Obsessive-compulsive disorder (OCD), is an anxiety disorder that traps people in endless cycles of repetitive thoughts and behaviors. A person with OCD is plagued with recurring and distressing thoughts and fears that they spend hours distressing over (obsessions) that they cannot control. The anxiety produced from these thoughts lead to urgent need to perform rituals on a continuous basis (compulsions). The compulsive rituals are performed trying to attempt of preventing the obsessive thoughts and make them go away. The ritual might make the anxiety go away for a time, the person then must perform the ritual again when the obsessive thoughts return. Sometimes this cycle can take hours in a person’s day that will interfere with “normal” daily activities. A person most often know their obsessions and compulsions are unrealistic, they cannot stop from doing them (Webmd, n.d,.).
The purpose of this project is to provide a comprehensive five part project on obsessive-compulsive disorder. Part I describing the disorder, how it became a psychological disorder. OCD is classified as an anxiety disorder in the DSM-IV and the ways it has been studied. Part II Neurotransmitters that are linked to OCD; then the medications that are prescribed to a person with OCD. Will give information on how genetics contribute to OCD and the part of the brain that is affected. Part III the little known environmental influences that causes a person to be acceptable for OCD. Genetics play more to this disorder than the environment. Part IV Explain the best medical treatment and most effective treatment in helping a person overcome OCD. Then will present a treatment plan for Maria. Part V will explain the best psychological model that best applies in treating OCD and the new treatments that are developed and how Maria can have a productive life without obsessive-compulsive disorder.
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Maria who is a 38 year old woman, who lives in Pittsburgh, married and has four children. She was raised in a strict catholic family and continues to be devoted to her believes. 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 and hours of her day. Wit with anxiety she become more obsessed with staying clean and holly where she became more extreme in washing and cleaning, so she will feel clean and pure. Maria personal habits throughout her life include:, keeping her house clean, tidy, and free from clutter, brushing her teeth three or times a day, and wash her hands six to eight times a day, until 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 and insists they wash their hands all the time.
The DSM-IV code for Obsessive-Compulsive Disorder is 300.03. OCD is considered as 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 or attempts to restrain or not pay attention to these thoughts and recognizes 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 excessive and unnecessary and unreasonable. These behaviors take up a person’s time and interfere with a person’s daily normal functions (APA, 2002).
Obsessive thoughts can include:
* 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.
Compulsions included:
* Checking doors, stoves, water faucets, and lights.
* 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
* Repeating phrases
* Excessive washing that takes up hours of each day.
(List taken from Rais, 2008 article titles Obsessive Compulsive Disorder).
The things Maria did that are considered typical signs of OCD were 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). Understanding the symptoms and history of OCD is important in determining why Maria had OCD in order to help her. First we will look at the biological reasons then the environmental reasons that would contribute to someone having obsessive-compulsive disorder.
II
Genetic
There are several biological aspects of OCD. There are neurotransmitters that are linked to it, genetic contributors to this disorder, and different brain abnormalities that influence this disorder. Neurotransmitters transmit chemical impulses from neurons to neurons. Each neurotransmitter has various functions and different names (Durand, & Barlow, 2007). Serotonin is of the neurotransmitters that influence our behavior. Serotonin is a chemical that takes one messages from one neuron to another (Dryden-Edwards, 2005). When serotonin are too low a person does things they normally would not do and tend to overreact doing impulsive actions. A person with low levels of serotonin are more quick to do abnormal behaviors. Serotonin is not found to cause the problem (Durand, & Barlow, 2007). The brain looks normal in a person who has OCD. It has been found in the brain of a person with OCD, that there is more activity in the frontal lobe of the cerebral cortex, there are increased activity in other parts of the frontal area and the thalamus. A person with OCD is considered to have a “faulty brain circuit,” because of the low levels of serotonin (Durand, & Barlow, 2007). When the cerebral cortex are under active a person has a hard time controlling their OCD behaviors and actions (Dryden-Edwards, 2005).
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).
Dr. James Kennedy, a Neurogeneticist, said “a role in a person developing OCD if they have a relative that is affected with this disorder.” 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). Durand, & Barlow state that genes play a role in certain abnormalities, the environmental causes need to be triggered in order to activate a disorder such as OCD (2007). After getting an understanding the research that has been done on the biological aspect of OCD, Researchers researched and noticed a strong correlation that genetics play a big role in a person developing OCD, but no factual evidence. Researchers have investigated and determine that an environmental factor influences a person having OCD. we can turn to what environment plays on someone have this disorder.
III
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 the desire and the actions of their conscious and their unconscious mind. They are urge to complete the actions of their unconscious mind, to get temporary relief from their high intense anxiety. Their conscious mind knows it is ridiculous and bizarre it is to continue to do these actions (Allison, 2008). In Maria’s mind she felt she wasn’t religious enough, where to get relief from her anxiety she would devote more hours than a “normal” religious person would to perform religious rituals hours each day.
In Maria’s case she grew-up as a strict Catholic, which she continued through her life. She worried that she didn’t measure up to the expectations to be considered pure or holy. This could have been the reason she had great amounts of guilt that caused her to do her religious obsessions and cleaning compulsions. Durand and Barlow (2007) state that in every psychological disorder, both genetics and environment have to be considered. Both are needed to activate OCD. Research supports that 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 which a person is vulnerable to, which can be activated under stress or an environmental situation (Durand, & Barlow, 2007). As mentioned before, Maria was predisposed to OCD and it was activated from the environment by the petunias at the funeral. Once the genetic and environment influences are understood they can determine the best treatment
In Maria’s case her mom showed strong OCD tendencies with the her many superstitions (genes). 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.
Environment factors that came from a horrible divorce or from traumatic events of sexual abuse (Grisham, Anderson, & Sachdev, 2008). Religious factors 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, is religious factors, the reason for this is a person feel they lack in their faith and feared 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 over and over again, repeatedly confessing to purge the fear that they are “Doomed to hell” (Higgins, 1992). Maria was apprehensive about her dedication and that 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.
IV
February 19, 2009, the Food and Drug Administration (FDA) approved deep brain stimulation (DBS) therapy for those who suffer with OCD and 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).
The DBS is surgically implanted in the brain. It delivers electrical impulses to different areas of the fiber bundle in the front of the brain. It is programmed by a clinician and is based on an individuals needs (Bates, 2009). This device is not exempt from side effects, One that has been know is cerebral hemorrhage and brain infections, non life threaten have ever been reported. Studies had shown that this device has made great improvement in people’s life and some has even returned back to work (De Noon, 2009).
A study that was conducted were quasi-experiments designs, which is where researchers 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).
Therapy and medications are helpful to help people with obsessive compulsive disorders. One known therapy that works for OCD is behavioral exposure. This works by having the person face objects, situations, places, and thoughts that the person fears and avoids. A person needs to be exposed repeatedly to the “fearful things” in order for it to work. Rituals are prevented by not allowing the person to perform their compulsions (Dell’ Osso, Altamura, Mundo, Marazziti, Hollander, 2007).
Medications that seem to work for OCD people are antidepressants, those that are serotonin reuptake inhibitors (SRIs). The six that are commonly used are fluvoxamine (Luvox), fluoxetine (Prozac), sertraline (Zoloft), paroxetine (paxil), citalopram (celexa), and clomipramine (anafranil). Studies that have been conducted concluded that Anafranil has been the most useful in treating OCD. 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). With each of these medications come possible side effects, which do not cause any permanent damage. The most common side affects are sleepiness, dry mouth, and nausea. Anafranil has a few harsher side effects such as, heart racing, difficulty in concentrating, slower thinking ability, and weight gain. Anafranil (Korn,2001).
Treatment for OCD
In peer reviewed article, “Cognitive behavior therapy and medications in the treatment of obsessive compulsive disorder,” the researcher’s studied to determine what treatment would best help a person suffering from this disorder. In their research they wanted to determine if cognitive behavior therapy (CBT) would be the best therapy, or Cognitive behavior therapy and medication, or just medication, or just a sugar pill known as a placebo. They concluded that CBT plus medication had the greatest outcomes. It was interesting the study showed no noticeable difference among those that took medication and those that took placebo, but when the person added therapy with the medication they made major improvement. Medications that seemed to work the best were those that are serotonin reuptake inhibitors (SRI), 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). Another therapy that is known to be beneficial and make significant changes in their brain activity after four weeks is an intensive cognitive behavior therapy program. This program consisted of a 90-minute individual therapy session, and four hours of homework five days a week. 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 anterior cingulated cortex activity along with improvement in their OCD symptoms (Douglas, 2008).
Durand & Barlow (2006) stated that the most common psychosocial treatment that is used to treat a person with OCD is exposure and ritual prevention (ERP). This is where 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).
When it comes to insurance companies or other third party reimbursement such as Medicaid fast 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).
Purposed treatment for Maria
Maria treatment plan would consist of cognitive behavior therapy (CBT), medication and family counseling. I think Maria will need spiritual counseling, first because of her religious Catholic background that has put a lot on her; she does not feel she can live up to those expectations where she spends many hours a day performing rituals in order to feel clean and pure. I would start by having her talk to her priest to get an understanding that she is clean, God accepts her, and she does not have to pray hours a day in order to feel accepted and considered clean. I feel spiritual counseling is needed first because if she can feel accepted by God she can begin working on the other OCD behaviors. It would be supportive for Maria to start on some medication to help decrease her anxiety when she begins cognitive behavior therapy.
A plan for therapy would be then to begin with cognitive therapy to change Maria’s old thinking patterns concerning fears of contamination, plus to find different ways to handle stress and change her intense fears (Owens, 2009). The counselor would have Maria touch thing that she fears are contaminated and not be allowed 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 a few time’s day and limited to how many times she can clean and straighten her house, eventually she would have to skip a day in cleaning her house. Maria need realize nothing bad will happen if she doesn’t have a clean house. Maria will also be restricted to the total of spiritual rituals she could do. It would be important to still be involved in her faith, but needs to limit the amount the time on spiritual rituals such as praying. The goal would be to change the total number of hours she spends in praying down to five minutes no more than two times a day.
Family therapy would be, not to allow Maria to place huge demands on her children and husband to stay clean by not giving into her by taking a shower when they come home and not washing their hands every time she demands. Maria’s family will have the opportunity to express how they feel and doubt her love because she does not touch or get near them so she understands how her disorder affects them. It would be good to have a doctor explain OCD to her family. I would give Maria assignments each week to help Maria begin to be comfortable touching and hugging her children and husband. How this will be done is after leaning relaxation techniques she will be advised to do the weekly assignments in a relaxed state. On week one she will touch each family member on the shoulder and if it is fearful to do deep breathing techniques, then on weeks to come get her to comfortable hug her children without the need to shower. By going to family therapy will help change the dynamics in Maria’s family.
In conclusion, there has been research done that suggest that genetics is the main factor in developing OCD. 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 that Maria can change through hard work if she has spiritual and family counseling along with cognitive behavioral therapy and medication to overcome her compulsive behaviors that have taken many years of her life and rejoin her family in a healthy relationship. After, learning what researches believe the best treatment are and discussion a treatment plan I think will help Maria, we will discover the different therapeutic theories and new medication that are being devised. I will determine the final outcome of Maria’s disorder by applying these techniques.
V
To determine which psychological model that would best help a person with obsessive compulsive disorder it is important 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 influences behavior. This therapy was pioneered by Albert Ellis in 1950 and workes 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. The rationale for this is 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 been approved for OCD is Luvox CR in January 2007. Luvox CR is an extended release from of Luvox SSRI. People are paying more attention to this method of having more beneficial outcomes (Jeffery, 2008).
Now we know and understand the different treatments and medication in helping a person with OCD, I believe there is a strong possibility that Maria can overcome her OCD behaviors that she has. If Maria wants it and puts her whole heart into her treatment plan, she can have a bright fulfilling future. Once a person is able to get their OCD under control and is able to cope with the environment influences (stressors) in their life they may or may not need to continue medication. A person can be free from the problems of OCD and live a “normal” life. Maria can have this; it will be hard work but worth the price she has to pay to be free of this disorder that has held her hostage for so many years.
