05 Apr 2018
Case Study 1 (Phillip)
Phillip is displaying multiple adverse psychological symptoms that would best fit the diagnosis of obsessive compulsive disorder (OCD). Specifically Phillip is a compulsive washer as he maintains a high level of cleanliness, having showers up to three times a day. He also only eats frozen food in order to avoid contamination and organises his furniture, making sure that they are all perpendicular to the wall. These compulsions are repetitive, purposeful behaviours designed to prevent or reduce anxiety (De Silva, 2003). Some, if not most, of Phillip’s anxiety arises from the intrusive thought of stabbing his mother which has become a clinical obsession because he believes that the thought has personal significance and meaning. This may be because Phillip has an inflated sense of responsibility and so believes that he is responsible for preventing the intrusive thought from actually happening (Rheaume et al., 1994). This has led to Phillip avoiding people, his Mother especially, but this has only increased the frequency and severity of his compulsions. It appears that Phillip is stuck in a vicious cycle of his obsessions and his compulsions feeding off one another and so intervention will be needed in order to help him.
There are two central aspects of OCD, the cognitive aspects which include intrusive thoughts, obsessions and cognitive distortions, and the behavioural aspect of compulsions. In cognitive theory, intrusive thoughts (e.g. I want to stab my mother) occur automatically and usually have no emotional significance but can take on significance, depending on the context in which intrusions happen (England & Dickerson, 1988). Such thoughts are very common and have been reported to occur in almost 90% of the population (Rachman & de Silva, 1978) but once an individual deems these thoughts as significant it can cause distress and the belief that they are personally responsible for preventing the thought from actually happening. The distress caused by high levels of perceived responsibility has been found in multiple studies (Shafran, 1997; Roper & Rachman 1975) as obsessional patients felt a lot more uncomfortable performing checking rituals when they were on their own and calmer when the therapist was there as the patient felt less responsibility. This sense of responsibility is associated with both worry (Wells & Papageorgiou, 1998) and OC symptoms (Salkovskis et al., 2000a). Specifically, the lowering of responsibility is associated with a significant drop in discomfort and need to check (Lopatka & Rachman, 1995). One explanation for inflated responsibility is the ‘thought-action fusion’ (TAF) theory which suggests that obsessions occur in people who believe that thinking about a disturbing event is the same as doing it and that having an intrusive thought is morally equivalent to acting on said thought (Rachman, 1993; Shafran, Thordarson & Rachman, 1996). TAF is an example of ‘thinking errors’ outlined by Beck (1976) which are used by most people all the time but can be detrimental when thinking errors become central to thought processes (Nisbett & Ross, 1980). The most prevalent thinking error in those with OCD is that having any influence over the outcome means that you are responsible for the outcome.
Due to the distress caused by the appraisal of intrusive thoughts, individuals aim to neutralise the anxiety caused through mental reassurance and overt compulsions (such as washing and checking) (Salkovskis, 1985). However attempts to neutralise the thought can sustain and potentially increase responsibility beliefs and the occurrence of intrusive thoughts. A common type of neutralising behaviour which is present in Phillip’s case is compulsive washing. Almost 50% of patients with OCD are compulsive washers (APA, 1994) and it is even more common in childhood cases of OCD like Phillip’s with 85% of young patients displaying washing rituals (Swedo et al., 1989b). It has been suggested that one of the main attributes of compulsive washers is perfectionism (Tallis, 1996). Tallis claims that most compulsive washers do not exhibit such behaviour because they are concerned about contamination or illness, instead they are more concerned with maintaining their environment perfectly and thus feeling fully in control. Research has found that there is a significant link between perfectionism and OCD in general, not just in compulsive washing (Bouchard et al., 1999). As Phillip appears to be displaying the perfectionist personality trait, it is important to consider this in therapy.
As perfectionism has been found to correlate with depressive symptoms (Enns & Cox, 1999; Flett et al., 1991) it is possible that a negative mood may be a factor in Phillip’s thinking errors. The mood-as-input theory (Martin et al., 1993) suggests that people use their mood as a factor to decide whether or not they have completed a task. When people are in a positive mood they are more likely to take their affect as a sign that they are progressing in a task and achieving more (Hirt et al., 1996). Whereas those in a negative mood experience the opposite and interpret their mood to mean that they haven’t progressed enough and so must continue with the task (Schwarz & Bless, 1991; Frijda, 1988). This may occur because people in negative moods have been found to process tasks more extensively than those in positive moods (Mackie & Worth, 1989). This is a significant theory for Phillip’s case as individuals with OCD tend to use internal states that are difficult to achieve such as ‘having a gut feeling’ to help them decide when to stop compulsive behaviour (Salkovskis, 1998). They therefore have stricter personal requirements for making decisions and so what should be an automatic decision becomes a strategic one and the strict criteria have to be met before anxiety is reduced and the compulsive behaviour can stop (Salkovskis et al., 2000a).
Phillip presents all of the issues outlined in the theoretical framework which will act as the foundations for intervention. Figure 1 shows the main aspects of Phillip’s case and highlights his rules for living and the cycle in which he is trapped.
From the information given in Phillip’s case, it appears as though the bottom line of his psychology is “I have to have full control over every aspect of my life” which may have been caused by authoritarian parenting (Timpano et al., 2010) or childhood trauma (Lochner et al., 2002) which have both been found to significantly correlate with OCD symptoms. Whilst there isn’t enough information about Phillip’s childhood to speculate if such things have happened to him, these are factors to bear in mind during treatment. This strict bottom line in Phillip’s life has led to certain maladaptive rules of living including his perfectionism (control over actions) and inflated responsibility (control over thoughts and feelings). He also has a generally negative mood as an input to his thought processes because he can never fully satisfy the strict standards that he sets himself.
Then, when Phillip was a teenager he began experiencing intrusive thoughts about stabbing his mother. Such intrusive thoughts are not usually enough to trigger anxiety but due to Phillip’s rules of living, he finds personal meaning in the thought and feels responsible for preventing the thought from happening. This triggers anxiety and so he seeks to neutralise the thought through compulsive washing, arranging furniture and socially isolating himself. When these neutralising behaviours reduce his anxiety it reinforces Phillip’s thinking errors, his rules of living and his bottom line. Thus, when his anxiety is triggered again he repeats the behaviour and so Phillip is trapped in a cycle of his compulsions and obsessions reinforcing one another.
Figure 1. Problem Formation flow chart for Phillip
Phillip’s treatment can start with cognitive therapy aiming to focus and modify his thinking errors and inflated sense of responsibility. At the same time as this Phillip can take part in group therapy designed specifically to treat perfectionists. After these treatments and once Phillip feels ready to, he can move on to exposure and response prevention (ERP) using virtual reality to simulate dirty and contaminated environments. This will help him to control his compulsions and get him out of the obsessive-compulsive cycle.
For Phillip, cognitive therapy will start by focussing on the distinction between intrusive thoughts and his negative appraisal of those thoughts. As outlined by Menzies and de Silva (2003), this begins by asking patients to reflect upon the last time they had an intrusive thought and what their behavioural reaction was to this thought. Phillip will then be encouraged to recognise that it was not the thought itself that cause his subsequent behaviour but how he interpreted the thought. It is important that the client understands the distinction between his intrusions and their appraisal before moving on to further intervention as it may otherwise confuse them. Next, Phillip taught about how common intrusive thoughts can be, to help him dismiss any feelings of shame or guilt that he may be feeling. It is suggested by Salkovskis (1999) that patients should be encouraged to view intrusive thoughts as a potentially positive and useful occurrence that can help with problem solving and foresight. The goal of this is not to eliminate their intrusions but to help them feel more positive by normalising them. Phillip is also encouraged to modify his responsibility appraisals in order to reduce his inflated sense of responsibility. Van Oppen & Arntz (1994) found that even when people with OCD understand how unlikely it is that their intrusive thoughts will become reality, they continue to show compulsive behaviours because they feel a sense of responsibility to stop it from happening. Van Oppen & Arntz (1994) suggest creating a pie chart with patients that they can divide up to represent the importance of factors that may contribute to a feared outcome. Once Phillip assigns percentage values to each factor he will be able to visualise that his role of responsibility is much smaller than he originally thought. This technique will help Phillip to reassess the overestimation of his responsibility and realise the importance of other uncontrollable factors.
Whilst undergoing cognitive therapy Phillip will join group therapy to help him with his perfectionism. Ferguson and Rodway (1994) outlined a group therapy programme for perfectionism based on cognitive-behavioural theory. This programme will aim to help Phillip understand the problems that can arise from perfectionism and what strategies can be used in order to change his perfectionist way of thinking. The therapy will also be based on the outline provided by Kutlesa and Arthur (2007) which applies a psycho-educational approach to perfectionism, using interpersonal theory (Yalom,1995) as the psychological component which will ask Phillip and others in the group to focus on the present rather than worrying about the future. The educational component will use elements of cognitive-behavioural theory (Ellis, 1991; Beck, 1993) to teach the group about the thinking errors involved in perfectionism and skills to cope with and change these thinking errors.
Once Phillip has made progress in both treatments and feels ready for the next step he will move on to ERP as a treatment for his compulsive behaviour. Firstly, Phillip will be steadily and gradually exposed to environmental triggers. He will write a list of situations in which he could be contaminated, started with the one that makes him the least anxious and working his way up to the worst. Most ERP treatments ask participants to experience these situations either through images or in vivo but a new method of virtual reality (VR) is being used in the treatment of OCD and it has been found to be effective (Kim et al., 2009; Belloch et al., 2014). Using VR, Phillip will then be exposed to the items on his list one by one, experiencing each one repeatedly until anxiety is completely reduced and Phillip is ready for the next item. Another aspect of this treatment is response prevention which aims to help patients control their compulsions in advance of triggering events (Meyer et al., 1974). This involves strategies such as using alternative behaviours and modifying compulsive rituals which can be integrated into the VR exposure. This treatment aims to expose Phillip to his triggers in a safe way reducing his anxiety for those situations and learning to control his compulsions in the process.
Using cognitive and behavioural treatments together is crucial for Phillip’s intervention as they both deal with either the obsessions and the thinking errors or the compulsions but not both. If only one of these elements is dealt with then it is likely that the other will return. Whilst cognitive therapy has been found to be potentially effective on its own (Cottraux et al., 2001) studies have found that when ERP is combined with cognitive therapy it produces lower dropout rates, greater general coping and decreased obsessive-compulsive symptoms (Kyrios et al., 2001; Freeston et al., 1997). A major aspect of Phillip’s case that wasn’t dealt with in cognitive-behavioural therapy that was not covered was his perfectionism. Research has found that CBT doesn’t significantly reduce perfectionist symptoms (Egan & Hine, 2008) whereas Richards etal. (1993) found lower scores on perfectionism and depression scales and increased levels of self-reported wellbeing and self-esteem in response to group therapy. The incorporation of VR is a modern approach to ERP but it is one that is becoming very popular in the treatment of many anxiety disorders (Kim et al., 2009) and has been found to be as effective as in vivo exposure (Belloch et al., 2014).
One aspect that wasn’t addressed in Phillip’s treatment is that of his family. As mentioned earlier it is possible that authoritarian parenting (Timpano et al., 2010) or childhood trauma (Lochner et al., 2002) could be involved in Phillip’s case as these are common causes of childhood OCD. There are family-based therapies that are shown to be effective in these cases (Lebowitz, 2013) but there wasn’t enough information about Phillip’s family to make such assumptions. If, in therapy, similar issues are revealed then family-based therapy may be very useful for Phillip. Also, little attention was given to biological factors even though pharmacological treatments are very effective in the treatment of OCD (Abramowitz, 1997; de Haan et al., 1997). This is because it would only tackle Phillip’s symptoms whereas cognitive therapy with ERP and group therapy will help Phillip to understand his rules of living, his bottom line, and how to potentially change or cope with this.
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