This article discusses about Obsessive Compulsive Disorder and Provisional Social Anxiety Disorder. A detailed case formulation, literature review, treatment goals and treatment plan for a client diagnosed with Obsessive Compulsive Disorder and provisional Social Anxiety Disorder
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Obsessive Compulsive Disorder and Provisional Social Anxiety Disorder
A detailed case formulation, literature review, treatment goals and treatment plan for a client diagnosed with Obsessive Compulsive Disorder and provisional Social Anxiety Disorder
Referral Source: General Practicioner
Diagnosis: Obsessive Compulsive Disorder with provisional diagnosis of Social Anxiety Disorder
Client Age: 27 years old
Client Gender: Female
Marital Status: Married (for 3.5 years)
Children: 2 year old son
Employment: Part time work in a nursing home,
Study: Studying nursing part time
Andrea reports that she has difficulty trying to relax and worries about what people think of her, especially when it comes to how tidy her house is. She has rules about how her house should be maintained and as a result engages in compulsive cleaning, straightening and ordering behaviour (explained in more detail under perpetuating factors) to manage her anxiety and avoid distress.
She also expects her husband and son to live by these rules and becomes agitated and angry if they do not. Andrea has a good level of insight, as she is aware that her rules are excessive. She wants to be able to relax more and improve her relationships with her husband and son.
Andrea’s parents separated when she was a child, which may have predisposed her to developing her current symptoms. Andrea received some counseling after her parents separated, which indicates that the separation may have caused significant distress for her. Andrea has displayed obsessive compulsive symptomology from early childhood, which could indicate an ongoing chronic condition.
Andrea reported that she has created rules for herself for as long as she can remember. For example, keeping her bedroom immaculate and only going to bed on a palendromic number when she was a child. Andrea reported that if she didn’t do these things, she would worry that bad things would happen to her or her family.
Andrea has a two-year-old son and reports that she finds it particularly difficult to keep her house tidy, finding herself getting frustrated, angry and agitated when her son and husband make a mess and don’t abide by her rules. It is possible that Andrea is finding it difficult to cope with the demands of parenting a toddler who is becoming increasingly more autonomous, balancing work, study and housework (especially with her rules about how her house must be kept).
Andrea worries about what other people will think of her, particularly in relation to the cleanliness and order of her house. As a result of this and her rules about how things should be, Andrea typically spends several hours a week cleaning her house, which increases if she is having people over. Andrea’s rules about how her house should be maintained, include; always having the labels of the pantry facing the same way, standing fruit juice in the fridge in a particular order and having the TV volume set at an even number at all times.
This creates a perpetuating cycle, as Andrea’s anxiety about things not being perfect and concern about what people think of her perpetuate her compulsive cleaning, ordering and straightening behaviours. Andrea also avoids social situations, as she fears she will be embarrassed or that people will see how horrible she is, which is likely one of her irrational beliefs.
Andrea endures social situations if she is forced to and does not talk to others through fear she might say something stupid (another irrational belief). Other psychological factors reported include; an ongoing belief that she has failed at everything she has ever tried, despite evidence to the contrary, feeling horrible about her life and having no direction, thoughts that there is no point getting motivated about anything and that she is not well liked by others. Andrea’s negative core beliefs seem to be focused around themes of worthlessness and hopelessness and her distress about not being able to keep her house tidy may be perpetuated by cognitions about feeling helpless.
Andrea has good insight and recognises that her rules are excessive. Even though Andrea initially appeared apprehensive about counseling, she demonstrated some motivation for change, as she was able to identify the things she would like to work on and improve in her life. She has important relationships in her life (with her husband and son), which she hopes to improve through therapy and is working and studying nursing, which would suggest that she values caring for and supporting others.
A brief clinical interview with the client and a mental status examination were the basis for the following primary and provisional diagnoses using the Diagnostic and Statistical manual of Mental Disorders (DSM-5):
300.3 (F42) Obsessive Compulsive Disorder, with good/fair insight
300.23 (F40.10) Social Anxiety Disorder (Social Phobia)
Andrea also met some of the criteria for a depressive disorder, possibly Major Depressive Disorder or Dysthymia.
Rationale for Diagnosis of OCD
Andrea’s symptoms fit the diagnostic criteria for Obsessive Compulsive Disorder, as outlined in the DSM-5. Andrea’s compulsions to arrange, order and straighten things in her house are often present and are linked to her obsessive concerns and rules about symmetry, order and exactness (American Psychiatric Association, 2013). Andrea’s obsessions cause discomfort and provoke anxiety and distress, which she tries to avoid or neutralize by engaging in compulsive behaviour (APA, 2013).
In his book, Treatment Plans and Interventions for Obsessive-Compulsive Disorder, Rego (2016) outlines five obsessional themes typically associated with OCD: (1) fear of contamination, (2) doubting ones actions and/or conversations, (3) Unacceptable thoughts or impulses directed towards self and others, (4) concerns about symmetry, ordering, completeness, exactness and the need for things to be just right, and the need to maintain a rigid routine, and (5) Other, miscellaneous obsessions that don’t fit neatly into the above categories.
The most common examples include obsessions about numbers. Rego (2016) also outlines six types of compulsions typically associated with OCD; (1) frequent washing and cleaning, (2) checking more than is necessary, (3) repeating specific phrases or redoing routine actions, (4) counting compulsions, (5) arranging and ordering things so they are straight, sequenced, or in a certain order, and (6) needing to ask, tell or confess. In the following discussion, Andrea’s obsessions and compulsions are discussed in relation to the above categories and to the criteria for OCD from the DSM-5.
Andrea experiences obsessions and compulsions about symmetry, ordering and exactness and needs for things to be organised and arranged in a particular way (e.g., having all the labels in the pantry facing the same way). She also needs objects to be placed on surfaces in specific ways, i.e. standing the juice in the fridge in a particular order. Andrea also has a strong preference for certain numbers (i.e. even or palendromic numbers) and has particular rules about needing the TV channel to be set at an even number (Rego, 2016).
Andrea becomes quite distressed and agitated if her rules about the maintenance of her house are not adhered to until she is able to put things back the way she likes them. There is also historical evidence to suggest that she may fear that harm will come to herself or her family if she does not live by these rules.
Andrea neutralises her obsessive thoughts through various compulsive behaviours. These behaviours appear to be aimed at reducing the distress associated with her rules not being met and fear of judgment by others (which may be related to symptoms of Social Anxiety Disorder, which will be discussed in the following section).
Andrea’s rigid rules, obsessions and compulsions cause significant distress, take up many hours of her week and significantly interfere with her relationships with her husband and son, especially now her son is getting older and becoming more autonomous and unpredictable.
More information is needed to confirm a diagnosis of OCD and to ascertain whether Angela is fearful of harm coming to herself or her family if she does not perform certain rituals etc, as she did when she was a child. See section on Treatment Plan and Interventions below for a discussion on how this information will be gathered.
Rationale for Provisional Diagnosis of SAD
Andrea avoids social situations as she fears the scrutiny of others and believes that she will embarrass herself. She also worries excessively about what other people will think of her, fears humiliation in front of others, and believes she is not well liked, which fits criteria A for Social Anxiety Disorder (American Psychiatric Association, 2013). Andrea fears that she will act in ways that will be negatively evaluated, i.e., she will be embarrassed, or people will see how horrible she is, or that she will say something stupid (criteria B for SAD).
Social situations appear to provoke fear and anxiety (criteria C), as she avoids them if she can and if forced to attend a social event, Andrea tries not to speak through fear that she will say something stupid (Criteria D). She also reports cleaning more excessively if she is having people over (which could be a feature of SAD that triggers her OCD symptoms).
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Andrea’s negative self-evaluations seem to perpetuate her avoidance of social activities. It is unclear how long Andrea’s social avoidance and anxiety has persisted, however, there is evidence to suggest that her childhood rituals, obsessive thoughts and compulsive behaviours may have prevented her from spending time with her peers as a child, which may have predisposed her to the development of SAD symptomology.
While Andrea’s SAD symptoms appear to significantly impact her social functioning, it is unclear whether they cause clinically significant distress. As she manages to attend work and university, it is unclear how significantly Andrea’s anxiety impacts her day-to-day life outside of the home. More information is needed to confirm a diagnosis of SAD. See section on Treatment Plan and Interventions Below for a discussion on how this information will be gathered.
Andrea meets some of the criteria for Major Depressive Disorder and/or Dysthymia, including; depressed mood that comes and goes, loss of interest and enjoyment in usual activities and lack of motivation, as well as reduced self esteem, feelings of worthlessness and a sense of failure, which are all common features of MDD and Dysthymia (American Psychiatric Association, 2013).
Andrea does not fit the criteria for Panic Disorder or General Anxiety Disorder. However, Andrea does meet DSM criteria for social anxiety disorder, see discussion above (American Psychiatric Association, 2013).
Autism spectrum disorder:
Social anxiety and social communication deficits are characteristic of autism spectrum disorder (APA, 2013). However, Andrea’s presentation is similar to individuals with social anxiety disorder, as she has appears to have age-appropriate social relationships and social communication capacity (American Psychiatric Association, 2013). She appeared to have impairment in these areas during the initial assessment, however, this is common when first interacting with unfamiliar peers or adults (American Psychiatric Association, 2013).
Andrea’s obsessions and repetitive behaviours are also similar to those often seen in ASD, however, Andrea does not seem to derive any pleasure form her excessive tidying. Her behaviour appears to be associated with neutralizing and avoiding anxiety and distress, as seen in OCD.
Major depressive disorder:
Andrea does meet some of the criteria for MDD and Dysthymia, however more information and further assessment is needed to conform or rule this diagnosis out.
Other obsessive-compulsive and related disorders:
Andrea’s obsessions and compulsions are not related to concerns about physical appearance, as in body dismorphic disorder. No evidence of trichotillomania (hair-pulling disorder), excoriation (skin picking), or hoarding behaviour.
Other compulsive-like behaviors.
Andrea does not appear to display other addictive behaviours that are considered compulsive, such as unhealthy sexual behavior, gambling, and substance use.
Obsessive-compulsive personality disorder.
Obsessive compulsive personality disorder is not characterized by intrusive thoughts, images, or urges or by repetitive behaviors that are performed in response to these intrusions; therefore, Andrea does not meet the criteria for OCPD.
Cognitive Behavioural Models of Obsessive Compulsive Disorder and Social Anxiety Disorder
The following discussion will focus on cognitive behavioural models of OCD and SAD. Cognitive-behavioural models are the most widely established theories in explaining and understanding Obsessive Compulsive Disorder (Dykshoorn, 2014), as well as other disorders, such as MDD and SAD (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012).
Beck’s 1976 Specificity Hypothesis proposes that different types of dysfunctional beliefs cause different types of psychopathology. For example, beliefs about being a failure, negative self-appraisals and feeling a sense of loss are all cognitions associated with MDD (Beck, 1976). Social Anxiety Disorder on the other hand is believed to be associated with beliefs about judgment and ridicule from others and fear of rejection (Beck and Emery, 1985).
Cognitive-behavioural models of OCD suggest that intrusive thoughts are almost universal and experienced by around 8090% of the general population (Briggs & Price, 2009). Furthermore, the content of irrational thoughts in the general population are indistinguishable from clinical obsessions (Rachman & de Silva, 1978). So why don’t the majority of people develop OCD?
The difference between a normal and an obsessional intrusive thought lies in the meaning an individual attaches to it and their response to their obsessional thoughts. Individuals with OCD attach significant meaning to the occurrence and/or content of their intrusive thoughts and therefore find it difficult to dismiss them (Rachman, 1997). Individuals diagnosed with OCD can take on personal responsibility for events related to their thoughts, believing if they think about certain things, they will happen unless they do something to prevent it or take extra precautions to ensure it doesn’t happen (Dykeshoorn, 2014).
Salkovskis (1985) was one of the first to develop a comprehensive cognitive-model of OCD that combined behavioural theory and cognitive theory. Behavioural therories alone ignored the obvious link between cognition and psychopathology and Salkovskis (1985) hoped that combining it with cognitive theory would help clinicians to develop new approaches and interventions to treat OCD more effectively.
Salkovski’s model suggests that individuals who struggle with obsessional thinking actively avoid potentially triggering stimuli. When the intrusive thought is viewed as being important and the individual places meaning on it, the perso’s belief system shifts. The person takes on ownership, responsibility, or blame for the intrusive thoughts, which become automatic thoughts and result in psychological distress (Salkovskis, 1985).
In Salkovskis (1985) model, the individual with OCD engages in neutralizing behaviour to reduce the distress of compulsive thoughts (i.e. only going to bed on a palendromic number to neutralise the distress that if this doesnt happen, harm will come to family members), which in turn reinforces this behaviour.
Salkovski (1985) found that if the neutralizing behaviour does not succeed in reducing anxiety, those with OCD feel some relief that if they perform the compulsion/ritual behaviour then the unwanted event may not happen. This can be a strong reinforcer and encourage more neutralizing behaviour in the future (Salkovski, 1985).
Salkovskis theory created the groundwork for more advancement of the cognitive-behavioural understanding of OCD.
Following on from Salkovski’s (1985) cognitive theory, Rachman (1997) proposed a cognitive theory of obsessive thoughts. Rachmans (1997) theory suggests that obsessions are caused by catastrophic misinterpretations of the significance one places on intrusive thoughts. As noted above, most people experience intrusive thoughts, but Rachman (1997) identified differences between typically intrusive thoughts and atypical obsessional thoughts.
Rachman found that obsessions last longer, have a greater intensity, are more persistent, cause greater distress, and have a more lasting impact (Rachman, 1997). To differentiate between problematic and typical obsessions, Rachman (1997) identified that the meaning an individual places on an intrusive thought can change a typically experienced thought into an obsession. For example, those with OCD often interpret these thoughts as being very important, personally significant, threatening, or catastrophic (Rachman, 1997).
Rachmans (1997) theory also suggests that heightened stress often triggered obsessional thoughts and found that the more stressful the external stimuli, the greater the frequency of intrusive/obsessional thoughts and subsequently, the greater the distress the individual experienced (Rachman, 2002). In 2002, Rachman suggested a similar theory for compulsions (specifically, compulsive checking) where compulsions occur when an individual believes they have a special responsibility to prevent unwanted events from occurring.
Cognitive Behavioural Models of Social Axiety Disorder
Clark & Wells (1995) and Clark (2001) developed a cognitive model for the maintenance of SAD, which is an adaptation of the ABC formula. The model suggests that when an individual with social anxiety enters a social situation, certain rules (e.g. I must always appear intelligent and be liked by others), assumptions (e.g. If people really get to know me they will see how horrible I am) or unconditional beliefs (e.g. I’m stupid and not well liked by others) are activated (Clark, 2001).
When an individual believes they are in danger of negative evaluation or possible humiliation, their attention is directed towards detailed self-observations and monitoring of bodily sensations (Clark and Wells, 1995). Therefore, socially anxious individuals use this internal information to presume that others are evaluating them negatively.
Recent research supporting the efficacy of Clark’s (2002) approach, suggests that recurrent images associated with SAD can be activated by asking clients to recall a social situation associated with extreme anxiety and that these images are often linked to early memories (Priyamvada, Kumari,Prakash, &Chaudhury, 2009).
Priyamvada et al. (2009) suggest that the therapist can ask the client when they remember first having the experience represented in the recurrent image and recall the sensations and meaning attached. For example, someone who had an image of being stupid remembering being teased as a child for answering a question wrong in class and being laughed at, which resulted at the time in feelings of humiliation and rejection. Safety behaviours and anticipatory and post-event processing are also factors that maintain social anxiety (Salkovskis, 1991).
Evidence Based Interventions for Obsessive Compulsive Disorder and Social Anxiety Disorder
Cognitive Behavioural Interventions are the most widely researched and well validated treatment interventions for a number of different disorders, including OCD, SAD and Depression (APS, 2010). The following literature review will outline relevant systematic reviews and randomized control trials demonstrating the effectiveness and efficacy of CBT, specifically Ex/RP, in the treatment of OCD and SAD. The literature review was conducted using the following databases: PsycINFO, ProQuest, EBSCO Host and MEDLINE Complete. The evidence reviewed and recommendations for treatment will be discussed below.
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In the most recent review of evidence-based research conducted by the Australian Psychological Association (APS, 2010), level I evidence was found for CBT in the treatment of OCD, SAD and MDD in adults. Level I evidence refers to there having been a systematic review of all relevant randomized control trials and level II evidence implies that there has been at least one properly designed randomized control trial demonstrating the effectiveness of a particular therapeutic intervention.
Level II evidence has also been found for self-help (primarily CBT-based) in the treatment of obsessive-compulsive disorder (OCD) in adults, and one study provided Level IV evidence (through four case examples) for acceptance and commitment therapy, however, they will not be discussed in this review.
Historically, OCD has been considered relatively difficult to treat. The first significant breakthrough in the treatment of OCD was when Myer (1966), successfully treated two clients with a behavioral therapy program which is now referred to as exposure and ritual prevention (Ex/RP). Exposure refers to prolonged exposure to objects and situations that the client finds distressing in combination with prevention of rituals (compulsive behaviours) (Foa, 2010).
In subsequent trials, Meyer and his colleagues (1966) found that Ex/RP was highly successful in 10 out of 15 cases, and moderately effective in the remaining cases. Furthermore, it was found that only two patients in the case series relapsed post treatment.
Due to the success of Meyer (1966) and his colleagues in treating OCD, a number of clinical researchers conducted controlled research studies examining the effectiveness of Ex/RP to build on their findings. In 1971, Rachman Marks and Hodgson conducted a treatment study of 10 inpatients with chronic OCD who received 15 sessions of relaxation control treatment before being treated with Ex/RP.
They found that those treated with Ex/RP had a significant reduction in their OCD symptoms and that individuals in the study had maintained their reduction in symptoms and not relapsed at a 3 month follow-up. Furthermore, at a 2-year follow-up, three quarters of the participants continued to maintain their improvements, suggesting that Ex/RP is effective in the long term reduction of OCD symptoms.
Following on from Rachman, Marks, and Hodgsons (1971) research, Foa and Goldstein (1978) conducted a comprehensive study of 21 adults diagnosed with OCD and assessed the severity of OCD symptoms before and after treatment. Information about the history and type of OCD symptoms was collected prior to treatment and then patients were treated with EX/RP. Foa and Goldstein (1978) used imaginal exposure (which involves asking the individual to imagine the distressing thoughts or situations in detail) in addition to in-vivo exposure (exposure in real life, in their homes etc) in the EX/RP treatment (Foa, 2008).
The majority of patients in Foa and Goldstein’s (1978) study were treated as outpatients rather than as inpatients, which differed from previous studies, which provided evidence that ExRP techniques can be well utilised in the persons home and other common environments where most of the compulsive behaviour is predicted to occur.
In contrast to the severity of OCD symptoms measured before treatment, a highly significant improvement was found in symptoms after EX/RP treatment. Furthermore, 66% of patients were very much improved and 20% partially improved at a post treatment follow up (Foa, 2008). Three patients did not benefit from the treatment program, which was attributed to poor insight, which could be a complicating factor in the treatment of OCD.
More recently, a meta-analysis examining data from 15 clinical trials of Ex/RP, CT and active and passive control conditions found that, overall, approximately two thirds of the patients who completed treatment improved, but only a third met the criteria for recovery from OCD (Eddy et al., 2004).
Findings were stronger for EX/RP than CT, and individual therapy was more effective than group therapy (Eddy et al., 2004). Following on from this, Rosa-Alcazar et al (2008) conducted a meta-analysis examining data from 19 controlled psychotherapy studies for OCD. No significant differences were found between EX/RP and CT and both treatments alone and in combination were found to be highly effective.
Foa (2010) in a review of evidence based treatments for OCD, reported that it is possible that EX/RP is more effective than CT, but that the studies comparing EX/RP with CT often avoided the use of cognitive elements in EX/RP which resulted in an incomplete application of EX/RP, whereas CT in research studies usually includes elements of exposure (Rosa-Alcazar et al., 2008).
Despite the efficacy of Ex/RP, engaging in exposures can be either too overwhelming or may not result in complete resolution of symptoms (Brauer, Lewin and Storch, 2011). As a result, more recent research has included methods to enhance motivation to engage in exposures or alternatively strengthen cognitive components of treatment. Motivational interviewing (MI) is a strategy that helps to prepare an individual for change and also increases feelings of self-efficacy in making the desired change (Merl