john ocd case study

Obsessive Compulsive Disorder Treated without Medication – John

Severe OCD since 4th Grade

John was a very bright young fellow who was heading off to an Ivy League university in the fall. He was suffering from very severe OCD since 4th grade. He had tried Cognitive Behavioral Therapy, however it didn’t help. He refused exposure and response prevention therapy. Eventually, his OCD became so severe that he refused to extend his elbow because of his belief that such an action would cause harm to someone he loved. He also refused medication.

Headaches, GI Problems, and Weight Problems

His Yale-Brown Obsessive Compulsive scores was= 29 (obsessive=12, compulsive=17). He complained of headache, many gastrointestinal problems (nausea, diarrhea, constipation, stomach pains, flatulence, reflux, and perhaps related, and inability to gain weight, despite a well balanced and healthy diet).

Family History of OCD

John’s family history revealed OCD in his grandmother, a suicide by that grandmother’s sister, using a gun. His father was anxious, depressed and impulsive, but high functioning and successful. His father’s sister was described as very intense, persistent, and obsessive. His other grandmother was depressed and his grandfather’s father was alcoholic.

Other Health Problems

John’s physical exam revealed an obvious contracture in his right elbow, with the right hand being cyanotic and colder than the left. His skin was dry, with severe acne on his face and back. His tongue was coated white, suggestive of Candida overgrowth, and his throat was red. He had bilaterally swollen cervical lymph nodes, white spots on his nails, hyper-pigmented scars suggestive of excessive ACTH output and adrenal insufficiency. He had chronic sinusitis.

Evaluation Points to Nutrition, Digestion, Immune Systems

In summary, my initial evaluation, (a three hour history and physical and laboratory testing), suggested problems in the areas of nutrition, digestion and immune/inflammatory processes. I suspected genetic problems in his methylation.

Lab Results Show Health Issues

The laboratory evaluation showed the following: Nutrition: Low vitamin D, L-tryptophan was low, B5, B2;  B12, folate, Kryptopyrolles were elevated at 40.6 (consistent with acne, immune system problems), iron was low normal, low red blood cell size ( 83). Genetic: ++MTHFR Gastrointestinal: Candidiasis, anti-gliadin antibodies, WBC’s + in stool, HLA DQ2 (Coeliac’s). Immune/Infection:  5 infections: salmonella, Endolimax Nana, Bartonella, Babesia, Candida, plus chronic sinus infections, delayed food sensitivities (IgG mediated). Hormones: TSH: 4.11, melatonin was 7.1, ACTH was 42 ([norm=7-50], cortisol output was low at 20 [23-42], DHEA low normal (4), cholesterol was 131.

Now Willing to Do Everything

John was now willing to implement all of the recommendations because he had an understanding of what was causing his problems. He was a model patient. At his first 1st visit to review his lab results in May of 2007 I recommended L-tryptophan, D, B-vitamins (per his test results), high dose L-methylfoalte, inositol, three antibiotics for infections, candidiasis as well as anti-parasitics, probiotics, and a medical food product to support healthy bacteria and strengthen the gut-immune barrier.

Sleep back on Track

At his 2nd Visit on June 23rd 2007 he reported that his GI problems were gone, and his sleep was “back on track”, however his anxiety was unchanged. I recommended exposure and response prevention therapy.

Headaches Gone, Sinuses Cleared

At his 3rd Visit on July 19th 2007 he had had exposure and response prevention therapy and he reported his anxiety was “way down”. His headaches—which he had not told me about earlier—were gone. His sinuses had cleared completely.

By August 21st of 2007, John was still on his antibiotics, and he reported that the OCD was “ a million times better”, and no longer interfering with his activities”. He later was able to do cognitive behavioral therapy with exposure and response prevention.

Free of OCD without Medication

At follow up 3 ½ years (after his father’s death) he continued to be free of OCD, however at that time he was having some anxiety, which a short course of CBT was able to address. No medications were used in his treatment.

Unraveling OCD: A Comprehensive Analysis of Case Studies and Examples

From Howard Hughes’s compulsive hand-washing to the silent struggles of millions worldwide, the labyrinth of Obsessive-Compulsive Disorder unfolds through a tapestry of compelling case studies that illuminate the complexities of the human mind. Obsessive-Compulsive Disorder (OCD) is a mental health condition characterized by persistent, intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) that individuals feel compelled to perform to alleviate anxiety or prevent perceived catastrophic outcomes. While the disorder affects approximately 2-3% of the global population, its impact on individuals’ lives can be profound and far-reaching.

Case studies have long been a cornerstone of OCD research, offering invaluable insights into the nuanced manifestations of the disorder and the effectiveness of various treatment approaches. These detailed examinations of individual experiences provide researchers and clinicians with a deeper understanding of OCD’s complexities, helping to refine diagnostic criteria and develop more targeted interventions.

In this comprehensive exploration of OCD case studies, we will delve into the intricate world of obsessions and compulsions, examining notable examples, analyzing patterns, and discussing the implications for research and clinical practice. By unraveling these compelling narratives, we aim to shed light on the diverse presentations of OCD and the ongoing efforts to improve the lives of those affected by this challenging disorder.

The Anatomy of an OCD Case Study

To fully appreciate the value of OCD case studies, it’s essential to understand their key components and the methodologies employed in their creation. A well-constructed OCD case study typically includes several crucial elements:

1. Patient background: This section provides relevant demographic information, medical history, and any significant life events that may have contributed to the development or exacerbation of OCD symptoms.

2. Symptom presentation: A detailed description of the patient’s specific obsessions and compulsions, including their frequency, intensity, and impact on daily functioning.

3. Diagnostic process: An outline of the steps taken to diagnose OCD, including any assessments or screening tools used.

4. Treatment approach: A comprehensive account of the interventions employed, such as Cognitive Behavioral Therapy (CBT), Exposure and Response Prevention (ERP), or medication management.

5. Treatment outcomes: An evaluation of the patient’s progress, including any changes in symptom severity, quality of life, and overall functioning.

6. Follow-up and long-term prognosis: Information on the patient’s status after treatment completion and any recommendations for ongoing care.

Researchers employ various methodologies when conducting OCD case studies, ranging from single-subject designs to more extensive case series. These approaches allow for in-depth analysis of individual experiences while also identifying patterns across multiple cases. Some common methodologies include:

– Single-case experimental designs: These studies involve repeated measurements of an individual’s symptoms before, during, and after treatment interventions.

– Qualitative case studies: Researchers use interviews and observational techniques to gather rich, descriptive data about a patient’s experiences with OCD.

– Longitudinal case studies: These investigations follow individuals with OCD over extended periods, often years, to track the course of the disorder and the long-term effects of treatment.

It’s crucial to note that ethical considerations play a significant role in OCD case study research. Researchers must obtain informed consent from participants, maintain confidentiality, and ensure that the potential benefits of the study outweigh any risks to the individual. Additionally, researchers must be sensitive to the potential impact of participating in a case study on the individual’s OCD symptoms and overall well-being.

Notable OCD Case Study Examples

One of the most famous OCD case studies is that of Howard Hughes, the American business magnate, aviator, and film producer. Hughes’s struggle with OCD has been well-documented and offers a compelling example of how the disorder can manifest in extreme ways, even in individuals of exceptional talent and success.

Hughes’s OCD symptoms reportedly included:

– Extreme fear of contamination, leading to compulsive hand-washing and elaborate cleaning rituals – Obsessive concerns about germs and disease – Strict control over his environment, including detailed instructions for staff on how to handle objects – Hoarding tendencies, particularly related to tissues and other personal items

The case of Howard Hughes illustrates the potential severity of OCD and how it can significantly impact an individual’s life, regardless of their social status or achievements. It also highlights the importance of early intervention and appropriate treatment in managing OCD symptoms.

While Hughes’s case is well-known, contemporary OCD case studies continue to provide valuable insights into the diverse manifestations of the disorder. For instance, a case study exploring one of the most severe cases of OCD might reveal the extreme lengths to which individuals may go to alleviate their anxiety and the profound impact on their daily functioning.

Other notable OCD case study examples include:

1. The case of “Mary,” a 32-year-old woman with contamination-related OCD who spent up to 8 hours a day showering and cleaning her home. Her case study highlighted the effectiveness of Exposure and Response Prevention (ERP) therapy in reducing her symptoms and improving her quality of life.

2. “John,” a 45-year-old man with religious scrupulosity OCD, who experienced intrusive blasphemous thoughts and engaged in excessive prayer and confession rituals. His case demonstrated the importance of tailoring CBT techniques to address specific OCD themes.

3. “Sarah,” a 16-year-old girl with symmetry and ordering compulsions, whose case study showcased the potential benefits of family-based interventions in treating adolescent OCD.

These diverse case studies underscore the heterogeneity of OCD presentations and the need for individualized treatment approaches. They also reveal fascinating aspects of OCD that may not be immediately apparent, such as the wide range of obsessions and compulsions that can manifest in different individuals.

Analyzing OCD Cases: Patterns and Insights

When examining multiple OCD case studies, certain patterns and themes begin to emerge, offering valuable insights into the nature of the disorder and its treatment. Some common themes observed across various OCD cases include:

1. Age of onset: Many case studies report that OCD symptoms often begin in childhood or adolescence, although the disorder can develop at any age.

2. Comorbidity: A significant number of individuals with OCD also experience other mental health conditions, such as depression, anxiety disorders, or eating disorders. This raises important questions about whether OCD should be classified as an anxiety disorder or as a distinct entity.

3. Impact on relationships: OCD frequently affects interpersonal relationships, with many case studies highlighting the strain placed on family members and partners.

4. Fluctuating symptom severity: Case studies often reveal that OCD symptoms can wax and wane over time, influenced by various factors such as stress, life events, and treatment adherence.

5. Treatment response variability: While many individuals respond well to evidence-based treatments like CBT and ERP, case studies also illustrate that some patients may require more intensive or prolonged interventions.

Despite these common themes, each OCD case presents unique aspects that contribute to our understanding of the disorder. For example:

– Specific trigger events: Some case studies describe particular life events or traumas that seemed to precipitate or exacerbate OCD symptoms, providing insights into potential environmental factors in OCD development.

– Cultural influences: Cases from diverse cultural backgrounds highlight how OCD manifestations can be shaped by cultural beliefs and practices, emphasizing the need for culturally sensitive assessment and treatment approaches.

– Atypical presentations: Certain case studies document unusual or less common OCD symptoms, expanding our understanding of the disorder’s potential manifestations.

By analyzing multiple OCD case studies, researchers and clinicians can draw valuable lessons that inform both theory and practice. These insights include:

1. The importance of early identification and intervention in improving long-term outcomes for individuals with OCD.

2. The need for personalized treatment plans that address the specific obsessions and compulsions of each individual.

3. The potential benefits of involving family members or support systems in the treatment process.

4. The value of long-term follow-up and maintenance strategies to prevent relapse and manage residual symptoms.

5. The significance of addressing comorbid conditions alongside OCD symptoms for comprehensive care.

These lessons derived from case studies contribute to the ongoing refinement of OCD treatment approaches and help clinicians better understand the complexities of the disorder.

Treatment Approaches Highlighted in OCD Case Studies

OCD case studies have been instrumental in showcasing the effectiveness of various treatment approaches and highlighting areas for improvement. Cognitive Behavioral Therapy (CBT), particularly Exposure and Response Prevention (ERP), emerges as a cornerstone of OCD treatment in many case studies.

For instance, a case study of a 28-year-old man with severe contamination OCD demonstrated how ERP techniques, such as gradually touching “contaminated” objects without washing, led to significant symptom reduction over 16 weeks of treatment. This case highlighted the importance of a structured, gradual approach to exposure exercises and the role of the therapist in providing support and encouragement throughout the process.

Another case study focused on a 42-year-old woman with checking compulsions related to fear of harming others. This study illustrated the effectiveness of combining traditional ERP with cognitive restructuring techniques to address the patient’s overinflated sense of responsibility. The case emphasized the importance of tailoring CBT interventions to address specific OCD themes and underlying beliefs.

Medication management, particularly the use of selective serotonin reuptake inhibitors (SSRIs), is another treatment approach frequently discussed in OCD case studies. For example, a case series examining the use of fluoxetine in treating pediatric OCD demonstrated the potential benefits of medication in reducing symptom severity and improving overall functioning. However, these cases also highlighted the variability in individual responses to medication and the need for careful monitoring and dose adjustments.

Some case studies have also explored innovative treatment methods for OCD. For instance:

1. A case study of a 35-year-old woman with treatment-resistant OCD documented the successful use of transcranial magnetic stimulation (TMS) as an adjunct to traditional CBT, resulting in significant symptom improvement.

2. Another case report described the application of virtual reality exposure therapy for a patient with OCD related to fear of contamination in public spaces, demonstrating the potential of technology-enhanced interventions.

3. A case series examining the use of mindfulness-based interventions for OCD showed promising results in reducing symptoms and improving overall well-being, particularly for individuals who had not fully responded to traditional CBT approaches.

These case studies not only showcase the effectiveness of established treatments but also point to potential new directions in OCD management, emphasizing the importance of continued research and innovation in the field.

The Impact of OCD Case Studies on Research and Practice

OCD case studies have had a profound impact on both research and clinical practice, influencing diagnostic criteria, treatment protocols, and our overall understanding of the disorder. One significant contribution of case studies has been their role in informing and refining the diagnostic criteria for OCD.

For example, case studies have helped to elucidate the diverse manifestations of OCD, leading to a broader recognition of less common symptom presentations in diagnostic manuals. This expanded understanding has improved clinicians’ ability to accurately identify and diagnose OCD, even in cases where symptoms may not align with more stereotypical presentations.

Case studies have also played a crucial role in shaping OCD treatment protocols. By providing detailed accounts of treatment successes and challenges, these studies have:

1. Helped to establish the efficacy of CBT and ERP as first-line treatments for OCD. 2. Informed the development of treatment guidelines and best practices. 3. Highlighted the importance of tailoring interventions to individual needs and symptom presentations. 4. Demonstrated the potential benefits of combining multiple treatment modalities, such as psychotherapy and medication.

Furthermore, OCD case studies have influenced future research directions by:

1. Identifying gaps in current knowledge and treatment approaches. 2. Generating hypotheses for larger-scale studies. 3. Providing preliminary evidence for novel interventions or treatment combinations. 4. Highlighting the need for research on specific OCD subtypes or populations.

As we look to the future, case study research in OCD continues to evolve. Emerging trends include:

1. Increased focus on long-term follow-up studies to better understand the course of OCD over the lifespan. 2. Exploration of the role of new technologies, such as smartphone apps and wearable devices, in OCD assessment and treatment. 3. Investigation of the neurobiological correlates of OCD through case studies incorporating neuroimaging and other biological measures. 4. Examination of the impact of cultural factors on OCD presentation and treatment outcomes through diverse, cross-cultural case studies.

These ongoing efforts in case study research promise to further enhance our understanding of OCD and improve outcomes for individuals living with the disorder.

In conclusion, the examination of OCD case studies provides a wealth of insights into the complex nature of this challenging disorder. From the famous case of Howard Hughes to the countless unnamed individuals whose experiences have been documented in research, these studies offer a window into the diverse manifestations of OCD and the ongoing efforts to improve diagnosis and treatment.

Key takeaways from our exploration of OCD case studies include:

1. The importance of individualized assessment and treatment approaches, given the heterogeneity of OCD presentations. 2. The effectiveness of evidence-based treatments like CBT and ERP, as well as the potential of innovative interventions. 3. The value of long-term follow-up and comprehensive care that addresses comorbid conditions. 4. The ongoing need for research to refine our understanding of OCD and develop more effective treatments.

As we continue to unravel the complexities of OCD through case studies and other research methodologies, it is crucial to maintain a sense of empathy and awareness for individuals living with this disorder. By sharing these stories and insights, we not only advance scientific understanding but also help to reduce stigma and promote compassion for those affected by OCD.

The journey to fully understand and effectively treat OCD is ongoing, and case studies will undoubtedly continue to play a vital role in this process. As we look to the future, the lessons learned from these individual narratives will guide researchers, clinicians, and individuals with OCD towards more effective management strategies and, ultimately, improved quality of life for all those affected by this challenging disorder.

References:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

2. Abramowitz, J. S., Taylor, S., & McKay, D. (2009). Obsessive-compulsive disorder. The Lancet, 374(9688), 491-499.

3. Veale, D., & Roberts, A. (2014). Obsessive-compulsive disorder. BMJ, 348, g2183.

4. Öst, L. G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive behavioral treatments of obsessive–compulsive disorder. A systematic review and meta-analysis of studies published 1993–2014. Clinical Psychology Review, 40, 156-169.

5. Brakoulias, V., Starcevic, V., Belloch, A., Brown, C., Ferrao, Y. A., Fontenelle, L. F., … & Kyrios, M. (2017). Comorbidity, age of onset and suicidality in obsessive–compulsive disorder (OCD): An international collaboration. Comprehensive Psychiatry, 76, 79-86.

6. Sookman, D., & Steketee, G. (2010). Specialized cognitive behavior therapy for treatment resistant obsessive compulsive disorder. In D. Sookman & R. L. Leahy (Eds.), Treatment resistant anxiety disorders: Resolving impasses to symptom remission (pp. 31-74). Routledge/Taylor & Francis Group.

7. Fineberg, N. A., Brown, A., Reghunandanan, S., & Pampaloni, I. (2012). Evidence-based pharmacotherapy of obsessive-compulsive disorder. International Journal of Neuropsychopharmacology, 15(8), 1173-1191.

8. Pallanti, S., & Grassi, G. (2014). Pharmacologic treatment of obsessive-compulsive disorder comorbidities. Expert Opinion on Pharmacotherapy, 15(17), 2543-2552.

9. Hirschtritt, M. E., Bloch, M. H., & Mathews, C. A. (2017). Obsessive-compulsive disorder: advances in diagnosis and treatment. JAMA, 317(13), 1358-1367.

10. Skapinakis, P., Caldwell, D. M., Hollingworth, W., Bryden, P., Fineberg, N. A., Salkovskis, P., … & Lewis, G. (2016). Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 3(8), 730-739.

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A True Story of Living With Obsessive-Compulsive Disorder

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

Posted April 3, 2017

• What Is Obsessive-Compulsive Disorder?
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Contributed by Tiffany Dawn Hasse in collaboration with Kristen Fuller, M.D.

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

The consequences associated with my OCD

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

Seeking help

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

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

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

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

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

How I conquered my OCD

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

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

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

Facebook image: pathdoc/Shutterstock

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

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

Information & authors, metrics & citations, view options, introduction, introduction to the case, stabilization, treatment structure, and medication management, psychotherapy for ocd: cbt component, the ickiness hierarchy.

When CBT Alone Does Not Suffice: Psychodynamic Component

Psychoanalysis and cassandra, existential and metaphor therapy, contemplating existence and metaphors with cassandra, narrative therapy, weaving the narrative, a note on team dynamics and countertransference, follow-up interview, discussion and conclusions, acknowledgments, information, published in.

• pediatric obsessive-compulsive disorder
• psychodynamic psychotherapy
• cognitive-behavioural therapy
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A case of obsessive-compulsive disorder triggered by the pandemic.

1. Introduction

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

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

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

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

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

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

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

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

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

Case presentation

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

Conclusions

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

Peer Review reports

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

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

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

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

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

Instruments

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

Patient vignettes

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

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

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

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

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

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

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

Treatment recommendations

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

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

Parent-oriented CBT intervention

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

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

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

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

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

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

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

Conclusions and clinical implications

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

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

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

Availability of data and materials

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

Abbreviations

Obsessive compulsive behavior

Child Yale-Brown Obsessive Compulsive Scale

Cognitive Behavior Therapy

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

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

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

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Obsessive-Compulsive Disorder

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Note:  Other psychological treatments may also be effective in treating Obsessive-Compulsive Disorder, but they have not been evaluated with the same scientific rigor as the treatments above. Many medications may also be helpful for Obsessive-Compulsive Disorder, but we do not cover medications in this website. Of course, we recommend a consultation with a mental health professional for an accurate diagnosis and discussion of various treatment options. When you meet with a professional, be sure to work together to establish clear treatment goals and to monitor progress toward those goals. Feel free to print this information and take it with you to discuss your treatment plan with your therapist.

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Case Study: Obsessive-Compulsive Disorder

In a previous article we reviewed a range of treatments that are used to help clients suffering from obsessive-compulsive disorder (OCD). In this edition we showcase the case study of Darcy [fictional name], who worked with a psychologist to address the symptoms and history of her OCD.

Marian, a psychologist who specialised in anxiety disorders, closed the file and put it into the filing cabinet with a smile on her face. This time she had the satisfaction of filing it into the “Work Completed” files, for she had just today celebrated the final session with a very long-term client: Darcy Dawson. They’d come through a lot together, Darcy and Marian, during the twelve years of Darcy’s treatment for Obsessive-Compulsive Disorder, and they had had a particularly strong therapeutic alliance.

Marian reflected on the symptoms and history which had brought Darcy into her practice.

Obsessions at age nine

Now 37, Darcy reckoned that she had begun having obsessions around age nine, soon after her beloved grandma had died. Already grieving the loss of the person she was closest to in life, Darcy experienced further alienation – and resultant anxiety — when her father relocated the family from the small town in Victoria where they lived to Melbourne. Adjusting to big-city life wasn’t easy for someone as anxious as Darcy, and she soon found that she was obsessing. She had fears of being hit by a speeding car if she stepped off the kerb. She feared that the new friends she began to develop in Melbourne would be kidnapped by bad people. And she was terrified that, if she didn’t do an elaborate prayer routine at night, all manner of terrible things would befall her family.

The prayer routine, relatively simple at first, grew to gigantic proportions, containing many rules and restrictions. Darcy believed that she had to repeat each family member’s full name 15 times, say a sentence that asked for each person to be kept safe, promise God that she would improve herself, clap her hands 20 times for each person, kneel down and get up 5 times, and then put her hands into a prayer position while bowing. She “had” to do this routine at least 10 times each night, and if she made a mistake anywhere along the way, she had to start totally over again from the beginning, or else something bad would happen to her parents or little brother. Once she went flying to her mother’s side in the kitchen, tears streaming down her face, because she couldn’t get her “prayers” right. Darcy was certain that she was a huge disappointment to God and everybody.

Just like Granddad

Marian had asked Darcy if her parents were similar at all, and Darcy couldn’t think of many ways in which they were. Then she remembered something. “Ah,” she said, “my parents aren’t having these awful thoughts like me, but I remember my mum often telling me, ‘You’re just like your grandfather.’” Darcy’s grandfather had died when she was only five, so she didn’t have strong recollections of him, but there were two images that she always remembered about him: Grandfather standing by the kitchen sink in their farmhouse, washing his hands – always washing his hands. And if they decided to take a walk around the farm, he would take a seeming eternity to check that all the windows and doors were locked, even though they were on good terms with everyone within a ten-mile radius!

Obsessions and compulsions worsen through Uni

Marian had felt huge compassion for Darcy as she outlined the course that the disorder had taken. While the intrusive thoughts waxed during high-stress times and waned when Darcy felt relatively stable, there was nevertheless a general broadening of the obsessions – and resultant compulsion to do certain repetitive acts – throughout Darcy’s growing-up years. In high school, for instance, Darcy began to have an aversion to looking at any woman with a scoop-neck top on, going so far as to grab a glass and pretend to be holding it high up near her lips (as if to drink) if she had to talk to someone dressed in any but the most conservative top. In that way, she felt, she would be blocked from seeing what she should not see and thus sinning. Short skirts were also a problem, as Darcy feared that she was looking at people in inappropriate ways, and was offensive.

If anyone at a party crossed their legs while she was looking at them, Darcy assumed that they had done that because they were offended by her having glanced at them; she feared that they would think she was looking at their crotch area. She prayed constantly for forgiveness, but ended up ceasing hugs to family and friends because she felt like a hypocrite. Of course, not feeling that she could/should touch anyone made for huge social problems, and dating anyone became impossible: a huge punishment for a friendly extravert like Darcy. She petitioned God relentlessly, asking to be a better, less sinful person. It did not seem to help.

When Darcy began University, the experience was defined by a series of irrational obsessions. She would worry incessantly about having written something offensive on an email or an assignment. Walking around campus, she would pick up rubbish: papers that she had never seen before; she would worry that she might have written something on one of them. She feared that she would accidentally hurt one of her fellow students by something that she might do or say. By this time Darcy was repeating certain phrases over and over again to ward off disaster. She was amazed that she was getting through school at all (she often made straight A’s), because her rampant perfectionism caused her to take at least twice as long as other students to complete assignments, and she still wasn’t happy then. The anxiety and depression were overwhelming Darcy to the point where she recognised that she could barely function and something needed to change.

The Uni psychologist says, “You’re fine”

Marian shook her head in amazement as she recalled how Darcy’s first attempts to find out what was wrong with her had been fruitless; all the health professionals had completely missed the OCD! Upon first coming to Marian, Darcy had recounted how getting along to the University psychologist in her senior year was a “non-event”. He had asked a few questions, chatted to her about her schoolwork, told her she was basically fine, and then told her to go see a psychiatrist, who merely prescribed a sleeping pill. Darcy had taken this, as instructed, because the intrusive thoughts in her mind often did keep her from sleeping, but when she was awake she still had the thoughts and the horrible compulsion to perform the anxiety-alleviating acts: routines which now occupied several hours each day. Moreover, Darcy’s parents still didn’t believe that anything was wrong with her; they even found it funny that she was “quirky” like her grandfather.

Age 25: Treatment begins

Darcy was to graduate and spend another three years being held prisoner by her out-of-control mind before a chance meeting of her mother with a specialist in OCD at a conference. The specialist didn’t live in Melbourne, but – by incredible coincidence – he had a highly recommended colleague who did: Marian. Marian recalled with some fondness how Darcy had sat in her office during the first session, shedding tears of joy at being truly “seen”: both as a person and in her disorder. When Marian had issued the magical words, “Obsessive-Compulsive Disorder”, Darcy had been surprised – after all, her sense of OCD was people who continually washed their hands – but she also felt like she had just been given the key to her prison. Her treatment began soon after.

Marian worked intensively with Darcy at first, and then steadily. She helped Darcy get onto an even keel emotionally first by raising her serotonin levels (which had been quite low). Marian then began the laborious process of helping Darcy to change her habits of thinking: the assumptions that she made, the irrationalities that controlled her behaviour, and the intrusive obsessions that seemed to take over her life. Marian helped Darcy to see the importance of an exercise regimen, a good diet, and a stillness practice. Darcy joined an online support group, and Marian and Darcy enlisted the help of Darcy’s family and a few close friends. Partway through the therapy, Darcy was even able to come off the medications: a goal she had long sought, because she had married a “wonderful” man and they wanted to start a family.

At 37, Darcy is a happy and fulfilled person, with a solid marriage and an eight-year-old daughter. She believes that she worries about her “like a normal mother”, rather than in the obsessional way she used to pray in order to protect her family from imagined harm. She still petitions God, as she is active in her church, but now the petitions are free of the superstitious routines she used to perform, and she is quick to be thankful for her many blessings.

Unwanted thoughts still come to her, but now she has tools to focus elsewhere, and when the intrusive thoughts come, Darcy knows how to keep them from causing her to repeat irrational acts in a compulsive way. She knows that she will probably always be managing her disorder, as there is no cure for OCD. But the difference now is that she controls it, rather than having it control her. As far as Darcy is concerned, Marian gave her back her life.

Marian smiled again as she recalled Darcy’s journey and her original fear of being a “disappointment to God and everyone”. Indeed, Marian felt blessed to have had Darcy as a client.

This article is an extract of the upcoming Mental Health Academy “OCD and OCPD Case Studies” CPD course. Click here for a full list of currently available MHA continuing professional development courses.

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ORIGINAL RESEARCH article

Imagery rescripting on guilt-inducing memories in ocd: a single case series study.

• 1 Associazione Scuola di Psicoterapia Cognitiva (APC-SPC), Rome, Italy
• 2 Department of Social and Developmental Psychology Sapienza, University of Rome, Rome, Italy
• 3 Department of Human Sciences, Marconi University, Rome, Italy

Background and objectives: Criticism is thought to play an important role in obsessive-compulsive disorder (OCD), and obsessive behaviors have been considered as childhood strategies to avoid criticism. Often, patients with OCD report memories characterized by guilt-inducing reproaches. Starting from these assumptions, the aim of this study is to test whether intervening in memories of guilt-inducing reproaches can reduce current OCD symptoms. The emotional valence of painful memories may be modified through imagery rescripting (ImRs), an experiential technique that has shown promising results.

Methods: After monitoring a baseline of symptoms, 18 OCD patients underwent three sessions of ImRs, followed by monitoring for up to 3 months. Indexes of OCD, depression, anxiety, disgust, and fear of guilt were collected.

Results: Patients reported a significant decrease in OCD symptoms. The mean value on the Yale−Brown Obsessive Compulsive Scale (Y-BOCS) changed from 25.94 to 14.11. At the 3-month follow-up, 14 of the 18 participants (77.7%) achieved an improvement of ≥35% on the Y-BOCS. Thirteen patients reported a reliable improvement, with ten reporting a clinically significant change (reliable change index = 9.94). Four reached the asymptomatic criterion. Clinically significant changes were not detected for depression and anxiety.

Conclusions: Our findings suggest that after ImRs intervention focusing on patients’ early experiences of guilt-inducing reproaches there were clinically significant changes in OCD symptomatology. The data support the role of ImRs in reducing OCD symptoms and the previous cognitive models of OCD, highlighting the role of guilt-related early life experiences in vulnerability to OCD.

Introduction

Obsessive-compulsive disorder (OCD) is a common clinical condition experienced by about 1.2% of the population and with an estimated lifetime prevalence of 2.3% ( 1 , 2 ). OCD produces suffering and seriously compromises patients’ overall quality of life, weighing heavily also on the quality of life of the co-habiting family ( 3 – 6 ).

OCD is characterized by obsessions and compulsions. Obsessions are “ recurrent and persistent thoughts, urges, or impulses that are experienced at some time during the disturbance, as intrusive and unwanted, and that in most individuals causes marked anxiety or distress” . Compulsions are “repetitive behaviors … or mental acts … that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation” ( 7 ).

A crucial role in OCD onset and maintenance has been attributed to responsibility and guilt by Rachman ( 8 – 10 ) and by Salkovskis ( 11 ). Results from different studies have corroborated this thesis. OCD patients experience more intense guilt and higher responsibility when compared to other people ( 12 – 17 ). OCD patients are characterized by high levels of fear of guilt ( 18 – 20 ). Takahashi et al. ( 21 ) found similar brain activity between OCD patients when exposed to stimuli eliciting OCD symptoms, and nonclinical subjects when exposed to stimuli eliciting guilt. Moreover, studies have corroborated the hypothesis that compulsions are aimed at reducing or preventing responsibility and guilt. Lopatcka and Rachman ( 22 ) and Shafran ( 23 ) have shown that OCD symptoms diminish when the level of responsibility is lowered, by asking to put an agreement in writing, so the responsibility for any consequence for not carrying out the compulsions was of the experimenter or by varying the presence or absence of the experimenter during the behavioral task. Cognitive Therapy Interventions (e.g., Socratic dialogue, pie-technique, double-standard technique, and the court technique) aimed at reducing the responsibility and consequentially the risk of being guilty ( 24 – 26 ) lead to a significant reduction of OCD symptoms. Additionally, when responsibility and fear of guilt are induced experimentally, especially when associated with the fear of making mistakes, nonclinical participants begin to behave in an obsessive-compulsive–like way and those with OCD show an increase in obsessive-compulsive behaviors ( 16 , 18 , 27 – 29 ). Arntz and colleagues ( 30 ) experimentally induced the sense of responsibility and the fear of guilt in OCD patients, in other-clinical and nonclinical groups. Checking behaviors were higher in OCD patients than in the other two groups. This result suggest that OCD patients, regardless the subtype, are particularly sensitive to responsibility and fear of guilt. One might ask if checking behaviors are aimed at reducing or preventing responsibility and guilt, while washing behaviors are only aimed at reducing or preventing disgust and not responsibility and guilt. According to Bhikram et al. [( 31 ), 300] “ exaggerated and inappropriate disgust reactions may drive some of the symptoms of OCD, and in some cases, may even eclipse feelings of anxiety .” Two questions arise: What is the relationship between guilt and disgust? Is it possible that guilt implies the activation of disgust resulting in washing behavior? Some studies ( 32 , 33 ) found the so-called Macbeth effect “ that is, a threat to one’s moral purity induces the need to cleanse oneself … physical cleansing alleviates the upsetting consequences of unethical behavior and reduces threats to one’s moral self-image .” [( 32 ), 1451]. This effect has not been detected in some studies ( 34 ), but Reuven et al. ( 35 ) found it particularly prominent in OCD. Ottaviani et al. ( 36 ) found that in nonclinical participants, the induction of a specific sense of guilt, the deontological guilt, which is related to having transgressed moral norms, regardless of whether someone has been harmed ( 37 , 38 ) elicits obsessive-like washing behaviors, which reduce guilt and increase positive emotions ( 39 ).

It is plausible, therefore, that all obsessive symptomatology, not only checking compulsions, are the expression of an intense concern for one’s own morality, in particular for the deontological morality ( 37 , 38 , 40 ).

Such moral concern is found in Ehntholt’s and colleagues work ( 41 , 779):

“OCD patients reported more fear that others would see them in a completely negative manner, e.g., others would “loathe” or “despise” them if it was possible that they would cause others harm or problems, suggesting a sensitivity to blame and criticism. Our findings that those in the OCD group are more sensitive to the criticism of others is also consistent with Turner, Steketee & Foa ( 1979 )” .

In line with these results are those from a small pilot study from Mancini and colleagues ( 42 ), where OCD participants, compared to non-OCD, showed higher distress when exposed to Ekman’s Pictures of Facial Affect of contempt, anger, disgust, if requested to imagine that such expressions were addressed to them and, above all, that they deserved them. Moreover, OCD participants declared, more than other participants, that they reminded them the faces of the parents, or one of the two, and their parents’ facial expressions at a time when they were being reproached and experiencing intense distress. In fact, families of obsessive patients are described as demanding and critical [see ( 43 – 45 )]. In a recent study, Basile et al. ( 46 ) found that OCD patients reported significantly more painful memories of guilt-inducing blame/reproach compared to a non-OCD group.

An interesting observation of the type of discipline used by parents of future OCD patients is the threat to the continuity of the relationship itself ( 47 ). Clinical observations show that in cases of reproach, parents of future OCD patients withdraw love, ignore the child and are not prone to forgive ( 45 ). It is plausible that these experiences have taught the patient that a small mistake is enough to receive serious, aggressive, contemptuous, demeaning reproaches by significant figures such as parents, without having the possibility to justify oneself or be forgiven, and that his/her behavior can determine the end of such significant relationships ( 45 ). Briefly, the expectation that guilt has catastrophic consequences may derive from these kinds of experiences. Along the same lines, according to Pace et al. ( 43 ), obsessive behaviors may be considered as strategies used by the child to avoid criticism and obtain approval. According to Cameron ( 48 ), obsessive behaviors may be created as methods to obtain the parents’ satisfaction and avoid being criticized. Some studies suggest that obsessions could also be intrusive mental images that evoke adverse early experiences ( 49 ), and that obsessive thoughts have implications for a person’s sense of self ( 50 ) as well as such guilt-inducing experiences.

It is possible to modify the meaning attached to past adverse or traumatic events, especially childhood or adolescence events, intervening in those events’ memories through imagery rescripting (ImRs). ImRs is an experiential technique that has shown promising results in different clinical disorders ( 51 , 52 ). It has been theorized that the way ImRs works is by changing the meaning attached to memories ( 53 ).

ImRs has been employed in OCD by Veale et al. [( 54 ), 230] who stated that:

“Cognitive Behavioral Therapy (CBT), including exposure and response prevention, remains the psychological treatment of choice for Obsessive-Compulsive Disorder … However, a significant proportion of cases still fail to respond to CBT … This has prompted the search for new target areas for intervention, in the hope that outcomes can be improved.”

Veale et al. ( 54 ) examined the efficacy of one single ImRs session, as a standalone intervention, where intrusive images linked to aversive memories were present. The presence of intrusions linked to aversive past events has been detected in many studies ( 49 , 55 , 56 ). In the study of Veale et al. ( 54 ) after ImRs, nine patients showed a reliable change and seven a clinically significant change at the 3-month follow-up session. A major change was detected three months after the end of treatment. More recently, Maloney et al. ( 57 ) investigated the efficacy of ImRs as a treatment for OCD cases that were not responsive to standard exposure and response prevention. In the study, the authors investigated the efficacy of 1–6 ImRs sessions in 13 OCD patients who experienced intrusive distressing images associated with OCD. Of those 13 patients, 12 reached an improvement of at least 35% in OCD symptoms. Six patients reached the improvement after only a single ImRs session, whereas the rest required 2–5 ImRs sessions. The results of both studies were very promising, suggesting the opportunity to carry out other studies on ImRs’ efficacy on OCD.

Starting from the work of Veale et al. ( 54 ) and considering the role of guilt-inducing reproaches in the development of the fear of guilt, we hypothesize that an intervention of ImRs on childhood memories of guilt-inducing reproach in OCD people could reduce current obsessive symptoms.

The main hypothesis that we wanted to test is that after an intervention of ImRs, OCD symptoms—regardless the subtype—would decrease and that change would be maintained.

We also hypothesize a reduction in both the fear of guilt and in the propensity to disgust.

In addition we measured the effect of ImRs on anxiety and depression, to control the effect of ImRs on these two emotions. We expected that the effect of ImRs would be less than the one on specific obsessive symptoms, due to the specific nature of ImRs intervention on memories for OCD.

The study is centered on a single-case series experimental design. According to Lobo et al. ( 58 ), in single-case studies, indexes are assessed repeatedly for each participant across time. The different interventions are defined as “phases,” and one phase is considered as a baseline for comparison. In single case studies, a control group is not required because each participant represents a proper control.

Participants

A sample of 18 participants seeking treatment for OCD at “Studio di Psicoterapia Cognitiva” in Rome was enrolled for the study. At an early stage, recruitment was attempted through the Internet and flyers’ announcements, but these modalities were ineffective.

Twenty-four people, seeking treatment voluntarily, were asked to enroll in the study and two refused to take part. Of the 22 participants who accepted, 18 completed the procedure, two dropped out and two were excluded due to a change of psychopharmacological drugs during the procedure.

Approximately two thirds had received prior treatment and were not awaiting other treatments, but a few started a treatment after the last follow-up. Nobody was in treatment during the 9 months of the experimental trial.

The participants were not preselected for showing a relevant memory, but all showed at least one memory, Table 1 reports gender, age, disorder duration in years, and OCD subtypes for each subject. Mental contamination refers to that form of contamination arising from “ experiencing psychological or physical violation. The source of the contaminations is a person, not contact with an inert inanimate substance ” ( 4 , 59 ).

Table 1 Clinical summary of participants.

Inclusion Criteria

Participants were included if they were aged 18–65 years with an OCD diagnosis according to DSM-5 ( 7 ) and a score on the Yale–Brown Obsessive Compulsive Scale (Y-BOCS) higher than 18.

Exclusion Criteria

Patients were excluded if they were having ongoing psychotherapy, if psychotherapy had ended less than three months prior to the beginning of the procedure or if psychopharmacological drugs had been changed in the last three months or during the procedure.

To monitor for possible changes in drug therapy, at each assessment meeting the participants were asked whether the therapy had remained constant. The participants received the same procedure but if there was a change in drugs their data were not considered in the analysis because we could not be sure whether the effect on symptoms was attributable to the intervention or to the change in drugs.

A further exclusion criterion was a comorbid diagnosis of psychosis, schizotypy, mania, borderline personality disorder, alcoholism, impaired cognitive function (assessed on the basis of the educational level and with a clinical interview) or dissociation symptoms [a score higher than 30 on the Dissociative Experiences Scale: ( 60 )].

1. The Structured Clinical Interview for DSM-5 [SCID-5; ( 61 )] is a clinician-administered semi-structured interview, aimed at assessing diagnoses according to the fifth edition of the DSM [DSM-5; ( 7 )].

2. The Dissociative Experiences Scale [DES; ( 60 )].

   The DES is a 28-item self-report questionnaire that assesses forms of dissociation. The scores range from 0 (never) to 100 (always). The DES has proven to have adequate test–retest reliability as well as a good internal consistency, and good clinical validity ( 62 , 63 ). A cutoff score of 30 to detect dissociative psychopathology in clinical sample is recommended ( 64 , 65 ).

3. The Yale–Brown Obsessive-Compulsive Scale [Y-BOCS; ( 66 )].

4. The Y-BOCS is a 10-item clinician-rated scale that assesses the severity of obsessive-compulsive symptoms and the effectiveness of treatment. The clinician attributes a score from 0 (absence of symptoms) to 4 (very severe symptoms). The total score is in a range from 0 to 40. Higher scores indicate more severe OCD symptomatology. The scale has proven to have high internal consistency [alpha = 0.82; ( 67 )].

5. The Obsessive-Compulsive Inventory [OCI-r; ( 68 )].

   The OCI-r is an 18-item self-report questionnaire, which assesses the severity of OC symptoms on the 5-point Likert scale. There are six subscales (washing, checking, ordering, obsessing, hoarding, and mental neutralizing). The total score ranges from 0 to 72. The OCI-r Italian version ( 67 ) showed good internal consistency as well as a convergent and divergent, and criterion validity [alpha = 0.85; ( 67 )].

6. The Beck Depression Inventory-Second Edition [BDI-II; ( 69 )]. The BDI-II is a 21-item self-report, measuring the severity of several components of depression. The Italian version of the BDI-II has proven to have good internal consistency [alpha = 0.80; ( 70 )] as well as good convergent and divergent and criterion validity ( 70 , 71 ).

7. The Beck Anxiety Inventory [BAI; ( 72 )]. The BAI is a 21-item self-report, that measures the severity of anxiety. The BAI Italian version shows good internal consistency [alpha = 0.89; ( 70 )] as well as good convergent and divergent, and criterion validity ( 70 , 73 ).

8. The Fear of Guilt Sclale [FOGS; ( 19 , 20 )]. FOGS is a 17-item self-report scale, ranging from 0 to 7, assessing the extent to which a person values and fears guilt and how she/he behaves in relation to guilt. The FOGS consists of two factors: Punishment (drive to punish oneself for feelings of guilt) and Harm Prevention (drive to proactively prevent guilt). The FOGS demonstrated strong internal consistency as well as convergent and divergent validity [alpha = 0.92; ( 20 )]. It also significantly predicted OCD symptom severity over measures of neuroticism, depression, trait guilt, and inflated responsibility beliefs ( 19 ).

9. The Disgust Propensity Questionnaire [DPQ; ( 74 )]. DPQ is a 33-item scale aimed at assessing the individual’s propensity for disgust. The participant expresses the agreement on a 5-point Likert scale from 0 (“not at all”) to 4 (“very much”). The total score range is from 0 to 132. The questionnaire has been proven to have a one-factor structure, as well as good internal consistency [alpha in the range 0.85–0.91; ( 74 )] as well good test–retest reliability (ICC = 0.85) and also construct validity ( 74 ).

Participants who accepted to be enrolled in the study signed an informed consent form. In an initial clinical interview, we checked for inclusion and exclusion criteria. The inclusion criteria were assessed through clinical interview and the Structured Clinical Interview for DSM-5 (SCID-5: 61). Diagnostic interviews were conducted by experts who had a master’s degree in psychodiagnosis, were trained to administer the SCID and conducted the interview according to the reference manuals; they were also blind to the study’s hypothesis. In the second session we measured the obsessive symptoms’ subtype and severity; and in the third meeting we ran an ad hoc interview on memories (see Appendix) in order to detect guilt-inducing reproaches memory that could be examined in the three following ImRs sessions. The selection of the memories was driven by the aim of intervening on generic memories of guilt-inducing reproaches not necessarily related to the current symptomatology. We selected memories in a different way from Veale et al. ( 54 ), where the authors selected participants who experienced intrusive imagery as part of their OCD, which was considered by the participant and assessor to be emotionally linked to memories of past aversive events, and from Maloney et al. ( 57 ), where intrusive imagery was selected because it was associated with OCD and considered by the patient to be linked to memories of aversive events.

We asked participants to recall reproaches similar to those which had been found by Basile et al. ( 46 ).

As already stated, we found, for each participant, generic memories of guilt-inducing reproaches, and so no one was excluded for this reason.

In particular, we focused on generic reproach experiences not necessarily related to the symptom domain. For example, a childhood memory selected by an OCD patient with washing symptoms was not directly related to being reproached for being dirty, but rather was independent of the symptom domain. The first criterion used for the memory’s selection was the earliest childhood memories reported by the participants, the second was the most intense memory from an emotional point of view.

Participants received a symptoms’ assessment and then as Veale and colleagues ( 54 ) did were randomized to 4, 8, 12, or 16 days of symptom monitoring before receiving ImRs (4 participants in the condition of 4 days monitoring, 5 in the condition of 8 days monitoring; 4 in the condition of 12 days monitoring; 5 in the condition of 16 days monitoring). Within the three 45-min ImRs treatment sessions, the previously selected memory was addressed and rescripted. For each participant, we selected one memory that was rescripted during the three sessions. The clinicians who ran the ImRs sessions were all experts in cognitive-behavioral therapy (CBT) for OCD (with an average of 10 years of experience) and in imagery techniques and the adherence to the protocol was supervised by three trainers and supervisors in ImRs. Based on the work of Veale et al. ( 54 ), we carried out each ImRs session according to Arntz’s three-stage technique ( 75 ), adapting it to the Schema Therapy suggestions ( 76 ) for patients with difficulty meeting their needs autonomously. The technique consisted of a first phase in which the patient was invited to relive the memory with his/her eyes closed, from the standpoint of their childhood self. In the second phase, the patient looked at the same event as an adult, tried to detect the unmet need of his/her childhood self and proposed an imaginative change (the rescripting) aimed at satisfying the unmet emotional needs. In the third phase, the patient as a child looked at the event with the changes proposed by the adult. In line with the procedure, if the patient could not find a solution to the unmet need in the second phase, the therapist then suggested some interventions or asked the patient to include the therapist into the image of their childhood, in order to meet the patient’s needs. The traditional protocol was employed as proposed by Arntz—“ part of rescripting involves a secure adult that meets the child’s needs to be reassured and comforted ” [( 53 ), 467]. By unmet need we mean the core emotional need, whose unfulfillment is the cause of the emotional sufferance. The intervention of the adult in the second phase, and the rescripting, are stimulated by the clinician’s questions: “Is there anything you would like to do?” “Is there anything that should be done?”

After each session, as per the traditional protocol ( 53 , 77 ), the patient listened to a recording of the session between one session and the next. Data were not collected between sessions. After clinical intervention, four follow-up assessment sessions (at 7, 30, 60, and 90-day intervals, respectively) were held, as in Veale et al. ( 54 ).

An outline of the procedure is shown in Figure 1 and the procedure has been approved by the ethical committee of Guglielmo Marconi University.

Figure 1 Procedural timeline.

Appendix Table 1 shows a summary of the contents of the rescripted memories. It reports the event and the emotion experienced, the participant’s age in the memory and meaning attached to the memory, verbally expressed by the participant. The “Emotion and meaning of memory” refers to the answers that participants gave when, in the first phase of rescripting, the patient was invited to relive the memory with his/her eyes closed, from the standpoint of their childhood self. In that phase of the technique they were asked: “What is happening?” “What do you feel?” “What do you think about the situation?” and the therapist just wrote down the participant’s verbal expression. “New meaning” after the ImRs refers to the event’s appraisals after the third intervention and the answers to the question the therapist asks “What do you think about the situation?,” which is asked in the third phase of rescripting, when the patient as a child looked at the event with the changes proposed by the adult in the second phase of the technique.

Statistical Analysis

Data were analyzed using the Statistical Package for Social Science (SPSS 25, Inc., Chicago, IL) for parametric and nonparametric analyses, while the Leeds Reliable Change Indicator was used to calculate change indexes ( 78 , 79 ).

Beyond initial descriptive analyses, we calculated reliable and clinically significant change indexes for all clinical measures (Y-BOCS, OCI-r, BAI, and BDI-II). Like Veale and colleagues ( 54 ), we considered the over-time change of the Y-BOCS total score. In particular, we considered indexes related to (a) reliable change and (b) clinically significant change ( 80 ). We evaluated the change in scores from screening to 90-day follow-up of at least 2 standard deviations (SDs) from the original mean. A reliable change was identified by the Leeds Reliable Change Indicator as a 10-point reduction on the Y-BOCS. A clinically significant change is the condition where criterion a was satisfied and the participant’s scores were under the clinical cutoff (for the Y-BOCS, score less than 17). As proposed by Veale and colleagues ( 54 ), we considered Pallanti’s asymptomatic criterion ( 81 ), which refers to an approximate total absence of OCD symptoms. The asymptomatic criterion for OCD has been defined as a recovery on the Y-BOCS (score 7 or less). The same analysis was performed for the OCI-r total score.

Paired samples t-tests and Wilcoxon signed-rank tests on the different measures (e.g., Y-BOCS, OCI-r, BAI, and BDI-II) were also performed between screening and 90-day follow-up, as well as, between pre-ImRs baseline and 90-day follow-up.

Afterward, two distinct linear mixed regression models were performed in order to test the fixed effect of the ImRs treatment on the OCD-related measures (i.e., Y-BOCS and OCI-r) and its random variations across patients. The strength of these kinds of models’ lies in the fact that the random variability of the parameters is also taken into account. Thus, the analysis allowed us to estimate whether the OCD-related symptoms decreased after the ImRs intervention and across the different measurement times, simultaneously considering the random variability of such hypothesized reduction for each of the 18 patients. Before running the analyses, it was necessary to carry out a restructuring of the data. Thus, we changed the data matrix from a wide format to a long format. Afterward, we stacked the scores of the Y-BOCS and OCI-r, obtained at each measurement time, into two distinct variables. These variables were in turn associated with an indicator of the measurement times (i.e., pre-ImRs baseline, 7-, 30-, 60-, and 90-day follow-up). Since we were interested in testing the effectiveness of the ImRs intervention, we focused our attention on the observed changes starting from the pre-ImRs baseline. Thus, the indicator variable was centered on the pre-ImRs assessment by coding such time point as 0. In this way, we were able to test the fixed effect of the time and the related random variability of intercept and slope. Moreover, we also estimated the quadratic effect of the time to test whether the differences that had emerged were in the extremes of the experimental region or inside it. These analyses were performed with the lme4 package ( 82 ) using RStudio ( 83 ), a graphical interface for R software. Both models were tested using a restricted maximum likelihood method (REML).

Then, a mixed ANOVA was conducted to determine the extent to which levels of change on fear of guilt (low vs. high) affected ImRS intervention on obsessive symptoms.

Finally, we computed intercorrelations among all the variables investigated at the 90-day follow-up in order to explore the relationships among them after the ImRs intervention.

First, we explored the structure of our data by means of some descriptive statistics (see Table 2 ). Thus, we computed the mean and the related standard deviations of each measure at the different detection times. Moreover, because of the reduced size of the sample under examination, we also computed the median and considered the interquartile range as a measure of the data dispersion from their central value.

Table 2 Descriptive statistics: Means, Standard Deviations, Median and Inter-Quartile Range (IQR) of the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS), Obsessive–Compulsive Inventory revised (OCI-r), Beck Depression Inventory - Second Edition (BDI-II), Beck Anxiety Inventory (BAI), Fear of Guilt Scale (FOGS), Disgust Propensity Questionnaire (DPQ), Dissociative Experience Scale (DES).

Clinical Response to Imagery Rescripting

At the 3-month follow-up, 14 of the 18 participants (77.7%) achieved an improvement of ≥35% on the Y-BOCS, defined by Farris ( 84 ) and Mataix-Cols et al. ( 85 ) as corresponding to the most predictive of treatment response. Based on the results of the retrospective investigation of Tolin et al. ( 86 ), that is, the reduction criterion of at least 30% on the Y-BOCS as optimal for determining clinical improvement, it is possible to say that 15 participants (83%) reported a significant improvement.

Eleven of the 18 participants (61%) reached an absolute raw score of 12 or less on the Y-BOCS measure, which is identified by Lewin et al. ( 87 ) as optimal for predicting remission in a clinical setting. Based on Pallanti’s asymptomatic criterion ( 81 ), four participants reached the asymptomatic criterion (7 or less on Y-BOCS) at 90-day follow-up.

Reliable and Clinically Significant Change on the Y-BOCS

Of the whole sample, 13 patients reported a reliable change, with 10 of them revealing a clinically significant change on the OCD clinical measure (RCI = 9.94) using criterion A. The average scores from pretreatment and post-treatment met the criteria for reliable and clinically significant change.

Figure 2A reports single participants’ pretreatment Y-BOCS scores on the x-axis and post-treatment scores on the y-axis. Participants, who were in the lower-right quadrant and under the parallel lines achieved a reliable and clinically significant change.

Figure 2 Reliable and clinically significant change for (A) Y-BOCS (Yale–Brown Obsessive Compulsive Scale) and (B) for OCI-r (Obsessive-Compulsive Inventory revised) at 90-day follow-up.

Reliable and Clinically Significant Change on the OCI-r

At the 90-day follow-up, considering the OCI-r, 12 patients showed no significant improvement, 1 deteriorated (reached 17 points on the scale), while five participants reliably improved, with four of them showing a clinically significant change (RCI = 13.49), using criterion C. According to Jacobson and Truax ( 80 ), if you do not have an externally determined cut score you can use one based on statistical criteria. Criterion C is the one suggested, when clinical and comparison groups’ norms overlap. The average scores from pretreatment and post-treatment did not meet the criteria for reliable and clinically significant change.

Figure 2B reports single participants’ pretreatment OCI-r scores on the x-axis and post-treatment scores on the y-axis. Participants, who were in the lower-right quadrant and under the parallel lines achieved a reliable and clinically significant change.

Reliable and Clinically Significant Change on the BDI-II and BAI

Of the total sample, nine patients did not show any improvement in depressive symptoms as assessed with the BDI-II (RCI = 11.36). One deteriorated, eight reliably improved, and six showed clinically significant change. When assessing for any clinically significant change on the BAI, 12 showed no improvement, and 6 improved (RCI = 11.69). The average scores from pretreatment and post-treatment did not meet the criteria for reliable and clinically significant change.

Parametric and Nonparametric Comparisons

In order to obtain an estimate of the reduction of the scores on the examined measures after the ImRs treatment, we implemented both parametric and nonparametric tests. As parametric test, we conducted several paired samples t-tests. The comparisons concerned the scores obtained by the patients at the screening phase and at the 90-day follow-up on all the measures used in the study, except for the Dissociative Experiences Scale ( 60 ). Table 3 clearly shows that at the 90-day follow-up (vs. Screening) there are significant reductions in all the measures considered, and that these significant decreases are accompanied by remarkable effect sizes. A unique exception was represented by the comparison concerning the DPQ, which turned out to be only marginally significant.

Table 3 Paired samples t-test for the scores at the Screening detection time compared to 90-day follow-up and for the scores at pre-ImRs baseline compared to 90-day follow-up.

Furthermore, we also tested further comparisons between the scores obtained on the clinical measures of Y-BOCS, OCI-r, BDI-II, and BAI at the pre-ImRs baseline and at the 90-day follow-up. This analysis was therefore more focused on the effectiveness of the ImRs treatment. As expected, our hypotheses were corroborated: The paired samples t-tests revealed a significant decrease in scores on the four clinical measures. Also, in this case the reductions were associated with an effect of noticeable magnitude. The effect size of each paired samples t-test was computed by dividing the emerged differences by the standard deviation of the interested baseline. As highlighted by Morris ( 88 ), this procedure provides more reliable effect size estimates compared to using post-test or pooled standard deviation as denominator.

The results that emerged from the t-tests therefore seemed to provide empirical evidence about the effectiveness of the ImRs treatment. Given the relatively small number of participants, in order to provide some evidence to the robustness of the findings, we ran a post-hoc power analysis on the t-test conducted in the study, by using GPower. Specifically, we implemented a post-hoc power analysis for testing difference between two dependent means (matched pairs). By setting a medium effect size (Cohen’s d) of 0.7, error probability of 0.05, and two tailed distribution, the analysis revealed a statistical power of 0.80 associated to the sample size of 18 participants.

Moreover, we tried to provide further support and robustness to our results through a nonparametric test. Thus, we implemented a Wilcoxon signed-rank test for the nonparametric comparison of the Y-BOCS, OCI-r, BDI-II, and BAI scores between the pre-ImRs baseline and at the 90-day follow-up. As can be seen in Table 4 , results were consistent with those of paired samples t-tests. Specifically, the Wilcoxon tests showed a decrease of both scores of Y-BOCS and BAI for 16 participants, as well as, a reduction in the scores of BDI-II and OCI-r for 12 and 11 patients, respectively. Moreover, all test statistics were associated with an effect size (r) between medium and high values. These effect sizes were computed by dividing the z test statistic by the square root of the total number of observations ( 89 ).

Table 4 Wilcoxon signed-rank test (nonparametric).

OCD Scores in the Different Protocol Phases

In order to detect OCD symptom severity across time, we performed two distinct linear mixed regression models for the Y-BOCS and OCI-r, respectively. The first linear mixed regression pertained to the changes of OCD-related symptoms detected by the Y-BOCS. We expected to find a significant reduction in the Y-BOCS score across the measurement times. In particular, we expected to find a remarkable difference between the pre-ImRs baseline and the 7-day follow-up. For this reason, in addition to the linear fixed effect of the time, we also estimated its quadratic effect. This allowed us to test whether the differences that had emerged were in the extremes of the experimental region or inside it. Moreover, we expected to find such significant relationships regardless of the randomized duration (i.e., 4, 8, 12, or 16 days) of symptoms monitoring before receiving ImRs. Thus, we estimated the fixed effect considering the time indicator variable as a predictor and the scores obtained on the Y-BOCS at the different detection time, stacked into a single variable, as the criterion. The duration of symptoms monitoring at the pre-ImRs baseline represented the covariate in the model.

Analysis revealed a negative and significant main effect of the time on the Y-BOCS ( B = −.18; SE = .04; t = −3.82; p <.001; 95%CI = −.2684, −.0836), which indicated a reduction of the OCD symptoms severity across the different detections (see Figure 3A ). Moreover, analysis also highlighted a significant quadratic effect of the time ( B = .001; SE = .0004; t = 2.11; p = .041; 95%CI = .0004, .0020), suggesting that the stronger differences were to be found in the protocol phases. The more pronounced difference was indeed between the pre-ImRs baseline and the 7-day follow-up. This result was also corroborated by the pairwise comparisons conducted on the estimated marginal means scores of each detection time (see Table 5A ). The randomized duration of symptom monitoring did not exert any effect ( B = .01; SE =.28; t = 0.04; p = .97; 95%CI = −.5893, .6099).

Figure 3 Quadratic fixed effect of time (A) on Y-BOCS and (B) on OCI-r scores.

Table 5A Pairwise comparisons based on Y-BOCS estimated marginal means at the different protocol phases.

Regarding the random variability of intercept and slope, we found further support for our hypothesis. Analysis yielded a significant random variation of the intercept ( B = 39.1; SE = 15.9; Z = 2.45; p = .014; 95%CI = 17.60, 86.98), which simply indicated that patients reported different degrees of OCD symptom severity at the pre-ImRs assessment. More importantly, we also found a nonsignificant random effect for the time slope ( B = .001; SE = .013; Z = 0.80; p = .423; 95%CI = −.0001,.0117). Such a result strengthens our result, highlighting how the ImRs intervention produced similar effect across the 18 patients (see Figure 4A ).

Figure 4 Intercept and slope random variability of time (A) on Y-BOCS and (B) on OCI-r scores across the 18 patients.

The second linear mixed regression model followed the same procedure as the first, but considering the scores on the OCI-r as dependent variable. Also, in this case, we found results consistent with our expectations. Specifically, analysis showed a negative main effect of the time on the decreases of the OCI-r across the protocol phases ( B = −.23; SE =.08; t = −3.15; p = .003; 9 5%CI = −.3910, −.0875), as well as a significant time quadratic effect ( B = .002; SE =.0008; t = 2.49; p = .016; 95%CI = .0003,.0037). Graphical representation of the quadratic effect is shown in Figure 3B . Note that these coefficients represent unique associations, once the duration of symptom monitoring was checked ( B = .17; SE =.48; t = 0.34; p = .735; 95%CI = −.8614, 1.193). The more remarkable reduction of the OCD symptom severity emerged between the pre-ImRs baseline and the 7-day follow-up. Furthermore, in this case the pairwise comparisons supported such result (see Table 5B ). Moreover, random effects estimates revealed a nonsignificant random variation in the slope ( B = .002; SE = .003; Z = 0.69; p = .492; 95%CI = −.0001,.0363), as well as an expected significant variation in the pre-ImRs baseline scores ( B = 117.18; SE = 46.65; Z = 2.51; p = .012; 95%CI = 53.70, 255.68) of the OCI-r across patients (see Figure 4B ).

Table 5B Pairwise comparisons based on Oci-r estimated marginal means at the different protocol phases.

Differences Between High and Low Change at FOGS

In order to clarify the role played by guilt in the change of OCD symptom severity, we implemented two distinct mixed ANOVA on the OCI-r and Y-BOCS. In both analyses, the within factor was thus represented by the scores on these measures at the pretreatment and at the 90-day follow-up measurement times. With regard to the between factor, we split the sample into two subgroups based on the FOGS change score from the prescreening to the 90-day follow-up. Specifically, we computed the differences between the FOGS scores at such phases and then we divided participants based on the sample median value of 5.5. In this way, we obtained low and high FOGS change groups, respectively composed by 8 and 9 participants.

The mixed ANOVA on the OCI-r showed a significant effect of the treatment ( F[1, 15] = 8.29, p = .01), as well as a significant interactive effect among the within factor and the FOGS change groups ( F[1, 15] = 7.99, p = .01). As can be observed in Figure 5 , we found a significant decrease in the OCD symptom severity for participants who reported a high FOGS change score ( Mean Diff = 14.22, se = 3.42, p = .001, 95%CI = 6.93, 21.51), whereas nonsignificant differences emerged in the group of low FOGS change score ( Mean Diff = .125, se = 3.63, p = .97, 95%CI = −7.61, 7.86). Pairwise comparisons also revealed a marginally significant difference between the average score of the two groups at the 90-day follow-up ( Mean Diff = 15.22, se = 7.89, p = .07, 95%CI = −1.74, 31.91) and no difference at the pretreatment. These differences were respectively accompanied by standardized effect size (i.e., Cohen’s d ) equal to 1.7, 0.01, 0.93, 0.07. Consistently, between-subject analyses highlighted a nonsignificant main effect of the FOGS change score factor ( F[1, 15] = 1.28, p = .27).

Figure 5 Differences between high and low change at FOGS on the OCI-r.

In contrast, the mixed ANOVA on the Y-BOCS revealed that the decrease on such measure was not moderated by the FOGS change score ( F[1, 15] = 1.34, p = .26), and also that the between-subject effect of this factor was not significant ( F[1, 15] = 0.77, p = .40). In this case, we only found a significant within-subjects main effect of the treatment, which showed that the Y-BOCS scores decreased similarly for participants with both high and low change on the FOGS ( F[1, 15] = 37.99, p <.001).

Intercorrelations Among Measures at the 90-Day Follow-Up

Finally, in order to observe the correlations among the measures involved in the study, we computed correlations between all the outcome variables at 90-day follow-up. As can be seen in Table 6 , we found significant correlation among most of the interested variables. Specifically, we observed a positive association between OCD symptomatology (both assessed with Y-BOCS and OCI-r), BDI, BAI and DPQ, whereas we witnessed that the FOGS was only positively related with the OCD symptomatology assessed by OCI-r.

Table 6 Intercorrelations among the measures assessed at the 90-day follow-up.

The main result of our study is that after three ImRs sessions on guilt-inducing memories, OCD participants experienced a significant clinical reduction of symptoms.

Comparison between OCD measures at screening and at the 90-day follow-up indicates a significant clinical improvement in symptomatology, in terms of greater management of thoughts and obsessions, less time occupied and less interference in general, greater control over compulsions and an increased awareness of discomfort and exaggerated thoughts, as assessed by Y-BOCS. At the 90-day follow-up, the total OCI-R scores significantly diminish, the average scores from pretreatment and post-treatment did not meet the clinically reliable change criteria.

The difference between Y-BOCS and OCI-R is not surprising, in fact it is in line with the work of Abramowitz and Deacon ( 6 ), which found a low correlation between the OCI-r and Y-BOCS severity scores in a group of OCD patients. Sulkowski et al. ( 90 ) suggested that this might be because of the differences in symptom “coverage” by the OCI-r and Y-BOCS as stated by Maloney and colleagues who concluded that “ the clinician-administered Y-BOCS and the self-report OCI capture different aspects of symptomatology or of its improvement ” [( 57 ), p. 6].

Our results are in line with the study by Veale et al. ( 54 ) and Maloney et al. ( 57 ). ImRs confirms its promising application in treating OCD, underlining the importance of working on memory of past events. Veale et al. ( 54 ) and Maloney et al. ( 57 ), who focused on past aversive memories emotionally linked to present recurrent, intrusive and distressing images, detected through Speckens’s interview ( 49 ). We, instead, chose to focus on childhood memories of guilt-inducing reproaches, detected while asking the participants to remember events characterized by features found by Basile et al. ( 46 ). What is interesting is the meaning attached to the memories selected by Veale et al. ( 54 ), which, in many cases, related to a negative moral judgement about the self. The beliefs reported by participants in the work of Veale et al. ( 54 ), are similar to those reported by the participants of this study, even though the memories are somewhat different. This may suggest that the interpretation of guilt-inducing reproaches may be similar to how future OCD patients interpret even other experiences. Although the memories selected in this study were not necessarily related to current symptoms, they may have been related if they were associated with intrusive images.

It is interesting to observe that all the participants found events characterized by the features found by Basile et al. ( 46 ). All the participants remembered having felt, during the episodes, an intense sense of guilt and having thought themselves to be a “bad person.” Looking at Appendix Table 1 , subjects reattribute the causes of what happened to something external and not to their own wickedness, worthlessness, lack of ability, or defect. In particular, for the case of the reattribution of culpability, the new meaning after intervention is more flexible and participants recognize that the fault committed was not so serious or that they too have the right to make mistakes. As proposed by Arntz ( 53 ) ImRs confirms its efficacy in changing the meanings attached to past adverse events in childhood or adolescence.

ImRs, as hypothesized, showed a significant reduction of the fear of guilt. Interestingly, participants who showed a higher reduction in fear of guilt displayed a higher reduction in obsessive symptoms, when assessed by OCI-R. This result suggests that fear of guilt moderates the ImRs effect on obsessive symptoms and this effect is consistent with the hypothesis that fear of guilt plays a central role in the onset and maintenance of OCD symptoms ( 18 , 91 ).

ImRs reduced the disgust propensity, but in a marginal way, less intense than what was hypothesized, as ImRs doesn’t directly targeted disgust.

The intervention on the memories of guilt-induced reproaches reduced depression and anxiety in a statistically significant way. A similar result was observed in the work of Maloney et al. ( 57 ). However, the improvement did not meet the criteria for reliable and clinically significant change. At the last follow-up a correlation was observed between anxiety and depression and OCD symptoms when assessed by Y-BOCS. The reduction in anxiety is easily understandable, since very often this emotion accompanies obsessive symptoms. Zandberg et al. ( 92 ) found a reduction in depression following the improvement in obsessive symptoms. This is understandable considering that, in many cases, depression is related to the frustration and distress of having obsessive symptoms. For example, obsessive symptoms may involve a reduction in interpersonal relationships and may also produce a reduction in self-esteem and self-effectiveness.

The present work sheds light on the role that repeated experiences of criticism, and consequent guilt induction, might play in the genesis of dysfunctional beliefs about the self that are related to OCD development. This evidence should encourage clinicians to consider the role of sensitizing experiences in OCD treatment, addressing guilt-specific intervention.

Limitations

The findings of this study must be viewed in light of some limitations.

The main limitation of this study is the small sample size. A larger sample would allow an evaluation specifically separated by subtypes, to test whether ImRs on guilt-inducing memories of reproaches shows the same result in all OCD subtypes. Certainly, considering that our study, together with the study by Veale et al. ( 54 ) and the study by Maloney et al. ( 57 ) that assess the efficacy of ImRs in OCD, it may be worth investing more resources to conduct a randomized controlled trial study. Another limit of this study is related to the absence of a control group, in fact, without it, we cannot exclude that ImRs on guilt-inducing reproaches is not effective in other disorders, for example in social phobia, and therefore its effect in OCD is nonspecific. In addition, we are unable to say whether ImRs on memories noncharacterized by guilt-inducing reproaches, such as abandonment, can be equally effective in treating obsessive symptoms.

Moreover, the study is missing multiple assessments carried out in different phases and between sessions. The intensity of beliefs and emotions that were connected to the episode targeted in ImRs were not measured.

Future Directions

Assessing the effectiveness of ImRs on memories of guilt-inducing reproaches for participants with different disorders may be carried out, with the aim of understanding the similarities and differences between the effect of sensitizing experiences with OCD participants. When considering OCD, future research could consider randomized controlled trials, comparing the effect on OCD symptoms of ImRs on guilt-inducing memories, of other techniques aimed at changing the emotional valence of memories and comparing the effect by selecting memories with other emotional valences.

This research supports the importance of taking into account work on the historical vulnerability of OCD in CBT. In line with this proposal, recent work ( 93 ) has offered the first suggestion of an integration between CBT and Schema Therapy, aimed at reducing OCD’s historical vulnerability. However, further studies on techniques aimed at changing this vulnerability are necessary.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Ethical committee of Guglielmo Marconi University. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author Contributions

KT, BB, TC, BS, SF, AG, OIL, CP, GR, and AMS carried out the interventions. KT wrote the manuscript with support from BB and VP, who analyzed the data. GF contributed to sample preparation and FM conceived the original idea and supervised the project. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We thank Flavia Sorbara and Federica Visco Comandini for their assistance with assessment and organization of the data. This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

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Table A1 Summary of the contents of the rescripted memories.

Procedure to Detect Guilt-Inducing Reproach Memories

The target of the intervention is memory of:

● Guilt

● Hypo-/Hyper-responsibility

● Observation of the guilt-inducing experiences on someone else

● Have caused real harm

● Responsibility for choosing the right partner

Interview on Guilt-Inducing Memories

PLAN A (Direct questions to the patient, examples are requested):

● Did you often feel guilty as a child?

● As a child, were you afraid you might be guilty of something?

● Have you ever caused anyone real harm?

● As a child, did you feel responsible for the well-being of someone close to you?

● Were there times when you felt you were not up to your responsibilities?

Questions about the family of origin:

How old is your father? What is/was your father like? Give me three adjectives to describe him.

When you were a child, did your father make you feel guilty? (ask for examples)

Were you afraid of being scolded by your father? (ask for examples)

When you were a child, did your father often scold you or someone close to you? (ask for examples)

The same procedure with mother or other significant figures (e.g., grandparents)

NOTE: WHEN THE PATIENT PROVIDES MORE THAN A MEMORY OF EQUAL RELEVANCE, CHOOSE THE OLDEST, THAN THE MOST PAINFUL.

PLAN B (Imagery assessment):

We ask the patient, using his/her imagination, to describe the last time she/he felt guilty.

Through the floating back, using emotion and mental status as a bridge, we ask her/him when she/he felt this way as a child.

NOTE: TO AVOID PROLONGED EXPOSURE OF THE PATIENT TO THE MEMORY, ONCE THE MEMORY HAS BEEN RECALLED, ASK THE PATIENT TO DESCRIBE THE MEMORY FACE TO FACE.

PLAN C (Scripts of memories):

We ask the patient to read some prototype memories and ask whether she/he has similar memories:

Guilt-inducing

When Peter was in elementary school, his father usually accompanied him to school. Despite his efforts, Peter had some difficulty getting out of the house on time and his father often became furious. Peter remembers the time when his father went on a rant in a loud and angry voice, with an outraged expression on his face and without looking him in the eye, while tinkering with the car keys to start the car: “The daily drop of poison!” and, “Life is good, huh. Who cares if your dad wakes up at 6:00 every morning to drive you to school on time then runs to work to support the family and allows you and your sister to study! This is the thanks I get!” After that the father did not speak for the rest of the day. At that moment, Peter was stunned, intimidated and mortified. What most distressed him was that he faced at least five hours of school, knowing he would feel a kind of boulder in his stomach and could not do anything to remedy it.

Hyper-responsibility

When Albert was nine years old, his mother had a health problem and his father was often out of the house because of work. He was considered by all to be a very responsible child for his age.

He was very diligent, taking his two younger sisters to school when their mother couldn’t get out of bed. He also prepared lunch for his sisters and reminded his mother to take the medication the doctor prescribed. Albert put others’ need ahead of his own. For example, he once gave up going to his best friend’s birthday party, which he had been looking forward to for a long time, because his mother was in bed with a headache and he wouldn’t leave her alone.

Observation of someone else’s guilt-inducing experiences

Anna has a sister named Silvia, who is seven years old and attends elementary school.

Once, Silvia got a teacher’s note saying her behavior was too lively in class. When she came home, Silvia didn’t tell her parents, and wanted to keep the note hidden from her father.

At some point, she confessed it to her mom, who told her dad. Anna saw the father who, having “discovered the lie,” got very angry and screamed at Silvia in an aggressive and contemptuous tone: “You have a guilty conscience, like a panty dirty with poo. You are not sincere, you are not truthful.” Anna saw Silvia burst into tears and felt a strong sense of guilt, for both the note and the lie, and for not knowing how to remedy the situation.

Having caused real harm

Maria is eight years old and has a younger sister and often plays catch in her arms, pretending to be her mother. Maria loves her sister very much and her mother is very happy with the relationship that is being established between the two sisters. One day, while she is in the kitchen with her mother, Maria takes her little sister in her arms and tenderly begins to play with her. The little one, unpredictably, waddles, falls to the ground and starts to bleed from the lip. The mother rushes to rescue the little one and says nothing to Maria, who is frightened by the blood that she sees dripping from the baby’s lip and feels deeply guilty for harming her sister.

Relationship OCD

Mario remembers how worried he was when his parents got divorced. Every night, for example, and during the night, he would go to the bedroom to check that his parents were sleeping together. They argued daily, and the arguments were often very heated and ended most often with the mother crying and the father slamming the door. In these discussions Mario took sides with his mother, was angry with his father, and thought that he had married her only for economic convenience, not because he loved her, since he humiliated her constantly. The mother suffered greatly from the father’s attitude toward other women and toward the family; attentive and seductive toward the former, cold and detached at home. Mario recounts this episode: the whole family was at the table with his mother’s cousin, her husband and their two children. He remembers how his father was full of attention toward his mother’s cousin: “He changed physically, almost became taller, the tone of voice, his eyes, his face, his smile, all bent to seduce, not caring that my mother and all of us were there.

It was really humiliating for her and I felt anger and disgust growing inside me.”

Hypo-responsibility

Antony is 18 years old and has recently left his small village of origin to move to a large city to attend university. It was a big change: Now Antony has to take care of the house, do the shopping, and also devote himself to his studies. One day, when there are only a few days left before the first exam, Antony realizes that he has completed only half of the planned program. At that moment Antony feels unable to face his responsibilities and remembers how his mother protected him all the time and how, when he was at home with her, he was relieved not to have any responsibilities.

Keywords: obsessive-compulsive disorder, imagery rescripting, memories, criticism, guilt

Citation: Tenore K, Basile B, Cosentino T, De Sanctis B, Fadda S, Femia G, Gragnani A, Luppino OI, Pellegrini V, Perdighe C, Romano G, Saliani AM and Mancini F (2020) Imagery Rescripting on Guilt-Inducing Memories in OCD: A Single Case Series Study. Front. Psychiatry 11:543806. doi: 10.3389/fpsyt.2020.543806

Received: 07 May 2020; Accepted: 03 September 2020; Published: 30 September 2020.

Reviewed by:

Copyright © 2020 Tenore, Basile, Cosentino, De Sanctis, Fadda, Femia, Gragnani, Luppino, Pellegrini, Perdighe, Romano, Saliani and Mancini. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Katia Tenore, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Case Study of an Adolescent Boy with Obsessive Compulsive Disorder

Susan S. Woods, Ph. D.

Youth Services, Department of Psychiatry, University of Michigan

P.Q. is a boy from Ohio, thirteen years, nine months of age. He was admitted to

Children’s Psychiatric Hospital on an emergency basis on 28 March 1975. He had

been noted by both parents to have had increasing emotional difficulties since the

previous summer. Thes.e became worse during the week prior to .his admission. His

symptoms were primarily of an obsessive ritualistic nature involving repetitious

behavior, compulsive repetitive hand washing, and gradual elaboration of rituals

around bedtime. During the week before admission he was described as

“immobilized to the point that he cannot get out of bed”, spending the larger part of

his waking hours in rituals, and being generally unable to function. His primary

symptom on.admission was that he found members of his family and certain objects

“germy” and was therefore “unable to deal with them” His father believed the

problem began in mild form during the previous summer, following a visit to his

maternal grandmother. One incident during this visit involved a trip to a

convalescent hospital, with P. subsequently being concerned and upset by sick or

damaged people, He started then by being unable to wear certain clothing because

“it was contaminated.” As time went by, areas of the house became off-limits to

him. Similarly, he felt that one of his stepbrothers “was unclean” (germy), a situation

that soon extended to all the members of the family. They were all felt to be

contaminated, with the exception of his father. His stepmother however felt that P.

had been having difficulty for a substantially longer period of time. in fact, it seems

that his symptoms had been apparent to some degree for several years, having

started some months after his mother’s death. The stepmother described the

appearance of what proved to be a long series of “strange habits” about five years

earlier during the summer. For instance, he began hopping every so many steps.

That was followed by repetitive smelling of the table and the walls, eye-blinking,

head-jerking and pausing with hands in

148 Obsessional Neuroses

praying position before entering rooms. Simultaneously, his peer relationships

deteriorated and for a year or so now his brothers and stepbrothers had been teasing him

about this behavior. More recently they had developed a strong hatred of him. Further, his

symptoms had been increasing very noticeably for the five months previous to the referral

to this institution. Thus, shortly before this happened, the Q.’s received a call from P.’s

school one evening stating that P, had been trying to get through the door and out of his

classroom for a period of over two hours. This Fall P. was referred for evaluation

somewhere else, and therapy was recommended and begun on a weekly basis with a

psychologist affiliated with the Department of Pediatrics of Ohio State University.

Three weeks prior to his admission here P. reported that he had “lost the key” to his

mental processes. His parents were uncertain as to the meaning of this and could think of

no precipitating events either within the family or with P.’s personal life.

Dr. and Mrs. Q. (P.’s stepmother) were eager for adMission at Children’s Psychiatric

Hospital and it has subsequently become obvious that they are relieved by his absence and

reluctant to have him rejoin the family unit. The Q.’s are involved in marital therapy at the

present time in Ohio, the marriage having become very rocky as a result of the stresses of

P.’s psychopathology.

P. expresSed concern upon admission that there would be retarded or weird children at

C.P.H. He was relieved after seeing the place because he saw no “weirdos” and found the

hospital to look “very clean.”

From the beginning P. has had a generally positive attitude toward admission, seeing it

as “the only way to get rid of my problem.” He can be expected at times to resent the

family’s splitting him off or scapegoating him as the one with the problems,

Description Of The Child

P. is a small, thin adolescent who has been described as an, Oliver Twist type. Indeed

he often walks around with a haunted expression, hair falling into his eyes, shirttail

hanging out, holes in.

hiS pants, etc.

Clinical Examples 149

He hardly gives the impression of a. compulsive personality, judging from his unkempt

appearance. There have been occasions when he takes care as to how he looks. These

times usually accompany a trip home or an outing with his family where he has enjoyed

Upon admission most of his clothes were rather old and shabby. He explained that he

had plenty of “cool” clothes but that they became germy after his trip to his grandmother’s

home. Finally P. was having to use safety pins to hold his pants together, wore no socks

and had large holes in his sneakers (the only shoes he would wear). He was upset, crying

when the staff finally felt that his father should be approached to ask him to buy P. some

new clothes. Dr. Q. was angry and somewhat embarrassed, explaining that P. had many

new articles of clothing including new shoes but to his and the family’s endless frustration

P. wouldn’t wear them. Dr. Q. finally bought P. some trousers and socks and a new pair of

sneakers. P. was amazed and overjoyed that his father had bothered to buy him clothes

and had spent so much money on him.

Generally P.’s behavior in the various areas of the milieu were consistent. Upon arrival

everyone was concerned about his need for repetition; for example, on his first morning at

breakfast he felt a need to throw away and retrieve his milk carton numerous times,

stating he had to “think right.” Showers and bedtime preparation were another source of

concern, often consuming the better part of the evening. Any attempt to interrupt the

rituals or hurry P. were met by his whining and crying that people didn’t understand him

or his problem. A staff member commented that he had rarely seen such pain in another

human being.

Group activities in the school and with his ward group also became problematic.

Briarwood Mall (a large, new shopping center near the hospital) for example was germy

because it was so “modern and weird.” The arboretum later became off-limits because it

bordered a cemetery. Most recently anything related to magic i.e., the color black,

sparkles, glitters, psychodelic posters, record album covers, or book covers, movies about

ghosts or witches, have produced enormous fear and given P. difficulties when trying to

“think right.”

Classroom behavior has been good and appropriate for the most part with occasional

problems with some students. After Passover P.

150 Obsessional Neuroses

developed an intense interest in Judaism, making a Star of David in Occupational

Therapy and wearing it around his neck. For a time another class member drew swastikas

on the blackboard, During TB’s vacation this rivalry became so intense that P. spent most

of his class time in the hall voluntarily and began to carry a transitional object, a ceramic

bunny, which he had made in Occupational Therapy. In P.’s Occupational Therapy group

he is the oldest member the other children ranging from ages eight to ten. The group has

changed from five to three members since P. was admitted. It is reported that P.’s

intelligence, gross and fine motor skills and creativity all appear to be age appropriate or

higher. Initially P. did not accomplish much, He spent much time•perfecting his projects.

The planning and organizational aspects of. the project were difficult for P. For example,

he wanted to make a Star of David and it was suggested to him to bend the wire to the

desired angles. He rejected this suggestion and became involved in finding a mathematical

formula to approach the problem. P. spent the remainder of the hour, approximately thirty

minutes, attempting to devise a mathematical formula. He became anxious and frustrated

with being unable to solve the problem. The next day however he was able to enter the

shop and just bend the wire to the desired angle, This seems to be P.’s approach to

problems—many times he must try to find a means of ordering or perfecting a project

before he is able to work at a more appropriate pace.

Initially P. remained apart from the group. He appeared very anxious and withdrawn.

He spoke only when addressed and interacted minimally with other group memberi. As he

became more comfortable with the others he began to interact more. He appeared to be

more at ease and seemed to enjoy the group. It appears that this group of younger children

allows him to regress to behavior inappropriate for his age i.e., making animal noises etc.

P. approached his occupational therapist on several occasions, asking about her

family and her. practice of Judaism. These conversations were precipitated by her

announcement to the group that she was taking several days off for Passover. Of late there

have been no questions concerning Judaism.

P.’s concern about a family have been brought up on a number of occasions in the

group. Once he made a family of ceramic rabbits and in a childlike manner stated “a

family—isn’t that cute?”

Clinical Examples 151

Generally P. relates N,vell to ward staff and peers and is not considered a behavior

P,’s relationship to two of his ward staff have been significant. K. and J. became

vehicles for P.’s lingering phallic-oedipal conflicts, and were loved objects. P.

frequently told K. that he wanted J. to tuck him in at night, He became anxious when

he discovered his liking for J. was greater than that for K., and he found it difficult to

understand that both could be loved .in different ways at the same time.

After K. left, P.’s liking for J. as a maternal object developed into a “crush.” He

discussed her constantly in therapy, voicing his anger after learning she was married

but seeing how futile his desires were because “she is a lot older than me,” He wanted

to be “mature” to win her attention.

During J.’s vacation P. decided that she was germy since she flew through the

“Bermuda Triangle.” Their relationship was over as far as P. was concerned. P. also

knew thatbpon J.’s return she would become a primary staff and thus have relatively

little to do with him, He attempted to leave her before she left him.

Family Background and Personal History

Mother: P.’s mother, H.Q., is deceased. A slim, dark-haired woman, she married P.’s

father in 1952, and suffered a reactive depression upon leaving her mother. After the

birth of each child except P. she suffered post-partum depressions. At each of these

times Mrs. Q.’s mother would come to aid her daughter. Mrs. Q. felt her mother could

“magically” help her to improve. Mrs. Q.’s mother was described in one report as an

“aggressive unloving woman. Mrs. Q. seemed to thrive on her criticism.”

Mrs. Q. was admitted to N,P,1. on four separate occasions for severe anxiety and

depression, She was expecting P. during her fourth hospitalization. This is a part of

the report of her psychiatrist:

If I were to speculate on some of the psychodynamics, I feel that unconsciously

Mrs. Q, felt she won the oedipal struggle against her mother. The patient’s mother is

a very hostile and aggressive woman who constantly yells and degrades the patient.

Mrs. Q. felt that she

152 Obsessional Neuroses

must have done something wrong and therefore felt guilty. We can see that since

childhood and especially since the patient has been married any symbolic libidinal or

aggressive energy (such as buying a house, having children, etc.) makes the patient

very anxious and depressed as a reaction to her guilt and she seeks the reassurance and

acceptance of her mother via the mother’s hostile and degrading comments. The patient

described a very hostile, symbiotic, sadomasochistic relationship that she had with her

mother. She felt she always had to go to her mother who in turn would berate and

belittle her, in order that Mrs, Q. should feel that she was still loved and accepted by

her mother.

The patient went on to describe that she would even provoke situations as a a child

which would ’cause her mother to yell at her and this would reassure the patient that

her mother still “cared for her,” Mrs. Q.’s mother exhibited both overtly hostile and

passive aggressive attitudes toward the child and the only way that Mrs. Q. could

retaliate was in her own passive-aggressive way by dawdling or doing things just the

opposite from the way that her mother wished.

During her hospitalization Mrs. Q. expressed suicidal thoughts and fears of harming

her children.

During her last pregnancy (P.) Mrs. Q. was told by her mother that she should never

have any more children because she couldn’t care for the ones she already had.

. Mrs. Q. went to her father as a child for emotional support and felt he loved her more

than he did his wife.

Mrs. Q. had a sister whom she viewed as “the bad daughter” and felt she had to be “the

good daughter.” Mrs. Q.’s sister has also been hospitalized for depression.

Mrs. Q. was always involved in aggressive battles throughout her life. In college she

and her husband-to-be were in the. same class. She was the valedictorian and he the

salutatorian. She went on to obtain a master’s in chemistry. On her third admission to the

psychiatric ward she talked about her husband’s attitude, stating he felt her

hospitalization was not necessary and that she was taking the easy way out.

Mrs. Q. was tremendously conflicted about motherhood. She felt

Clinical Examples 153

One can assume that during this period there was little emotional energy for nurturing

the young children in. the home.

she was still a child and wanted to be a child, Mother’s Day was apparently an enormous

symbol for her. She was admitted once just before Mother’s Day complaining that she

“couldn’t handle her life.” On another admission she became “preoccupied”, staring into

space and complaining of being frightened after a conversation among the patients

regarding Mother’s Day.

On Mother’s Day 1970 Mrs. Q. took an overdose of barbiturates and died two days

Father: R.Q. is a forty-five-year-old physician somewhere in the State of Ohio. He and

his wife were both originally from Boston where they met and married while attending

the university.

The couple moved several times early in the marriage, to Arizona, New Mexico, and

finally to Detroit, where Dr. Q. completed his residency in medicine..

Dr. Q. was seen twice on Mrs. Q.’s first admission in 1960. He was quite anxious and

seemed uncomfortable. He also seemed depressed and agitated, stating that he was unable

to concentrate on his work. He intellectualized -a great’ deal, saying that he thought his

reaction was a typical one to a depressed wife. He added that he was quite ldnely and did

not like being away from his wife. He felt that if he could be with her he could be

supportive of her as he had been in the past. Dr. Q. felt that the only person he could

accept reassurance from was a doctor who was treating his wife. Dr. T. (wife’s therapist)

called Dr. Q. daily to support him and tell him of his wife’s progress. Dr. Q.. felt that this

was not very effective in easing his anxiety but that it was all he had to hold onto. Dr. Q.

also stated that when his wife was depressed he felt depressed too and when she felt better

he felt better. The report of the treating psychiatrist goes as follows:

The highly interdependent nature of the relationship described above was confirmed

by Dr. Q.’s statements to me that he thinks his own willingness to be constantly

available to his wife tended to feed her dependency on him and that the two of them

seemed locked ,together in the ups and downs of this depressions

154 Obsessional Neuroses

Dr. Q. placed a great deal of emphasis on the kind or quality of therapy his wife

might be receiving. He was concerned that she be treated by a staff psychiatrist rather

than a resident, He resented seeing a social worker about-his adjustment to his wife’s

illness. Remnants of this are still visible in Dr. Q.’s wondering why neither he nor P.

saw psychiatrists at C.P.H. He asked about his son’s therapist’s credentials. P. too

shares these feelings, frequently asking what a social worker is, what M. S. W. stands

for, and on one occasion commenting that he believed his therapist could probably

help him as well as a senior psychiatrist. Dr. Q. is a rigid, obsessive-compulsive

character himself. This became evident in his endless ramblings from subject to

subject during the time of history taking. It was impossible for him to get through

recounting a simple event without trying also to include every minute detail of his

association to the event. He feels that his memory is poor and confused and he never

ends satisfied that he has really told the story “right.” He described himself as having a

“stubborn streak.”

Stepmother: This is the report of the parent’s therapist: During the summer

following P.’s mother’s death, – Dr. Q. arranged for a housekeeper, now Mrs. S. Q , to

come into the home. She had just divorced her first husband and was supporting three

sons from her first marriage. Her sons were away at camp during the first few weeks

after she came to the job, and she recalls that P. was the first of the Q. boys to make

friends with her, She had a great deal of time to devote to P. during these weeks and it

was only when her own children returned that she and Dr. Q. began going together. P.

then began to distance himself from her, When the marriage became imminent the

following fall, P.’s siblings reacted quite angrily and P.’s more quiet reaction seemed to

go unnoticed. Following the marriage P. became more and more withdrawn. He

especially had difficulty accepting her youngest son, who is described as being quite

different from P., i.e., rough and aggressive.

The family moved in 1971 to Toledo, where Dr. Q, practices. P.’s siblings were very

unhappy about the move and again their more obvious behavior pushed P.’s into the

background. One had problems in school and another became very depressed. O. cried

frequently, withdrew, developed colitis. At his school’s suggestion a began

Clinical Examples 155

psychiatric treatment of problems described as “similar to P.’s.” This treatment has

been ongoing to the present time. Mrs. Q. described the relationship between herself

and 0. at that time as very poor. 0. is described as being much like his mother, the first

Mrs. Q., bright and close to his dad. P. was closest to 0. of all his sibs and would often

try to emulate him (this relationship has now dete’riorated to the point that the boys

rarely speak). As relationships became more strained throughout this period it was

more and more difficult for Dr. and Mrs. Q. to communicate with each other about the

children. In 1971 the Q.’s daughter, B., was born. According to both parents her birth

was greeted quite positively by the older children. Currently B. is the only sibling

within the family with whom P. is willing to interact on his home passes and she is the

only child who inquires when he is coming home.

Developmental history: P.’s mother was hospitalized at N,13

.1, for the third and

fourth time during her pregnancy with P., for symptoms . of anxiety and depression.

She was admitted and discharged in May of 1961 and readmitted in June of 1961. Just

before Mother’s Day in 1961 she phoned her psychiatrist and described suicidal

thoughts. This pregnancy was obviously a strain for Mrs. Q. and increased her fears of

inadequacy about motherhood.

P. Was born two weeks early as was the pattern of all Mrs. Q.’s children. Labor

lasted one hour and ten minutes. P. was a six-pound, eleven-ounce infant delivered

under caudal, anesthesia. Mrs. Q. recovered quickly with no complications for either

mother or son. P. was breast-fed.

from birth and follow-up interviews with Mrs. Q. at

N. P.1. found she experienced this as pleasant and took pride in the care of her infant.

P. was described as a peaceful sleeper and he slept completely throughout the night

very early .on.

P. developed atopic dermatitis which Dr. Q. described as a red rash occurring in the

creases of his body. He said that P. did not seem to be uncomfortable with this. For

several weeks P. was put on a special diet in an attempt to determine the source of his

allergy. Dr. Q. again recalls no difficulty or food refusal during this time and the

special diet was finally stopped as the pediatrician seemed to feel it was not helping

diagnostically.

Dr. Q. says that he recalls very few specifics regarding the P.’s age at

156 Obsessional Neuroses

the various early developmental milestones, However he feels that P. accomplished most

things just a bit earlier than his two older brothers. For example, he believes his son held

his head up quite early, was responsive to external stimuli and began picking up. and

playing with crib toys at a very early age. Although he cannot recall when P. was weaned

it seems that it was fairly early and he does recall that by the age of one P. was feeding

himself, While recounting this history Dr, Q. often interjected that he recalled his wife

being troubled and anxious and on’many occasions emotionally tied up within herself. He

says that even though Mrs. Q. took good physical care of the children he feels now that

they probably were emotionally, neglected.

P. toilet trained himself at age two and half “almost overnight,” Dr. Q. does not recall

the development of P.’s speech but does remember that once he began talking he talked

almost incessantly. P, rarely played with children his own age, preferring to spend his

time with adults or playing with his older brothers,. When P. went to

kindergarten at age five, Dr. Q. recalls him telling long stories about what had happened

at the end of the day. He also recalls himself and P.’s mother being amused at what a long

story P. could make out of a very small event. The father remembers no difficulty in

separation from Mrs. Q. when P. began kindergarten.

The following information was learned from the second Mrs. Q.: Mrs. Q. said that by

the time she met P, at age seven almost all of his interests and interpersonal relationships

centered on adults. He struck her as being a very dependent but cooperative child. She

even described Him as “a model child.” She recalls that he always liked to have his things

in order although he was not really fastidious. It was always quite difficult for him to get

off to school•in the mornings as it was quite a chore to get through all of his routines. By

the age of twelve P,’s compulsive mannerisms and rituals had become a point of great

contention between him and his siblings. Mrs. Q. remembers that approximately ten

months prior to P.’s hospitalization his brothers began to noticeably withdraw from him

and make fun of him. Before long all of the siblings seemed to be angry with P. It was

also during this year, fall of 1973, that P,’s grandfather died. Although the parents would

not characterize P.’s relationship with his grandfather as a close • one, he did visit with the

grandparents annually and seemed to greatly

Clinical Examples 157

enjoy walking downtown with his retired grandfather and being a part of the

interaction with all of his grandfather’s “old cronies.” When the grandfather died the

maternal grandmother sent • the grandfather’s personal watch to O. rather than to P.

Dr. Q. •stated somewhat resentfully that this was typiCal of his former mother-in-law,

that is, to be more interested in a tradition of giving a gift to the oldest grandchild

rather than giving it to the one who had been closest to her husband.

The summer prior to this hospitalization all three of the older Q. boys were invited

to visit the grandmother. True to form, •only P. accepted the invitation and remained

with the grandmother for about three weeks. .Upon his return from this trip Mrs. Q.

states that she began really pushing for help for P.

Possibly Significant Environmental Circumstances

Timing of the Referral: The timing of the referral seems to have coincided with the

severe manifestation of the obseSsive compulsive neurosis, however the problem in

earlier more manageable stages seems to have been present for some time longer.

Since P. often has difficulties determining when events happened and how long he has

experienced difficulty, both the extent and duration of his symptoms are still

unknown, He believes, however, in agreement with his father, that the major

disturbance began last Summer after a visit to his maternal grandmother in

Connecticut.

This visit was an event for P. each year.. He was the only grandchild who enjoyed

these trips to Connecticut and last summer he went alone. This was P.’s first trip to his

grandmother’s after his grandfather had died of a heart ‘attack a year before. P. had felt

very close to his grandfather, more than to his grandmother whom he described as

“mean and al vays telling me what to do.” It is significant that P. was concerned to

maintain the ties with his mother’s parents. P. is also the only child who wants to

practice Judaism, something which is frowned upon by the rest of the family but

which was highly regarded by P.’s mother, It seems P. is trying very hard to keep his

mother alive in a sense by holding onto the significant objects in her life.

Causation of the Disturbance: Four areas can be delineated as causally significant:

1.158 ObsessionalNeuroses

2. The mother’s suicide. H.Q.’s suicide is a pivotal issue in P.’s psycho- pathology. He failed to mourn her loss, fearing that to express his feelings would be

against his father’s wishes. He is now engaged in the draining process of keeping

her alive (which he believes his father, a physician, failed to do) by holding onto

her traditions. as previously mentioned, Significantly P.’s stepmother is neither

Jewish nor religious and he resents the fact that the family has given up all Jewish

traditions. A particular blow came on P.’s thirteenth birthday when his father

offered him money and said that would take the place of being bar rnitzvahed. P.

felt this cheapened what is to him an important event – symbolizing his “becoming a

man.”.

In therapy P. had tremendous difficulty remembering his mother or any experiences

they shared. He vividly remembered, however, the day she died and described it several

times. The most significant aspects seem to have been when his mother was taken to the

ambulance. She opened her eyes for a second and looked at P. He also remembered how

angry his father became when P. told a neighbor that his mother was

1. The father’s remarriage. P. was initiallS

, warm and accepting of the present

Mrs. Q. before she married his father. After the marriage their relationship

deteriorated, She describes P. as acting like “a twoyearTold.”

The division between old family and new has continued to worsen. P. cannot accept

his stepbrothers especially now that they “have changed.” What this change entails

is their move into adolescence with a concommitant increase in foul language, rough

behavior and less care in personal hygiene.

1. The father-son relationship, ,In one session, P. described his relationship

with his father as being like the song, “Little Boy Blue and the Man in the Moon,”

where a little boy all through his life asks for time with his father but the father is

always too busy. Later the father retires and wants to be with his son but the son by

that time has his own life and says he’s too busy to see his father.

P. has tremendous difficulty expressing his feelings to his dad. He perceives him as

all-knowing and all-powerful but very inaccessible. P. is visibly elated by the grief times

he spends with his father but it seems he does not convey this when he is actually with

his father. Dr. Q. describes P.’s behavior when they are together as passive, bored and

Clinical Examples 159

angry toward sibs. When P. and his father are together they talk about science. P becomes

anxious when he runs out of things to say to his dad. (This happens in therapy too.) He

needs a mental script Well planned out before he feels comfortable.

Dr. Q. is a rigid, authoritarian person who seems to have provided an atmosphere

where P.’s feelings could not be exhibited. Childish emotions of glee or anger were

scorned. To show them meant to risk rejection and withdrawal of IOW. P. learned from an

early age to control himself, to measure up, to be adult in order to obtain parental

acceptance.

4. Adolescence. P. wants to be a man but fears outdoing his dad. He has tried to avoid

any competition with him so far, Now he is beginning to see that his father may have

problems but at the same time he has decided that all doctors are perfect and able to

overcome all difficulties.

Physically P. is small and underdeveloped. This concerns him because he wants to

be strong so he can “beat people” in games and frequently taLks of beating people up

when they upset him.

He likes to be with younger children so he can be superior but resents their childish

Adolescence has also raised the unresolved oedipal issues which are central to P.’s

difficulties.

Possibly Favorable Influences: P. is a bright, interesting, and interested child. He

relates well to peers and staff and relates warmly to particular staff, mainly women. He is

an attractive . child and is frequently described as cute.

His interests are varied and socially he is quite sophisticated.

His parents though severely troubled themselves have engaged in marital counseling. It

family is trying hard to get back on its feet. What place P. will have upon

reuniting with the family is hard to guess. P. has tremendous motivation in thearapy. He

is insightful and frequently makes his own interpretations which are often accurate.

160 Obsessional Neuroses

Assessments of Development

Drive Development

development

P. is developmentally a preadolescent. He has brodd interests in art, science, music,

especially popular music, i.e., John Denver and the Beatles. He has good relationships

with peers and adults but has difficulty when peers exhibit aggression which could be a

physical threat, or when staff is authoritarian. He expresses dislike for the rules that are

imposed and would like to liVe in the wilderness all alone, free from society’s restrictions.

Oral Phase: The oral remnants are seen in P.’s occasional sucking motions and sounds

at the end of therapy sessions, in. his dislike of young children, and in the oral-sadistic

rituals around food (putting food into his mouth and then taking it out, difficulty entering

the dining room). He also has difficulty swallowing (he must think right) and he cannot

eat, for example, at the Detroit Zoo because it is surrounded by cemeteries. (Notice the

anal-sadistic connotations of this.)

Anal phase: P. strives to control his anal-sadistic impulses and fantasies with rituals and

obsessive thoughts. One such fantasy he described as “the pool of imagination, a horrible,

dirty, black gooey place that wants to pull me into it. Sometimes my eyes fall in.”

Whenever he thinks of this he must repeat what he has been doing to avoid anxiety.

Unconsciously he is, as his stepmother described, “a two year .old” expressing

ambivalence, sado-maSochism, tendencies toward stubbornness and rebelliousness.

Rdaction formation is P.’s main defense. The move toward adolescence has undoubtedly

contributed heavily to this pattern,

Phallic-oedipal: P. describes himself as “curious George” and expresses an interest in

sex. He developed a “crush” on one of his female child-care-workers but he found this

relationship odd when in therapy he saw her as both girlfriend and mother and said “but

you can’t have sex with your mother,”

Generally P. idealizes adults, particularly men but fears his own adulthood because it

might lead him to be better than his dad,

Clinical Examples 161

P. is just beginning the adolescent phase and has not reached phase dominance. He is

expressing an interest in sex though he is having difficulty with feelings of

embarrassment. He has recently begun to discuss some of his sexual feelings in therapy.

Often they have a decided oedipal component. Recently too he has shown some interest in

a twelve-year-old girl in his class and behaved quite appropriately with her, as opposed to

infantile behavior with another girl.

b. Libido distribution

i. Cathexis of self,

Primary narcissism: P. does not have difficulty in primary narcissism. Secondary

narcissism: P. considers himself to be intelligent with a good sense of humor, however

physically his estimation of himself goes way down.. He fears he is

inadequate, not

strong, uncoordinated and thus unable to successfully compete in athletics or engage in

physical fighting with peers. To some degree his older brother’s move into adolescence

was threatening to P. and may be responsible for the symptom formation to some extent.

He believes he never got enough love or attention from his father. He desperately tries

to prove himself to his dad but is always disappointed to learn how his dad “didn’t notice”

how happy he was to be with him. His chief complaint now is that his dad is strong and

capable, so why shouldn’t he let P. come home on weekends?

P. has developed a split between his natural mother as a good mother and his

stepmother as the bad mother. He can no longer have needs satisfied by his real mother

and he fears rejection by 1-

tisstepmother.

P. is highly invested in his memories and fantasies of his mother. He recalls that when

he was about four he and his mother had mumps. The whole family was concerned about

them. P. became deaf in one ear because of his illness. He is identifying with his mother

now and says he is a replica of her because he is hospitalized “for being crazy,” He

fequently talks of suicide when difficult material is raised in therapy. One day he even

said that he tried to commit suicide by cutting his wrist with a comb but it only made

white scratches. He said that he wasn’t interested in really killing himself, he just

wondered what other people would think if he did.

His goal now is to be like his father. He wants to be a doctor (a

162 Obsessional Neuroses

neurologist) so he can learn how the brain works. He depends on his father to supply

him with the guidelines so he will not fail. His father told him “a healthy body is a

healthy mind,” after his admission to C. P. H. P. immediately began an exercising

.program. He runs contests with himself. He wants to set records, which mean

winning to him, for instance brushing his teeth every night for a year. His favorite

hero is Einstein.

His relationships with other people are warm and accepting. However, once a strong

relationship develops and any hint of rejection is present he rejects before he can be

rejected. When he learned K,D. was leaving, K. became “germy.” When P,’s primary

staff was taken away from him and assigned to another child, she became germy. He

now realizes what this behaVior means and says that if he likes someone a lot they

can’t be germy for very long,

P. is dependent on external objects to regulate his self-esteem. However he is

capable of independent action and thought, the only motivation seeming to be self- satisfaction. He has difficulty accepting praise, usually laughing or saying “sure, sure,”

but it is obvious that he likes it an agrees with it,

ii. Cathexis of objects

P. has the capacity to form and maintain relationships with peers and adults. It often

seems that the peers who become objects of competition are rejected, for example,

brothers, and a friend from Ann Arbor whom he had not seen in several years. P. was

excited about seeing this friend again but this fifteen-year-old had matured and grown

quite .a lot in the meantime. P. felt weak and small by comparison and has not

contacted his friend since. Very recently, he has expressed interest in seeing him

again. –

P, attempts to control adults with his problems. “1. can’t do that because of my

problem” This has led to concern on staffs part as to how much to push or give in to

“the problem.” At first P. would take over an hour for an evening shower, and bedtime

rituals were an agony for all involved in his care.

P.’s closest and most enjoyable relationships have been with female peers or staff.

He was very proud when a young girl from fourth level showed some interest in him

(gave him a yo-yo and sat next to him at a movie) but was somewhat embarrassed

since she was “too young” for him, His relationship with J, (female staff) has been

primarily positive

Clinical Examples 163

but very much tied to oedipal conflicts. Recently he has shown some interest in a twelve- year-old girl in his class and feels she is “the right age for him” “not half as old or twice as

old” as with his other two female interests. P.’s relationship with K.D. was good but he

felt K. was not strong enough at first. Later he felt that K. was one of the few people who

could “really understand me.” Strong authoritarian men are seen as “fair” by P. though he

resents their orders.

2. Aggression

The expression of aggressive impulses has been one of P.’s major areas of conflicts.

Until quite recently he has denied angry feelings, particularly those addressed toward his

father. However a great deal of aggressive energy is bound up in his rituals and obsessive

thinking, which ward off his expressed fantasy of hitting people over the head with coke

bottles (particularly vacationing staff) or sending authoritarian staff through a bologna

slicer! For example, if he thinks of putting someone through a bologna slicer he must put

them back through to make them all right again (thinking right).

Aggression is also seen in his tremendous need to control the environment. Angry

crying spells and stubborn refusals often accompany change of plans for any

unanticipated event,

P.’s aggression not only inflicts pain on the environment but is most often more painful

to him. He feels trernend ously *anxious and guilty over his aggressive thought, and the

rituals also serve as punishment for his self-peiceived “badness.”

Ego and Superego Development

a. Ego apparatus: his ego apparatuses are intact.

b. Ego functions:

Affected by and interfered with by his psychopathology, he is nevertheless clearly a

highly intelligent child with reading skills, mathematical reasoning, and mathematical

fundamental skills above his chronological age.

a. Ego reactions to danger situations:

P.’s fears are lodged in the external world in the form of fear of loss of objects. The id

impulses are also feared characteristically because they may force him to become out of

control and do things (show anger

164 Obsessional Neuroses

or aggression) which would be severely punishable by his superego. d. Defensive system:

Denial: P.’s obsessional substitutions utilize magic and rituals and are a defense which

fosters power and strength in a world where he feels helpless and weak.

Rationalization: Since P. fears the “weakness” he thinks is implied in tender feelings,

he recently denied his anger and sorrow at the vacation of an important P . C. W by

claiming she had a “right” to the vacation and he should not.feel bad because it was her

“right” to go away.

Intellectualization: Enormous energy is spent in .holding back feelings by

intellectualization. P. has such an explosive need to love and hate (punish) his father for

rejecting him and/ or his mother but the only way he can deal with his father is through

scientific discussion, He feels anxious if he is with his father without some specific

intellectual topic to discuss, Unfortunately his father relates to P. in the same way.

Reaction-formation: Classic obsessive concerns for cleanliness, order, being good, are

perceived as knowing the rules and following them, according to P.’s pattern.

Paradoxically, he expresses a great longing to live in the wilderness free from human rules

and regulations and living exactly the way he please.

P. also belches frequently and then immediately bows his head and whispers “excuse

me please” sometimes three or four tlines in a row.

Doing and undoing: P. uses this defense in many areas but perhaps the most suggestive

is his need to read a line and then “unread” it, For example, read backwards, This may

indicate his need to know or his fear of knowing or the ramifications of the quest for

knowledge, related to the suppression of information regarding his mother and her death.

Extensive use of displacement, isolation of affect and content are noticeable,

e. Secondary interference of defense activity with ego achievements:

P.’s defensive system keeps him vulnerable to the fears he experiences in every new

situation. It prevents him from learning by experience. He is so involved in creating

reasons not to be somewhere or not to express feelings that he is virtually paralyzed by a

system where there is no relief and where every day poses a threht of defeat, f, Affective

states and responses:

P. is capable of expressing a wide range of affective responses. He is

Clinical Examples 165 •

a sensitive child and the potential loss of loved objects evokes anger, hate and guilt. It is

only recently and only to certain staff members that P, is able to tell how he feels. Sad

affects are usually masked by imitation crying or sarcasm,

P.’s self-esteem is low and this is particularly evident when gifts or praise are given to

him, He says he never felt anyone gave him anything because they loved him but only

because they wanted to “satisfy him,” The only area where he acknowledges success and

accepts praise is with his intelligence. Though P. is capable of affective responses and

often displays them appropriately, his behavior becomes inappropriate when he is moved

by a person important to him

P. is still somewhat egocentric and narcissistic. For example, he feels everyone

thinks the way he does, and should, therefore, understand his problem, He is

terrified of the anger of others especially – if it might result in physical confrontation,

Authoritarian people are disliked and criticized even when he believes their rules are fair

and right. He whimpers and cries and impotently feigns rage when forced to do something

he doesn’t want to do.. Often his responses can be described as overreaction. Usually the

anger or hurt is not long-lasting though he tends to hold a grudge against those who have

caused him to display negative affects.

Superego Development

a. Superego:

P.’s superego is overly developed, punitive, nonpleasure-giving, unrelenting, and

constricting, The superego introjects which contribute to this pattern stem from the anal

and phallic-oedipal stage based primarily on his overly restrictive father and his perhaps

uninvolved, distant or permissively ambivalent mother. He felt he had to be good to win

parental approval. “Bad behavior” meant risking parental rejection, The id has a need to

discharge its persistent drive and the ego is left as the battleground for the two opposing

sides. Normal childish feelings of gratitude, happiness, excited joy, sorrow, or pain and

anger came to be viewed as weaknesses to be avoided, denied or isolated, so that he could

be the good, calm, placid child he felt his parents desired.

a. Superego ideals:

166 Obsessional Neuroses

The most obvious and most frequently mentioned superego ideal stems from his

identification with the aggressor (father) and his wish to outdo or overcome his father.

He wants to be a brain surgeon who will find the definitive cure for cancer and be the

first to perform successfully brain and spinal-cord transplants. Not only will he be the

first but he will be nationally famous and admired.

a. Other types of ideal formation:

Certainly his desire to become a physician is an appropriate ego ideal as his

intelligence and latent personality strengths suggest. It is clear also that even as an ego

ideal there is the apparenridentification with the aggressor” and his own self-desribed

“little-boy-blue” phenomenon.

a. Development of the total personality:

In general P. has not reached age-appropriate development and may be found in the

preadolescent stage. His over-all development suggests an initial ease in the

developmental milestones without disruption.

There is no noted separation-anxiety in Anna Freud sense of the word, and since he

was the youngest child in the original family there was no conflict there. His illness,

mumps, along with his mother at age four, served to increase his identification with

her and left a permanent reminder of their shared experience.

P. did not want to attend nursery school (possibly a fear of • separation). He recalls

(or has been told) that he stubbornly refused to go and would not dress himself or

allow himself to be dressed for the occasion. This is reminiscent of his present

aggressive behavior around bedtime rituals. Ile states with pride “and 1 never did go to

nursery school.”

School itself was not a problem and both parents recall delight in observing P.’s

reaction to it. We can only speculate that the kind of disturbance observed -now, with

its anal-sadistic qualities, indicates difficulties stemming from the anal phase, though

toilet training-wasn’t a problem. The mother’s frequent depressions may have

contributed to these difficulties along with his father’s authoritarianism. Mrs. Q.’s

depressions continued to the phallic-oedipal stage and we may assume P. felt he could

have given her more suppoil and protection than his father did. The mother’s suicide at

the beginning of his latency caused an upset in this relatively peaceful period and sent

P. back to using the

Clinical Examples 167

defenses of an earlier developmental level and caused a hiatus in further growth.

Latency was accomplished, as seen in his adequate move from play to work, but the

damage was there, P. recalls that his repetitions began at about eight or nine years of

age, soon after mother’s death and his father’s remarriage. The suppression of

information about his mother and the birth of another child served to reinforce P.’s

feeling of being.

left out and unncessary.

The threatening arrival of adolescence was probably the last straw in P.’s ability to

ward off the instinctual impulses and oedipal conflicts tha t we r e then r e ignit ed.

P, is now beginning to feel that he needs his father less than before and this can be

seen as a sign of the impending move into adolescence. P. finds this very upsetting

however, because of his paradoxical view of loving and hating his “all-powerful”

Assessment of Fixation Points and Regressions

There is a fixation to the anal-sadistic and phallic-oedipal stages, with defenses

against regression to oral wishes and fantasies, This can be seen in his obsessive

compulsi-ve behavior and need to re-enact the oedipal situation. There are also some

elements of regression to oral sadism as exemplified in his food rituals.

Assessment of Conflicts

P.’s conflicts have an internal and internalized nature. The internal conflicts are:

(1) general ambivalence—his decision making is tortured, as when he wanted to give

his stepmother a Mother’s Day present but felt to do so might make her unhappy, even

though he also thought it might make her happy; (2) masculinity vs. femininity; and

(3) sadism vs. Masochism.

The internalized conflicts reflect the internalization of previously external conflicts.

There are regressive traces of the oral, anal and phallic-oedipal phases: (1) oral: eating

difficulties previously mentioned; (2) anal: reflected in his fears of aggression, death,

and his reference to death wishes, concerns with germs and magic; (3) phallic-oedipal:

as seen in his crushes and wish to re-enact the oedipal triangle.

168 Obsessional Neuroses

The latter is expressed in jealousy of his therapist and a female ward staff whenever

separations are imminent or when they are observed by P. to be interacting with male

staff. P. is also expressing some concern that his problems will make his therapist

depressed, necessitating her treatment as an inpatient at N. P. I. There is an obvious

sadistic wish here since he is angry about her impending vacation but there is also

guilt .perhaps reminiscent of the guilt he felt for not “making his mother happy” and

thus preventing her depreisions and subsequent suicide, for which he no doubt feels

responsible.

Assessment of Some General Characteristics

Frustration tolerance: 1

1s frustration tolerance is poor because of the pervasive

nature of his obsessions and compulsions. He feels he must do his repetitions even

though they take up a lot of time, If he is pushed beyond his own limit he will cry and

become very stubborn and accuse people of not understanding him or his problem.

Attitude toward anxiety: P. is engaged in a constant struggle to avoid anxiety. The

defenses he uses create the illusion of power and control and temporarily reduce_

At present, P.’s anxieties are so severe that he invests more and more time in

warding them off. His obsessive rituals consume most of his time and overshadow all

other events in his life. Despite their initial intensity they became worse during a

period when P. began to ask questions about his mother and to criticize his father’s

handling of her death. After this the obsession took on a more magical representation

(voodoo), attempting to hide the death wish he felt toward his father.

Sublimation potential: In view of the -present behavior crisis it is difficult to judge

the true sublimation potential, One can assume that it is quite high judging by his

latency-age creativity. For example, P. is making a report on the state of Israel,-This

reflects his search for an identity and his questioning about his mother. However this

has been interfered with and is now a problem for P. He may substitute.the study of

Saudi Arabia because he ‘feels that –

too many magical events happened in the creation

of the state of Israel, that the number 13 appears very often in its history. The one

example he uses is that Israel

Clinical. Examples 169 .

was formed on 13 May 1948; Robert was born on the 13th of the month and his mother

died on the 13th of the month.

Progressive vs. regressive tendencies: P. has a tremendous desire to move forward

and be rid of his problem. He has the potential for progressive movement. He also

acknowledges a disbelief that he will ever be without it or that certain areas of conflict

will cease to concern him. There is also an element of fear of what would happen if he

were no longer obsessive.

He wants to become an adolescent, mature, date, marry, go to medical school but all of

these things pose the threat of failure or worse, success (outdoing father). Sometimes P.

regresses, especially in O.T. groups when he is with younger children. Fear of a

classmate and separation from a teacher several weeks ago prompted P.’s need for a

transitional object, a small clay rabbit which he had made in 0.T. was carried to school

and brought to therapy.

There are a cornbination of permanent regressions which cause extraordinary

developmental Strain, and crippling symptom formation according to the location of the

fixation point and the amount of ego superego involvement. The symptomatic picture is

that of an obsessive compulsive neurosis.

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• v.10(10); 2022 Apr 6

Woman diagnosed with obsessive-compulsive disorder became delusional after childbirth: A case report

Department of Psychiatry and Psychology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China

Jing-Fang Gao

Department of Psychiatry and Psychology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China. moc.361@7931gnafgnijg

Corresponding author: Jing-Fang Gao, MD, Chief Doctor, Full Professor, Department of Psychiatry and Psychology, The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54 Youdian Road, Hangzhou 310000, Zhejiang Province, China. moc.361@7931gnafgnijg

Obsessive-compulsive disorder (OCD) is a common mental disorder that varies greatly in manifestation and causes much distress to individuals. We describe a case in which a Chinese woman with OCD became delusional after childbirth, and discuss the possible phenomenological and psychological alterations.

CASE SUMMARY

A 27-year-old woman presented to the Psychiatry Department of our hospital with obsessions and compulsions. After taking medication, her symptoms were alleviated. Three years later, during her pregnancy, the obsessions returned and even progressed into paranoid delusions after childbirth. After multiple adjustments of treatment along with several fluctuations, she finally achieved remission and gained reasonable insight.

This case suggests that the patient with OCD appeared to move along a continuum of beliefs, and highlights the importance of effective intervention during pregnancy, which would exert a significant impact on postpartum exacerbation outcomes.

Core Tip: Obsessive-compulsive disorder (OCD) is a common mental disorder that varies greatly in manifestation and causes much distress to individuals. We describe a case that developed over a decade where a Chinese woman with OCD became delusional after childbirth, seriously affecting her marriage and parent–child relationship. We hope it can remind psychiatric practitioners to attach more importance to perinatal interventions for those who suffer from OCD.

INTRODUCTION

Obsessive-compulsive disorder (OCD) is characterized by obsessions or compulsions that are distressing and anxiety provoking. Researchers are now increasingly recognizing that OCD is a clinically heterogeneous disorder that varies greatly in the specific content of obsessions and compulsions and has discrete subtypes[ 1 ]. Although the significant variability in the presentations of individuals creates difficulties for differential diagnosis of OCD, it also provides opportunities for research.

Here, we present the case of a woman who suffered marked anxiety and experienced a continuum of beliefs during the perinatal course of pregnancy, with obsessive beliefs eventually progressing into delusions and leading to secondary obsessions, which aroused our discussion and reflection. We describe the patient’s symptom progression and treatment and discuss the possible underlying phenomenological and psychopathological alterations, hoping to remind psychiatrists to attach more importance to perinatal interventions for OCD.

CASE PRESENTATION

Chief complaints.

A 27-year-old woman presented to the Psychiatry Department of our hospital with obsessions and compulsions.

History of present illness

A 27-year-old woman named Laura came to our clinic in 2009, stating that she was quite anxious due to preparing for the national postgraduate entrance exam. She gradually manifested the symptoms of feeling compelled to turn pages over and over again, to rearrange objects in order on her desk, and to repetitively check whether doors and lamps were closed before going out. She did not resist these behaviors or feel miserable, but these behaviors were quite time-consuming and obviously interfered with her studies. She sought help from a psychiatrist in our department. After finishing laboratory and imaging tests, which ruled out physical disease, as well as psychiatric interviews and psychological assessments [she scored 21 on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Obsession-7, and Compulsion-14; she scored 72 on the Self-rating Anxiety Scale (SAS)], she was diagnosed with OCD. The psychiatrist prescribed sertraline for her and titrated it up to 75 mg/d. The symptoms of compulsion were greatly relieved, and after reassessment, she obtained a total score of 7 on the Y-BOCS and 53 on the SAS. She adhered to the medication for 3 years.

In 2012, Laura got married. She wanted to stop the medication to prepare for pregnancy. Under the guidance of the psychiatrist, sertraline was gradually discontinued. Soon Laura found she was pregnant. After calculating the date of conception, she found that the time to conception was only three weeks after withdrawal, and she had drunk some beer and applied some ointment to treat nail inflammation after conception. Hence, Laura was worried that the fetus might be unhealthy and wanted to have an abortion, but her family discouraged this. Her husband thought these conditions would not affect the fetus. Her husband was an only child and his father was terminally ill. To enable his father to see his grandchild before he died, he insisted that Laura keep the baby despite her concerns.

She kept going to many departments of different hospitals and asking for all kinds of tests and examinations, but doubted all positive answers the doctors gave. She was quite sensitive during that period and increasingly believed the fetus would be unhealthy and should not be born. The idea that she might give birth to an unhealthy baby made her uneasy. She suffered from anxiety, irritability, and insomnia. Despite her complaints as well as strong demands for an abortion, she never attempted to injure the fetus in any way. She came to our department again [she scored 19 on the Y-BOCS, 75 on the SAS, and 55 on the Self-rating Depression Scale (SDS)]. We offered supportive psychotherapy and relaxation therapy in every follow-up during pregnancy, but the effect was not good. Considering that the patient was deeply tormented by the symptoms, we recommended medication treatment to her. She declined in view of possible adverse effects on the fetus. Ultimately, because no one gave permission for an abortion, the standoff lasted until the moment of delivery.

In March 2014, Laura gave birth naturally to a baby girl; no abnormalities were found in the physical examination after birth. However, she denied the results and insisted there was definitely something wrong with the baby. She thought it was wrong for her to bring an imperfect child into the world. She had a strong, overwhelming impulse to kill the baby and imagined all kinds of methods, such as strangling her or throwing her down the stairs. Three days after giving birth, her husband took the baby away for the sake of safety and brought the baby to the grandmother.

Laura came to us again, accompanied by her father, telling us she had given birth to an imperfect child; this thought tormented her frequently. She even planned to take the train to find the baby and kill her. Her family hid her ID card and was required to watch her around the clock. We reevaluated her, she scored 31 on the Y-BOCS and 71 on the SAS. Sertraline was administered again for almost 2 wk without any improvements. Taking her anxiety and insomnia into account, sertraline was discontinued, and fluvoxamine was introduced and quickly increased to 200 mg/d. Because of her agitation and insomnia, sodium valproate was introduced and added up to 0.5 g/d. After her mood was stabilized, sodium valproate was discontinued. Meanwhile, Laura exhibited obvious somatic symptoms, such as headache, chest tightness, and shortness of breathing. After a general examination, no physical problems were detected. We switched medications by adding duloxetine and titrating it to 60 mg/d. Then, the somatic symptoms alleviated. She still insisted that her baby had problems and should not have been born, although the urge to kill her baby was not as strong or frequent as before. She felt incompetent at work after giving birth and changed to a different job. Her relationship with her husband had been strained since her pregnancy. In August 2015, a divorce judgment was finalized. The judge persuaded her that the child was innocent. At that moment, she felt what he said was reasonable, and there was no need to kill her baby. From then on, the impulse to kill her baby occurred much less, and she was not bothered by it . During follow-up visits, which normally took place every 3 to 4 wk, she stuck to the medication.

In 2016, Laura met her ex-husband by accident. He showed her a picture of the baby and expressed his desire to get back together. Moreover, Laura’s aunt persuaded her to get back with him and sarcastically indicated that nobody would marry a divorced woman like her. She came to feel she was an imperfect woman because she had given birth to her daughter. She could not bear to let the baby become a reminder that she was an imperfect woman. The belief that the baby was problematic and the impulse to kill her relapsed. At this time, we discontinued duloxetine and introduced aripiprazole and quickly titrated it up to 25 mg/d. Her impulse to kill the child was greatly mitigated. She even came to realize that killing a child was against the law and she would be put in prison. She feared she would lose control and let the child be taken far away to avoid a possible encounter. After adding aripiprazole for 1 mo, she felt greatly relieved (she scored 15 on the Y-BOCS and 45 on the SAS). Aripiprazole and fluvoxamine were maintained for treatment.

Personal and family history

Laura is an only child, outgoing and gentle, and mostly lived with her mother before she was 15, when her mother died of cancer. After that, Laura began to live with her father, a businessman who was strong and stubborn. Her clothing style gradually became more androgynous, her personality slowly became stubborn and intolerant of uncertainty, and she tended to be a perfectionist and expected everything to be exactly right.

FINAL DIAGNOSIS

Obsessive-Compulsive Disorder, with absent insight/delusional beliefs.

OUTCOME AND FOLLOW-UP

Her condition has been stable since then. She has no desire or impulse to kill her daughter any more. However, she still believes the child is not good enough and is imperfect, and that it was wrong to give birth to her. Moreover, she complained that her ex-husband did not respect her and just wanted to carry on his family line. She argued that a baby should bring hope and happiness to life, whereas this child made her miserable and led her to divorce. However, these thoughts no longer bothered her. After three years of persistently taking medication, she is now competent at her job and leads a stable life. Upon returning to visit in 2020, she scored 5 on the Y-BOCS and 39 on the SAS, and her relationship with her ex-husband improved. Now, she remarries her husband and lives with their daughter. She even plans to have a second child.

In our case, Laura experienced a recurrence of OCD during pregnancy, which was exacerbated after childbirth. A few studies suggest that the perinatal period increases the risk for the development and deterioration of OCD in some women[ 2 ]. However, there are conflicting results. The only prospective study on OCD in a community sample of pregnant women in the third trimester reported that of the 15 women (out of 434) identified with OCD, the vast majority experienced an improvement or no change in symptomatology during pregnancy and postpartum[ 3 ]. In one study, 83% of the sample reported either an improvement or no change in pre-existing symptomatology during pregnancy[ 4 ]. Hence, there is no clear picture regarding OCD onset and exacerbation in pregnancy and the postpartum period.

Anxiety and paranoid thinking

In our case, Laura suffered increasing anxiety given her improper behaviors in the early stages of pregnancy. Her obsessions and compulsions were present, and she repetitively went to many departments of different hospitals to inquire about her concerns, but doubted all positive answers she received and insisted there was something wrong with the fetus. It seemed that she had developed paranoid thinking about fetal abnormalities, similar to the hypochondriacal idea. Studies have found that paranoid thinking is associated with recent anxiety levels; anxiety is considered to predict or even cause paranoid thinking and lead to negative interpretations of ambiguous events[ 5 - 8 ]. Anxiety can result in negative anticipation, which in turn generates incredible ideas or beliefs and causes a change in one’s perceived state. The cognitive model of OCD suggests that misinterpreting intrusive thoughts as unacceptable outcomes leads to increased anxiety[ 9 ]. In this framework, it is not the content of intrusive thought, but its interpretation that results in increased anxiety and preoccupation. A range of cognitive-affective processing biases are active in people with paranoid thinking[ 10 ], and cognitive processes are mediators of the links between anxiety and paranoid thinking.

It was quite confusing whether Laura should initially be diagnosed with postpartum psychosis or OCD. It seemed that her symptoms conformed to both of the diagnoses. However, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, if an individual with OCD is completely convinced that his/her beliefs are true (which is considered a special subtype of OCD), then the diagnosis of OCD with absent insight/delusional beliefs should be given, rather than a diagnosis of delusional disorder or postpartum psychosis. The revision seems to expand the diagnostic range of OCD based on symptomatology. Nevertheless, the paranoid thinking beneath delusion in our case is worth studying.

Distinction of the continuum of beliefs in OCD

There is increasing evidence that in the general population, each psychotic experience of an individual is manifested by a continuum of features. In our case, during the perinatal period, Laura’s obsessions recurred and were exacerbated; at first, she repetitively went to many departments of different hospitals to inquire about her concerns but doubted all positive answers she received, and she was almost completely convinced that the fetus was abnormal. After delivery, she strongly believed she had given birth to an unhealthy child, regardless of the examination results, and even felt a strong impulse to kill her daughter, which reflected irrationality and absurdity. Her belief was delusional, and her insight was absent. Her strong impulse to kill her baby was secondary to delusional belief.

Beliefs play an ambiguous role in OCD. The characteristics of beliefs vary widely along the continuum, and delusions seem to be at the severe end of the spectrum. Delusions refer to beliefs held with conviction and subjective certainty in light of conflicting evidence[ 11 ]. Overvalued ideas are ‘‘unreasonable and sustained beliefs that are associated with strong affect ( e.g. , anxiety or anger) and are more likely to lead to repeated action that is considered justified”[ 12 - 13 ]. According to Kozak and Foa[ 12 ], overvalued ideas lie on a continuum of ‘‘strength of belief’’ between OCD-related, non-delusional beliefs and delusions. Obsessions are recurrent and persistent thoughts, urges, or images experienced as intrusive and unwanted. The distinction between a delusion and obsession depends in part on the degree of conviction with which the belief is held, despite clear contradictory evidence regarding its correctness. However, this is not always effective. One study[ 14 ] proposed an approach in which beliefs arising in the context of OCD are assessed along the following well-defined characteristics: conviction, fixity, fluctuation, resistance (to beliefs), insight pertaining to an awareness of the inaccuracy of one’s belief, and insight referring to the ability to attribute the belief to an illness, which may allow for a clearer distinction between non-delusional beliefs, overvalued ideas, and delusions. In addition, emerging empirical evidence suggests that obsessions and delusions might not be mutually exclusive. In the literature on body dysmorphic disorder and eating disorders, Phillips et al [ 15 ] concluded that non-delusional and delusional variants of both disorders likely constitute a single disorder containing a range of insights, with an entire spectrum characterized by obsessions. This insight can range from good (obsessions) to bad (overvalued ideas) to absent (delusions). Therefore, it is reasonable to speculate that Laura experienced an alteration of the continuum of belief, from obsessions to delusions, and that delusions and even secondary obsessions coexisted, which had a significant impact on her parent–child relationship and marital status.

Perfectionism and anxiety in OCD

Many individuals with OCD have dysfunctional belief domains. In the cognitive model, three types of intermediate beliefs have been hypothesized to contribute to obsessive-compulsive symptoms, one of which is perfectionism and the intolerance of uncertainty. Perfectionism, typically defined as setting extremely high standards along with critical evaluations of one’s own behavior[ 16 ], has long been regarded as a risk and maintenance factor for OCD and robustly associated with anxiety[ 17 ]. In our case, Laura experienced excessive and marked anxiety during pregnancy in fear of fetal abnormalities, which interacted with her perfectionism, leading to obsessions and compulsions. She even felt a strong urge to do away with her “imperfect” child after childbirth to reduce anxiety and maintain her own sense of perfection. After taking medication, her obsessions and paranoid delusions underwent several fluctuations, and she finally entered a state of remission. Data indicate that high levels of perfectionism impede treatment responses across different psychopathologies, and treatment of perfectionism results in a reduction in symptoms, including anxiety[ 18 - 19 ]. Therefore, perfectionism may be a promising area regarding cognitive interventions for OCD. It is hoped that such a focus will help to improve the efficacy of treatment for OCD and potentially reduce a potent risk of exacerbation, especially for perinatal women in avoidance of potentially adverse effects on fetuses if taking medicine. We suggest that psychiatrists routinely assess and address perfectionism in OCD, aiming to alleviate symptoms and avoid the exacerbation of OCD.

We reviewed the literature in terms of anxiety and paranoid thinking, as well as perfectionism, and tried to analyze the alterations and distinctions of a continuum of belief in OCD in the perinatal and postpartum periods. The patient developed OCD over a decade, and it seriously affected her marriage and parent–child relationship. We hope this case will remind psychiatric practitioners to attach more importance to perinatal interventions for those who suffer OCD given a range of adverse maternal and fetal developmental outcomes. Due to the great heterogeneity in the clinical presentation of OCD, we hope we will make a major breakthrough in etiology and treatment research on OCD.

ACKNOWLEDGEMENTS

The authors would like to thank Professor En-yan Yu for providing insight into this case and the colleagues of the department in the course of writing this article.

Informed consent statement: Informed verbal consent was obtained from the patient for publication of this report and any accompanying images.

Conflict-of-interest statement: The authors declare that they have no conflict of interest.

CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

Provenance and peer review: Unsolicited article; Externally peer reviewed.

Peer-review model: Single blind

Peer-review started: October 22, 2021

First decision: December 17, 2021

Article in press: February 23, 2022

Specialty type: Psychology

Country/Territory of origin: China

Peer-review report’s scientific quality classification

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P-Reviewer: Hosak L, Zhang Y S-Editor: Ma YJ L-Editor: A P-Editor: Ma YJ

Contributor Information

Si-Si Lin, Department of Psychiatry and Psychology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China.

Jing-Fang Gao, Department of Psychiatry and Psychology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China. moc.361@7931gnafgnijg .