Case Studies

Case 8 - A 25-year-old woman with a fear of contamination

A 25-year-old woman lives with her mother and half-sister who has bipolar affective disorder. She was referred by her GP after she told him at a routine appointment that she often has an overwhelming impulse to jump in front of a train when she is standing at a station. This has alarmed her as she does not want to die. She has never harmed herself and has never wanted to. She has recently lost her job due to consistent poor time-keeping. Although she wakes several hours before she needs to leave the house, she cannot bear to leave until she has washed herself at least five times. If she touches the floor with her bare feet after her shower she has to start again. If she does not do this the thoughts of being contaminated with dirt become unbearable. She comments that she knows her thoughts are "not logical" and feels frustrated that she cannot stop her excessive washing.

• a. What is the risk of suicide in this patient?

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  Correct answer:

  Low; there are no suicidal thoughts, intent or plans and no history of self-harm. The thought of jumping in front of a train is an obsessional impulse rather than a suicidal thought because she experiences it as unwelcome and she tries to resist it.

• b. What is the most likely diagnosis?

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  Correct answer:

  Obsessive compulsive disorder (OCD) – she gives a clear history of obsessional thoughts, impulses and compulsions that occupy several hours each day. Her thoughts are ego-dystonic (i.e. they are unwelcome and she tries to resist them). This is important in differentiating OCD from a psychotic disorder.

You want to find out if the patient has other symptoms of OCD that she has not mentioned yet.

• c. What other potential symptoms might you ask about?

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  Correct answer:

  Obsessional images or other obsessional thoughts (e.g. regarding sex, blasphemy); other compulsions such as checking (e.g. the gas), counting, touching and constant rearrangement of objects to achieve symmetry; hoarding or excessive tidiness (see Chapter 12).

• d. What is the initial management of OCD?

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  Correct answer:

  OCD can respond well to SSRIs or clomipramine, together with cognitive behaviour therapy.

• e. You tell the patient you would like to refer her for CBT. She asks you what the therapy might involve. What would you tell her?

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  Correct answer:

  The therapist will discuss her symptoms in detail and with her to identify those that are causing her most distress. In her case this may well be the excessive hand-washing. The therapist will then design a programme with her of graded exposure and response prevention (see Chapter 33).

• f. What is the prognosis of OCD?

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  Correct answer:

  Chronic, with waxing and waning of symptoms. Patients with compulsions only, those with severe symptoms, persistent life stresses or premorbid obsessionality fare worst.