This case study illustrates how obsessive-compulsive disorder (OCD) impacted Darcy, and how working with a psychologist enabled her to live a happier, more fulfilled life.
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Introduction
Disclaimer: This case study contains fictional names and modified details to protect the privacy and confidentiality of individuals and entities involved.
Marian, a psychologist who specialised in obsessive-compulsive disorders, closed the file and put it into the filing cabinet with a smile on her face. This time she had the satisfaction of filing it into the “Work Completed” files, for she had just today celebrated the final session with a very long-term client: Darcy Dawson. They’d come through a lot together, Darcy and Marian, during the twelve years of Darcy’s treatment for obsessive-compulsive disorder, and they had had a particularly strong therapeutic alliance.
Marian reflected on the symptoms and history which had brought Darcy into her practice.
History of OCD Symptoms
Obsessions at age nine
Now 37, Darcy reckoned that she had begun having obsessions around age nine, soon after her beloved grandma had died. Already grieving the loss of the person she was closest to in life, Darcy experienced further alienation – and deep anxiety – when her father relocated the family from the small town in Victoria where they lived to Melbourne. Adjusting to big-city life wasn’t easy for someone as anxious as Darcy, and she soon found that she was obsessing. She had fears of being hit by a speeding car if she stepped off the kerb. She feared that the new friends she began to develop in Melbourne would be kidnapped by bad people. And she was terrified that, if she didn’t do an elaborate prayer routine at night, all manner of terrible things would befall her family.
The prayer routine, relatively simple at first, grew to gigantic proportions, containing many rules and restrictions. Darcy believed that she had to repeat each family member’s full name 15 times, say a sentence that asked for each person to be kept safe, promise God that she would improve herself, clap her hands 20 times for each person, kneel down and get up 5 times, and then put her hands into a prayer position while bowing. She “had” to do this routine at least 10 times each night, and if she made a mistake anywhere along the way, she had to start totally over again from the beginning, or else something bad would happen to her parents or little brother. Once she went flying to her mother’s side in the kitchen, tears streaming down her face, because she couldn’t get her “prayers” right. Darcy was certain that she was a huge disappointment to God and everybody.
Just like Granddad
Marian had asked Darcy if her parents were similar at all, and Darcy couldn’t think of many ways in which they were. Then she remembered something. “Ah,” she said, “my parents aren’t having these awful thoughts like me, but I remember my mum often telling me, ‘You’re just like your grandfather.'” Darcy’s grandfather had died when she was only five, so she didn’t have strong recollections of him, but there were two images that she always remembered about him: Grandfather standing by the kitchen sink in their farmhouse, washing his hands – always washing his hands. And if they decided to take a walk around the farm, he would take a seeming eternity to check that all the windows and doors were locked, even though they were on good terms with everyone within a ten-mile radius!
Obsessions and compulsions worsen through Uni
Marian had felt huge compassion for Darcy as she outlined the course that the disorder had taken. While the intrusive thoughts waxed during high-stress times and waned when Darcy felt relatively stable, there was nevertheless a general broadening of the obsessions – and resultant compulsion to do certain repetitive acts – throughout Darcy’s growing-up years. In high school, for instance, Darcy began to have an aversion to looking at any woman with a scoop-neck top on, going so far as to grab a glass and pretend to be holding it high up near her lips (as if to drink) if she had to talk to someone dressed in any but the most conservative top. In that way, she felt, she would be blocked from seeing what she should not see and thus sinning.
Short skirts were also a problem, as Darcy feared that she was looking at people in inappropriate ways, and was offensive. If anyone at a party crossed their legs while she was looking at them, Darcy assumed that they had done that because they were offended by her having glanced at them; she feared that they would think she was looking at their crotch area. She prayed constantly for forgiveness, but ended up ceasing hugs to family and friends because she felt like a hypocrite. Of course, not feeling that she could/should touch anyone made for huge social problems, and dating anyone became impossible: a huge punishment for a friendly extravert like Darcy. She petitioned God relentlessly, asking to be a better, less sinful person. It did not seem to help.
When Darcy began University, the experience was defined by a series of irrational obsessions. She would worry incessantly about having written something offensive on an email or an assignment. Walking around campus, she would pick up rubbish: papers that she had never seen before; she would worry that she might have written something on one of them. She feared that she would accidentally hurt one of her fellow students by something that she might do or say. By this time Darcy was repeating certain phrases over and over again to ward off disaster. She was amazed that she was getting through school at all (she often made straight A’s), because her rampant perfectionism caused her to take at least twice as long as other students to complete assignments, and she still wasn’t happy then. The anxiety and depression were overwhelming Darcy to the point where she recognised that she could barely function and something needed to change.
The Uni psychologist says, “You’re fine”
Marian shook her head in amazement as she recalled how Darcy’s first attempts to find out what was wrong with her had been fruitless; all the health professionals had completely missed the OCD! Upon first coming to Marian, Darcy had recounted how getting along to the University psychologist in her senior year was a “non-event”. He had asked a few questions, chatted to her about her schoolwork, told her she was basically fine, and then told her to go see a psychiatrist, who merely prescribed a sleeping pill. Darcy had taken this, as instructed, because the intrusive thoughts in her mind often did keep her from sleeping, but when she was awake she still had the thoughts and the horrible compulsion to perform the anxiety-alleviating acts: routines which now occupied several hours each day. Moreover, Darcy’s parents still didn’t believe that anything was wrong with her; they even found it funny that she was “quirky” like her grandfather.
Age 25: Treatment begins
Darcy was to graduate and spend another three years being held prisoner by her out-of-control mind before a chance meeting of her mother with a specialist in OCD at a conference. The specialist didn’t live in Melbourne, but – by incredible coincidence – he had a highly recommended colleague who did: Marian. Marian recalled with some fondness how Darcy had sat in her office during the first session, shedding tears of joy at being truly “seen”: both as a person and in her disorder. When Marian had issued the magical words, “obsessive-compulsive disorder”, Darcy had been surprised – after all, her sense of OCD was people who continually washed their hands – but she also felt like she had just been given the key to her prison. Her treatment began soon after.
Marian worked intensively with Darcy at first, and then steadily. She helped Darcy get onto an even keel emotionally first by raising her serotonin levels (which had been quite low). Marian then began the laborious process of helping Darcy to change her habits of thinking: the assumptions that she made, the irrationalities that controlled her behaviour, and the intrusive obsessions that seemed to take over her life. Marian helped Darcy to see the importance of an exercise regimen, a good diet (related article: How Nutrition Impacts Mental Health), and a stillness practice. Darcy joined an online support group, and Marian and Darcy enlisted the help of Darcy’s family and a few close friends. Partway through the therapy, Darcy was even able to come off the medications: a goal she had long sought, because she had married a “wonderful” man and they wanted to start a family.
Epilogue
At 37, Darcy is a happy and fulfilled person, with a solid marriage and an eight-year-old daughter. She believes that she worries about her “like a normal mother”, rather than in the obsessional way she used to pray in order to protect her family from imagined harm. She still petitions God, as she is active in her church, but now the petitions are free of the superstitious routines she used to perform, and she is quick to be thankful for her many blessings. Unwanted thoughts still come to her, but now she has tools to focus elsewhere, and when the intrusive thoughts come, Darcy knows how to keep them from causing her to repeat irrational acts in a compulsive way. She knows that she will probably always be managing her disorder, as there is no cure for OCD. But the difference now is that she controls it, rather than having it control her. As far as Darcy is concerned, Marian gave her back her life.
Marian smiled again as she recalled Darcy’s journey and her original fear of being a “disappointment to God and everyone”. Indeed, Marian felt blessed to have had Darcy as a client.
Questions
- Which subtype of obsessive-compulsive disorder does Darcy seem to show the most? What is your evidence for this?
- How typical was the onset of Darcy’s OCD? What factors demonstrate this?
- Which of the principal factors thought to cause OCD seem to have been responsible for it being triggered in Darcy’s case? What facts show this?
- How might Marian have worked with Darcy’s fears that she had been sinning or offensive when merely talking with somewhat skimpily dressed women?
- Internet stories about OCD are rife with regrets that the diagnosis of OCD came only after many years of suffering. Discuss why you think Darcy’s family and the University health staff all missed the correct diagnosis.
- Were Darcy’s OCD symptoms ego-syntonic or ego-dystonic? Identify aspects of her case that support your choice.
- What sort of therapy do you suppose Marian conducted with Darcy: more along the lines of CBT or more like a psychodynamic type of psychotherapy? Why do you believe this?
- Many people who have reclaimed their lives from the clutches of OCD have gone through treatments of ERP: exposure and response prevention. Would this have worked in Darcy’s case? Why or why not? If you believe that Marian could have used it effectively with Darcy, state how it could have been employed.
Case Analysis
Which subtype of obsessive-compulsive disorder does Darcy seem to show the most? What is your evidence for this?
In Robinson, Smith, and Segal’s (2013) classification, Darcy would be considered to have principally a “doubter/sinner” subtype of OCD. The way that she obsessed about possible bad things happening to her (struck by a speeding car when stepping off the kerb) her friends (being “kidnapped by bad men”) and her family (many obsessions) are one example. The elaborate compulsion-driven prayer routines Darcy had as a child in order to protect her family from harm also support this classification. Darcy’s aversion in high school to looking at women with scoop neck tops and/or short skirts is an obsession that engendered the “sinner” compulsive acts of holding a glass up to block her view and making repeated prayers to become a less “sinful” person. At Uni, her wide-ranging fear of doing, saying, or writing anything that would harm someone are other examples.
How typical was the onset of Darcy’s OCD? What factors demonstrate this?
As one-third to one-half of OCD adults begin having obsessions and performing compulsive acts in childhood, Darcy’s onset is typical, demonstrated by her recollection that she began obsessing around age nine. Also showing typical onset is the fact that the obsessions and related compulsions began following on from traumatic events: the death of her grandmother and having to relocate to Melbourne.
Which of the principal factors thought to cause OCD seem to have been responsible for it being triggered in Darcy’s case? What facts show this?
The principal factors triggering Darcy’s OCD may have been:
- Heritability. Her grandfather exhibited OCD routines of the “washer” and “checker” subtypes.
- Low serotonin. When Darcy was finally diagnosed with OCD, she was found to have low serotonin levels, which are often implicated in the triggering of OCD.
- Environmental stress. As noted above, Darcy’s symptoms began appearing shortly after two traumatic events in her life: the death of her grandmother and her family’s move to Melbourne.
How might Marian have worked with Darcy’s fears that she had been sinning or offensive when merely talking with somewhat scantily clad women?
In similar cases, therapists have tried cognitive behavioural therapy, and in particular, a form of it known as ERP: Exposure and Response Prevention. In Darcy’s case, Marian is likely to have done some of the following:
- Gradually exposed her to more and more skimpily dressed women while simultaneously preventing (or at least discouraging) her from putting a glass up to her lips to prevent her seeing any cleavage, or praying furiously to be a better person.
- Worked with Darcy to help her see how illogical it was for her to call herself a “sinner” merely because she happened to be in the company of a woman with a low-cut top or short skirt.
- Gotten Darcy to observe that at social gatherings, people often shift in their chairs, crossing and uncrossing their legs many times in an evening for comfort. Most if not all of the time it would have had nothing to do with her and thus Darcy’s belief that they were crossing legs because they were offended by her glancing at them was not accurate or realistic.
- Replaced the beliefs of (2) and (3) with more logical beliefs, such as that someone else’s mode of dress is their choice, and merely talking with a scantily-clad person is not a sin.
Internet stories about OCD are rife with regrets that the diagnosis of OCD came only after many years of suffering. Discuss why you think Darcy’s family and the University health staff all missed the correct diagnosis.
Darcy’s family was already “de-sensitised” to OCD symptoms by virtue of observing her “quirky”, hand-washing, window-checking grandfather. OCD sufferers can lead relatively normal lives, especially when their environments are fairly stable, as her grandfather’s probably was on the farm. Thus, they can be just “under the radar” in terms of severity or weirdness of symptoms. With her grandfather being regarded as dear but somewhat eccentric, he may never have been formally diagnosed, and the family may therefore not have appreciated the depth of Darcy’s suffering or departure from normal functioning.
The university health practitioners have less excuse for not picking up on the OCD! That said, many people – like Darcy before diagnosis – think of OCD as the “hand-washing” disorder. Because Darcy had the “doubter/sinner” type of OCD, her type of obsessions and compulsions are not as commonly known. Her anxiety was clearly on display, and it would have been easy to assume that she was just an anxious person. Because she was a top student, often getting straight A’s, it would have been easy to assume that she was functioning alright, albeit with anxiety, and overlook the dysfunctional obsessing. The prescription of a sleeping pill seems to support this hypothesis.
Were Darcy’s OCD symptoms ego-syntonic or ego-dystonic? Identify aspects of her case that support your choice.
Clearly Darcy – as most OCD clients – was bothered throughout her pre-treatment life with obsessive thoughts of impending harm to those she loved and the frantic performing of compulsive routines in order to stave off disaster. By the time she came to Uni she was overwhelmed and barely functioning. Thus the disorder was ego-dystonic (disturbing to her, as opposed to obsessive compulsive personality disorder (OCPD) individuals who believe they are totally normal with others being the “wrong” or “sick” ones, which means OCPD individuals experience ego-syntonic symptoms).
What sort of therapy do you suppose Marian conducted with Darcy: more along the lines of CBT or more like a psychodynamic type of psychotherapy? What other treatments does she seem to have employed? Why do you believe this?
We are told that Marian helped Darcy to “change her habits of thinking”: a CBT-oriented type of treatment, as opposed to a psychodynamic psychotherapy, which would have had Darcy analysing her childhood, and particularly, her relationship with parents and family members. Darcy’s family seemed to be normal, and she didn’t seem to have salient unfinished business with either parent. Moreover, there is evidence for a genetic link to the disorder through her grandfather, so psychodynamic psychotherapy would not have been the treatment of choice. It does seem that Marian helped Darcy get onto a medication to bring up her serotonin levels; this is likely to have been an SSRI-class anti-depressant medication. The write-up also mentions Marian working with Darcy to ensure good diet, an exercise regime, a stillness practice, and shoring up her social supports: all very good non-medical interventions to help the OCD sufferer self-manage his or her symptoms.
Many people who have reclaimed their lives from the clutches of OCD have gone through treatments of ERP: exposure and response prevention. Would this have worked in Darcy’s case? Why or why not? If you believe that Marian could have used it effectively with Darcy, state how it could have been employed.
As per question (4), ERP hopefully was used in Darcy’s case. It would have been aimed at exposing her to barely-dressed women (and perhaps men as well later on) and preventing her from making a compulsive response (such as using the glass or going into an intense, fear-fuelled prayer session). Her obsessions around writing or saying or doing something that would offend or harm someone could have been worked with by helping her to see the irrationality of thinking that, for example, she might have written something on some rubbish that she had never seen before which was blowing around campus. Such irrational beliefs would then be replaced by more logical, kinder-to-Darcy beliefs, such as: “I have never seen that paper before. Thinking that I might have written something on it is just my obsession talking. I can let that go. I don’t normally find that I have written on rubbish paper flying around.”
Importantly for Darcy’s sense of social support, it is to be hoped that Marian worked with any leftover obsession from high school around not feeling comfortable to hug or touch people. Presumably that got sorted out along the way as Darcy eventually married. If any professionals such as Marian worked with her on that, they would have employed the same general CBT principle of identifying the irrational belief and the concomitant obsession or “should” fuelling it, such as “I shouldn’t hug people because I’m a sinner” or “I shouldn’t touch those I love because I am offensive, and therefore a hypocrite.” The irrational belief(s) would then have been gradually replaced by more logical, compassionate ones, such as “I may not be perfect, but I still deserve to have physical closeness to people and emotional support.”
OCD courses and resources
This case study was extracted from Mental Health Academy’s course, OCD and OCPD Case Studies. This course – a case study companion to Understanding OCD and OCPD – illustrates the theoretical understanding of OCD and OCPD through two real-life case studies.
Read other case studies:
- Case Study: Healing from Trauma as a Soldier
- Case Study: DBT and Bulimia Nervosa
- Case Study: Narcissism in Family Relationships
- Case Study: Narcissism in a Romantic Relationship
- Case Study: Emotional Freedom Technique (EFT) for Burnout
Appendix
DSM-5-TR diagnostic criteria for OCD and OCPD
OCD
The DSM-5-TR notes that sufferers of OCD can have either obsessions or compulsions.
A. Obsessions as defined by (1) and (2):
- Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted and that in most individuals cause marked anxiety or distress.
- The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralise them with some other thought or action (i.e., by performing a compulsion).
Compulsions as defined by (1) and (2):
- Repetitive behaviours (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
- The behaviours or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviours or mental acts either are not connected in a realistic way with what they are designed to neutralise or prevent or are clearly excessive.
Note: Young children may not be able to articulate the aims of these behaviours or mental acts.
B. The obsessions or compulsions are time-consuming (e.g., take more than one 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 (e.g., excessive worries, as in generalised anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin-picking, as in excoriation [skin-picking] disorder; stereotypes, as in stereotypic movement disorder; ritualised eating behaviour, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behaviour, as in autism spectrum disorder).
The clinician is urged to specify how much insight the individual has, as demonstrated by the person’s recognition that the obsessive-compulsive disorder beliefs are “definitely or probably not true or may not be true” (good or fair insight) or “probably true” (poor insight), or alternatively, the person’s conviction that the beliefs are true (absent insight/delusional beliefs) (APA, 2022).
OCPD
In contrast, the DSM-5 description of OCPD symptoms states that the “pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expensive of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, is indicated by four or more of the following symptoms:
- Is preoccupied with details, rules, lists, order, organisation, or schedules to the extent that the major point of the activity is lost
- Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)
- Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)
- Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)
- Is unable to discard worn-out or worthless objects even when they have no sentimental value
- Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things
- Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes
- Shows rigidity and stubbornness” (APA, 2022).
References
- American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., Text Rev.). American Psychiatric Publishing.
- Robinson, L., Smith, M., & Segal, J. (2013). Obsessive-Compulsive Disorder: Symptoms and treatment of compulsive behaviour and obsessive thoughts. Helpguide.org. Retrieved on 24 April, 2013, from: http://www.helpguide.org/mental/obsessive_compulsive_disorder_ocd.htm