C.D.*, a 27-year old woman, complained of excessive checking. Her symptoms dated back to her childhood when she spent hours on homework because of a need to have each page perfect with no erasures or cross outs and hours arranging her room so that it was in perfect order before sleeping. By high school she couldn't complete assignments until after the term had ended and did not participate in any extra curricular activities because her time was spent checking work assignments. When C.D. entered college she developed new checking rituals to assure herself that she had not caused harm to anyone around her (e.g., checking electrical appliances for fear that she had started a fire, faucets for fear that she had left them running, and door locks for fear that she had left them open). These rituals began to consume several hours a day leading her to be late for class or to miss it entirely. Although she sought therapy, she did not tell the therapist about her obsessions and rituals for fear she would be labeled "crazy." Her bedtime rituals grew to three to four hours, leaving her practically no time to sleep or study. Her appetite and mood plummeted and she stopped attending class. She left college and returned home. Her parents, alarmed at the changes in their daughter, took her to a psychiatrist who diagnosed depression and started her on a standard dosage of a serotonin reuptake inhibitor. After six weeks on the medication, her mood was slightly improved but her rituals were unchanged. Her medication was changed to a second serotonin reuptake inhibitor, also at a low dosage, with no better results. A second opinion was sought and C.D. felt comfortable enough to admit to her "crazy" thoughts. Obsessive Compulsive Disorder (OCD) was diagnosed. Her serotonin reuptake inhibitor dose was raised and her obsessions decreased in intensity, reducing the amount of time spent checking to an hour a day. On the medication she was able to return and complete college.
D.S., a 35 year old male, complained of elaborate cleaning and washing rituals. His particular concerns were with bodily waste or secretions (especially urine, feces, saliva, and semen). His specific feared consequences were about contracting HIV disease and/or spreading the HIV virus to others. His rituals included elaborate handwashing routines, prolonged and stereotyped showers, and lengthy wiping and cleaning rituals after using the toilet. The possibility that he might contract HIV disease and/or that he might spread it to others dominated his waking hours, and he only really felt safe when he was at home washing.
On initial evaluation, Dan was told about the two proven treatments for OCD: pharmacotherapy with a serotonin reuptake inhibitor (SRI) and cognitive-behavioral therapy consisting of exposure and ritual prevention (EX/RP or ERP). When Dan learned that EX/RP (ERP) treatment would require exposure to feared contaminants, he chose SRI treatment instead. After about 6 weeks on fluoxetine 60 mg per day, Dan reported that he was much less bothered by his obsessions, and he was more able to delay or stop his rituals. On the other hand, he continued to obsess about 3 hours per day about contaminants and to wash excessively. Thus, he was referred to twice-weekly EX/RP (ERP) with an experienced therapist.
Remaining on the SRI, Dan participated in 17 EX/RP (ERP) sessions. With the therapist's expert guidance, he confronted feared contaminants in session and at home without ritualizing. He started with situations that he found moderately distressing (e.g., touching the floor in the therapists office), progressed to situations that he found more distressing (e.g., touching the floor in public bathrooms), and finished with situations that were highly distressing (e.g., imagining contracting HIV disease and giving it to his whole family). Although the treatment triggered a lot of anxiety, he persisted, and he became less fearful over time as he repeatedly confronted his fears without ritualizing. By the end, his OCD symptoms were minimal, his work and his social functioning had improved, and he felt optimistic about his future.
OCPD Case Examples
Mrs. B. is a thirty-year old school teacher without previous treatment. She described having a book collection that she dusted daily and would not let anyone else, including her husband, touch. She insisted that her husband get into bed at night before her so that she could make sure that nothing in the house had been moved after she went to bed. If they were late for an engagement, she was unable to modify her routine of getting ready. Both at work and at home, she refused to allow others to do any tasks that might be helpful to her, as she felt that only she could perform these tasks correctly. When leaving the house, she insisted on driving or walking a predetermined route despite any obstacles, such as traffic, that presented themselves along the way. She was critical and outspoken about "shortcuts" that she thought other teachers took in their work. These patterns of behavior and attitudes caused major marital conflict and conflict with other teachers.
*Please note that all details are disguised to protect the privacy of the individual.