This paper examines the case study of 19-years old Caucasian male patient Carl. Carl demonstrates the behavior and symptoms, which could be characteristic of obsessive-compulsive disorder. The paper provides information on the recent epidemiological data about the obsessive-compulsive disorder, which is applied in general to the disease under consideration. In addition, it considers the etiology and pathophysiology, which can be determined by biological, psychosocial, and genetic factors.
The paper presents and examines several diseases with the similar symptoms that should be considered when making the differential diagnosis of obsessive-compulsive disorder. Along with that, it suggests the current approaches to the treatment of OCD.
Key Words: obsessive-compulsive disorder, obsessions, compulsions, differential diagnosis
From the case study # 18, it was found that Carl has an obsessive compulsive disorder. Obsessive-compulsive disorder is a mental disorder. It may have a chronic, progressive or episodic character (American Psychiatric Association, 2013). Carl has an 8-year history of behavioral and emotional problems that have caused his illness to become severe; in particular, he has issues with excessive washing, grooming, placement of objects, the way he walks, talks, and eats. Carl's behavioral problems do not allow the patient to contribute some time to personal hygiene.
The intrusive, disturbing or frightening thoughts resulted in spontaneously appearing obsessions. He constantly and unsuccessfully tries to get rid of the anxiety caused by the thoughts by means of the intrusive and tiring actions (compulsions). In Carl's case, obsessive-compulsive disorder is characterized by the development of intrusive thoughts, movements and actions, as well as a variety of pathological fears (phobias). This paper will discuss different aspects of the obsessive compulsive disorder.
At the moment, information on the epidemiology of obsessive-compulsive disorder is highly controversial. The prevalence of obsessive-compulsive disorder in the range of 1-3% is indicated quite frequently (Fireman, Koran, Leventhal, & Jacobson, 2001). According to other data, its prevalence is about 1-3 in 100 adults and 1 in 200-500 children and adolescents although clinically recognized cases are less common (less than 1%) since many cases of the disorder cannot be diagnosed due to stigma.
Obsessive-compulsive disorder most commonly declares itself between at the age of 10 to 30 (Fireman, Koran, Leventhal, & Jacobson, 2001). The first visit to a psychiatrist usually takes place only between 25 and 35 years (Fireman, Koran, Leventhal, & Jacobson, 2001). The average age of hospitalization is 31,6 years (Fireman, Koran, Leventhal, & Jacobson, 2001).
Obsessive-compulsive disorder occurs in representatives of all socioeconomic levels. Research on the distribution of patients by classes has found that 1.5% of the patients belong to a higher social class, 23.81% to the upper middle class and 53.97% to the middle class (Fireman, Koran, Leventhal, & Jacobson, 2001). These studies are essential for health care since the patients from the lower class may not always receive the necessary assistance.
The patients with obsessive-compulsive disorder are mostly men with a high level of intelligence. Among the patients with this disorder, there is a high frequency of IQ varying from 12% to 28.53% (Fireman, Koran, Leventhal, & Jacobson, 2001). At the same time, the patients have high rates of verbal IQ. The prevalence of obsessive-compulsive disorder is also associated with the level of education. The frequency of the disease is lower in those who graduated from a higher education institution (1.9%) than in those who does not have a college degree (3.4%) (Fireman, Koran, Leventhal, & Jacobson, 2001).
However, among those who graduated from a higher educational institution, the incidence is higher than in those who graduated with a scientific degree (respectively 3.1% and 2.4%) (Abramowitz & Jacoby, 2014, p. 101). Most patients who came for a consultation, cannot study or work. Only 26% of patients can fully devote their time to studying or working (Fireman, Koran, Leventhal, & Jacobson, 2001).
Up to 48% of patients with obsessive-compulsive disorder are unmarried (Fireman, Koran, Leventhal, & Jacobson, 2001). If the degree of the disease is severe before the wedding, the chance of marriage will be reduced. If the patient had married, in half of the cases, there were problems in the family. In addition, there are certain gender differences in the epidemiology of obsessive-compulsive disorder. At the age under 65 years, the disease has been diagnosed more frequently in men (except the period 25-34 years) than in women (Fireman, Koran, Leventhal, & Jacobson, 2001).
The maximum difference in the prevalence of the male patients was observed during the period of 11-17 years. After 65, in both groups, obsessive-compulsive disorder rate was falling. 68% of hospitalized patients are women (Fireman, Koran, Leventhal, & Jacobson, 2001).
Twin method shows high concordance among monozygotic twins. In 18% of parents of patients with obsessive-compulsive disorder, there are mental disorders: 7.5% have obsessive-compulsive disorder, 5.5% - alcohol abuse, 3% - obsessive-compulsive personality disorder, 2% - psychosis and affective disorders (Fireman, Koran, Leventhal, & Jacobson, 2001). 25% of patients with obsessive-compulsive disorder did not have comorbid conditions. 37% suffered another mental disorder, 38% - suffered from two or more disorders (Fireman, Koran, Leventhal, & Jacobson, 2001).
The most frequently diagnosed conditions are the major depressive disorder (MDD), anxiety disorder, panic disorder and acute stress reaction. 6% were diagnosed with bipolar disorder. The only difference in the sex ratio was the fact that in 5% of women, eating disorders were diagnosed (Fireman, Koran, Leventhal, & Jacobson, 2001).
Etiology and Pathophysiology
Within the given case, the etiology of the obsessive-compulsive disorder is unclear. Carl's obsessions and compulsions may be the symbols of unconscious desires, impulses, or fears that reflect the dynamic processes of adaptation to undesired aggressive or sexual impulses. However, etiology of the given case should be considered from psychodynamic, psychosocial, genetic, and biological points of view.
In groups of patients with obsessive-compulsive disorder, a number of biological abnormalities were found. The search for biological factor underlying this disorder is based on two observations. First, in patients with obsessive-compulsive disorder, often a trauma during childbirth is present, which indicates a possible role of injury in the etiology. However, Carl's parents did not report about such trauma (Geoffreys, 2015, p. 33).
Through positron emission tomography, increased metabolic activity of the left orbital lobe and the left and right caudate nuclei were found in patients with the disease. Although these biological characteristics do not allow definite conclusions, it can be suggested that the cingulate gyrus, in particular, is involved in the pathophysiological mechanisms of this disorder. It is hard to suggest some of these etiological factors within Carl's case without additional analysis and investigations.
Genetic studies of obsessive-compulsive disorder are difficult to conduct because the disorder is rare. However, at least several cases of this disorder have a genetic conditioning. The incidence of this disease in immediate family members of patients is 3-7%, which can be compared to a frequency of only 0.5% for relatives of patients with other forms of anxiety disorder (Geoffreys, 2015, p. 30). Carl's parents do not suffer from obsessive-compulsive disorder. Thus, it the genetic nature of his disorder cannot be suggested.
Carl's obsessive-compulsive disorder is not a severe form of compulsive personality disorder. As the majority of patients with obsessive-compulsive disorder, he did not have compulsive symptoms in premorbid. Therefore, it is neither necessary nor sufficient for the development of obsessive-compulsive disorder in the given case. Approximately 15-35% of patients have features of obsessions in premorbid. It can be compared to the fact that 50% of psychiatric patients without obsessive-compulsive disorders have similar premorbid features (Geoffreys, 2015, p. 34). However, when considering Carl's personal factors, it should be noted that his symptoms have deteriorated when he faced social tension from peers in high school.
Other Psychogenic Factors
One of the most interesting features of Carl's behavior, as well as other patients with obsessive-compulsive disorder, is their preoccupation with the certain order of things or cleanliness. On the basis of these and other facts, it can be suggested that in the Carl's case, the psychogenesis of obsessive-compulsive disorder lays in violation of normal growth and development related to the anal-sadistic phase such as ambivalence (Geoffreys, 2015, p. 37).
Ambivalence may be a direct result of changes in the features of pulse periods of Carl's life. It is an important feature of a normal childhood during the anal-sadistic phase of development, i.e., when the child feels both love and hatred to the same object, sometimes simultaneously. Carl may be one of those patients with obsessive-compulsive disorder who consciously feels love and hatred towards the object. This problem with conflicting emotions can be seen in the construction, elimination patterns of Carl's behavior and the presence of paralyzing doubt when it comes to making choices (for example, with his desire to save himself from AIDs while he understands that this fear is irrational). It is often peculiar to individuals with emotional disorders.
Differential Diagnosis of Obsessive-Compulsive Disorder
During the course of many psychiatric disorders, the symptoms of obsessions and elements of stereotyped behavior are noted. It is more correctly to speak of typical but not specific symptoms in a particular disease. Obsession syndromes are not heterogeneous structurally, constitutionally or etiologically. Hence, there is the complexity in differential diagnosis of obsessive-compulsive disorder. Recurring obsessional conditions and movements, and resembling the rituals are marked not only at a certain stage of ontogeny, for example, in early childhood, but also observed in many adults as it happened to Carl.
The peculiarity of the clinical manifestations and resistance of obsessional conditions in relation to the therapy suggest that there is an independent mental disorder characterized by its specific dynamics. The major symptom of it is the obsessions. However, obsessive-compulsive symptoms may be part of different primary psychiatric disorders including anorexia nervosa, dysmorphophobias, delusional disorder, schizotypal personality disorder, schizophrenia, somatization disorder, phobias, post-traumatic stress disorder, generalized anxiety disorder and affective disorders (Phillips & Stein, 2015, p. 78).
In regard to the differential diagnosis of obsessive-compulsive disorder, the problem of the spectrum of mental disorders should not be ignored. These diseases can include various similar obsessions or psychopathological phenomena including separate, not main and leading symptoms of the disease. Traditionally, disease spectrum involving obsessive-compulsive symptoms often include trichotillomania and skin picking (Arzeno et al., 2006). In addition, it can include sexual compulsions, borderline personality disorder (DSM-IV), and Tourette's syndrome (Phillips & Stein, 2015, p. 78).
Obsessive-Compulsive Personality Disorder
Obsessive-compulsive personality disorder, which is characterized by a constant concern for the order, the desire for control and perfection that interferes with doing things and/or interpersonal relationships should also be differentiated from obsessive-compulsive disorder. However, in obsessive-compulsive personality disorder, symptoms interfere with people around who characterize patients as inflexible, stubborn and closed.
However, in obsessive-compulsive disorder, obsessions and compulsions are primarily a source of discomfort and anxiety for the patient who is suffering from these unacceptable to the individual symptoms. Patients with obsessive-compulsive personality disorder perceive their symptoms as part of the need to control other people and current events meanwhile a patient with obsessive-compulsive disorder seeks to gain self-control and get rid of obsessions.
In terms of frequency of occurrence, significance and complexity of the differential diagnosis, it is important to differentiate neurotic obsessive-compulsive disorder from a personality disorder since in its clinical picture, the main place is also often occupied by anxious-hypochondriac character traits and various obsessions. In case of neurotic obsessive-compulsive disorder, symptoms are experienced by the patient in a conflict with his own identity it is stupid that I, again and again, need to check whether the curtains are twisted in a proper way or wastebaskets are tilting as they should be, but I need to do it).
In case of personality disorders, in general, there are no problems with obsessions. They are such as they are, they are a part of the character or its features, and they do not seem absurd but rather correct, and correspond to the experiences of the individual. Compulsive personality disorder is mostly different from socially acceptable or socially desirable behavior. Throughout life, invisible obsessions are periodically replaced by acute phases that usually reflect and provoke social conflicts.
Many patients suffering from diseases of the spectrum including the symptoms of obsessions periodically note impulses in their thoughts, which occupy a large amount of time and partly influence their behavior specifying its deviation by varying degrees of severity. However, in contrast to the obsessions that occur in obsessive-compulsive disorder, there is no element of invasion of obsessions or it is weakened. In general, there is no undesirability of obsessions.
Furthermore, the content of the cognitive component or obsessions also has its differences. An important criterion for the differential diagnosis is pleasure or desirability of the repetitive thoughts and behaviors for the patient (Phillips & Stein, 2015, p. 70).
Psychogenic Compulsive Disorder
Obsessive-compulsive disorder should be distinguished from the so-called psychogenic compulsive disorder. Perhaps, psychogenic obsessions should also be considered neurotic. Though, from pathogenic and therapeutic points of view, they still should be differentiated from obsessive-compulsive disorder. Psychogenic obsessions provoked by stress can also be called reactive. They are psychologically understandable due to their content. They are not accidental but rather important for the patient and are characterized by affective saturation.
At the same time, affective saturation does not allow representations associated with trauma to take their proper place in the general current of thoughts and merge with it. Obsessive thoughts arise form complexes that dominate over the rest of the content of consciousness, which acquires a certain autonomy and independence (Phillips & Stein, 2015, p. 85). Due to this isolation, the complex is not influenced by the contrasting representations and increasingly fixed.
Trichotillomania and Tourette's Syndrome
In their genesis, obsessive actions with trichotillomania and Tourette's syndrome (30-50% of patients with these syndromes noted obsessional conditions in their behavior) are different from the rituals formed in obsessive-compulsive disorder where they act as a protection against phobias and anxiety. The differences can be traced even in the time interval separating the obsessive thoughts from obsessive actions. In obsessive-compulsive disorder, it is longer (Phillips & Stein, 2015, p. 90).
Hypochondria, Body Dysmorphic Disorder, (BDD) and Eating Disorders
In the spectrum of diseases including the obsessions, there is also hypochondria, body dysmorphic disorder (BDD) and eating disorders (Erol, Yazici, & Toprak, 2007). Within these mental disorders, obsessional conditions have their nuances. Thus, for example, in case of eating disorders, obsessions are narrowly focused on a single theme (Erol, Yazici, & Toprak, 2007); in case of hypochondria, they are fixed on somatic sensations; and in case of BDD, they are associated with overvalued or delusional ideas.
Organic Diseases of Central Nervous System
It is often necessary to differentiate neurotic disorders provoked by psychogenic factors from organic diseases of the central nervous system. This is especially difficult at the initial stage of their development. The functional nature of neurotic disorders is similar to a functional stage by its organic symptoms. In addition, a combination of neurotic disorders on the background of the developing brain disease can be seen quite often.
Early recognition of organic disease, the importance of specific features of its treatment, as well as differences in the treatment of neurotic symptoms, and manifestations of personality disorder emphasizes the importance of the differential diagnosis. Complex intertwining of psychogenic, cerebral and somatic factors affects not only the pathogenesis of compulsion but also necessitates separate accounting of these factors in the course of their therapy (Phillips & Stein, 2015, p. 111).
It is extremely necessary to distinguish the obsessive-compulsive disorder from other diseases, in which obsessions and rituals are typical symptoms. In some cases, obsessive-compulsive disorder should be differentiated from schizophrenia, especially when the obsessive thoughts are unusual in content (for example, mixed sexual and profane themes) or rituals are very eccentric. Development of sluggish schizophrenic process cannot be excluded if there is an increase in ritual formations, their durability, appearance of antagonistic trends of mental activity (inconsistent thinking and behavior), and uniformity of emotions (Phillips & Stein, 2015, p. 119).
Protracted obsessive state of the complex structure must be distinguished from manifestations of paroxysmal schizophrenia. In contrast to neurotic compulsive disorder, they are usually accompanied by sharply increasing anxiety, significant expansion, and systematization of the range of obsessive associations, which acquire the character of obsessions with special value. For example, previously indifferent objects, events, random notes of surrounding people remind patients of the content of phobias, and thereby abusive thoughts acquire special, threatening significance in their view (Phillips & Stein, 2015, p. 126).
In practice, the criterion for the differential diagnosis of neurotic disorders and organic diseases of nervous system becomes the absence of evidence of structural brain damage while it is well known that at the onset of organic pathology, its symptoms are often not recognized.
Thus, with respect to the differential diagnosis, it is appropriate to recall that the signs of psychogenic (neurotic) disorders should be considered in their functional nature; affective and dynamic nature of the current; psychological clarity of experiences (mental link between reason and psychogenic reaction, especially in meaningful interaction of both contents, and the ability to make reverse conclusion from the formation of the symptom to the particular reason); universal manifestation as clinically neutral, i.e., unusual for a certain group of diseases, education; originality in the character of manifestations (Phillips & Stein, 2015, p. 129).
There are certain difficulties in diagnosing differentiating obsessive-compulsive disorder as compared to other disorders characterized by repetitive behavior. The shortcomings of the existing criteria of modern classifications of compulsive disorders that contribute to this problem are characterized by several factors. Among them, there is the fact that formulation of the need for obsessions and compulsions shows neither basic phenomenology of obsessive-compulsive disorder nor a link between these two phenomena. This fact allows including symptoms that are not really related to obsessive-compulsive disorder (fo example, craving for gambling).
In addition, due to the absence of the functional relationship between obsessions and compulsions (i.e., that the compulsions are performed to reduce the discomfort caused by the obsessions), any disorder characterized by repetitive actions can be attributed to the obsessive-compulsive disorder (for instance, trichotillomania.). Along with that, the emphasis is placed on the external manifestation of compulsive behaviors, repetitive and stereotyped activities. It also does not show the functional features of such behavior including hidden neutralization strategy, which is also used to reduce the discomfort caused by the intrusive thoughts (for example, avoidance) (Becker, Masheb, White, & Grilo, 2010).
Development of Obsessive-Compulsive Disorder
Although specific thoughts and actions with obsessive-compulsive disorder can vary from person to person, a process that is called obsessive-compulsive cycle repeats. As there is such a cyclic recurrence, a person becomes emotionally more sensitive to certain ideas, objects and situations. In other words, people develop a memorized answer, in accordance with which they will automatically start to worry as soon as such thoughts, things or situations occur. For people suffering from obsessive-compulsive disorder, cycles obsessions compulsions can become virtually permanent. In addition, for the development of obsessive-compulsive disorder, comorbidity is characteristic.
The gap between the first symptoms of the disease and the establishment of the diagnosis to start adequate therapy is sufficiently large. For example, in the US population, it starts in an average of 17 years. The development of the disease is characterized by periodic enhancement or suppression of symptoms that are often associated with a stressful provocation as in Carl's case.
Obsessive-compulsive disorder is most often noted in adolescence and young age (Grisham et al., 2011). In patients aged over 35 years, the first symptoms appear less than in 10% of cases. Almost 15% of cases of obsessive-compulsive disorder appear before puberty.
In 85% of patients, development of obsessive-compulsive disorder has an undulating nature with periods of worsening and improvement. In 5-10% of patients, it is a steadily progressive course. Only 5% of patients have true remission when periodical symptoms disappear completely. However, persistent spontaneous remission is observed even more rarely.
Phenomenon of obsessions tends to expand (Federici et al., 2010). Unfortunately, chronic character must be specified as the most prominent trend in the dynamics of the disease. Cases of episodic manifestations of disease or full recovery are relatively rare. However, for many patients, especially with the development and maintenance of some type of symptoms (agoraphobia, obsessive counting, the ritual washing of hands, etc.), long-term stabilization of the state is possible. In these cases, there is a gradual softening of psychopathology and social readaptation. Reverse development of symptoms occurs after 1 year - 5 years from the date of manifestation.
More severe and complex forms of obsessive-compulsive disorder, such as phobia of infection, contamination, sharp objects, contrasting idea numerous rituals, which are evidenced in Carl's behavior can become resistant to treatment, or detect a tendency to recur with preserving symptoms despite active treatment of the disorder. Further negative dynamics of these states indicates a gradual complication of the clinical picture of the disease in general. Thus, one can suggest the negative dynamics of Carl's state.
Modern therapy of compulsive disorder must necessarily include the aspects of a combination of psychotherapy and pharmacotherapy. In contrast to medication, after the abolition of which symptoms of obsessive-compulsive disorder are often exacerbated, an effect achieved due to behavioral psychotherapy lasts for several months and even years. Compulsions are usually more amenable to psychotherapy than obsession (Geoffreys, 2015, p. 44).
Usage of cognitive-behavioral psychotherapy helps to achieve good results in the treatment of obsessive-compulsive disorder. The developed technique allows the patient to resist their disorder, changing or simplifying the procedure of their rituals, and reducing them to the minimum. The basis of the methodology is understanding by the patient of his disease and stepping resistance to its symptoms (Geoffreys, 2015, p. 48).
According to the procedure of four steps developed by Jeffrey Schwartz, it is necessary to explain to the patients, which of their fears are justified and which are caused by the disease. The border between them should be determined explaining to the patient how healthy people would behave in a given situation. It would be better if a person representing the authority for the patient would serve as an example. As an additional technique, the method of stopping the thought can be used (Geoffreys, 2015, p. 50).
The most effective form of behavioral therapy for obsessive-compulsive disorder is exposure and prevention method. Exposure consists in the fact that the patient is placed in a situation, which provokes discomfort associated with obsessions. At the same time, the patient is given instructions on how to resist the implementation of compulsive rituals, which is also known as a warning reaction.
In addition, a group, rational, psychoeducational (education of the patient to be distracted by other stimuli, facilitating the alarm), aversive (use of painful stimuli when the obsessions occur), family and some other methods of psychotherapy are used (Geoffreys, 2015, p. 55).
Treatment with Psychotropic Drugs
Among all classes of psychotropic drugs, most effective in treatment of obsessive-compulsive disorder are antidepressants, especially tricyclic antidepressant clomipramine, which is effective in obsessive states regardless of their nosology both in obsessions combined with depression and in the framework of a neurosis or schizophrenia. In addition, antidepressants from the group of selective inhibitors of serotonin reuptake (sertraline, paroxetine, fluoxetine, fluvoxamine, citalopram, escitalopram) and the antidepressant mirtazapine have been found to be effective (Rego, 2016, p. 56).
With the presence of severe anxiety, in the early days, the appointment of pharmacotherapy by benzodiazepine tranquilizers (clonazepam, alprazolam, hidazepam, diazepam, Phenazepamum) is expedient. In chronic forms of disease, which are not treatable with antidepressants of group SSRIs (about 40% of patients), atypical antipsychotics can be applied (Rego, 2016, p. 56).
Carl is suffering from obsessive-compulsive disorder. It is a disease characterized by compulsive obsessions and compulsions that interfere with normal life. His obsessions are constantly arising unwanted views, concerns, thoughts, images or impulses. Compulsions are his stereotyped repetitive behavior. Carl's obsessions often cause anxiety and compulsive actions or rituals, which are conducted in order to reduce this anxiety. Carl's life is significantly impaired due to the obsessive-compulsive disorder.
Obsessive thoughts and actions are time-consuming and so painful that for Carl, it becomes difficult to lead a normal life. Due to this, his family is suffering and his social life is affected, as well as work performed by him. Unfortunately, most of the people with obsessive-compulsive disorder do not seek help for their illness because they are confused, ashamed or are afraid. Thus, many people suffer pointlessly.