal attempt which is also been reported highly comorbid with OCD ((Kamath et al., 2007) In the present comorbid diagnosis, inclusion of psychodynamic explanation of symptom origin and formation proved enormously helpful in improving both, dissociation and OCD.

Therapist tended to provide the interpretations mostly guided by Freud’s conceptualization (Freud, 1909). Her obsessions and compulsions seemed to express the moral anxiety against the sexual and aggressive impulses that had been associated with her past life events. Fear of losing her husband and seeking his attention, the guilt in disguised way (that she had cheated her husband) and strong moral anxiety reflects obvious unresolved oedipal themes and the anal sadistic ego regression. Isolation of affect linked with the names and images of significant males she was having. Strong empathetic therapeutic alliance and the cognitive sophistication of patient could make it possible to explore her inner life in depth as she herself came up with many such associations. Therapy was successful when ego was strengthened enough to attain the ability to accept its impulses and their existence without using defence, and demolished the ambivalence of self and other. Obvious sexual-aggressive themes and oedipal conflicts, interpersonal stressors, and high moral values can be identified as the primary factors for the application of such approach and short term success.

Previous studies have used cases with OCD to illustrate unconscious determinants (Lang, 1997; ) or describe ongoing analysis with a patient (Boehm, 2002; Willick, 1995) or report successful outcome (Parfitt, 1999; Chatterji, 1963) rather than to report outcome measures in any systematic way. Present study never attempted for traditional psychoanalytic therapy but with the course of therapy, assessment guided various therapeutic principles were employed as per requirement of sessions. Successful outcome was measured with the help of session-wise changes in OC symptoms, depression and dissociative experiences. However, follow up assessment after two months of termination could not be done quantitatively. More importantly, the individualised nature of intervention makes it difficult to replicate. Generally, such combination treatments display little about the effect of each individual intervention, and the absence of outcome measures precludes any conclusions regarding treatment efficacy. The literature is also limited and restricted to no well-designed clinical case reports of one or more adults with OCD with minimal replication for any approach. Hence, this demands consideration in further researches.

This study explores a new dimension of therapeutic management in OCD that doesn’t seek to follow any particular therapy regime but where empathic immersion into inner life and understanding in depth of the meaning of symptoms to the patient is important.
Conclusion: The appreciation and assistance in working through unresolved conflicts and troublesome developmental issues with the application of eclectic approach of behavioural, cognitive and psychodynamic principles regarding symptom development and maintenance, perhaps aided by SSRIs, demonstrated significant efficacy in improving OCD and depression from severe to mild level in a case with comorbid dissociative disorder which was not manageable with pharmacotherapy alone. Thus, there is a need to explore the relevance of an eclectic approach including psychodynamic interpretations in OCD to understand the specific procedural and process-based aspects.

 

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