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Case Report 2

Obsessive Complusive Disorder

Submitted By: Noor Fatima

Roll No: 3

Submitted To: Dr. Sadia Malik

Date: 25-11-2024
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CASE HISTORY

Demographic History

Miss NS is a 23-year-old woman currently residing in a village near Bhalwal city, Punjab,

Pakistan. She completed her intermediate education and took admission in a BSc program but

was unable to continue due to health issues. She is the eldest of two siblings, with one younger

brother. Her father, who suffered from schizophrenia for the last 22 years, has recently passed

away. Her mother accompanied her during the initial session and provided collateral information

about her background and current situation.

Presenting Complains

She was initially a quiet and less talkative individual but managed to attend college normally

until her symptoms began to manifest in 2021. She suddenly stopped talking altogether and

exhibited obsessive-compulsive tendencies, such as repeatedly checking her college bag and

books to ensure all necessary items were present. She developed a compulsion to repeatedly

reassure others by saying, “ ‫“( ”میں نے آپ کے بارے میں کوئی بات نہیں کی‬I haven’t said anything about you”)

to everyone she encountered, including college workers. She also experiences sudden

awakenings during sleep, during which she states, “I haven’t said anything against you,”

suggesting possible auditory hallucinations.

Her symptoms progressively worsened over time. She began crying excessively and would

follow her mother everywhere, even waiting outside the bathroom when her mother was inside.

Whenever visitors came to their home, she would cry upon seeing them and avoided any

interaction. Miss NS experienced significant sleep disturbances, an intense fear of writing or

saying anything that could be perceived as offensive to others, and compulsively recorded her

conversations. She frequently sought reassurance from everyone, including workers, to confirm
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that she hadn’t said or written anything against anyone. In addition to her psychological

symptoms, Miss NS suffers from dysmenorrhea, experiencing painful menstrual periods, which

adds to her distress.

History of Presenting Complaint

She experienced symptoms of obsessions, compulsions, social withdrawal, sleep problems,

intrusive thoughts. These symptoms have persisted since 2021, although there has been some

improvement with ongoing medication. However, she is yet to make a full recovery.

Past Psychiatric History

Miss NS does not report any prior psychiatric or substance abuse history before the onset of her

current symptoms in 2021.

Medical History

Miss NS did not report any significant medical or psychological issues prior to the onset of her

current symptoms, except for dysmenorrhea, for which she occasionally took over-the-counter

painkillers without consistent medication. Following the onset of her symptoms, she consulted

multiple doctors in Lahore and Sargodha and underwent various physical tests, including CBC

and LFTs, which did not reveal any major abnormalities.

Developmental History

She was born in a hospital via C-Section without complications. She did not report any significant

illnesses or accidents during her childhood.

Family History
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She reports a psychiatric issues within her family as her father was schizophrenic. He was a

former government officer, left his job due to schizophrenia, which severely impacted his later

years. He lacked insight into his condition and passed away in March 2024. Her mother is a

gentle and supportive woman, but Miss NS perceives a weaker emotional bond with her,

believing that her mother loves her younger brother more. Schizophrenia is present in the family

history through her father, while her mother and brother have no reported psychological

conditions.

Educational History

Miss NS was a very good and obedient student throughout her academic journey. She completed her

Matriculation in Science and later pursued FSc Pre-Medical from Superior College, achieving excellent

grades. She then took admission in the same college for further studies but was unable to continue due to

health issues.

Social History

Miss NS did not have any close friends during her school or college years. Although she was

polite and spoke gently when engaged in conversation, she did not socialize much with her

classmates or spend time with friends like others typically do. She preferred a more reserved and

solitary lifestyle, which continued into her college years.

Mental State Examination

Miss NS presented with a neat appearance, but her speech was tangential, as she often responded to

questions with unrelated answers, and her speech was slow in pace. She did not maintain eye contact and

exhibited slow motor activity. Her mood appeared depressed, and although she was oriented to person

and place—recognizing her mother, herself, and her home—she was unable to recall the time or date.

Miss NS showed impairments in long-term memory, as she could not recall details from her childhood or

her school and college years. She reported auditory hallucinations, though she denied having suicidal
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thoughts or ideations. She expressed a fear of harming others through her words or writing, though she

had no intention to act on this fear. Her behavior was withdrawn, and her insight into her condition was

average, while her judgment appeared poor.

Psychological Assessment

After a comprehensive psychiatric interview following test battery was selected for

psychological assessment:

Informal Assessment Formal Assessment

Mental Status Examination (MSE) Cross cutting measures (level 1)

Repetitive Thoughts and Behaviors (level 2)

GAD-7 Anxiety

Obsessive-compulsive Inventory (OCI)

Clinical Interview (CI)

Clinical Observation

Psychological Test Results

The psychological assessment of Miss NS included a series of informal tests to assess her

symptoms and severity of the condition:

1. Cross-Cutting Measures Level 1; Miss NS scored high in three domains: Depression,

Anxiety, and Repetitive Thoughts and Behaviors. These scores indicate significant concerns in

these areas, supporting the presence of both anxiety and obsessive-compulsive tendencies.
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2. Repetitive Thoughts and Behaviors Level 2: Her score was very high, indicating the

severity of her obsessive-compulsive tendencies. This further highlights the intensity of her

obsessions and compulsions, particularly her repetitive checking behaviors and intrusive

thoughts.

3. Generalized Anxiety Disorder (GAD) Scale: Miss NS scored at a *moderate level* on the

Generalized Anxiety Disorder Severity Scale (GAD-7), indicating the presence of generalized

anxiety, which is likely contributing to her obsessive-compulsive behaviors and distress.

4. Obsessive-Compulsive Inventory (OCI): Miss NS scored at a high level on the Obsessive-

Compulsive Inventory, confirming the presence of significant obsessional and compulsive

tendencies, including repeated checking, reassurance-seeking, and the need for validation.

Provisional diagnosis

Her psychiatric history and psychological test results indicate the possibility of the following

tentative diagnosis, which needs further information for succinct criteria;

 The combination of obsessive thoughts (fear of saying or writing something against

others, reassurance-seeking behaviors) and compulsive actions (repeated checking of

belongings, recording conversations).

Principal diagnosis

 Obsessive Compulsive Disorder

According to the DSM-5-TR criteria, OCD is characterized by the presence of obsessions

(recurrent, persistent, and intrusive thoughts or urges) and compulsions (repetitive behaviors or

mental acts). In Miss NS’s case:

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Obsessions: Miss NS experiences persistent intrusive thoughts about harming others through her

words or writing and constantly seeks reassurance from others, which are classic signs of

obsessions.

Compulsions: She engages in repetitive behaviors such as checking her bag and belongings, and

recording conversations to seek validation, which are compulsions aimed at reducing the anxiety

caused by these obsessive thoughts.

The severity of her symptoms is evident in the high scores on the Repetitive Thoughts and

Behaviors Level 2 and Obsessive-Compulsive Inventory (OCI), indicating significant distress

and impairment in her daily functioning. These symptoms are consistent with the diagnostic

criteria for Obsessive-Compulsive Disorder (OCD) as outlined in the DSM-5-TR

Comorbidities

 Generalized Anxiety Disorder (GAD)

Treatment recommendation

Based on the clinical presentation and the results of the psychological assessments, the following

evidence-based treatment recommendations are provided for Miss NS:

1. Cognitive-Behavioral Therapy (CBT)

Cognitive-Behavioral Therapy, specifically Exposure and Response Prevention (ERP), is the

most effective treatment for Obsessive-Compulsive Disorder (OCD). The therapy will focus on

helping Miss NS confront her obsessions (intrusive thoughts) and resist engaging in compulsive

behaviors (e.g., checking, reassurance-seeking). The goal is to reduce her anxiety and prevent the
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reinforcement of compulsions, leading to a decrease in symptom severity over time. ERP should

be conducted in a structured manner, gradually exposing Miss NS to anxiety-provoking stimuli

while preventing her from performing rituals.

2. Psychoeducation

Educating Miss NS about Obsessive-Compulsive Disorder and its impact on her daily

functioning is crucial for her understanding and cooperation in treatment. Psychoeducation will

help her understand the cognitive-behavioral processes involved in OCD, normalize her

experiences, and reduce stigma. It should also include information about the co-occurrence of

anxiety and depression with OCD, helping her to better recognize and manage these symptoms.

3. Medication Consultation

Given the severity of Miss NS's OCD symptoms, a consultation with a psychiatrist to discuss

pharmacological treatment options is recommended. The first-line medications for OCD include

Selective Serotonin Reuptake Inhibitors (SSRIs), such as Fluoxetine or Sertraline, which have

been shown to be effective in reducing both obsessive thoughts and compulsive behaviors.

Additionally, if depression and anxiety symptoms remain significant, medications like SSRIs or

SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors) could help address those concerns.

4. Family Involvement

Family therapy and involvement are critical, especially as Miss NS’s mother has been a major

figure in her care. Involving the family will not only help educate them about OCD but also

provide them with tools to support Miss NS in managing her symptoms. Family members can

assist in implementing CBT techniques at home and reinforcing treatment goals.

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5. Lifestyle Modifications

Encouraging Miss NS to implement healthy lifestyle changes is essential for overall well-being

and symptom management. These changes could include regular physical exercise, balanced

nutrition, and improved sleep hygiene. A routine of healthy activities may help reduce anxiety

and depressive symptoms, improve her mood, and increase her resilience to stress.

6. Coping Skills Training

Teaching Miss NS coping strategies such as relaxation techniques, mindfulness, and breathing

exercises can help her manage the anxiety associated with her OCD. These skills can be

incorporated into her daily life and can be particularly useful in moments of high stress or when

compulsive urges arise.

7. Relapse Prevention

A detailed relapse prevention plan should be developed as part of her treatment. This plan

should address how Miss NS can maintain progress after therapy and medication, including

identifying early warning signs of symptom relapse, coping strategies for managing those signs,

and ensuring that she continues to engage in therapeutic activities. Regular follow-up

appointments should be scheduled to monitor her progress and adjust treatment as necessary.

Session 1:

During the first session, the primary focus was on building rapport with Miss NS and creating a

safe, supportive environment for her to share her concerns. A comprehensive history was taken,

including her demographic, family, educational, and medical history, which provided context for

her presenting symptoms. The therapist introduced Miss NS to the treatment process, explaining
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the goals and structure of Cognitive-Behavioral Therapy (CBT), specifically Exposure and

Response Prevention (ERP), to address her obsessive-compulsive behaviors. Miss NS was

encouraged to keep a journal of her obsessive thoughts and compulsive behaviors, with a focus

on identifying patterns and triggers for future sessions. The session also included

psychoeducation about Obsessive-Compulsive Disorder (OCD) and the treatment options

available, which helped normalize her experiences and reduce any stigma.

Session 2

The second session focused on identifying specific triggers for Miss NS’s obsessions and

compulsions. We reviewed her journal from the previous session, which highlighted her intrusive

thoughts about harming others and her compulsive behaviors, such as checking her bag and

seeking reassurance. The therapist introduced Exposure and Response Prevention (ERP)

techniques, which involved creating a list of situations that provoke anxiety and planning gradual

exposure to these triggers. Miss NS was taught how to resist engaging in compulsions during

these exposures. The session also included psychoeducation on the relationship between anxiety

and OCD, further reinforcing the connection between her anxious thoughts and the need for

compulsive behaviors.

Session 3

In this session, the therapist continued to focus on implementing ERP techniques, with Miss NS

gradually exposing herself to anxiety-provoking situations. We discussed the importance of

tolerating discomfort without engaging in compulsive behaviors. Miss NS reported some initial

distress, but she was encouraged to continue practicing exposure exercises at home. We also

explored her generalized anxiety symptoms, as she scored moderately on the Generalized

Anxiety Disorder (GAD-7) scale. Coping strategies for managing her anxiety, such as relaxation
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exercises and deep breathing techniques, were introduced. The therapist also emphasized the

importance of setting small, achievable goals for her progress and how these goals could

contribute to reducing both anxiety and OCD symptoms.

Session 4

In this session, we focused on reinforcing ERP techniques and reviewing Miss NS’s progress.

She was encouraged to continue practicing her exposures at home and to record any challenges

or breakthroughs in her journal. The therapist reviewed her coping skills, including mindfulness

and relaxation exercises, to help Miss NS manage any residual anxiety from the exposures. We

also addressed her memory impairments, which had been affecting her ability to recall her school

and childhood experiences. Cognitive strategies were introduced to help her reframe negative

thoughts and promote a more balanced view of her past experiences. Miss NS demonstrated a

slight improvement in her ability to tolerate anxiety without engaging in compulsive checking or

reassurance-seeking behaviors.

Session 5

This session focused on reviewing Miss NS’s overall progress and addressing any difficulties she

faced in implementing ERP exercises. The therapist reinforced the importance of consistency in

practice and encouraged Miss NS to share any setbacks or successes from her exposure

exercises. We also discussed her depressive symptoms, which were indicated by her high score

on the Cross-Cutting Measures Level 1 for depression. Cognitive restructuring** techniques

were introduced to address negative thoughts associated with her low mood, and she was taught

how to identify and challenge these thoughts. Miss NS was encouraged to continue using the

relapse prevention strategies that had been discussed earlier, ensuring that she remained
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proactive in managing her symptoms moving forward. We concluded by setting goals for the

next few weeks and planning follow-up sessions to monitor her progress.

These sessions provide a structured approach to treatment, focusing on both the cognitive and

behavioral aspects of OCD while addressing any comorbid anxiety and depressive symptoms.

Through continuous evaluation and practice, Miss NS will be supported in making meaningful

progress toward managing her OCD symptoms.

Appendices

Appendix 1: Cross cutting Measure Level 1:

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Appendix 3: GAD- 7 Anxiety Results

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Appendix 4: Obsession-complusion Inventory

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