Case studies

1. Obsessive compulsive disorder Case 1

2. Case Summary • 20 year old female belonged to lower class family of Azad Kashmir. • She came up with the symptoms of loss of interest, anxiety, irritability, irrational recurrent thoughts, night mares, obsessions and compulsions, loss of appetite and insomnia. • Interviews with her and her mother, along with Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was administered for assessment. • According to DSM 5 criteria and results of the psychological tests as well as case history and behavioral observations indicate that client is having Obsessive Compulsive Disorder 300.3. • Recommended treatment includes Cognitive-Behavior Therapy (CBT), family therapy and Anxiety management techniques for OCD.

3. Presenting complaints • Mujygandagideikh k ghabrahathotihai • gandicheezenmjsebardashtnhihoten • Mjybechainisimehsooshonylgtihai • Mujykhuwab m apny hr trfgandaginazrati hen or isiwjh s main so b nhipati

4. Clinical symptoms According to DSM 5 • Loss of interest • Insomnia • Irrational recurrent thoughts • Anxiety • Irritability • Night mares • Obsessions & compulsions

5. Diagnostic criteria • DSM-5 Diagnostic Criteria for Obsessive-Compulsive Disorder (300.3) • A.    Presence of obsessions, compulsions, or both: • Obsessions are defined by (1) and (2): • 1. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. • 2.The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). • Compulsions are defined by (1) and (2): • 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. • 2.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 are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. • Note: Young children may not be able to articulate the aims of these behaviors or mental acts. • B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. • C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. • D. The disturbance is not better explained by the symptoms of another mental disorder

6. Personal history • Childhood history According to the referral, all the prenatal or postnatal development milestones of the patients were normal and there were not any noted deviations or complications. She was last born child and only sister of 3 brothers. She was very active and playful child. • Educational history • Patient had studies up to 9th grade. She was an average student. She had great respect for her teachers and had very good relations with them. She left education after the death of her father due to poor financial condition of her home.

7. Contd. • Family history: patients’ family has no history of any medical and psychological disorder. • pre-natal history: Patients’ birth was normal with no prenatal complications. She was a normal and healthy child with average weight. • post-natal history: According to clients referral she achieved all her developmental milestones timely.

8. Medical history She was physically healthy individual. All base line tests cholesterol, blood, thyroid and diabetes were normal. And there was no problem indicated in these tests. • Sexual History Client reported that she reached puberty at the age of 13. and it was normal experience for her as she was well informed. She got information related to puberty and sexual matters from her mother. The client reported that she was not worried at all over her physical changes.

9. Premorbid Personality • Before the onset of the illness client had been very kind, active, caring, loving personality. According to her she is still kind and helpful to others. she has been taking interest in almost all activities of life. she was not very social and confident that’s why she has limited friends. She remains at home most of the time and helps her mother in cleaning , dusting and washing clothes. she used to share her things with her brothers. • She was the last born and only daughter so she was very attached with her father .

10. Onset of illness • Patient had suffered from typhoid fever few months back which she recovered. Her symptoms deteriorated from last 2 months. She had become irritable, experience obsessions about germs and dirt along with compulsions and night mares. • Her mother reported that she spent most of her time in washing clothes or cleans hands 20 times a day for about 15 minutes.

11. In Formal assessment • The patient was interviewed casually about his problems after rapport building. • Patient’s history was taken from herself and her referral was also interviewed to cross check his report. • The clients’ behavior was also observed to note any resistance. • When complete information was obtained , patient was assessed formally with the help of standardized tests.

12. Formal assessment • The patient was assessed formally by these tests. • Yale-Brown Obsessive Compulsive Scale (Y-BOCS) • Manifest Anxiety scale.

13. Yale-Brown Obsessive Compulsive Scale (Y-BOCS) • Yale-Brown Obsessive Compulsive Scale (Y-BOCS) Is commonly used a research tool for assessing Obsessive Compulsive symptoms, and is used in adolescent aged 14 and above. • It is a scale of 10 items first 5 items measures obsessions and 6-10 items are designed to check compulsions • Patient scored 29 (13+16) on the scale which indicates severe OCD.

14. Manifest Anxiety scale. • The utility of the MAS is that it is a way to relate anxiety directly to performance in a certain area. The scale is able to measure anxiety levels and use the scores to determine performance on certain tasks.  • Essentially, the scale measures, trait-anxiety, that is , the tendency to experience anxiety in a wide range of situations. Subjects’ total scores on MAS was found to be 36, which is above the cut of score of 25 revealed her anxiety symptoms.

15. Tentative diagnosis Obsessive compulsive disorder 300.03 pg # 237

16. Differential Diagnosis • Anxiety disorders • major depressive disorder • Eating disorders • Tics (in tic disorder) and stereotyped movements. • psychotic disorders • obsessive-compulsive personality disorder

17. Case formulation The causes of OCD are not fully understood There are several theories about the causes of OCD, including: • Compulsions are learned behaviors,which become repetitive and habitual when they are associated with relief from anxiety.  • OCD is due to genetic and hereditary factors.  • Chemical, structural and functional abnormalities in the brain are the cause. • Distorted beliefs reinforce and maintain symptoms associated with OCD. • It is possible that several factors interact to trigger the development of OCD. The underlying causes may be further influenced by stressful life events, hormonal changes and personality traits.

18. Obsessive-Compulsive Disorder Treatment and Therapy • Pharmacotherapy : Anti-depressant medications, specifically several SSRI’s, have been used to treat OCD, along with the concurrent use of Cognitive-Behavior Therapy. 

19. Obsessive-Compulsive Disorder Treatment and Therapy • Various treatments have been effective in reducing the symptoms of OCD. • Evidenced-based treatments such as Cognitive-Behavior Therapy (CBT) techniques are typically the first-line course of treatment, which primarily consist of Exposure and Response (Ritual) Prevention methods. Psycho education plus relaxation training (PRT) may be used to treat severe functional impairment in children. Modifying family accommodation strategies has also been used with PRT (Piacentini et al., 2011). • We can mentally rehearse with them a typical time in which the obsessive compulsion rears its head, using the SALT technique: Stop and focus on what is happening. Ask the OCD what it is trying to do for you right now. Listen to what it’s trying to do for you (such as trying to make you feel safe or in control). Think of three ways you could feel safer or more in control outside of the OCD, and write them down.

20. Contd. • Family therapy : Obsessions and compulsions can frequently interfere with the lives of all family members who live with someone who evidences Obsessive-Compulsive Disorder. The attitude and reaction of family members toward an individual with OCD can have a significant impact (positive or negative) with respect to the course, severity and treatment effectiveness. • Anxiety management techniques for OCD Anxiety management techniques can help a person to manage their own symptoms. Such techniques can include relaxation training, slow breathing techniques, mindfulness meditation and hyperventilation control. 

21. Reference • https://www.theravive.com/therapedia/obsessive--compulsive-disorder-dsm--5-300.3-(f42) • https://thriveworks.com/blog/obsessive-compulsive-disorder • https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/obsessive-compulsive-disorder#causes-of-ocd • https://www.unk.com/blog/3-vital-cbt-techniques-for-ocd/

23. Bipolar 1 disorder, most recent episode manic with psychotic features (296.44). Case 2

24. Case Summary • Client was 22 year old female belonged to lower class family of Chakwal. • She is divorced and is living with her mother and brothers. The patient had 4 brothers, all were unmarried. She was brought to Pakistan institute of Medical Sciences hospital by her brother and maternal grandmother. • She came up with the symptoms of Aggressive outbursts most of the time, restlessness, repetition of words, hallucinations and grandiose delusions. • Interviews with her and her grandmother, along with The Bipolar Spectrum Diagnostic Scale (BSDS) and Young Mania Rating scale were administered for assessment. • According to DSM 5 criteria and results of the psychological tests as well as case history and behavioral observations indicate that client is having Bipolar 1 disorder, most recent episode manic with psychotic features (296.44). • She is taking medical treatment as well as psychological treatments. Recommended treatment includes Cognitive Therapy (CT), social support group and Interpersonal therapy

25. Presenting complaints • Mujylgtahaimujynenedaarhihaiagr main so gai to main coma m chalijaongi • Merizindagiaik din kahani ban jayegi or sb log uskoparhengy • Merypaasitnailmhaijiskikoiintihanahiagrksi n meri bat namani to main qayamat le aongi • Jo kuch ho rhahaiqayamatkinishanihai • Meryjism or sar m shadeeddardhotahaijbzikrkrtihon to theak ho jatahai

26. Clinical symptoms According to DSM 5 • Insomnia • Restlessness • Repetition of word • Aggressive outbursts most of the time, • hallucinations and • grandiose delusions.

27. Diagnostic criteria • A . Currently (or most recently) in a manic episode.B. There has previously been at least one major depressive episode, manic episode, or mixedepisode.C. The mood episodes in Criteria A and B are not better accounted for by schizoaffective disorder and are not superimposed on schizophrenia, schizophreniform disorder, delusional disorder, or psychotic disorder not otherwise specified.Specify (for current or most recent episode: • Severity/psychotic/remission specifiers • With catatonic features • With postpartum onset • Longitudinal course specifiers (with and without interepisode recovery) • With seasonal pattern (applies only to the pattern of major depressive episodes) • With rapid cycling

28. Personal history • Childhood history According to the referral, all the prenatal or postnatal development milestones of the patients were normal and there were not any noted deviations or complications. She was first born child and only sister of 3 brothers. She was very active and playful child. • Educational history • Patient had studies up to 7th grade. She was an average student. She had great respect for her teachers and had very good relations with them. She left education when her father divorced her mother, due to poor financial condition of her home.

29. Medical history She was physically healthy individual. All base line tests cholesterol, blood, thyroid and diabetes were normal. And there was no problem indicated in these tests. • Sexual History Client reported that she reached puberty at the age of 13. and it was normal experience for her as she was well informed. She got information related to puberty and sexual matters from her mother. The client reported that she was not worried at all over her physical changes.

30. Contd. • Family history: patients’ maternal grandfather and maternal aunt also experienced bipolar disorder. • pre-natal history: Patients’ birth was normal with no prenatal complications. She was a normal and healthy child with average weight. • post-natal history: According to clients referral she achieved all her developmental milestones timely.

31. Premorbid Personality • Before the onset of the illness client had been very kind, active, caring, loving personality. According to her she is still kind and helpful to others. she has been taking interest in almost all activities of life. she has been social and confident that’s why didn’t get time to get mingle. she used to share her things with her brothers. • After her marriage she became quiet and hesitant due to harsh and aggressive behavior of her husband and mother-in-law.

32. Onset of illness • Patients’ symptoms has deteriorated from last three months. she has become overly agitated, aggressive. Moreover, she experience racing thoughts and crying spells. • The major stressor contributing to her illness were parental divorce , economic stressors, marital conflict which ended in divorce and her concerns for two year old son who is in custody of her cruel ex-husband.

33. In Formal assessment • The patient was interviewed casually about his problems after rapport building. • Patient’s history was taken from herself and her referral was also interviewed to cross check his report. • The clients’ behavior was also observed to note any resistance. • When complete information was obtained , patient was assessed formally with the help of standardized tests.

34. Formal assessment • The patient was assessed formally by these tests. • The Bipolar Spectrum Diagnostic Scale (BSDS) and • Young Mania Rating scale

35. The Bipolar Spectrum Diagnostic Scale (BSDS) • is a descriptive story that captures subtle features of bipolar illness. The English version of the scale consists of 19 question items and two sections. It differs from most scales in that it does not list separate items, but rather presents a short paragraph talking about experiences that people with bipolar spectrum disorders often have. The person checks off which phrases or experiences fit them. Bipolar spectrum disorder includes bipolar I and II, and other cases not meeting criteria for those disorders. • The Bipolar Spectrum Diagnostic Scale (BSDS) was used to test the severity of the subject’ illness . • The patient scored 15 on BSDS which is above than cut of score indicates that she is experiencing moderately high level of disorder.

36. Young Mania Rating scale • The Young Mania Rating Scale (YMRS) is one of the most frequently utilized rating scales to assess manic symptoms. The scale has 11 items and is based on the patient’s subjective report of his or her clinical condition over the previous 48 hours.. The items are selected based upon published descriptions of the core symptoms of mania.. There are four items that are graded on a 0 to 8 scale (irritability, speech, thought content, and disruptive/aggressive behavior), while the remaining seven items are graded on a 0 to 4 scale. • Young Mania Rating Scale was used to test the severity of the subject’ illness • Her Y-MRS score was40, indicating severity.

37. Bipolar 1 disorder, most recent episode manic with psychotic features (296.44). Tentative diagnosis

38. Differential diagnosis • Major depressive disorder • Other bipolar disorders • Generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or other anxiety disorders • Substance/medication-induced bipolar disorder • Personality disorder

39. Case formulation • Genetic Studies:The risk of BD among children of BD parents is four times greater than the risk among children of healthy parents. However, the risk to children of BD parents of developing a non-BD psychiatricdisorder (for example, attention deficit hyperactivity disorder) is 2.7 times greater than the risk to children of healthy parents. Thus, aproportion of the familial risk

40. NeurotransmitterDeregulation Three neurotransmitters have received the mostattention in studies of mood disorders: nor epinephrine, dopamine, and serotonin. The original neurotransmitter models suggested depression was tied to low levels of nor epinephrine and dopamine, whereas mania was tied to high levels of nor epinephrine and dopamine.

41. Environmental factors:Environmental factors: Life events, such as abuse, mentalstress, a “significant loss,” or another traumatic event,may trigger an initial episode in a susceptible person

42. Treatment PLAN & management Pharmacotherapy Bipolar disorder is treated with three main classes of medication: • Moodstabilizers, • Antipsychotics,and • Antidepressants.

43. Psycho therapy • Cognitive therapy.This type of approach involves learning to identify and modify the patterns of thinking that accompany mood shifts. cognitive restructuring. This process focuses on correcting flawed thought patterns by learning how to become more aware of the role thoughts play in your mood, how to identify problematic thoughts, and how to change or correct them. The therapist teaches the patient how to scrutinize the thoughts by looking for distortions, such as all-or-nothing thinking, and generating more balanced thinking.  • Interpersonal TherapyThis involves relationships and aims to reduce strains that the illness may place upon them. • Support groupalso help people with bipolar disorder. You receive encouragement, learn coping skills, and share concerns. You may feel less isolated as a result.

44. Reference • https://www.theravive.com/therapedia/obsessive--compulsive-disorder-dsm--5-300.3-(f42) • https://thriveworks.com/blog/obsessive-compulsive-disorder • https://www.betterhealth.vic.gov.au/health/ConditionsAndTreatments/obsessive-compulsive-disorder#causes-of-ocd • https://www.unk.com/blog/3-vital-cbt-techniques-for-ocd/ • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2812439 • https://www.ncbi.nlm.nih.gov/books/NBK519712/table/ch3.t8/ • https://www.medicalnewstoday.com/articles/37010