23 Mar 2015
Obsessive-compulsive disorder (OCD) is an anxiety disorder that traps people in endless cycles of repetitive thoughts and behaviors (Bates, 2009). A person with OCD is plagued with recurring and distressing thoughts and fears that consume time distressing over obsessions that they cannot control. The anxiety produced from these thoughts lead to urgent impulses to perform rituals on a continuous basis (compulsions). The compulsive rituals are performed trying to attempt or preventing the obsessive thoughts and make dissipate. However, the rituals may satisfy an urge for a short amount of time, but it comes back when triggered. Having this burden of OCD may consume so much time in a day that it interferes with the normal daily activity (Bates, 2009).
This paper will be a comprehensive five part project addressing obsessive-compulsive disorder also known as O.C.D. Part I will give a description of the disorder and how it's perceived to be a psychological disorder. The DSM-IV classifies OCD as an anxiety disorder due to the ways it has been studied. According to the American Psychiatric Association in discussing the part II, Neurotransmitters that are linked to OCD rather than the medications that are prescribed to the person will give information on how genetics contribute to OCD and the part of the brain that is affected (American Psychiatric Association, 2000). Part III will talk about environmental influences that may play a huge part in someone having OCD; however, genetics have more relevance than environment (Grisham and Sachdev, 2008). Part IV will discuss medical and/or effective treatment in helping someone cope and overcome the OCD disease. The last part will explain how one can have a productive life without OCD by new treatment. Lastly, part V will also discuss psychological model that will best overcome OCD in treatment.
In discussing OCD, this paper focuses on a married woman with four kids named Maria who is a 38 year old woman residing in Pittsburgh. She was raised in a strict catholic family and continues to be devoted to her beliefs. Maria sometimes worries if she is devoted enough and over whether she is performing the rituals perfectly where she began doing rituals that takes up hours on end with her time. The overwhelming anxiety created more of an obsession with staying purified and holy which transcends into the extremity of feeling the urge to constantly wash and bathe so she can feel clean and pure.
Maria's personal habits throughout her life include: keeping her house clean & tidy from clutter, brushing her teeth three or times a day, and wash her hands six to eight times a day. Just two years ago she became more obsessed with cleanliness and religious rituals where she spent six to eight hours washing her hands, and cleaning her house that is already cleaned. Her relationship with her husband and children are alienated. She refuses to allow them to touch or hug her. She is insistent they wash their hands repetitively and imposes her OCD views upon them.
On the technical side, the DSM-IV code for Obsessive-Compulsive Disorder is 300.03 (Hill and Beamish, 2007). OCD is considered an anxiety disorder. The diagnostic criteria are either obsessions or compulsions. Obsessions are recurring and persistent thoughts, impulses, or images that are intrusive that are not only "excessive" worries A person with OCD tries to stop or avoid paying attention to these thoughts and realizes that it is only in their mind. Compulsions on the other hand are repetitive behaviors. Obsessions and repetition are intended for a person with OCD to prevent or reduce their stress or a frightful situation or event. The person recognizes their obsessions or compulsions are deemed excessive and unnecessary and unreasonable (Owens, 2009).
Obsessive thoughts can include, but not limited to the following (Rais, 2008):
Persistent fear of harming others or self.
Concern with being contaminated with germs that is unreasonable
Intrusive religious, violent or sexual thoughts.
Need to things perfect and is excessive in doing so.
Checking doors, stoves, water faucets, and lights multiple times
Making lists over and over again.
Rearranging or realigning things.
Collecting or hoarding objects that are useless, such as, outdated newspaper, plastic utensils, or food.
Doing actions a certain amount of time.
Rereading or rewriting unnecessarily
Excessive washing that takes up hours of each day.
Obsessive Compulsive Disorder is considered an illness because it traps a person in an endless cycle of repetitive thoughts and a continuous set of behaviors. A person with OCD suffers with reoccurring thoughts or fears (obsessions). These thoughts cause the person to do some sort of routine (compulsion). A person does these sets of compulsions hoping to make their obsessive thoughts go away (Dell' Osso, Altamura, Mundo, Marazziti, Hollander, 2007).
To relate, Maria's typical signs of OCD include: spending six to eight hours cleaning her hands so she would feel clean, performing religious rituals that occupied hours of her day, cleaning an already clean house for hours a day, and avoiding coming in contact with her husband and children (Case Study 1, Kaplan University). In order to help Maria find a treatment for her OCD, it's important to understand the signs and symptoms throughout her history. It's essential to evaluate her biological background and assessing the environmental factors that may contribute to her disorder.
In addition, there is different biological relevance to OCD. Scientifically, neurotransmitters transmit chemical impulses from neurons to neurons. Each neurotransmitter has various functions and different names (Durand, & Barlow, 2007). Serotonin is one of the neurotransmitters that influence a person's behavior, especially the way information is processed. A person with OCD has a "faulty brain circuit," which correlates to the levels of serotonin. When serotonin in the brain is too low a person would do things that are not normal in their behavior, and sometimes overreact and do spontaneous actions (Durand, & Barlow, 2007). A person with low levels of serotonin is more pertinent to show abnormal behaviors; there are no found evidence that serotonin is causes the problem (Durand, & Barlow, 2007). When the cerebral cortex is under active a person has a hard time controlling their OCD behaviors and actions (Dryden-Edwards, 2005).
Moreover, there has been a twin study on monozygotic twins to find if genetic and environment had an effect on OCD. Data was collected on the family structure, health of the family, lifestyle of the family, if there were any complications at the babies' birth, events that happened in their life, and other environment factors in their life. The results were more twins (both of them) had OCD behaviors later in life if they had parents that were anxious and depressed. This article concludes that genetics played a more role in OCD then the environment. The author suggested that more studies would need to be conducted to determine the exact nature between Genetics and the environment factors of OCD (Cath, Van Grootheest, Sillemsen,Van Oppen, & Boomsma, 2008).
According to Dr. James Kennedy, a Neurogeneticist, quoted, "a role in a person developing OCD if they have a relative that is affected with this disorder, (Dennon, 2009). In his article he said that the DNA (5HT1 D Beta) receptor gene is passed to their offspring (Mundo, Richter, Zar, Sam, McBride, Macciardi, & Kennedy, 2002). They indicate that genes play a role in certain abnormalities; but something in the environment needs to be triggered in order to activate a disorder such as OCD (Durand & Barlow, 2007).
After understanding the research that has been done on the biological aspect of OCD, researchers noticed a strong correlation that genetics play a huge role in a person developing OCD, but no factual evidence has been indicated (DeNoon, 2009). However, researchers have investigated and determine that an environmental factor influences a person having OCD.
In the fourth century OCD was considered to be "melancholia" which is a Greek word that means black bile, if a person's OCD behaviors lasted a long time. In England in the seventeenth century, religious melancholy was established as part of an OCD disorder and derived from "overzealous devotion to God" (Allison, 2008). In 1907, Freud stated, "OCD resembled religious rituals. Rituals are done over and over to get rid of guilt, Religion was the universal "obsessional neurosis" (Yossifova, & Loewenthal, 1999, p. 145).
Freud also believed that obsessive-compulsive behaviors are caused by conflicts unconsciously in the mind that manifested in OCD illness. A person struggles between a desire and an action of their conscious and/or unconscious mind. They are trying to complete the actions of their unconscious mind, with their urges, to get temporary relief from their high powerful anxiety. Their conscious mind knows it is ridiculous and bizarre it is to continue to do these actions (Allison, 2008).
To relate to Maria's case, her mind made her believe she wasn't religious enough. In order to find release from her anxiety she would have to devote more time than the average religious person to perform religious rituals hours each day to make her feel complete. Though Maria grew-up as a strict Catholic family throughout her life, she still worries that she does not measure up to the expectations to be considered pure or holy. Her OCD created a great amount of guilt that caused her to perform religious obsessions and cleaning compulsions. Durand and Barlow stated that in every psychological disorder, both genetics and environment have to be considered, (2007). Both are needed to activate OCD (2007). Research supports genetics play a major role in OCD, but need more research on the environmental factors to support Durand and Barlow theory.
The diathesis -stress model is the best way to explain that situations in the environment along with the biological system will influence OCD behaviors. There are behaviors that are inherited from a vulnerable person, which can be triggered under stress or an environmental situation (Durand, & Barlow, 2007). As previously mentioned, Maria was predisposed to OCD and was triggered by the petunias at the funeral (environment). After determining the genetic and environment influences are understood, the best treatment can be decided. According to Rais, Maria's mom showed strong OCD tendencies with her many superstitions which can suggest the Maria's OCD was genetic (2008). Seeing petunias at a funeral (environment) triggered the start of Maria's obsessive compulsive behaviors. Maria had a genetic vulnerability for OCD; the environment was a factor in the onset of her illness.
Furthermore, environmental factors may be triggered from a horrible divorce or from traumatic events of sexual abuse (Grisham, Anderson, & Sachdev, 2008). Also, religious factors can play an enormous environmental influence that is correlated as a risk factor of having OCD (Higgins, 1992). Researchers found more often the causes of this disorder results in religious factors. This could be due to the lack of faith. Perhaps they fear they haven't prayed enough or hard enough; their behaviors were sinful; or got contaminated from thought that were impure and sinful. Guilt thrives from these thoughts where they pray obsessively; repeatedly confessing to purge the fear that they are "Doomed to hell" (Higgins, 1992). Maria was apprehensive about her dedication and felt she did not measure up to her religious expectations to be considered pure and holy. This could have influence her to have so much guilt which in turn caused her to do have religious obsessions.
In discussing treatment, on February 19, 2009, the Food and Drug Administration (FDA) approved deep brain stimulation (DBS) therapy for those who suffer with OCD when all other treatments have failed. To qualify for this procedure a person has to have had at least three SRIs that have failed. This device has been an on going study in four Catholic Universities since 1998 (Bates, 2009).
To relate, the DBS is implanted in the brain surgically. It carries electrical
impulses to different areas of the fiber bundle in the front of the brain. It can only be programmed by a clinician that has been trained and is based on an individuals needs (Bates, 2009). This device is not exempt from side effects. One that has been known is cerebral hemorrhage causing brain infections, non life threaten has ever been reported. There has been studies conducted, it had shown that this device can make great improvement in a person's life and it is interesting that some have returned back to the working profession (De Noon, 2009).
A quasi-experiments design was conducted. This design manipulate the independent variable (the variable they manipulate) while measuring the dependent variable (what is being measured), (Durand, Barlow, 2007). They observed the relationship between the different medications that were used to treat OCD to see if OCD behavior improved and which psychologically treatment made the most improvement. For example, in the article "Brain Changes Quickly Following Intensive Behavioral Therapy for OCD", the author concludes there is a strong correlation between the increased brain activity and improvement in OCD symptoms (Douglas, 2008).
Thankfully, those who are diagnosed with OCD can find remedy in therapy and medications. One therapy includes facing the fears by means of physical objects, role playing, viewing places, and triggering thoughts that are fearful or things they avoid; also known as behavioral exposure (Matson, 2008). A person needs to be repeatedly exposed to the things they fear most in order for this therapy to work. Rituals are prevented by not letting the person perform their compulsions (Dell' Osso, Altamura, Mundo, Marazziti, Hollander, 2007).
Another form of therapy includes antidepressant medication that contains serotonin reuptake inhibitors (SRIs) (Hill and Beamish, 2007). Serotonin reuptake inhibitors work by slowing the reuptake of serotonin and postponing how it is affects the synapse. This serotonin increase produces changes in the receptors in nerve membranes (Korn,2001) The ones that are most commonly used are Fluvoxamine (Luvox), Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil), Citalopram (Celexa), and Clomipramine (Anafranil) (Hill and Beamish, 2007).
Though the medications may cause some sort of side effects; however it does not cause permanent damage. Some of the side effects include sleepiness, dry mouth, and nausea. Conducted studies concluded that Anafranil has been the most useful in treating OCD due to the few harsher side effects such as, heart racing, difficulty in concentrating, slower thinking ability, and weight gain (Korn, 2001).
In the peer review article, "Cognitive behavior therapy and medications in the treatment of obsessive compulsive disorder," the researcher's studied to see what treatment would best help a person suffering from this disorder (Hill and Beamish, 2007). In their research they wanted to determine which therapy treatment would be the best solution. They considered the following: cognitive behavior therapy (CBT) by itself, cognitive behavior therapy and medication together, just medication alone, or just a sugar pill known as a placebo. After the research they concluded that CBT plus medication had the greatest outcomes (Hill and Beamish, 2007). It was interesting to learn that the study showed no noticeable difference among those that took medication and those that took placebo. However, when the person added therapy with the medication they made major improvement.
On the other hand, medications that seemed to work the best contained serotonin reuptake inhibitors (SRI), (Schonbeck, 2005). Serotonin reuptake inhibitors showed more improvement in their moods to where they could finally work on their OCD behaviors. Combining CBT and medication has been known to be effective in treating OCD (O'Connor, Aardema, Robillard, Pelissier, & Todorov, 2006).
In addition, another therapy that therapist use to help a person with OCD that is known to be favorable and help a person make significant changes in their brain activity is a four weeks of intensive cognitive behavior therapy program. This program consisted of a 90-minute individual therapy session, and four hours of homework five days a week. A PET scan was taken after the four week course and the PET scans showed changes in normalized regional glucose metabolism and bilateral decreases in normalized thalamic metabolism. The PET scores also showed an increase in a person's right dorsal anterior cingulated cortex activity along with improvement in their OCD symptoms (Douglas, 2008).
According to Durand & Barlow stated that the most common psychosocial treatment that is used to treat a person with OCD is exposure and ritual prevention (ERP), (2006). In this treatment a person is exposed to a threaten situations they fear or think are invasive. For example, if a person has a fear that their hands being contaminated, the therapist will encourage the client touch the object they fear and ride it through to the end without washing their hands, such as door knobs (Durand, & Barlow 2007).
In addition, when it comes to insurance companies or other third party reimbursement such as Medicaid rapid outcome are important. They expect therapists to provide written documentation to justify the treatment and expected length of the client's treatment (Hill, & Beamish, 2007).
Maria proposed treatment plan would consist of cognitive behavior therapy (CBT), medication and family counseling. In addition, I feel spiritual counseling would be beneficial to Maria. I say this because she feels her religious Catholic background has placed a lot of pressure on her to be cleansed and holy at all times. However, she feels inadequate to live up to those expectations resulting in consuming rituals to satisfy her repetitive urges and compulsions.
To start, I would suggest she has a one on one meeting with her priest to discuss her concerns. This will help her understand what the church is asking and not what she is lacking. It's important she understands God accepts her unconditionally and that she does not have to pray hours on end to feel accepted and cleansed. I feel spiritual counseling would create a solid foundation since it is the root of her OCD in order for her to improve in her other troubled areas of her disorder. Also, it would help if Maria sought relief from an effective medication to help decrease her anxiety when she begins cognitive behavior therapy.
After doing so, A plan for therapy would be implemented with cognitive therapy to change Maria's old thinking patterns concerning fears of contamination; plus to find different strategies to find resolution for stress and intense fears (Owens, 2009). The counselor would have Maria touch contaminated thing and not allow her to wash her hand afterwards. She will need to find ways to cope with her anxiety and stress when she has to reframe from washing her hands. Maria would be put on a plan that only lets her brush her teeth by half of the average time she normally would brush them. She would also be limited to how many times she can clean and straighten her house. She would also be forced to skip a day in cleaning her house. It's important to help Maria understand and realize nothing bad or fearful will happen if she doesn't perform these rituals to satisfy her urges.
Furthermore, Maria will also be restricted to the total number of spiritual rituals she could do. Though it's important that she is still involved in her faith, but needs to learn how to limit the amount the time on spiritual rituals such as praying. The goal is to change the total number of hours/time she spends in praying to decrease by five minutes from the average to no more than two times a day.
In addition, family therapy would suggest Maria to not place such huge demands on her children and husband to constantly stay physically clean. I would suggest that they do not give into her when showers and baths or washing hands are demanded. It's important Maria's family understands this transition and that her love is not being compromised due to this transitional period with her therapy. I would suggest a trained and experienced doctor hold a counseling session to help Maria's family understand the disorder and create expectations on what to expect.
In addition, Maria will have weekly assignments to help her become more comfortable in touching and hugging her family without feeling contaminated or dirty. This could be learned after performing various relaxation techniques on weekly bases to help strengthen her relaxed state.
On week one she will touch each family member on the shoulder. Deep breathing techniques would be applied in this initial fearful therapy session to help calm nerves and anxiety. As time progress, she would slowly move closer in affection as she builds on her trust and strengthen her courage. The goal is for her to give her family a full hug without hesitation and anxiety. In continuing family therapy, it would benefit her family by creating positive change to help Maria cope and overcome her fear taken by OCD.
Though, research suggests genetics is the main factor in developing OCD. However, more research needs to be conducted on the environmental reasons a person has obsessive compulsive disorder to sustain that the combination of genetic and environmental factors a person end up having psychological disorders. Through accepting the biological and environmental factors of this disorder, specialists can comprehend the reasons of Obsessive Compulsive Disorder to better provide better therapeutic treatment so that it might be minimized in the future.
I fully believe Maria can change through hard work to overcome her disorder if she has spiritual and family counseling along with cognitive behavioral therapy and medication to rejoin her family in a healthy relationship. After learning effective treatments for OCD we will discover the different therapeutic theories and new medication to benefit Maria's condition. I will then be able to determine the final outcome of her disorder by applying these techniques.
In deciding the best psychological model that would help a person with obsessive compulsive disorder it is imperative to understand the basic concept of each.
Psychoanalysis is a verbal therapy to help a person receive freedom from their emotional pain. This model accepts the view of Freud's that the unconscious motives are created from some sexual motive (Fine, 2007).
Cognitive Model suggested that our thoughts influence behavior. This therapy was pioneered by Albert Ellis in 1950 and works to get people to change their attitudes. This therapy is known as talk therapy and focuses on thoughts and emotions that lead to behaviors (Schonbeck, 2005).
Psychodynamics Model uses expressive or supportive methods to treat a disorder. Expressive attempts to relieve symptoms through understanding their thought and feelings that possible they might not be aware of. Expressive is that adults problems are created in childhood where they don't have the maturity at that point to make appropriate choices because how they coped to their problems as a child stopped working as an adult. This therapy teaches the person to learn new ways to solve problems to relieve stress and cope in more appropriate ways (Fine, 2007).
Behavior Therapy Model deals with changing and eliminating behaviors that are troublesome. This therapy was pioneered by Joseph Wolpe which includes assertiveness training, operant conditioning, and desensitization (Schonbeck, 2005). Wolpe reported great success with the stigmatic desensitization for those with phobias (Durand, & Barlow, 2001).
Humanistic Psychology emphasizes a person to control their mental health. It suggests that environment factors influence a person's behaviors. It removes the stigma that people think "therapy" is and allows the individual to determine their own care on mental health (Wagner, 2009), it is a person-centered therapy ,where the therapist is passive in the clients care and tries to avoid interpretations (Durand & Barlow, 2001).
I would choose a combination of the cognitive and behavioral models in order to treat OCD. Rationale research has shown cognitive behavioral therapy (CBT) to be the most effective method to the treatment of this disorder. The cognitive model works on the thought processes, and the behavioral model works in changing undesirable behaviors (Schonbeck, 2005).
The newest medication that has already been approved to help a person with OCD is Luvox CR in January 2007 (Jeffery, 2008). Luvox CR is an extended release from of Luvox SSRI. Therapist are paying more attention to research and are using this medication so their client's are having more beneficial outcomes.
In conclusion, I believe there is a strong prospect that Maria can overcome her OCD behaviors that she has due to the different treatments and medication in helping someone with this disorder. If Maria is dedicated in putting her efforts into her treatment plan, she can have a productive lifestyle and a fulfilling future with her family. Once a person is able to overcome OCD and deal with with the environment influences and stressors in her life that she may eventually not need to continue medication. Therefore, leaving the victim liberated from the problems of OCD to live a normal and stress free life. Maria can have this, but it will take devoted dedication, family support, repetitive therapy sessions/medication, patience, and strength to relinquish her to freedom from all the years her OCD has kept her hostage in her own skin.
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