Successful Treatment of Refractory Obsessive-Compulsive Disorder

Article excerpt

A case study is presented of a 40-year-old man with obsessive-compulsive disorder (OCD). He had been treated with long-term institutional placement electroconvulsive therapy, exhaustive pharmacotherapy. and psychodynamic and cognitive-behavioral psychotherapy. Nothing had relieved his excessive. hand washing and door checking. Records from previous treatment revealed, diagnosis of dissociative identity disorder (DID). This information led to reconceptualization of the OCD symptoms as manifestations of the patient's ego fragmentation. When his fragments were catalogued and addressed, all overt OCD symptoms abated within weeks. It is believed that the patient's most anxious ego fragment communicated dread from the background of the patient's psyche, the executive component only being aware ofthe anxiety and not the triggering stimulus. The patient was taught to address this fragment verbally to elicit its cooperation, whereupon the fragment stopped sounding alarm, creating anxiety and driving the patient to check and recheck, wash and rewash. Symptoms have returned only when the patient has suspended his announcing behavior and have abated when this was resumed. Connections between OCD and DID are addressed. Conclusion: patients exhibiting refractory OCD symptoms should be assessed for dissociative symptomatology.

INTRODUCTION

The thoughts and behaviors characteristic of obsessive-compulsive disorder (OCD) can be extremely difficult to eradicate. Obsessions are defined as recurrent and persistent distressing thoughts, impulses or images, not due to real-life worries alone, that cannot be suppressed or ignored by these patients and that are perceived by them as originating from within their own minds. Compulsions are defined as repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or to comply with rigid rules. These behaviors are aimed at relieving or reducing distress. Typical compulsions are hand washing, counting or ordering of items, checking of door locks or stove knobs, repetitive rubbing, touching or blinking. Patients suffering from OCD can become so incapacitated by their obsessions and compulsions that by the time they finally seek treatment, they are close to despair.

Until effective psychotropic medications were developed, psychodynamic therapies alone were used with unpredictable results. Because the obsessive patient was seen psychodynamically as "rigid" by definition, clinicians found them quite resistant to treatment. For this reason, successful alleviation of obsessive-compulsive symptoms typically took years of intensive and often mutually frustrating treatment (1). Then, as they emerged, a variety of medications were tried, and the first to achieve widespread use and frequent success was the tricyclic antidepressant, clomipramine (Anafranil). Such medical interventions have enabled patients to better utilize psychotherapy and shorten the lag between starting treatment and beginning to experience some relief. There are side effects and potential caveats to the use of tricyclics (2), which prevented some OCD patients from being helped, however, Many newer medications have been introduced and tried, but none had the successes of clomipramine until the advent of the newer selective serotonin reuptake inhibitor antidepressants (SSRIs). All the various SSRIs have been studied in the treatment of OCD, and each has proven effective in many cases (2-4). Fluvoxamine (Luvox) was one of the first SSRIs studied, and it produced excellent results. Research has indicated that fluvoxamine is as effective as clomipramine and presents fewer side effects (5). Sertraline (Zoloft) has also been cited as working as well as or better than clomipramine (6). Fineberg (6) stated that OCD, long considered a refractory disorder, has in the last 15 years become rapidly and effectively treatable, thanks to clomipramine and the SSRIs. Psychotherapy has remained a viable treatment for OCD but has generally been seen in psychiatry as secondary to pharmacotherapy because the latter has been so dramatically and rapidly effective in many cases. …