However, psychodynamic approaches advocate the interpretation of symbolic meaning of the overt symptoms and the resolution of intra-psychic conflicts in the management of psychopathology and subsequent mental health gain. Literature has also suggested that often in most patients, symptoms tends to persist to a mild to moderate degree following a course of cognitive behaviour therapy Eddy et al. This explores the need for some alternative conceptualizations and treatments that can be beneficial in a distinct group with OCD. Also, sometimes with the course of therapy new goals emerge that further makes it difficult to adhere to a particular regime and eventually leads to a demand for an eclectic approach.
Furthermore, application of therapy becomes more challenging when there are comorbid psychiatric conditions like depression, anxiety, psychosis or suicidal tendency associated. This study presents a successful demonstration of an eclectic approach where dissociation emerged as impediment for the continuation of cognitive and behaviour models. As non-pharmacological treatment proceeded, enriched understanding of psychodynamic explanations following cognitive drill therapy seemed more substantial over the continuous pharmacological treatment alone.
It potentially throws the light on pathogenesis of OCD. This study also questions the relevance of psychodynamic principles among the contemporary treatment approaches. Case report Mrs.
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The obsessions included names and images of some specific persons and theme of contamination of dead bodies. Patient was using overt and covert compulsions with some ritual. Whenever a name or image that came in her mind was interfered or followed by some sounds, like horn, sneeze or nearby on going conversations, she would make her husband and child to repeat the sounds, even whole conversations and other names to get relieved from anxiety.
Till the repetition, she would wait for them, escape meals and avoid doing any house-hold duties. She would also avoid touching dead bodies, discussing about death and would wash the cloths and accessories of her husband and children. If she was touched by any stranger, she would touch her husband. Through the clinical interview it was later found that patient would also have one or two episodes of dissociative stupor per month.
She also reported some paranormal experiences, nightmares and sleep paralysis. Severity had increased for past months. However, Dissociative experience scale revealed lower scores as compared to experiences by general population.
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Emergence of sexual aggression themes. Psychodynamic explanation Reflecting freud conceptualization. Association of common cognitive and psychodynamic concepts. Exposure and response prevention therapy could not be utilized as her anxiety would maintain for two to three days until she made her husband or child do the compulsive rituals. Hence, cognitive drill therapy was planned. The application of cognitive drill has yielded promising results in patients with OCD Kumar et al, Cognitive drill behavioural explanation Cognitive drill uses principles of exposure therapy and Pavlovian conditioning to deal with stimulus bond anxiety.
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Patient was explained how repeated exposure of anxiety provoking cues at cognitive and verbal level, causes extinction and habituation of acquired anxiety response. This exposure would initially boost the anxiety response and in the process would get reduced. Names and images were identified as anxiety cues and drill was prescribed.
Patient was first required to verbally repeat one name in bulk until anxiety reduction on a visual analogue scale. However, in the very first session, patient developed the dissociative stupor episode and drill was stopped. Dissociative episodes occurred sometimes when husband would try not to follow her imposed compulsions. Husband also reported that patient often tended to indulge in self-injurious behaviours like screaming, head banging, pulling hair and scratching self when the compulsions are curbed.
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Cognitive explanations Patient was unable to handle the exposure leaded anxiety thus it seemed difficult to adhere to drill or other behaviour therapies. Modification in therapy was indispensible.
Atypical Presentation of OCD in Children
It seemed dubious whether at this stage to what extent the therapeutic model for dissociation with patient would work apart from supportive psychotherapy and how much it would be beneficial to manage it first over OCD that was proving to be more perilous to the patient. Transition from cognitive drill to a traditional cognitive approach for OCD considered appropriate at this phase. It was started with discussing the cognitive model. Patient was taught the role of appraisal, exaggerated sense of responsibility, perception of threat and mood context in the origin and maintenance of obsession and compulsions.
Patient seemed cognitively sophisticated and this session, however, highlighted some sexual themes too. Simultaneously it seemed requisite to psychoeducate the husband about dissociation as he was worried. This, however, proved to be the pivot point for the successful management of OCD as symptoms appeared to have symbolic meanings. Many strong sexual and aggression themes and interpersonal issues were derived in the session that shaped the further course of therapy.
Discussion around these themes with the patient then assumed to be beneficial. Premises for psychodynamic explanation Patient reported non-congenial childhood atmosphere when interviewed further. She had constrained relationship with father. Father was authoritative with less emotional involvement in the family. She always sought for his affection and assurance. Her pre-morbid history revealed inability to handle criticism and inclination towards cleanliness, symmetry and preference for perfection. When got married she faced significant conflicts with her mother-in-law.
Adjustment problems and nil ventilation had led to first episode of dissociative stupor. Her obsessions were also found to have sexual and aggressive themes. The names and images belonged either to her adolescence emotional and physical attractions or alleged childhood molestation experiences. Psychodynamic explanation In the view of strong psychodynamic aspects that maybe contributing to her OCD and dissociation, psychodynamic understanding and explanations appeared essential for optimizing outcome.
Oedipal unresolved conflicts in relation to her father and the search for fatherly affection in males and father figures during her initial adulthood was analysed with the help of patient. She was made aware of the links between emotions in past and present. Her obsessions of names, touching strangers and contamination suggested emergence of strong morality, inhibition of sexual id impulses and ambivalent self.
An overview of the psychodynamic and developmental psychological theories of OCD facilitated the appraisal. Recently, Callie began to experience a recurrence in OCD symptoms. She reported that she is still taking her medication as directed, but she has experienced some significant transitions over the past six months. Callie sought therapy to help her sort out what is going on in her life and gain control of her OCD. Callie recently separated from her husband of 8 years. They have joint custody of their two children, ages 5 and 7. Callie and her husband decided to keep the primary residence to prevent the children from moving between two homes every week.
While this agreement seems to work well for the children, it is taking a huge emotional toll on Callie. Callie reports difficulty focusing at work, which results in difficulty keeping up with deadlines and workload. Callie also reports that spending time away from her children and home creates fear and doubt about how well they are cared for when she is not there.
She has developed a routine for the children and believes that structure and consistency are requirements for good parenting. Callie knows that her husband is less organized and persistent than she, especially when it comes to parenting and household management, two of their biggest problems as a couple.tinawilli.gq
Obsessive Compulsive Disorder Case Study: Callie
When she is away from the children and home, Callie is bombarded with intrusive thoughts about their well being. She calls her husband numerous times during the day to remind him of things she is afraid he will forget. Callie reportedly began exhibiting symptoms of OCD as a young child. She required a high degree of order in her environment to feel secure. Reportedly, any change in her routine at home or school resulted in extreme anxiety and agitation. The psychologist who performed the battery of test was hesitant to diagnose Callie at age four.
In fourth grade, Callie changed schools and psychologists. This transition was challenging for her, as was the loss of control over her surroundings. She was given a firm diagnosis of OCD and began taking medication. Callie also saw her psychiatrist for a medication evaluation. Initially, we set up designated times for her husband and the nanny to check-in with her as most parents would when away from their children before school, after school, and before bed.
Callie spoke with the children each morning before they left for school to wish them a good day and tell them she loved them. After school, they touched base to talk about their day and plans for the evening. Before bed, they called her to say good night.
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