Jake's obsessive-compulsive disorder: diagnosis and treatment analysis

Abnormal Psychology: OCD Diagnosis and Treatment

In this case, the reader is asked to evaluate the case of "Jake," who has an obsessive-compulsive disorder (OCD) which has reemerged after the birth of his child. Jake grew up in a relatively sheltered environment, close to his mother and distant from his father. Always uncomfortable with outside stimuli, Jake pursued a cautious and, in his father's eyes, less than manly life.

Jake had been able to cope with his panic attacks and compulsive concern for cleanliness at various points in his life, including in college and when he met and married his wife, Ally. He was able to tune his environment to cater to his desire for low stimuli: this extended to his wife (who liked quiet, indoor activities), his profession (accounting, which is an individual and rather isolated profession) and his choice of a place to live (not moving away from his home town).

A major change came in Jake's life with the birth of his daughter. This paper will seek to analyze how that and other changes may have reawakened Jake's OCD, and how it might be treated.

Diagnosis

Jake's case matches the DSM-IV criteria for OCD, as well as some of the associated sub-specialties of the disease (Hollander, 1993). The APA's DSM-IV criteria include the following characteristics:

Compulsions are defined as "repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly (Dziegelewski, 2002).

Note that this definition was changed in 2000, and is called "TR" because it represents a text revision which was performed after the DSM-IV criteria were introduced in 1997. OCD can exist in a number of forms, from moderate to severe. The symptoms which emerge may affect men and women differently: women can develop eating or self-mutilation disorders more commonly than men. Jake's cleaning- and germ-related phobias can be termed a "mild" or "moderate" form of OCD, which should lend itself to relatively straightforward therapy (as described in the following paragraphs).

Jake's disorder appears to show itself in behaviors, but the case does not present mental acts in detail that might help the diagnostician to determine if Jake engages in obsessive or compulsive mental acts.

In order to completely diagnose Jake's disorder, one must look at two characteristics (Goodman, 2000):

Symptom profile: intrusive obsessive thoughts and repetitive behaviors: it is clear that Jake engaged in obsessive behavior both in his childhood and early adulthood. Usually, OCD appears in later childhood or the teenage years, which corresponds with Jake's move from concern to obsession in the first attack when fishing with his father (Leckman JF, 1997).

Associated features, including family history and demographics: Jake's mother suffered from a similar disorder, although we do not have enough diagnostic information to discern if it emerged as OCD, or simply as a tendency to excessive worry and cleanliness. The case does illustrate that Jack's mother had been a worrier all his life, and this continued into Jack's and his sister's adult years. In fact, there may be a relation to the re-intensification of Jake's OCD after he and Ally had their child, and the increased concerns his mother expressed about him and his sister (Farrington D, 1990). In addition, Jack's father was only a distant influence, as he spent little time with his boy.

Recommended Treatment

Jake's OCD appears to be moderate enough (though of long duration) that it can be cured. A positive in his case is that he has functioned more-or-less normally in society for a number of years. Although it is not possible to imagine that Jake would change completely to an extrovert, the objectives of treatment should be to restore Jake's ability to function with his family and in his community and work environment, while maintaining his current personality.

If one were to choose the "easy" route of prescribing a serotonin inhibitor (such as Fluoxetine) alone, there is a concern that Jake's senses would be enhanced and he could therefore increase his anxiety. In this author's opinion, it would be advisable to treat Jake with a combination of CBT, or cognitive behavioral therapy, and serotonin inhibition, such as Fluoxetine.

In addition, Jack's wife should be implicated in two ways: (1) to explain the neurobiological and genetic factors which have affected Jake -- and could have an impact on their child in later life, and (2) to assess at a surface level whether Ally has tendencies to OCD or other forms of mental illness.

CBT would benefit Jake's OCD because it does not appear to be concomitant with other mental disorders, nor with major issues in his life (such as gambling, alcoholism, or a history of abuse). CBT's main advantages are that it is focused on the specific problem, is relatively short-term, and can have a long-lasting effect on curbing the irrational fears demonstrated in victims of OCD. If Jake showed additional symptoms or a more serious manifestation of the disorder, or a more complicated etiology due to deep psychological causes, treatment with CBT might need to be accompanied by talk therapy, meditation or other methods (Marazziti, 2001).

CBT concentrates on appealing to the rational mind and analyzing the fears, proving (in a rational fashion) that the stimulus of dirty hands, or floors, or other objects, cannot harm Jake or his family. The CBT therapist would encourage Jake note when he has urges to clean -- what are the triggering events. Then the therapist would help lead Jake through a series of aversion therapy exercises, demonstrating the positive outcomes when Jake is exposed to disorder, and gradually desensitizing him to the elements which concern him, or create tension.

Conclusion

What could be the outcome of CBT and Fluoxetine for Jake? The simplest indication would be that Jake reduces his obsessive-compulsive behavior a good deal. But there are additional indicators of progress or success, including better peer functioning, higher self-esteme, lower separation anxiety, and willingness to attempt new things. Thus "better" has a series of meanings, both direct and indirect (Curry, 1998).