Obsessive compulsive disorder: symptoms, causes, and treatment

¶ … dysfunctional behavior that strikes 1 out of 40 or 50 adults and 1 out of 100 children or 2-3% of any population. It can begin at any age, although most commonly in adolescence or early adulthood - from ages 6 to 15 in boys and between 20 and 30 in women -- according to the National Institute for Mental Health. This behavioral affliction is, therefore, more common than schizophrenia or panic disorder and affects people of all ages, gender, race, occupations, religions and socio-economic ranks. Its impact on the mental and emotional states of such numbers in the United States alone has been so strong that it accounts for more than $8 billion worth of social and economic losses - which is 6% of the country's total mental health bill, according to authoritative sources.

As if not depressing enough, these millions afflicted know that something is wrong with how they behave, yet do not know what it is that binds them to perform irrational and uncontrollable acts. What is worse, each of them feels alone and helpless. And ironically, this affliction is treatable with various modern and effective therapies.

This behavioral ailment is called Obsessive-Compulsive Disorder (OCD), a neurobiological mental illness, which is characterized by obsessions and usually followed by compulsions to quiet the obsessions. Obsessions are strong, repetitious, unreasonable, frightening and intruding impulses or images that cause great anxiety in the affected person. Compulsions are odd and ritualistic acts that the person feels must be performed in response to the obsessions. Both the obsessions and the compulsions are senseless, shameful and exasperating to the person, who nevertheless finds the behavior difficult to control or overcome. A person with OCD may have obsessions or compulsions only, but 90% of those affected have both.

Common obsessions are fears of contamination (dirt or germs), harming another person, making a mistake, social misbehavior, a lack of symmetry, sexual thoughts and impulses, doubt, repulsive religious thoughts or images, violent or terrifying thoughts that may occur to a loved one. These obsessive thoughts are then followed by the performance of compulsive acts meant to respond to these thoughts. Common compulsive acts or compulsions include repetitious washing of the hands or cleaning, too frequent showers, checking, reordering, collecting, organizing, counting, touching things. The afflicted person keeps repeating a particular compulsion until he or she feels gratified that his or her fear is gone and things are all right. They are performed rigidly to reduce or eliminate the agony presented by the obsessions, although these acts are not directly connected to the thing feared and, therefore, cannot prevent or minimize it. They are also clearly exaggerated.

This pattern should not be confused with the normal or admirable cautiousness exercised when assuring accuracy as regards measurements and counting; double-checking locks, ovens and electrical or gas equipment for safety; or insuring desirable hygiene and order. The person afflicted with OCD, in time, becomes conscious that his or her pattern of behavior is exaggerated, unreasonable and un-directed at the disturbance. Both his or her obsession and compulsion are distressing, lengthy - at least an hour a day -- and tiresome and disturb normal activities to his or detriment and embarrassment. Obsession over cleanliness, for example, can drive a person to compulsively wash hands, take a shower or perform some other sanitary actions in order to eliminate or avoid getting infections or passing them on. Obsession over order and harmony can impel the person to count repetitiously, keep organizing and reorganizing details, aim at perfect alignment of things in the house or office, testing and retesting exaggeratedly. A child may miss his lessons because he or she is preoccupied with counting the teacher's syllables. Or he may be avoiding pointing instruments for fear of hurting someone.

In the past, psychiatrists believed that OCD developed out of a person's traumatic past, such as the over-emphasis on cleanliness or order in a child by his or her parents. Sigmund Freud theorized that it proceeded from traumatic toilet training. Modern research, however, points to OCD as a neurobiological dysfunction when the difference between the brain neurons of OCD patients and those without OCD: the brain neurons of OCD patients appeared much more sensitive to serotonin, a chemical that sends signals to the brain. Modern psychiatrists assume that the over-communication between the frontal lobe (of the brain) and deeper parts of the brain accounts for the repetitive and excessive behavior (compulsion). This, they see as resulting in a kind of jammed transmission in a car, a condition that may conduce to the development of rigid thinking and repetitious movements. Persons with OCD have abnormal frontal lobes, basal ganglia and cingulum. The basal ganglia are involved in automatic behavior, such as grooming; the frontal lobes, in planning and organizing; and the cingulum has fibrous bands that help communicating the brain's behavioral and emotional information. Modern drugs that now raise the brain's serotonin level and consequently reduce OCD symptoms and the surgical cutting of the cingulum that has relieved or cured OCD link OCD to the brain chemical. This is called the Serotonin Hypothesis. A device, called a positron emission tomography (PET) scanner is used to examine the brain for OCD.

Risk factors for the development of OCD are genetics, postpartum delivery, and environmental stressors. A 25% predisposition rate among family members of an OCD person indicates that it is probably inherited. It has been observed to be prevalent among identical twins (70%) and 50% for fraternal twins. Medical researchers theorize that multiple genes are involved in the condition, while there is as yet no clear evidence or understanding of OCD's genetic make-up and mechanism.

Pregnant and newly-delivered women undergo a worsening of OCD symptoms, probably owing to unstable hormone levels, a recent study of 30% of observed women suggests. The arrival of a new baby means new responsibility, new concerns, changes in habits and even views and activities. This event causes normal anxiety but it can create disturbing thoughts and extreme behavior in those already predisposed. The obsessions and compulsions are observed to occur at four to six weeks after delivery.

Environmental stressors can be a depressing event like the death of a loved one or a divorce, which can trigger the beginning of OCD. Or if it is already existing, it can be made worse by physical, emotional or verbal abuse; changes in living conditions or situations; illness' changes or problems at work; relationship problems; and problems in school. Puberty may also enhance the development of OCD. Leading cognitive and developmental theorists and psychoanalysts provide us with their concepts on why and how mental and psychological dysfunctions, such as OCD, happen to a person. These theorists are Donald and Miller, Bandura, Berne, Piaget, Jung, Adler, Freud, From, Erikson and Murray.

In addition to genetic predisposition, a person's environment, beliefs and attitudes are considered linked to the development of OCD. Researchers and other experts also assume that those with OCD process information differently from those without OCD.

Other psychological disorders often accompany OCD, such as depression, eating disorders, substance abuse, dysfunctional personalities, attention deficit disorder or any of the anxiety disorders that pre-exists OCD, and can cloud or make the detection of OCD difficult.

The symptoms of other neurological conditions may also be observed in a person with OCD. A person with Tourette's Syndrome, for example, is likely to have a greater predisposition to or an increased rate of developing, OCD. A patient or person with Tourette Syndrome shows "tics" or involuntary muscular contractions and vocalizations.

Other illnesses or conditions linked or associated with OCD are trichotillomania (the urge to pull out scalp hair, eyelash, eyebrows or other hairs from the body); body dysmorphic disorder (undue preoccupation with body defects); and hypochondriasis (undue fear of contracting disease).

People with OCD are not lunatics, although they suspect that they are because of their uncontrollable impulses. Many of them hide their condition from others out of embarrassment. And out of embarrassment and inadequacy, they are not inclined to seek treatment for the condition. They cleverly manage to "mask" symptoms until these are "unmasked" by some disastrous event or experience. By then, the compulsions shall have become deeply rooted and harder to treat. In many cases, the condition is poorly diagnosed, as it often takes many years from the time it began to the time it is finally and correctly diagnosed and appropriate treatment administered.

Having OCD is not a sign of a weak nature of a lack of strong will. What is quite unfortunate is that these sufferers erroneously believe that they are alone in their condition and that there is no remedy. For them.

The truth is that, at present, OCD can be, and is, remedied or managed pharmacologically (or by drugs) through the use of serotonin reuptake inhibitors (SRIs); psychotherapy and cognitive-behavior therapy (CBT); neurosurgery; natural treatments; other therapies, including exercise; and the use of nutritional supplements. #

II. CASE PRESENTATION a. Presenting Problem

The patient is a 48-year-old unmarried Caucasian working housewife. She was admitted on an urgent basis and for the first time to the Adult Out-Patient Program of the College Hospital of Cerritos on May 28, 2002. She was earlier admitted to the College of Costa Mesa Hospital for stabilization of mental illness, medical management and relapse prevention, but she said that she was not coping and that she continued to be severely depressed and lack energy. So she was discharged from the Costa Mesa Hospital and, consequently, admitted to this College Hospital of Cerritos. The patient was anxious, mildly confused, disheveled and crying when her history was taken from her verbal and voluntary report and account.

B. Development History

The patient was the eldest child of a Japanese father and an American mother and the first to be subjected to distinct cultures in upbringing - Eastern and Western. Japanese culture, specifically, emphasizes efficiency and endurance in both sexes and an intolerance for failure and waste. American culture, on the other hand, puts much weight on self-reliance and productivity and loses out on the strength of the nuclear family. Both parents similarly had high expectations and imposed high moral and ethical values, while yielding low-level personal openness. But the patient reported that both parents were verbally and emotionally abusive towards her. Per record, the patient had tricotillomania, or the urge to pull out body hair, since she was only 7. Tricotillomania is a form of anxiety, and in the patient's case, it appeared to have later developed into full-blown OCD.

The patient did not give any more information about her father than his nationality and that he was alcoholic. Although she deplored this behavior in him, she nevertheless acquired the vice in 1989 and stopped only in 1997 when she had a nervous breakdown. Her poor father figure and his vice created a deep lack in her life and made her feel empty and wanting even as a child.

She described her mother as equally unsympathetic and unsupportive of her emotional needs, especially in times like this. Having been raised in another culture, her mother could hardly be expected to understand or condone the vice and irresponsibility of the patient's father.

Her younger siblings were twin boys, another boy and a girl. One of the twin brothers died in a car accident many years ago when he worked as a police officer. That was something that remained etched in her memory. On the whole, the patient described her childhood as lonely. Deep within, she yearned to escape from the situation but found no way to realize that escape. She sometimes felt something like depression or despair, except that she was unable to label it correctly when she was younger. And whether with flattery or guilt, she distinctly remembered that her father's friend kissed her, for she gave no additional information about the incident or experience.

She managed to finish high school and three years of college work. She hinted that her siblings finished school too But all those intervening years, she opened a small home business, avoiding the outside world while trying to survive. Soon, her parents had a divorce. Her mother since then had lived on her father's support, while her siblings grew up and out of the home, marrying and raising their own families, except herself. Somehow, she resigned herself to her situation - that there was nothing but loneliness for her.

But in 1986, she met this man. He was involved in her small business and, for a time, they went together. She thought had life would change. He was everything to her and she hoped he would make up for the void in her life. She waited and waited for him to propose marriage, but he never did. Instead, he asked her to leave her mother and live with him. She was not too happy about the proposal. All her siblings got married properly, just like her mother. Her boyfriend did not believe in marriage. He did not feel comfortable with it. She wanted to feel decent by being married to the man with whom she would live, but, decency at that time, was not as important as belonging to someone. And she was not getting any younger. She was not sure any other man would come to her life, and thought that some time in the future, the man would marry her.

Her mother was not too happy about the relationship. She was never happy about anything that concerned the patient. The patient found it difficult to conclude anything about the matter with her mother, not even to open the topic and gain some progress. Her mother and her boyfriend did not like each other and the patient had to make a choice.

She left her mother and some of her savings from their small business to keep the latter for some time. Her mother did not run after her, nor resent the patient's choice: it was not the first time the mother was abandoned. She simply became even more distant from the patient. She had enough to live with from her husband's support and the savings given by her daughter. She invested these modest amounts in the bank to keep her alive in relative comfort.

On their own, the patient's inborn diligence revealed the boyfriend's inborn idleness. He depended on the patient's income and gave nothing for the household needs. Instead, he used up the small salary he got from his casual employment with his unsavory friends in fun, drinks, and women. The patient and her boyfriend often quarreled about his waywardness, but he always had some justification and she always gave in. She was forever frightened about losing him, the last man in her life. In a year's time, she gave birth to their daughter, spending practically all her savings for it. She had to work harder because of increased expenses, another mouth to feed and a wastrel husband. There were times that she wanted to force him to change, but she didn't know how Just the same, she did not give up, hoping that he would change his ways and ask her to marry her, after everything. She did not build all that hope alone. When he felt that she would reach breaking point, he would somewhat make it up to her in simple ways - sometimes bringing her some goodies, asking her to dine out or to walk in the park. / and he always won her back, no matter how badly he behaved and how much he grieved her. The patient survived her ordeal by living in the belief that through it all, he actually loved her.

In their fourth year together, her boyfriend figured in an embezzlement case filed by his employer, an insurance firm. He did not remit the insurance premiums he collected from some policyholders. The patient pledged the repayment and the case was dropped but the insurance firm obtained a temporary restraining order against her boyfriend to stay away from its branches and all its policyholders. The event was most distressing to them. Her boyfriend lost his job and it was not easy for him to find another because he lacked educational capabilities as well as the motivation to hold a job. And worse, he would not stay away from the places he was restrained from. He was jailed temporarily but the patient always managed to set him free because she could not live without him, even if she had to sacrifice her business savings intended for their growing daughter.

The following year, she got pregnant again. On her fourth month in this second pregnancy, her doctor said that her baby had Downe's Syndrome. She was devastated by it. Her boyfriend and her mother were equally indifferent - she had hoped they would be more sympathetic. Instead, both of them blamed her for the defect. Her mother said the patient deserved it for all her misconduct and her choice of a man. And her boyfriend accused her of carrying the Downe's gene. Someone in her office suggested that she get an abortion. The idea was horrible even to think about, but there did not seem to be any other option open to her then. She simply felt alone, frightened yet wanting to keep the baby if she could.

The abortion left an indelible mark in her memory. She could not exactly figure out what she felt but the act of aborting a child rebelled inside her. A sense of helplessness and guilt kept coming back. There were times she would have nightmares and she would wake up in the middle of the night, screaming. To calm herself, she would resort to alcohol again.

In 1993, she got pregnant a third time. It was a normal pregnancy and she delivered a boy. She was then 39 years old and all through her pregnancy, she would hear rumors about her boyfriend carrying on with his former girlfriend. She remembered him talking about this girl in the past, but whom he said he dropped because she was demanding. But that year, he was coming home late too often and would not explain why. When she asked, he would behave threateningly. The patient thought that she could be driving him away by nagging and decided to be "more understanding." Maybe he was just trying to enjoy himself. Instead of tightening her hold, she loosened it. She pampered him all the more, more than she did their daughter and young son. She did not want to lose their father and the hope that someday, they would become a legal and happy family. In the meantime, her business was slowing down and her savings drying up. The patient knew she had to do something radical, especially because she needed to hold her boyfriend by giving in to his monetary demands for some good time.

One time, her mother came to talk to the patient unexpectedly. Her mother had kept the ugly news to herself for some time and now she came to tell her bluntly that the patient's boyfriend was seeing, not only his former girlfriend, but other young girls as well. This hit the patient hard where it should, because it came from her mother who would not exert all that effort to transmit a mere say-so. That night, she confronted her boyfriend with all the courage she could gather. But instead of the same pledge of love and loyalty from him, he blurted out how tired he had become of her and called her a hag; how much prettier, younger and more exciting was his earlier girlfriend and his other girlfriends at the time; how much he wanted to retch each time she solicited sex from him; and how much he would want to leave her if he could. At this point of her recollection, the patient cried bitterly for several minutes. Then she regained some composure and resumed her account.

Her boyfriend had just come home from some fun with his friends and former girlfriend and he still strongly smelled of alcohol. As she always did in the past, she wanted to excuse his words by excusing his behavior, but it was simply different that time. His insult pierced through her thick covering of defense and denial because it was the truth. She was no longer young nor beautiful. She had, indeed, looked like a hag and a wretched one. He no longer desired her but only needed her for support. And the fact that he was 9 years younger than she made her feel all the worse about herself. All the time, their two children could hear his insults. Perhaps, even the neighbors did, too. Her horrible life was an open book of shame and dejection, and she was the last to admit this reality because she wanted not only their relationship to last, but also for her to survive. But his revelations about her in this crucial confrontation were too much to deny, because she agreed with him. And she began to shake, scream and cry like she was exploding. She collapsed and yielded to a nervous breakdown, for which she was hospitalized.. That was 1997.

The patient did not know how long she lay unconscious, but when she opened her eyes for the first time, the first things she saw were the faces of her 3 younger siblings - her two brothers and sister. They embraced and comforted her in pity. It was their first time together since they eloped, escaped or got kicked out from their old house. Her siblings were not visiting their mother, as they too were distant from her. They said they had not heard about their father, either, and simply guessed he must have returned to his home country or loafing somewhere. As for them, they were coping with their own problems with their families, living in other States. But not without the same traumas of an unhappy childhood as the patient suffered from.

Of the four surviving children in their family, only the patient did not have the courage and enough self-respect to leave their parents' home. The patient's small business tied her to that home. And as the eldest, she felt it her responsibility to assure the welfare and health of whatever passed for a home. That image of a home was in the shape of their cold and insensitive mother. But each time a sibling left the house, something unconscious nipped the patient. Now, she realized that she envied them and wished that she had the same guts to leave the parental home and build her own life.

Her surviving twin brother, who then worked as a merchandise assistant in a supermarket chain suffered much humiliation from their father. In their father's eyes, this brother never did anything good or right. He was always compared to their deceased twin brother and he always lost the comparison. The patient was not the least surprised that this humiliated brother arranged that he be assigned to another branch of the supermarket in a distant State. They never heard from him for 15 years until the patient's hospitalization for a nervous breakdown. He related that he found a girl in that State, married her and began a family. A neighbor, who lived near the patient's house and worked in the same supermarket chain, informed him about the patient's hospitalization. He then contacted their younger brother and sister in two other States.

This youngest brother was by far the most professionally successful of the five children. He managed to finish an engineering degree with much help from the patient's small business. This brother was a diligent student and the sibling whom their father wanted so much to look and behave like him. Their father even wanted this youngest brother to give up American citizenship and settle in Japan, instead. Their father scorned American thinking and the American way of life as too loose. He said that their youngest brother's intelligence would be most useful in Japan and that he (their father) would give him (their youngest brother) all the backing he needed. But this never materialized, because the patient's youngest brother was very American in his thinking and life style and tried to learn Japanese ways only to please their father. This brother was a scholar from the university and hated sports, but their father coerced him into learning Japanese martial arts. They always clashed values, as their parents always did. What was most tragic to this brother was the fact that he looked most like their Japanese father, which he hated as he hated their father.

The patient's mother was also fondest of this youngest brother, with whatever form of fondness she could manage to show through her acerbity and nonchalance. She always prepared the food he liked best and would not begin dinner unless the youngest son was seated. She also reserved the best purchases for him whenever she could visit the department stores. And whenever their father and this youngest brother argued, their mother would surely come to the rescue of the latter. A simple comment from their youngest brother could and would escalate into full-blown and heated argument not only between the youngest brother and their father, but soon, between their parents. The argument would end with screams, cussing and throwing and breaking things on the floor. Then their father would leave in a rage to drink somewhere. This was among the usual scenarios at home until the last time their father left and never returned. A week later, a distant relative of their father came and told their mother that he was just sending his support to her and the children, because he was not coming back.

Their father's abandonment was very hard for all five of them, but their mother hardly reacted to it. Nothing was new to her. They never really matched and were never happy. In a real way, their mother was even relieved that she did not have to bear his occasional presence. Now, she could pay closer attention to her knitting, gardening and cooking for their youngest brother.

Despite their lack of happiness and tolerance for each other, their father kept his pledge of support for their mother. At least in this respect, the patient saw him as an honorable man.

The patient's youngest sister was a neglected one. She was born when the patient's parents did not want any more children. But she was pretty, much prettier than the patient and had the best looks of both parents. She loved to dance and sing since she was 5 and those were things that their father did not like. He would say, "Only geishas do that." He looked down on dancing and singing. This little sister's dancing and singing were, to the patient, rather sweet, but little sister never received compliments from her parents, who were forever busy with something else. The patient was the closes this little sister had for a parent or caretaker. She bathed, fed, changed, put her to bed and took her for a walk. They were 10 years apart and so their taste and times differed. Sometimes, their brothers would take little sister to the store, to the park or to the ice cream parlor. Aside from these little acts, no expressions of appreciation and love came her way from their parents.

The patient's sister also finished high school, where she caught attention for her fine dancing and singing during school programs. She could act, too. Both sisters attended the same school, which led the patient to feeling some envy because she was never noticed as a student. She got better grades than her younger sister did, though, partly because her little sister was not as engrossed in her lessons as she was on the school's dancing and singing activities. Before she graduated from high school, she had become a member of a small community performing team as a dancer and a member of its choir. There, she met a very likable fellow who became her boyfriend. Much as he wanted to make friends with little sister's parents, he never received anything close to warm greetings. The truth was that the entire family did not want little sister to have a boyfriend as yet, and they became very strict with her. First chance they had after her graduation, she eloped with him. The patient's parents were only momentarily enraged by the show of disrespect and disregard by little sister. The patient was sad for a while and worried about her little sister's welfare. But the worry soon disappeared with the assurance that little sister had learned how to take care of herself and assert it by leaving home. The patient felt embarrassed inside that their youngest sibling could have the courage to do so and she could not.

When all three siblings and their father had left, the patient was left alone with their mother and her very odd ways. She never took pleasure in anything the patient did and was always pointing to her little mistakes. It was during those years that the patient read something about tricotillomania and realized that she had it, but could not stop it. She always had it since she was a child and would find herself resorting to it during bouts of loneliness and boredom. It was in one of those loneliest moments that this boyfriend of 16 years made his first appearance.

For the first time, the patient felt some comfort when her younger siblings visited her. They are all doing well, but she was not. She told them that the money she was spending for her hospitalization was the last amount in her savings passbook from her dying business. Her boyfriend wasted everything she took years to build and keep. Upon her return home, she and her two children would be virtual beggars, while her children's father spent wild hours with his friends and girlfriend. His abandonment of her caused her this nervous breakdown and the hospital psychologist had not made a score in her therapy.

The patient's two brothers apologized for the little they could give for her welfare: they gave her modest amounts "to tide you and the children over." Her oldest brother's wife was taken ill and had to share the amount he had kept for emergencies. The second brother's wife just delivered their fourth child and he had to spend for that. Moreover, they were moving to China for an assignment and they needed to spend for that, although the transfer was mostly company expense. He promised to call the patient to inquire into her condition as often as his new assignment would allow. The patient did not realize how wonderful her younger siblings really were until those moments. They all insisted that the patient should leave her boyfriend or not to welcome him any more if he returned.

Little sister said that she could help the patient get a job as bookkeeper in the talent and management agency, owned by her friend's family. This agency was her and her husband's agency that booked them for performances. Now that the patient could no longer resuscitate her small business for absolute bankruptcy, she needed to work. This single meeting bolstered the patient's desire to go on and soon, she was discharged. Since then, she had not seen her younger siblings again, and they called in only infrequently.

Her long years of experience and skill in numbers added to her little sister's connection. Soon, the patient began work as bookkeeper and also performed some accounting functions. This job became her source of Medi-Cal and Medicare and sense of independence. She said nothing about what her boyfriend did for a living, whether he supported the children and the household. She also drove a van to take her around. She read periodically as her form of leisure, but was not yet considering completing college or acquiring additional education. She did not feel any zest to improve herself any more.

Her chief complaint consisted in severe depression, hopelessness and helplessness in her 16-year relationship with her boyfriend. The relationship began in 1986 when she was already 32. All that time, she did everything she could to make him happy. All she wanted was for him to marry her and love her. But he never married her nor loved her.

Their first child, a girl, was born when the patient was 36. The following year, she got pregnant again, but they decided to abort the unborn child because it was diagnosed to have the Downe's Syndrome. The experience made her feel very bad, but she was at a loss then and had no one to turn to for guidance and support. Two years later, she began drinking. And after two more years, she gave birth to a boy.

The last eight years were the most tormenting to the patient. She recalled being subjected to verbal and emotional abuse by her live-in boyfriend. During that time, she was on alcohol. And within that period, she suffered a nervous breakdown (1997). She was treated as an outpatient for the nervous breakdown and for post-traumatic stress disorder (PTSD).Part of the treatment she received and the warm visit by her younger siblings led to gradually give up on alcohol. For the last five years, she was sober..

C. Diagnosis

When interviewed for admission, the patient appeared alert, relatively capable and oriented, but anxious, crying and expressed her grief freely. She said that she was extremely depressed, feeling hopeless and helpless and no longer able to handle her situation any more. She also said that nobody was supportive of her and that nobody cared. For a short while, she thought that her younger siblings would be close enough to her to provide that kind of emotional support, but she was wrong. They had their own lives to live and they could not live for her. She realized that she was really living for her children only. Without her boyfriend, she could not see what she was worth.

She emphasized that her boyfriend's mental and emotional abuse caused her depression, and that her relatives already told her to leave him. Everything then appeared sad to her and this made her lose appetite for food. She likewise admitted to performing compulsive acts, such as repetitious arranging and organizing clothes, vases, baskets, ribbons, buttons and other similar items at home, according to size and color.

The patient refused to respond to questions or examination of her sexual history -- her sexual preference, whether she was then sexually active, practiced safe sex, needed special treatment related to or involving sex, and any history of sexual assault.

She had few acquaintances at work, but none close or trusted enough to confide in. She used to attend worship and had some religious convictions, but all these stopped when her mental problem developed. Her mother had remained unsupportive, distant and indifferent as ever. The patient frankly said that she had become unhappy with her boyfriend.

As a child, she had chickenpox and the other usual childhood illnesses. She also had a history of hand eczema, hypercholesterolemin, recurring tension headaches and hypertension. She had not suffered from any form of allergies. Some members of her family had hypothyroidism, Hepatitis B and tuberculosis. She complained of previous neck and low back injury. She had lived with her family, and all its members were negative for tobacco, alcohol and drugs.

Upon admission, she was diagnosed for depression, bipolar disorder. OCD, and post traumatic stress disorder due to psychosocial stressors related to her social situation. She also had elevated blood pressure and cholesterol. She added that her diet was regular, although she had been eating poorly lately because of depression and had nausea earlier. Although she said she lost appetite, she gained weight. Her abdomen was soft and non-tender, without mass or hernia. She had normal bowel sounds. Her lymph nodes and musculoskeletal system appeared normal. The patient, however, refused vaginal, rectal, and breast examinations, as she felt uncomfortable with them. She also refused to remove her pants above the knees.

Despite her claims of depression, hopelessness and helplessness, the patient admitted that she had some understanding and insight of her condition. She looked generally groomed and adequately educated. She could voluntarily verbalize her thoughts and feelings. She seemed to be in good physical health and physically active. She drove her own van. She appeared oriented with time, place, person and year. She had normal muscle tone and bulk with 5/5 strength and had no involuntary movements. She had normal gait and had no tardive dyskinesia. Her touch, pain and proprioception were within normal limits. Her deep tendon reflexes were equal and symmetrical bilaterally. She had no ataxia and no down-going toes. She was negative for Romberg. Her cranial nerves 1 to 12 were within normal limits. She could smell rubber coming from gloves within normal limits. She chewed normally, with good mastication and muscle strength. Her masseter muscles were palpable, symmetrical and not enlarged. Her facial movements and sensation were symmetrical and intact. She could hear a ticking watch. She had midline tongue, and her palate and tongue had no atrophy. Her gag reflex was intact. The movement and sensation of her tongue was normal and her trapezius and sternocleidomastoid had normal strength. The last time she saw a dentist was a year before the interview. Her physical and medical assessment consisted of weight gain, hand eczema, hypertension and hyperlipidemia.

Upon mental examination, the patient was found to be a personally adequate woman but whose overall psychomotor was slowed down. She was downcast, trembling and very tearful during the interview. She spoke softly and her voice was subdued. She exhibited a depressed mood, which was appropriate to thought content. Such thought content, though, showed no delusions and no hallucinations, as she herself denied having. Neither was there a loosening of associations or flight of ideas. She similarly denied homicidal ideas and intents and said that she could flee to safety.

The patient was lucid and intellectually capable. She could subtract 7 from 100 and back to 65. She recalled six digits forward and three digits backwards. She also recalled three objects after five minutes. She likewise displayed a store of knowledge about social and political issues. Judged clinically, the patient had normal IQ. She interpreted a proverb correctly and normally. When asked to interpret the proverb, "Don't change horses in the middle of the stream," she answered: "Don't start something until you finish another." She judged fairly and revealed an adequate insight of things.

Her admitting diagnosis consisted of severe psychosocial stressors, related to social situation;

depression; bipolar disorder; post traumatic stress disorder, OCD; alcohol abuse disorder but in remission; elevated blood pressure and cholesterol. #

III. TREATMENT HISTORY. TO-DATE

A. Treatment Plan

The patient was admitted to the Adult Out-Patient Program four times a week for two to four weeks. The Program had the following features:

structured and supportive milieu which would provide occupational, recreational and group therapy;

physical and psychosocial evaluation to help with discharge planning;

individual therapy which would be supportive and psycho-dynamically-oriented;

chemical copendency education group to deal with grief

The patient was to be followed up on by a private physician, and her low nect and back pain to be assessed if it recurred. A follow-up with the gynecologist was also scheduled.

B. Treatment History to-date:

The patient said that her situation became crucial for the last 8 years. She said that she increasingly got depressed and went on crying spells because of her relationship with her boyfriend and how he treated her. She said she could not concentrate, felt helpless and hopeless and progressively lost energy and interest for things.

In 1997, he was hospitalized when she had a nervous breakdown. She attributed the event her relationship with her boyfriend. In 2000, she was again hospitalized and for three weeks at the Del Amo Hospital for the same complaint. She was prescribed Serzone, which worked for her.

Recently, she was once more hospitalized psychiatrically at the College Hospital of Costa Mesa for two weeks. But because she was not coping, she was discharged and then moved to the College Hospital of Cerritos for further evaluation and study. In this Hospital, she was admitted to the Adult Out-Patient Program four times a week in AG B. track.

Her laboratory examinations revealed a white blood count of 7.2 thousand; hematocrit 42.7; sodium 140; potassium 8.2 initially and 4.2 upon repeat. When last taken, her weight was 132 pounds.

Upon admission, the patient was taking Neurontin800 mg three times daily; Paxil 20 mg in the morning; Buzpar 20 mg three times daily; Zyprexa 20 mg at bedtime; Klenopin 2 mg twice daily; and Lithium 900 mg at bedtime.

C. Transcripts of Sessions

The patient said that everything in her life collapsed when her boyfriend left her for his other girlfriend. Their children, her talents and her own life did not mean anything then. That was what she felt despite all his disloyalty, selfishness and lack of love. The patient saw the boyfriend at the center of her life and could not believe he would leave her despite everything that she did for him. She also considered fidelity or loyalty as the prime virtue she had to develop in order to be worthy of his boyfriend's love. This was the virtue inculcated in her by her disciplinarian father.

Intervention. Provided the patient with basic insight into her separateness as a person from everyone else and that her significance as such never depended on the acceptance of anybody else. Also tried to impress upon her that her practice of any virtue did not and could not diminish her intrinsic personal worth, and that this personal worth existed independently of anybody's recognition or approval, including her own. But the lack of unconditional acceptance of her by her parents proved to be a big barrier to her realizing her distinct worth as a person.

She was convinced that she was not a desirable woman because her boyfriend lived with her for 16 years without asking her to marry him. She also tried her best to look attractive and become lovable to him, but he did not seem to be attracted to her but only to her financial support of his vice and his needs. She lost self-respect and a feeling of attractiveness when he shouted insults at her that she was a hag and that he preferred his former girlfriend who was younger and more exciting.

Intervention Tried to explain in simple ways that beauty is not something seen or found on the face and body of a person, that beauty and love are found in the person himself or herself. Her boyfriend was incapable of seeing her true worth and that was a defect in him, not in her. Also impressed upon her that the urge to be married was impressed in her by her disciplinarian father, but that the goodness of a person or happiness itself can be found in any state of life. Also stressed that her boyfriend preferred his former girlfriend because they were both immature and because his girlfriend did not impose what the patient imposed upon her boyfriend. I also tried to drive the point home to her that she would be much better off without this boyfriend, but this was inaudible to her.

The patient relished deep sadness and a strong sense of rejection because of her parents' separation or the father's abandonment of his family. The patient admired her father's teaching of loyalty and then he displayed disloyalty towards their mother. The patient felt caught between the extremes. On one end, she resented her father's abandonment and tried to convince herself that he did not deserve their loyalty, either. But on the other end, she blamed her mother for having caused it. At one time or another, she harbored the idea of following her father and living with him rather than sticking it out with her mother who disliked her and whom she disliked just as much.

Intervention Tried to impress upon her that parents were/are just as human as anybody else: that they could get tired of each other's presence and separate. That behavior had nothing at all to do with the permanent significance of their children. Pointed to the fact that her father took to liquor for a reason, and quite often, the reason is personal inadequacy. Reminded patient that despite his abandonment, they should be thankful that their father continued to support them. Other husbands and father would try to make an exit and stop all support and communication.

Most of the time, she found no justification for their mother's emotional distance. The patient saw her mother as living her own world. There was absolutely no communication between them, except on very cursory and moment-to-moment matters. No communication ever existed between the couple and between the mother and her children. The only exception was their youngest of whom their mother was extremely fond. They had two very unloving, conditional and forbidding parents with whom life was an unbearable prison. The only frequent noise and only regular activity at home were their boisterous quarrels. She felt bad that she and her siblings did not have other good moments like those they had in the hospital

Intervention

Suggested that their mother, as well as their father, needed counseling although they may never consider it. They needed to be communicated to and to communicate. Maybe they had learned to hide what they really felt or thought inside. Their coldness and hardness were only defenses for something they had to protect. That was probably their means of coping, without which they felt they would not survive. If poor communication or the lack of any is seen or observed in a family situation, opening communication lines or removing barriers appeared to be the best approach to problems. #

IV. KEY THEORETICAL CONCEPTS

A. The Cognitive Theory as related to OCD

1. John Dollar and Neal Miller proposed that the aggressive drive and an aggressive behavior were learned. They assumed that, when an aggressive response was punished, the person (usually a child) would inhibit that response the next time. The aggressive drive, however, would not be reduced, but simply expressed in one of the options available at the moment. This would not reduce the aggressive drive but would simply be directed at the frustrating source or offending party.. Because the aggressive behavior towards the offender was inhibited, the offended person might displace his or her aggression towards a substitute person. The choice of substitute would depend on the similarity between the real source of frustration and the substitute person.

Quite often, the idea of substituting someone else to take one's anger was and is still frowned upon. Because of this, the offender person would hold on to the frustration without expressing it. When a similar frustration would be caused by another and unthreatening person, the aggressive drive would be higher and stronger than the first time. The theorists would say that this explained why some persons reacted quickly even to slight provocations.

Dollard and Miller also maintained that frustration did not always result in aggressive, because inhibitions prevented it from getting expressed. The theorists also believed that aggression always occurred because of frustration. This view was opposed and rejected by other theorists in that frustration could lead to a sense of helplessness, to regress into infantile behavior, or to be experienced as a challenge or fun. Moreover, aggression could be expressed without frustration preceding it, as in the case of predator animals. The patient clearly learned that expressing anger and aggression got punished or received rejection from either parent. She learned quite well how to inhibit her anger and this was expressed in helplessness, loneliness, hopelessness and anxiety, such as tricollimania which appeared at age 7. Dollard and Miller advanced the opinion that a child's critical training periods were feeding, cleanliness training, and early sex training. Our patient's symptoms appeared at the end of her formative years, indicating that it came as a response to a disturbance in her early childhood in one of these periods.

2. Albert Bandura's theory on the development of aggressive behavior or criminality came out of a process he called "behavior modeling." While it was not inherited, he believed that a person or child learned to be aggressive from his parents or at home, through the media and from the environment. These influences, he assumed, were reinforced by the reduction of tension, gaining financial rewards, gaining the praise of others or building of self-esteem.

He demonstrated through his famous Bobo doll experiment. how children learned violent behavior by observation. First, they observed their parents or other members of the family express violence. Then they retained the observed behavior for a long time in memory. Next, they reproduce or perform the learned violent behavior. Lastly, they received motivation for the behavior, such as being glorified in the media or praised by the crowd for the performance of some perceived feat.

In our patient's case, domestic violence was regular fare. She witnessed the enmity between her parents, between them and their father and the non-physical kind of cruelty and violence shown by their mother with her faultfinding, cold indifference, and at times, a display of temper.. From the start of their lives, aggressive or rejecting behavior was a given and the normal environment in their family. Like her father, the patient believed that her mother's despising attitudes not only enhanced the deep-rooted antipathy between them, but quite often, even provoked her father's harshness.

Having internalized not only her father's aggressions covertly but also her mother's hostile attitudes, our patient could have unconsciously desired to perpetuate the state of conflict with her boyfriend. Knowing in what domestic atmosphere she was raised, observers would not be quickly inclined to accept the patient's perceptions of her persecutions. The same was true of her younger siblings who were subjected to the same hostile and frustration-ridden home milieu.

3. Eric Berne was/is a co-founder of the famous Transactional Analysis (TA) Theory., a form of social psychology, which differed from psychoanalysis in that TA aimed at people's external behavior in the hope of understanding their interactions and in improving their social environment.

He saw that people interacted through the three "ego-states" of parent, adult or child, covertly or overtly. Each state is/was a dynamic system: the parent's state, of values; the adult's, of logic and rationality; and the child's, of emotions. For a person to function effectively, all three states should be available. But not all of these states were available to our patient in her lifetime.

Berne also described the "games" played by people with maladjusted behavioral patterns. These were mean and sometimes dangerous "games" they learned in order to gain "strokes" or the approval of those important to them. These were as important to them as the need for food, water and air - in other words, for psychological and physical survival. Such favorite games, according to Berne, used erroneous or deadly and life-long "scripts," which were decisions they made as children who pleased their parents (and others). These games and scripts were played and used all their lives to gain approval or "OK" until and unless they stopped playing the games and changed the scripts by acquiring a new and higher or better kind of awareness some time in the future.

As a child, our patient obtained such "strokes" by remaining passive, quiet, obedient, loyal to her parents and un-married. She constantly played the role of victim until she was left alone with her mother, whom she secretly rejected and abhorred. When she moved in with her boyfriend, it was his "strokes" she began seeking by using the scripts that won him back to her, until the script no longer worked.

4. Jean Piaget theorized that the infant gained knowledge of the world by forming skills he called schemas into which he introduced new knowledge by adaptations and assimilations. Soon, these adaptations and assimilations alternated and achieved a balance of the universe called an equilibrium between the infant's mind and the environment. He also theorized that cognitive development consisted of four stages, namely, the sensorimotor in the first year of life and involving circular reactions; the preoperational up to the seventh year, involving symbols; the concrete operations from ages 7 to 11 and involving the logical manipulation of these operations; and the formal operations stage from 12 years old onwards, involving hypothetical thinking.

Piaget developed the concept that, in many cases, abstract reasoning occurred in the adolescent, who learned to reason and conclude using identity, negation, reciprocity or correlativity. The patient in the case under study was supposed to be an adequately educated person, but her responses to stress were not at par with it. That is because her learning was purely in the mental level and confined to what she knew best: numbers. She used this skill well in her business and employment at a latter time. Applying Piaget's theory of growth and development, it is doubtful if the patient went beyond the third stage of concrete operations. She probably had much difficulty with hypothetical thinking, which was required in the fourth and last stage. He added that not everyone reached the fourth stage (formal operations). Even if some did, they did not always operate in that stage. Our patient could be one of those who did not, even if her education brought or led her into it.

B. The Psychoanalysis Theory as Related to OCD

1. Carl Jung offered three principles by which the psyche operated. Two of these appeared related to OCD. These were the first - the principle of opposites -- and the second - the principle of equivalence.

According to him, the principle of opposites always existed. For every good wish, a bad wish coexisted. A choice was always made between them, but the opposites were always present and possible, as, in fact, it was their opposition that created the energy. The principle of equivalence, on the other hand, meant that these opposites had equal force or energy. The energy that went in the direction of the chosen side also went into the chain of behaviors involved in such an act. The opposite energy remained un-used. Jung believed that if the person consciously acknowledged the existence of that other choice and had the right attitude towards it, its un-used energy would be directed towards, and conduce to, the general improvement of the person's mind and personality. He or she would, then, grow. But if the person, instead, ignored that reality and, instead, denied or suppressed it (the reality that he or she secretly but actually wished to choose it), the equally strong energy of that opposite side would develop into a complex. A complex is made up of suppressed thoughts and feelings, which form around a certain idea or suggestion provided by some archetype (the "dark side"). Suppressions and denials through the years can lead this complex to form a life of its own that could haunt and even "possess" the person to become what he or she had long denied to himself or herself. One fatal consequence was the development of a multiple personality.

The suppressions and repressions of our patient from childhood could have led to the development of obsessions and compulsions that were aggravated by a one-way and frustrating relationship with an opportunistic boyfriend for 16 years. Her initial refusal to divulge any information of her sexual history or medical examination indicated a sense of guilt and filth concerning sex. Her failure to attract a man in her younger years, the refusal of her boyfriend to marry her, her abortion, and her boyfriend's insults that she looked like a hag all contrived to convince her that she was undesirable and worthless.

2. Alfred Adler held that the striving for perfection was the single motivation behind our behavior and experience. It was the inherent desire to achieve our potential. He also believed that compensation was another basic motivation, whereby the human person would strive to overcome problems, mistakes, inferiorities and other things of that kind. But Adler thought that there were many who stayed behind in that pursuit because their own sense of inferiority "overwhelmed" them. This sense of inferiority, to Adler, was not a lack of social interest but an excess of self-interest, because their attention was more and more focused on themselves. At the opposite end was superiority complex, which involved covering up one's inferiority by pretending to be superior.-- bullies, brags, dictators and those who craved for attention and got it through their dramatics. Adler labeled both as types of neurosis, a lack of social interest. He classified neurotics into four, according to their levels of energy: the ruling (choleric), the leaning (phlegmatic), the avoiding (melancholy), and the socially useful (sanguine) types.

Adler recognized the three basic childhood situations that often led to a faulty adult life: organ defects or inferiorities and childhood diseases; pampering; and neglect. He added that in the birth order, the oldest or first child often felt dethroned, might act immaturely, was disobedient and rebellious, lonely or withdrawn. He believed that the oldest child was the likeliest to be the problem child. That child was also often sad and more conservative than the younger children.

In diagnosing a case, Adler would look for all the details - factual details - about the person. First, he would seek out the patient's medical history, particularly serious illnesses, which could resemble the latter's neurotic or psychotic symptoms. Immediately, he would ask about the patient's earliest childhood memory in pursuit of the prototype of his or her present lifestyle. Then, he would explore the person's childhood problems: ad habits, fears, stuttering, superiority or interiority symptoms. Adler also gave importance to how the patient expressed himself or herself, such as through body language or even the way he or she slept. He would also tend to take note of what he termed as common "triggers": sexual problems (uncertainty, guilt, impotence, pregnancy and childbirth for women, love life in general, divorce) work life, mortal danger or the loss of a loved one.

Our patient's passivity towards her parents, her lack of a love life until she met and began a relationship with her boyfriend when she was already 32, her being the firstborn, her long submission to the disrespectful and uncaring treatment of her boyfriend, which sent her to the hospital for a number of times and her refusal to separate from him despite the life they lived together would have yielded a lot if she consulted with Adler.

3. Sigmund Freud, the father of psychoanalysis, said that life was not easy and also explained it. He showed that the ego (or "I") stood between the powerful forces of reality (society and reality) as represented by the superego) and the impelling forces of the id. When the forces of the superego battled against the demands of the ed, the ego would be threatened, overwhelmed and tend to collapse in-between. The situation would result in anxiety, a signal to the ego that its survival is threatened

Freud classified anxiety into realistic, moral and neurotic. Realistic anxiety is/was concrete. Moral anxiety was/is produced from the internal social world of the superego, which produced shame and guilt and the fear of punishment. The last is neurotic anxiety, which is/was caused by overwhelming impulses from the id. It led the person to fell like he or she was about to lose control of his or her temper, his reason or mind. It was also called nervous anxiety, the kind that engaged Freud the most.

When the ego got caught and threatened by the clash of forces between the superego and the id, it would first struggle to deal with it. When the anxiety became too much, the ego would defend itself by unconsciously blocking stimuli or altering them into less threatening forms. This blocking function took any of the different ego defense mechanisms, such as repression, denial of reality, displacement, projection, rationalization, regression, reaction formation, identification, asceticism, isolation, altruism, undoing and sublimation.

Our patient could have employed denial of reality in her frustrating relationships both with her family and with her boyfriend; repression of her hatred towards her parents, especially her mother; reaction formation towards her boyfriend whom she could have really hated but pretended to love and accept; asceticism in taking in the hurts and frustrations in her family and relationship with her boyfriend; and "undoing" of her crime of abortion by feeling ashamed of sexuality and sexual parts.

4. Erick Fromm suggested that a person, who resorted to any of the defense or escape mechanisms, wanted to escape from freedom and his choice of mechanism depended on what kind of family he grew up in. Fromm named two kinds of such families: symbiotic and withdrawing. A symbiotic family was where some members depended or became submerged into other members, so that the former did not develop their own personalities. Children in those families, for example, were mere extensions of their parents. This was the case for most societies for billions of years: people were ranked according to those who dominated and those who were subject. It was quite a stable system of living, yet it allowed and still allows people to live in love and friendship.

The withdrawing family was cold and indifferent, if not repelling. This was where perfectionism by the rule was the internal rule and it was more important than people. It did not only avoid freedom but was also destructive.

Fromm also believed that the way of life people are/were born into became so ingrained and automatic that it turned unconscious, or turned into a "social unconscious." From this mold, he assumed, developed five orientation types of (economic) personality: the receptive, the exploitative, the hoarding, the marketing and the productive. Only three applied to the patient in our case study: the receptive personality, who was incorporated into his or her parental image or personality and became submissive to it; the exploitative personality, who ruled, was aggressive and conceited; and the marketing personality, who was opportunistic, childish, tactless and saw life and even love as forms of transaction. This last one was, according to Fromm, belonged to the modern times.

Using Fromm's theory in interpreting our patient's life and conditions, her family would be both symbiotic and withdrawing. All of the children were trained to assume the personality of either parent and were not allowed to develop their own personalities. They were also a withdrawing family that kept to itself and drove freedom out.

Their collective orientation was receptive, except the mother, to that kind of environment, although all the children eventually bolted out when the repulsion for their parents became uncontainable. Clearly, the patient's parents were both exploitative of their children. They also attempted to exploit each other. The Japanese father, though, had one edge in that, despite his hatred for his wife, he continued supporting her. He could have learned this single virtue from his culture. And the patient's boyfriend was the supreme illustration of the marketing personality, because was calculating, "opportunistic, childish and tactless." His life was an endless fun and irresponsibility, as long as someone - the patient or his girlfriend/s - was willing to sustain these.

The patient's younger siblings could work at becoming productive personalities if they tried hard enough to understand and overcome their lengthy and disastrous family orientations.