Doing Psychiatry Right: A Case of Severe Avoidant Personality Disorder with Obsessive-Compulsive Personality Disorder, Obsessive Compulsive Disorder, Intermittent Explosive Disorder and Sexual Paraphilias

By Hebbar, Sudhir | Indian Journal of Psychological Medicine, July-September 2014 | Go to article overview

Doing Psychiatry Right: A Case of Severe Avoidant Personality Disorder with Obsessive-Compulsive Personality Disorder, Obsessive Compulsive Disorder, Intermittent Explosive Disorder and Sexual Paraphilias


Hebbar, Sudhir, Indian Journal of Psychological Medicine


Byline: Sudhir. Hebbar

Over dependence on pharmacotherapy in psychiatry, known as biological imperialism, is a world-wide phenomenon. Some authors have opined that the inadequate and ineffective utilization of psychotherapeutic interventions and only dependence on pharmacotherapy amounts to institutional malpractice. Here is an example of such a case. A young male mainly received multiple psychotropic medicines, including clozapine (and also a failed psychotherapy) over a period of 4 years, without any benefit. His global assessment of function score remained at 30. However, with proper diagnosis and effectively conducted psychotherapy a significant improvement in Global assessment of functioning score of 70 was achieved, over a period of 11/2 years.

Introduction

In a book titled "doing psychiatry wrong" [sup][1] the author (a Psychiatrist) describes several cases treated with medications, mostly inappropriately (e.g., patient with borderline personality treated as bipolar disorder, multi drug abuser treated as schizophrenia), without much gain. He claims that such mismanagement is quite common. Another author [sup][2] (a Sociologist) argues that in spite of the evidence that psychiatric conditions improve best with a combination of medicines and therapy, psychotherapy is rarely offered. This trend is referred by the author as an institutional malpractice. That author's research has shown that such patients who were treated only with medicines "do less well, are readmitted more quickly, diagnosed more inaccurately and medicated more randomly." Here is a case report, which endorses all these aspects. This case was inaccurately diagnosed, randomly medicated and did less well. Properly conducted psychotherapy has improved the patient. Are we in to a second wave of anti-psychiatry movement against biological imperialism?

Case Report

A 23-year-old male, B.E student from upper middle socio-economic status, accompanied by his parents, presented with the complaints of anger outbursts, inability to mingle with people and inability to study. Insidiously symptoms started over a period of 4 years and gradually worsened. For the past 2 years, he attended neither the classes nor the home tuitions. He could not clear 15 papers. Most of the activities, which he tried to do ended in failure and angry frustrations. Most of the time was spent in sleep, which was aided by sedative psychotropic medicines. He could not tolerate inactivity as it led to boredom and this was intolerable. Remaining small time in the day he displayed a "typical pattern" of behavior as noted by Pedesky and Beck [sup][3] "they may discontinue a task or fail to initiate a task they had planned to do. They may turn on the television, pick up some things to read, reach for food or a cigarette, get up and walk around and henceforth." He was more or less home bound. Neither patient nor his parents could explain his anger and other symptoms. Mental status of the patient was that of an inhibited plump person with expressionless serious face, answering questions minimally, but relevantly without any psychotic symptoms.

Most of his anger outbursts erupted and lasted only for a few seconds and a few are followed by grumbling and shouting for about 10 min. Anger resulted in yelling with angry gestures, banging, crumpling, throwing, tearing and breaking of objects (one per attack) such as shirt, pen, pencils, spectacles, remote control and rarely, mobile phones or computers. Anger was followed by remorse. These outbursts were not expressed in front of others as it was shameful. Daily there were countless yelling and at least 2 tares or breaks. His father had become an expert at fixing the spectacles.

He avoided close relatives, strangers and crowds as it induced severe fear and inhibition. He was scared to talk to house maid, lift operator in the apartment, traffic police and ladies. He avoided ladies just like how people avoid a cobra. …

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