Pat’s History and Situation

Pat Montgomery was referred by her psychiatrist to a clinic specializing in psychological treatments for anxiety disorders. In the three years preceding her referral to the clinic, Pat had participated in two studies examining medications’ effectiveness in treating obsessive-compulsive disorder (OCD). In the first of these projects, Pat had taken a tricyclic antidepressant called Anafranil (clomipramine). In the second study, Pat was prescribed a different type of antidepressant medication, Prozac (fluoxetine). Although both drugs were antidepressants, research has shown that these medications can be effective for OCD. However, Pat’s symptoms had not responded to either drug. Since Pat had not benefited from two of the leading drug treatments for OCD, her psychiatrist recommended that she try a psychosocial approach to her problem.

At the time of her referral to the anxiety disorders clinic, Pat was a 40-year-old Caucasian woman with two daughters (ages 20 and 22). Pat reported that for the past six years, she had been intensely fearful of becoming contaminated by germs that would cause her to come down with some deadly disease. As a result, she would wash her hands several times a day. At the time of her first visit to the clinic, Pat claimed that she washed her hands more than 40 times per day. In fact, the psychologist noticed that Pat’s hands were very red and the skin around her fingernails had receded; each time Pat “cleaned” her hands, she would scour them with a rough pad and detergent. In addition to her handwashing, Pat repeatedly and excessively cleaned other things she came in contact with, including dishes, clothes, furniture, and doorknobs. On a typical day, Pat spent 4 hours washing her hands and cleaning these other objects. Although she usually took one shower daily, Pat would spend 60 to 90 minutes in the shower. When Pat washed her hair, she kept the soap until she counted to 100 to ensure that her head and hair were clean enough and free of contaminants such as germs.

Pat also feared that her food could contaminate her. In addition, she worried that her husband and children could contaminate her food. As a result, Pat kept her food separate from her family’s food and would not allow her family to come in contact with her food (nor would she touch her family’s food). For several food products, Pat kept separate containers for herself and for her family. For example, there were always two milk cartons in her refrigerator: one for her and one for the rest of the family. After completing meals, Pat washed her own dishes before washing her family’s dishes. After washing the dishes excessively (dishwashing often took 45 minutes), Pat spent a great deal of time cleaning her hands.

Pat reported that a principal source of contamination by germs related to funerals, funeral homes, and dead bodies. For example, Pat felt contaminated if she happened to drive by a funeral home or a funeral procession. Pat feared or avoided many objects because she worried that someone who had been to a funeral might have indirectly come in contact with the dead body and might then have come in contact with those objects. There were dozens of objects in Pat’s environment that she feared had been in contact with a funeral (e.g., clothes, shoes, doorknobs, toys, food, and rooms). One reason Pat considered so many things to be contaminated was that she believed something could become contaminated if it came in contact with something else that was already contaminated. For example, Pat owned a purse that she feared was contaminated by a friend of hers who had visited their home. Because this friend had mistaken Pat’s purse for her own, she had picked it up briefly. When Pat learned that her friend had recently attended a funeral, she insisted that her husband take the purse out of the house. Pat demanded her husband take the purse out of the house by going through the window because it was the shortest path out of their home. Her husband complied and put her purse in the storage shed. Although it had been four years since this occurred, Pat had not gone near the shed or the purse, even though the purse contained two hundred dollars and her credit cards. After her friend’s visit, Pat rarely visited other people because she feared they had attended a funeral.

Before Pat would begin washing, she always experienced strong urges to rid herself of germs and contamination. Whereas Pat had attempted to resist her urges to wash in the initial stages of her problem, she noted that she rarely resisted these urges now. In fact, now her attempts to resist the urges often triggered a panic attack. In addition to her fears of contamination, Pat worried that these panic attacks would cause her to go crazy or “flip out” until she gave in to the urges. Once she initiated her cleaning rituals, her panic attack usually subsided quickly.

Unlike some individuals with OCD (see the discussion section of this case), throughout the course of her problem, Pat could recognize that her obsessions and compulsions were excessive and unreasonable. Although Pat could sometimes hold an objective view that her chances of being contaminated were very low, her intense fear of contamination overrode this realization (similar in nature to the per- son who fears and avoids air travel but who can concede that the realistic chances of crashing are remote).

Clinical History

Pat reported that she began to notice the first signs of her problem during her high school years (e.g., she was more concerned with cleanliness than her peers appeared to be). However, not until six years before her first visit to the anxiety disorders clinic were Pat’s symptoms severe enough to warrant a diagnosis of OCD. Pat could not recall any factors (e.g., stressful life events, death or illness in the family, attendance at a funeral) connected to her increase in symptoms six years ago. Pat also could not recall if any of her family or relatives had a history of OCD-related difficulties. However, Pat did report that both her sister and her father had suffered and sought treatment for anxiety problems that appeared to meet the definition of panic disorder.

Since her problem had intensified six years ago, Pat said that her life had been pretty rough. As noted earlier, Pat had sought treatment on two occasions involving drug interventions with little success. Until two years before her first visit to the anxiety disorders clinic, Pat had worked as a vocational counselor at a state-run employment agency. Despite excellent job security and benefits, Pat had quit this position out of her fear of coming into contact with persons who had been to a funeral (or who had been in contact with another person who had been to a funeral). She had been unemployed since then. Pat reported that her family was very supportive of her problem. While her husband would occasionally become frustrated over her compulsions (i.e., washing) and her inability to do certain things or work outside the home, usually he would be cooperative with Pat’s cleaning rituals (e.g., he would take “contaminated” things out of the house and permit her to buy separate foods for herself).

As part of her first visit to the anxiety disorders clinic, Pat underwent a structured clinical interview designed to comprehensively evaluate the anxiety and mood disorders and associated conditions such as substance use and somatoform disorders. In addition to establishing the nature of Pat’s OCD symptoms, this interview revealed a few other problem areas. Although it was not a major concern, Pat reported a strong fear of snakes. More important, Pat reported ongoing difficulties with depression that had begun around the time that she completed the first medication program for her OCD and noticed that she was not getting any better. In addition to feeling down most of the time over the last few years, Pat reported moderate symptoms of poor appetite, sleep disruption, and decreased interest in activities she usually found pleasurable (all symptoms of depression). More recently, Pat reported an intensification in her depression. At the time of the interview, Pat stated that in addition to the symptoms that had been present for the past few years (e.g., poor appetite, insomnia), her depression had been accompanied by loss of energy, fatigability, feelings of guilt, concentration difficulties, and mild thoughts about the possibility that life might not be worth living. With regard to this last symptom, Pat denied thoughts or intent of suicide. She related her depression to her increasing doubts and sense of hopelessness about ever recovering from her symptoms of OCD.

Question 1

From reading the initial situational history and Pat’s clinical history. Please provide a few sentences about the signs and symptoms of her condition. What triggers has she been expressing, and which factors have contributed to her condition?

Question 2

When did Pat first begin to notice the first signs of her condition? Select the best answer.

In early adulthood.
During her childhood.
In junior high school.
During her high school years.
At what age did Pat finally seek treatment for her OCD? Please select the best answer.

15
20
32
40

DSM-5 Diagnosis

On the basis of this information, Pat was assigned the following DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis:

300.30 Obsessive-compulsive disorder, with good or fair insight (principal diagnosis)
300.40 Persistent depressive disorder, late-onset, with intermittent major depressive episodes with the current episode, moderate
300.29 Specific phobia, animal type (snakes)
In accordance with the impression of her therapist, Pat’s symptoms during her first visit to the anxiety disorders clinic were quite consistent with the DSM-5 definition of OCD (American Psychiatric Association, 2013). Although OCD was classified as an anxiety disorder in preceding editions of the DSM, it is now categorized as an obsessive-compulsive and related disorder in DSM-5 (body dysmorphic disorder is another example of a DSM-5 obsessive-compulsive and related disorder, see Case 6). In DSM-5, the essential features of OCD are recurrent obsessions or compulsions that are severe enough to be time-consuming (i.e., they take up more than 1 hour a day) or cause marked distress or significant lifestyle impairment (i.e., interfere with the person’s normal routine, occupational or academic functioning, or usual social activities or relationships).

DSM-5 defines obsessions as possessing both of these features: (a) the person has recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and that in most individuals cause marked anxiety or distress, and (b) the person attempts to ignore or suppress such thoughts, urges, or images or tries to neutralize them with some other thought or action (e.g., by per- forming a compulsion). In the previous edition of the DSM, obsessions were also defined by a third criterion—the person recognizes that the obsessions are a product of his or her mind. This criterion was believed to be important in differentiating OCD from psychotic disorders (such as schizophrenia), wherein intrusive and distressing thoughts or the individuals often perceive images as being inserted into their minds from an outside source. However, this criterion has been replaced in DSM-5 by a specifier that denotes the patient’s level of insight about their obsessive-compulsive beliefs.

Thus, when OCD is diagnosed under DSM-5 criteria, it should be assigned with one of the following three insight specifiers: (a) with good or fair insight (the individual recognizes their OCD beliefs are definitely or probably not true or that they may or may not be true), (b) with poor insight (the individual thinks the OCD beliefs are probably true), or (c) with absent insight/delusional beliefs (the individual is completely convinced that the OCD beliefs are true). As with the specifiers for other DSM-5 disorders (e.g., “with disso- ciative symptoms” in posttraumatic stress disorder), this specifier is included because it conveys more about the nature of the patient’s OCD, including its treatment prognosis. Indeed, there is some evidence that patients who have OCD with poor insight do not fare as well in exposure and response prevention treatment (Foa, Abramowitz, Franklin, & Kozak, 1999; Keeley, Storch, Merlo, & Geffken, 2008). Although it might be argued that the inclusion of the “with absent insight/ delusional beliefs” specifier obscures the diagnostic boundary between OCD and psychotic disorders (e.g., delusional disorder), OCD is diagnosed when the delusional beliefs are directly linked to obsessions and compulsions. The individual does not have other features of schizophrenia or schizoaffective disorder (see Case 16 for a discussion of psychotic disorders). Pat’s OCD was assigned with the “good or fair insight” specifier because she recognized her fears of contamination as somewhat irrational.

Pat suffered from one of the most common types of obsession: thoughts of contamination (e.g., contracting germs from doorknobs, money, toilets, etc.). In addition to fears of contamination, other types of obsessions include excessive doubting (e.g., uncertainty if one has locked the door or turned off appliances; concerns that tasks such as managing personal finances were not completed or were completed inaccurately), fear that one has caused accidental harm to oneself or others (e.g., accidentally poisoning someone, unknowingly hitting a pedestrian while driving), nonsensical or aggressive impulses (e.g., undressing in public, hurt- ing self or others intentionally), horrific or sexual images or impulses (e.g., images of mutilated bodies, images of having sex with one’s parents or a religious figure), and nonsensical thoughts or images (e.g., numbers, letters, songs, jingles, or phrases). Note from this list of examples and the DSM-5 criteria that obsessions may be thoughts, images, urges, and impulses.

DSM-5 defines compulsions as having the following features: (a) they are repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly, and (b) the behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive. Pat experienced one of the most prevalent forms of compulsions: washing and cleaning. Note that the DSM-5 criteria state that compulsions can take the form of either overt behaviors (such as Pat’s washing and cleaning) or mental acts. Other common types of behavioral compulsions include checking (e.g., assuring that doors are locked or appliances are turned off, retracing a driving route to make sure that one has not struck a pedestrian, reexamining waste baskets to ensure that important material has not been discarded) and adhering to certain rules and sequences (e.g., maintaining symmetry such as touching an object with one’s left hand if the object had been previously touched with the right hand, adhering to specific routine or order in daily activities such as putting on clothes in the same order). Types of mental compulsions include counting (e.g., certain letters or numbers, objects in the environment) and internal repetition of material (e.g., phrases, words, prayers) in order to “neutralize” one’s obsessions.

The DSM-5 diagnostic criteria for OCD do not require the person to experience both obsessions and compulsions to be assigned the disorder. For example, studies have indicated that roughly 25% of patients with OCD do not evidence compulsive behavior (e.g., Brown, Moras, Zinbarg, & Barlow, 1993). However, these studies were conducted when earlier editions of the DSM were in place. It was not until the fourth edition of the DSM (published in 1994) that mental acts such as internal repetition were considered a type of compulsion. Thus, there is likely a much smaller proportion of patients with OCD who do not evidence any form of compulsions whatsoever (as low as 2%; see Foa & Kozak, 1995).

A full discussion of the nature and treatment of OCD is presented in the remaining sections of this case. In addition to specific phobia, Pat was assigned persistent depressive disorder, a new category in DSM-5.

What is the purpose of the DSM-5 in the diagnosis of psychopathology? Please select all answers that apply.

The DSM-5 provides a common language forclinicians to communicate about their patients and establishes consistent and reliable diagnoses that can be used in research on mental disorders.
It provides different types of treatment plans.
It is a medical psychiatric assessment system.
The priority was to ensure the best care of patients possible and, in the process, improve usability for clinicians and researchers.