Anxiety Case Study
According
to Hansell and Damour (2008, p. 123), “Obsessive-compulsive disorder (OCD) is a condition involving
repetitive, unwanted, anxiety-producing thoughts and compulsive rituals intended
to protect against anxiety”. Obsessions in this case of psychology, are
upsetting thoughts that are not wanted, and compulsions basically are the
rituals irrationally used repeatedly to neutralize or control the anxious
feelings that the obsessions create. OCD is an anxiety disorder, and someone
with OCD will experience unwanted thoughts and compulsions, which will
interfere significantly with that person’s everyday life. OCD can develop
through a person’s fears, repeated doubts, or even trauma (Hansell &
Damour, 2008). The case of Bess explains more about OCD. An overview of Bess’s
case will be addressed as well as how biological, psychodynamic, cognitive, and
behavioral theories can be applied to developing her treatment to her disorder.
Case Overview
Bess is 27, she is attractive, lives
in an upper class apartment in the nicest part of town, but does not have many
friends. An ordinary evening for Bess would entail a late workday, dinner,
reading or television, a sleeping pill, and an alcoholic beverage prior to
going to bed and falling asleep. Bess is an accountant at a manufacturing
company. She is quite successful because of the many hours she spends at work.
Bess is a perfectionist, which is an advantage to her field of work.
Bess’s parents divorced when she was
10, she had no brothers or sisters. She was raised mostly by her mother and saw
her father only occasionally. Her mother was affectionate, but Bess hardly
remembers the time spent with her mother other than when she encouraged Bess to
improve and regularly enrolled her in lessons, where they would argue about how
much effort Bess put into those lessons. Bess’s mother regularly stressed the
importance of keeping clean and neat, which was something else they argued
over. Bess’s mother nagged her regularly if her room was not cleaned up, and
she would clean it up, but as soon as her mother turned away she would let her
room get messy. Bess’s mother repeatedly stressed that this behavior would be
trouble when she grew up, but failed to explain how. Her mother displayed
excessive distress over cleanliness and ensured Bess thoroughly washed her
hands every time she used the bathroom or touched her genitals for any reason.
Bess’s mother was disgusted by bathroom smells and used various candles and deodorizers
to control the smells. At times, Bess felt unhappy, but when she told her
mother, she would try to change Bess’s feelings right away. She would ask Bess
how she could be unhappy considering the amount of time she spent with her. Her
mother would appear upset if Bess continued to show her unhappiness.
Bess visited her father and enjoyed
her time with him because he was more relaxed. However, he was not successful
and could not keep a steady job. Her father was usually happy and took good
care of Bess when she visited, but her mother was not happy with Bess visiting
her father and tried to sabotage the visits when she could. Bess’s mother would
mention how her father was lazy and did not support the family efficiently
enough.
Bess lived the way her mother
insisted, although she resisted at times, she did well in school and worked
hard and meticulously on assignments. Bess was successful in school but was not
popular and did not involve herself in activities. She spent her time mostly
preparing for assignments and doing household chores instead. Bess was an
active Methodist because her mother raised her that way, and although it was
positive, there were times when she became upset and confused about being a
sinner or being saved. Bess would drown herself in schoolwork or church
activities to avoid the conflicted feelings. When Bess entered adolescence she
became overwhelmed with erotic fantasies. Bess believed this could be against
her religion and tried to manage her fantasies and distract her attention from
them by drowning herself in other activities, such as crosswords and jigsaw
puzzles to stay occupied for a length of time. However, her erotic fantasies
continued to arise, and she began to have orgiastic sessions of masturbating.
Bess interacted with male friends
easily, but did not know how to handle sexual or romantic issues. Therefore,
Bess rarely date. As a senior, she was charmed by a boy who regularly wanted to
have sex, but she refused to. However, on a drunken night, she agreed, and
continued to on a regular basis until she became pregnant and was forced by her
mother to abort the child. Her mother took her away to Europe and when Bess
returned, she discovered that her boyfriend had met someone else.
Bess involved herself into school,
became a top student, received honors, and obtained a career where she was
successful and spent the majority of her time. Vague anxieties continued with
Bess, including worry over dating, marriage, and family. She dealt with these
anxieties by continuing to throw herself into work. However, she simultaneously
experienced cleanliness symptoms similar to those displayed as a child. Her
concerns turned into rituals of thorough cleanings. Bess’s rituals would start
with her touching her anal or genital area. Bess’s ritual involved her taking
off her clothes in a specific sequence. She laid each piece of clothing out in
certain areas of her bed and inspects each piece to ensure they were clean. If
an article of clothing appeared dirty, it was put in the laundry and replaced
with another piece of clean clothing. Bess would scrub her body from her feet
upward using specific washcloths for specific areas. Bess would redress in the
reverse order from which they were taken off. If something was not right in her
mind, she would begin the sequence again, doing this four or five time some
days.
Eventually Bess acquired other
rituals and thoughts that were obsessive. These obsessions and rituals
generally were associated with using the bathroom, sexual issues, or coming
across dirtiness in public areas. Bess’s functioning in her daily life became
affected as her rituals increase. Her time and energy is spent on rituals and
Bess becomes aware of the absurdness of her behavior. However, Bess feels bound
to continue with the rituals and finally seeks help for her behavior.
Biological Perspective
Obsessive
Compulsive disorder is an anxiety disorder as classified by the DSM-IV-TR. One
of the criteria for this classification is the obsessive need to perform a
task, in which are known to the person as a ritual they feel the need to
complete. From a biological perspective, using a PET scan, researchers have
found that the four brain structures work together in unison and become
overactive as a result in a person that has Obsessive Compulsive Disorder
(Meyer, Chapman, & Weaver, 2009). As studied in previous classes, the
orbital frontal cortex operates as a person’s error detection circuit, this
section of the brain alerts the rest of the brain when something is wrong and
needs to be taken care of. In a person
that has obsessive compulsive disorder, this part of the brain is hyperactive,
so this person will keep fixing what they think is wrong such as making sure
the door is locked or the stove is shut off (Meyer, Chapman, & Weaver,
2009). Another section deep in the core of the brain signal that there is something
very wrong is the caudate nucleus and the cingulate gyrus. These parts of the
brain will make a person’s heart pound and give the feelings of anxiety (Meyer,
Chapman, & Weaver, 2009). The section of the brain in which the sensory
information is processed within the thalamus will also work in unison with the
other sections of the brain. When a person with obsessive compulsive disorder
becomes more active metabolically, the other structure do as well, which is not
the case in a healthy person (Meyer, Chapman, & Weaver, 2009).
A person with Obsessive Compulsive
disorder have a tendency of learning these behaviors from their parents or the
people they are around as a child, as in the case with Bess, she was taught to
be obsessive compulsive about keeping her room clean and studying hard by her
mother. Since Bess was raised by a single mother who had very little contact
with her father, Bess was influenced heavily by her mother and how and what she
had been taught growing up.
Psychodynamic Perspective
Since
obsessive compulsive disorder can be difficult to treat, there is a very wide
variety of treatments available in which psychoanalysts have had some success
(Meyer, Chapman, & Weaver, 2009). There is also a danger in this treatment
as an obsessive compulsive individual has a history of using
intellectualization as a defense mechanism, and the technique of free
association in psychoanalysis can be easily abused by intellectualization
(Meyer, Chapman, & Weaver, 2009).
Studies have
also shown that cognitive behavior modification can be effective in the
treatment of obsessive compulsive disorder. In these studies, Schwartz and his
colleagues have shown that cognitive behavioral modification can reverse the
obsessive compulsive physiological “locking up” of the brain and the four
sections that seem to work in unison with the obsessive compulsive individual
(Meyer, Chapman, & Weaver, 2009).
As in the
case with Bess, her treatment started with cognitive behavior modification as
well as thought stopping or response prevention (Meyer, Chapman, & Weaver,
2009). Her therapist set a regiment of thought stopping, Bess was trained to
stop the obsessive behavior as she shouted “stop” and to evaluate her
consciousness. As she did this there was an electric shock that reminded her
that her obsessive thoughts were being disturbed. This thought stopping process
integrated to Bess that her obsessive compulsive behavior could be changed or
controlled, which gave light to being trained in a new way with positive
behaviors.
Cognitive Explanations
Many
cognitive formulations have been created to explain obsessions and compulsions
like OCD, especially by psychologists like Clark (2002), Salkovskis (1985,
1989, 1998), and Rachman (1997, 1998). Although their ideas presented different
components, they all had the common underlying assumptions about the cognitive
roots of OCD, such as the explanations that most obsessions have their origin
in intrusive, distressing, and unwanted thoughts, impulses, and images.
Although these are present in most individual’s minds, some individuals lack
control over them, which results in obsessions (Frost &
Steketee, 2002).
In the case
of Bess, as it happens to most individuals who suffer from OCD, it is possible
to observe the common feature of an enlarged and inflated sense of
responsibilities over outcomes. In other words, patients tend to think that
their actions will eventually lead to harm to themselves or others. In this
case, Bess had a ritual of making sure her body and her clothes were impeccably
clean, by fear of being “contaminated”.
A very
effective treatment for patients like Bess is Cognitive-behavior modification,
which can actually reverse the OCD symptoms. By learning to relabel their
urges, and calling them for what they were (for example, instead of saying “I
need to wash my clothes again”, saying “I’m having a compulsion again”),
patients would learn to swift their attention to another activity and regain
control of their thoughts (Meyer, Chapman, & Weaver, 2009).
Behaviorist Perspective
Behaviorists believe that all behavior can be explained in
terms of rewards and punishments (Kowlaski & Westen, 2011). Therefore Bess
is being rewarded by her environment by performing her rituals and being overly
clean and tidy. When you consider the way that Bess’s mom expressed her love to
her as a child, and when she withheld her love it follows that Beth would do
her best to do things that make her mother love and accept her and avoid
behaviors that result in painful censure. When she was clean and orderly, her
mother Bess praised Bess. When her room or her environment were not clean then
she was punished. To gain the rewarding feeling of her mother’s love Bess
cleans and tries to be as orderly as possible.
Behaviorists also talk about the importance of modeling and
learned behavior (Decker, 2010). Bess did not learn how to cope in a vacuum,
rather she watched her mom deal with everyday stress and chronic stress by
cleaning and in being orderly. When the house was a mess her mother was unhappy
and Bess saw that. Cleanliness brought her mother joy, so Bess would learn this
as a coping strategy and use it when she felt lost and out of control.
In
conclusion, all the theories presented above offer alternatives to
significantly change Bess’ reality of OCD. By analyzing her past experiences
with her mother, having a doctor analyze her brain, and even try to learn new
thought processes, Bess and other patients suffering from OCD can finally
change their behaviors and thoughts and learn to live a normal life. Obsessive
Compulsive disorder is much more common that originally perceived, and it has
no cultural boundaries. Each of the approaches presented has its own specific
advantages to target different cases and challenges. Different theoretical
perspectives can be integrated, allowing therapists and physicians to have an
even broader spectrum of possibilities to help patients.
References
Deckers, L. (2010). Motivation: Biological, psychological,
and environmental (3rd ed). Boston: Pearson/Allyn
&Bacon.
Frost, Randy O., and Gail Steketee. Cognitive Approaches
to Obsessions and Compulsions: Theory,
Assessment, and Treatment. Amsterdam: Pergamon, 2002. Print.
Hansell, J., & Damour, L. (2008). Abnormal psychology (2nd ed.). Hoboken,
NJ: Wiley.
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