Anxiety & Family: Bess' Story - Case Study

Introduction

Bess, a 27-year old woman working as an accountant of a successful manufacturing company presented complaints about anxiety. She has few friends and cannot sleep without taking sleeping pills and alcohol. Bess was primarily brought up by her divorced mother, who was strict but loving and she only met her father occasionally. Bess' mother was inordinately concerned with self-improvement lessons, neatness and cleanliness and that became a point of contention herself and Bess. Also, her mother did not allow her to freely express her unpleasant feelings like other children or visit her father who was less strict with life.

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At school, Bess was disciplined, neat and performed above average. She found growing up in the Baptist church was a good experience for Bess though she worried about whether she was saved or not. She avoided these thoughts by occupying herself with school or church work. At adolescence, she began to have erotic fantasies, which tried to suppress with other hobbies like crossword puzzles that she did for many hours. However, she was occasionally overcome and ended up masturbating. She first had sex as a high school senior after drinking too much at a party, and this was followed by a few weeks of regular sex that led to pregnancy. Bess's mother arranged for an abortion and separated her from her boyfriend.

Bess became a top student and soon progressed into a career woman. She continued to experience vague anxieties about relationships, marriage and family life, which she suppressed with working harder. She gradually began to slip into an obsession with cleanliness. She developed a kind of cleansing ritual that began with the touching of her anus or genitals. She then removed her clothes in a specific sequence and put them in predetermined spots on the bed and inspected them for contamination. She then washed her body starting from her feet to her head, using a different washcloth for each part of the body. She washed any clothing that she perceived to be contaminated and put a clean one in its spot, then dressed in the opposite order that she took the clothing off. Whenever she missed a step in the sequence or was not sure if she might have noticed some contamination, Bess repeated the entire process. Sometimes, she did it even for times or more.

Over time, Bess also developed rituals and obsessions about sexual issues, using the toilet, and getting contaminated in public places. The rituals increased, impairing her functioning as she spent much energy and time in them. Despite her awareness that the behaviors were absurd, she could not resist or question them. Eventually, the behavior began to affect her working ability, making her seek help.

Diagnosis

The symptoms that Bess presented show that she suffers from obsessive-compulsive disorder (OCD). According to the DSM-5 (American Psychiatric Association, 2013, p. 138), OCD is characterized by the presence of either compulsions or obsessions or both. The patient's report has evidence of both obsessions and compulsions. Her obsessions are cleanliness, fear of contamination, and sexual issues. Bess' compulsions are her cleansing ritual, and her other rituals related to the toilet use and sexual issues.

DSM-5 (American Psychiatric Association, 2013, p. 138) further states that in OCD, the obsessions and compulsions have to significantly affect the patient's time management or cause a clinical problem. Bess said that she loses much energy and time in performing her compulsive rituals. Also, the compulsions that OCD patients exhibit are usually either excessive or do not logically relate to their obsessions. In this case, the fixed patterns that Bess strictly adheres to when performing her cleansing ritual have no sensible relationship with her fear of getting contamination at all. Besides, she overdoes the compulsions because she at times goes through the procedure several times a day.

Moreover, Bess reported a history of drug use as she has been taking alcohol since she was a high school senior. However, her symptoms do not point to the existence of another mental disease. Lastly, Bess performs her obsessions and delusions with fair insight because she thinks that the beliefs based on her obsessive-compulsive disorder may or may not be true.

Treatment

Bess's obsessive-compulsive disorder will be treated using cognitive-behavioral therapy (CBT) and medication. Studies have proven that CBT is the most effective therapy for patients suffering from generalized anxiety disorders, social anxiety disorder, phobias, panic disorder among several other mental conditions (Ray, 2018, p.32). CBT is concerned with distortions and negative patterns in how we look at ourselves and the world around us. According to Ray (2018, p.33), the cognitive-behavioral perspective shows that all psychological disturbances are characterized by dysfunctional thinking. Therefore, changing one's behaviors and emotional state as well as thinking patterns requires a therapy that can disclose their thinking.

In particular, Bess will be treated using a type of CBT known as Exposure and Response Prevention (ERP). ERP can be done by a licensed mental health worker such as a mental health counselor, social worker, or psychologist. The method involves exposing oneself to the situations, objects, images and thoughts that start their obsessions or make them feel anxious (Simpson & Hezel, 2019, p. 85). It also involves response prevention, which is about consciously choosing not to allow a compulsive behavior when the obsession or anxiety is triggered (Simpson & Hezel, 2019, p. 88). Owing to the difficulty of resisting compulsions, a therapist has to guide a patient through ERP at the beginning. However, the patient is expected to learn to do their own ERP and control the symptoms after a few weeks of therapy.

Besides therapy, Bess will use medication, which is a biological approach. Although medications are rarely effective when used alone, antidepressants work well in the management of obsessive-compulsive disorder when used alongside therapy.

Prognosis

The patient has shown great potential to attain the expected therapy outcomes because she is young, intelligent, and self-ware. She is excellently motivated to get back to her work, from which she derives great pleasure and is the only source of meaning in her world. She appears anxious about the idea of having to resist her cleansing compulsions since she has tried and failed many times in the past. Apart from her mental disturbances, the patient is in good physical condition. She is expected to be able to safely and successfully practice EPR after 7 sessions of outpatient therapy supervised by a professional. Overall, the patient should completely be in control of her anxieties and compulsions in four weeks.

Discussion

Bess's tough upbringing might have contributed to the development of her OCD in adulthood. McKay (2008, p. 169) states that research has shown that there is a connection between OCD and trauma experienced during childhood. Psychologist Stanley Rachman proposed a theory suggesting that exposing people to stressful situations is likely to make them experience obsessions (McKay, 2008, p. 169). Bess' mother subjected her to trauma by suppressing feelings and overemphasizing her virtues of hard work, cleanliness, and success. As a result, she failed to develop good social skills and resorted to rituals to suppress her emotions and anxieties.

These obsessive thoughts are normally triggered by external cues in the environment. For Bess, the primary external cue was her mother, who also exhibited similar obsessions. Rachman further explains that most people with anxiety disorders believe that they need to suppress or prevent undesirable behaviors, and this is what causes compulsion (McKay, 2008, p. 170). When Bess experienced trauma in her childhood, she likely responded with compulsions to prevent her undesired feelings both at home and school.

Moreover, Bess performs her compulsions to respond to certain obsessions. For example, her cleansing ritual arises from the unfounded fear of getting contaminated through her clothing or contact in public places. The obsessions trigger distress, which she tries to suppress by the repetitive behaviors. Therefore, the patient cannot control the behaviors because they are not voluntary. Therefore, while CBT has been proven to treat OCD, combining therapy with antidepressants enables the patient to overcome the obsessions and compulsions faster.

Finally, CBT as a method of treating anxiety disorders is based on the premise that our feelings are determined by our thoughts and not external events, which only act as triggers (Hofmann, et al., 2012, p. 427). It means that how one feels does not depend on the situation one is in but rather how they perceive the situation itself. CBT has two major components as its name suggests - cognitive therapy and behavior therapy (Hofmann, et al., 2012, p. 430). The cognitive element of this therapy establishes how cognitions or negative thoughts lead to anxiety while the behavior component examines reactions and behavior in situations that cause anxiety.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and Research, 36(5), 427-440. DOI:10.1007/s10608-012-9476-1

McKay, D. (2008). The Treatment of Obsessions. The Primary Care Companion to The Journal of Clinical Psychiatry, 10(02), 169. DOI:10.4088/pcc.v10n0214a

Ray, W. J. (2018). Abnormal psychology. Thousand Oaks, California: Sage Publications, Inc.

Simpson, H., & Hezel, D. (2019). Exposure and response prevention for obsessive-compulsive disorder: A review and new directions. Indian Journal of Psychiatry, 61(7), 85 -92. DOI:10.4103/psychiatry.indianjpsychiatry_516_18