Case Study Of 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.
It is not uncommon to hear lay people refer to themselves or others as 'OCD'. In many cases, these people are referring to specific patterns of behavior that may be associated with OCD, such as a need to to do things a certain way, in a certain order, etc. These behaviors are often referred to in the vernacular as ‘anal’ or ‘anal retentive’ or simply controlling.
Obsessive Compulsive Personality Disorder
For those who take these behaviors to the extreme, driven by perfectionism or fear of being not good enough, the problem may be OCPD – Obsessive-Compulsive Personality Disorder.
Unlike OCD, an anxiety disorder, people with OCPD do not experience the often bizarre, intrusive, unwanted obsessions on a regular basis; their compulsive behaviors are usually to control their environment or desired outcome, not to reduce the anxiety related to specific obsessive thoughts or compulsions.
Many people with OCPD experience anxiety, sometimes to the point of panic attacks, if they make a mistake, can’t control the outcome of a situation or control another person’s thinking or behavior. This anxiety is related to their fear of being perceived as imperfect, which is different from anxiety related to OCD where the anxiety is tied to the obsessive thoughts and need to carry out a specific mental or behavioral ritual. A primary difference between OCD and OCPD is OCD is considered an anxiety disorder with biological roots; OCPD is a result of personality traits (learned behavior) that create impairment in functioning, although OCPD may be accompanied by a separate anxiety disorder.
Sandy: A Very Strong and Competent Woman
Many years ago, I saw a woman in therapy who was very well-organized and took extreme pride in her work – we will call her Sandy. She was a supervisor and reportedly a real go-getter for a small publishing company. Allegedly, the place could not continue to function without her.
While there were no complaints about her work or work relationships in their very small office, she was exhausted. She pushed herself hard to do ‘everything’, and to do all of it perfectly. The result was that she worked very long hours and began to experience exhaustion and anxiety.
Sandy had been married to the same man for 30 years. She had adult children and grandchildren. Her life seemed to be going very well except for the oldest son who had recently moved back to their home. He had a problem with alcohol and was about to lose his wife and family. The reason Sandy came to therapy was to ‘fix’ him. She could not understand why he was so different from her other children and his parents. While she wanted him to get better, she did not want to bring in the family for therapy. She wanted me to help her understand him (without ever meeting him) and tell her what to do to correct the problem.
I convinced Sandy that our work together needed to focus on her, including her response to her son. We worked on relaxation techniques, which Sandy diligently used to help manage her anxiety at work. After meeting weekly for about two months, she missed an appointment and didn’t call to reschedule for a few weeks.
Upon her return, she reported that she had been burned quite badly while burning some trash and she was hospitalized for a few weeks. She said that her husband wanted to come to the next session.
Sandy’s husband was delightful but very worried about Sandy. He was concerned that she was not reporting the full story in therapy. Reportedly, she was so insistent on getting the trash burned that she would not wait for her husband to do on his day off. Instead, she tried to do it herself on a day when the local weather advised against it (she checked before she decided to burn the limbs). The fire quickly got out of control due to gusts of wind, resulting in her severe injuries.
Sandy felt ‘shame’ for making this choice that could have injured her granddaughter.
He also talked about her rigid adherence to ‘doing things her way’ that resulted in her doing all the housework, cooking, and cleaning. Most revealing, her husband said that she could not be pleased. And while she was not ‘mean’ about it, everyone knew they could not live up to her exacting standards at home, which greatly affected her relationships. The family had learned that Sandy believed she had to do everything herself to get it done properly. They stopped trying to please her, making jokes about her rigidity to ease the tension. However, they knew that Sandy silently judged and resented them for being incompetent. Sandy sadly agreed that these statements were true, and admitted that people at work may also fear her silent disapproval.
Treatment for OCPD
Once all the facts were in, Sandy agreed to see our psychiatrist on staff. She began to improve with a combination of medication, relaxation techniques, and cognitive behavioral therapy. Sandy realized that her beliefs about herself and others were creating unrealistic expectations. She started working part-time and found that other people in her office could do a lot of the work she had done previously, although they needed the space to do it their way as long as the results were ‘good enough’.
As Sandy started to make changes in herself, she was able to accept her son for who he was as a person. They addressed the alcohol problem as a family and Sandy learned more about letting go of expectations for other people. Her husband dropped in for some therapy sessions, providing valuable perspective for Sandy and her treatment. After six months, she completed therapy but continued to take low doses of medication and practice relaxation techniques daily.
What We Can Learn About OCPD from Sandy
1. Family involvement is critical to effective treatment.
2. Unraveling irrational thoughts and beliefs are key to successful, long-term recovery for OCPD.
3. Relationships at work and home are often damaged and need to be repaired in cases of OCPD.
4. Relaxation techniques and mindfulness are very helpful for OCPD.
5. People with OCPD often appear to have everything under control – but the costs to them and their relationships are great.
6. People with OCPD often externalize, blaming other people or circumstances when they cannot control things.
7. Medication may be necessary for those who are unable to manage their anxiety with therapy and self-help alone.
8. It is not unusual to see substance abuse and anxiety in the same family – anxiety often underlies addictions.
9. Families often cope with tension by avoidance or inappropriate joking or teasing.
10. OCD and OCPD have some overlapping signs and symptoms, but the causes of these are very different.