Identifying information

Susan (not her real name), 29years old, married with two daughters aged 7 and 6yrs. At 20, she married a man 24years old, mechanic a housewife. Finished twelfth grade. Spoiled little daughter of five siblings. Conservative sector.

The main complaint "in her words"

"Obsessions, cannot function normally at home, always busy thinking about things corrupted, thoughts clogging me up, feeling bound".

Contemporary psychological difficulties

Susan disturbed intrusive thoughts and compulsive behaviors around perfection: Stain or scratch an object causes her anxiety pushes her:

1. throw it
2. use it, and keep parallel new one.

Her obsessions are expanding to other issues such as anxiety to draw near stove or use materials as hazardous chlorine- for dangerous images. A touch of symmetry: if touching a dresser drawer she needs to touch the rest of the drawers. Otherwise she will feel distressed. The thoughts hang up her mind and inhibit her functioning as a mother and housewife. She usually goes to family and spends the day with them; the children come from school straight to aunt. A month and a half before the start of therapy she experienced a worsening obsessive content due to discovering very small hole in a hidden corner of new living room couch. she started to get CBT in my clinic, and hospitalization in day for four weeks to prevent a psychotic state or depression.

Obsessions began only after she married, nine years ago. There was during honeymoon thinking the first time bout a damaged object at home. Before marriage she functioned normally.

Environmental pressures

Tensions with her husband who always supported her until he gave up. The groom's parents, usually support her, but complain about the waste of money and care for their son's live. Her daughters complaining that have sometimes around their mother's behavior. Critical people in the neighborhood.

Psychiatric / Psychologic History from the past

Checking by a psychiatrist during her first pregnancy at age 22 due to deterioration with obsessions and bizarre around the embryo, and recommendation for treatment by Seroquel. Three hospitalizations in psychiatric ward because of an obsessive compulsive disorder that included psychotic symptoms due to a schizoaffective disease and depression. Six months before the start of CBT she recommended treatment by favoxilin addition to Seroquel.

Personal and social history

Conservative society Susan belongs to, a woman must remain a virgin until marriage. Other she is flawed, and may be rejected in the society. Sexual abuse experienced in childhood at age seven by one relative, a young man aged 20, drove her at age 14 fears losing her virginity that occurrence. Worries accompanied her until the age of 20 when he decided to marry with a man who is not attracted to him, having seen him inexperienced and did not recognize her virginity. After she married, she discovered that is still virgin.

Symptoms of repeated intrusive thoughts causing her distress could not control them and pushing her compulsive behaviors aimed at reducing distress when they have no realistic relationship with distress itself and inhibit her functioning. OCI Questionnaire^1‒3 for diagnosis OCD. Total score was 163:77 points frequency, 86 points distress. When test scores was associated with high cleanliness, completeness and punctuality. She knows that thoughts are irrational, and are a product of her consciousness and not from outside, to distinguish from a case of schizophrenia.

View cut on current insights and behaviors

Major dysfunctional negative automatic thoughts identified with her: perfectionism, dichotomous thinking, overgeneralization: "The whole house has been damaged," and personalization "living room out damaged because of me". Behaviors: throw away, avoid anceorrituals.

1. Forces: Good self-image, awareness of the problem and cooperation, support from parents, love and support from her husband, healthy, intelligent, good operational history.
2. Weaknesses: Weak, lack of control, losing her self-confidence, alone, bound, people criticize her, reduction in her husband support.
3. Emotions dominate: Sadness, despair, anxiety, disappointment, irritability, anger, frustration.

When there is an injury in entirety of an object, touching or thinking about touching materials which regards them as a danger (like cleaning materials), threatening thoughts wake up. These thoughts are causing her distress expressed by negative feelings accompanying with burdensome physical sensations. Her distress creates a strong urge to throw the object, avoid contact or perform rituals to eliminate the influence of thoughts that threaten the reality and her responsibility of imaginary damage. So relieved for a short time until the obsession returns, then battling it again. Entering a magic cycle that increasingly strengthens her obsession.²

General conceptualization

Sexual abuse experienced in childhood produces obsessions during the age of 14-20 worrying about not being a virgin, which means socio-damaged status. These sad experiences hope her perception that the world is of eligibility with no place to defects, while she is unsafe about herself. She should be eligible, other she is damaged and may be denied. She developing behavioral strategies to maintain eligible, as to marry a man who can't spot impaired. This man then identifies with her flaw suspect already inside, and everything related to their common world is becoming loaded deficiency. Her strategies are expressed in pursuit of perfection in concrete world as throwing an object sees as broken, do not risk things can damage her, behave symmetrically. In case she sees "defect" automatic thoughts arise: the house is damaged, she is corrupted that stress her behave according to strategies she developed. Feel simultaneously relieving, that strengthens her thoughts and behavior.

1. Problems: cannot fulfill her functions as housewife and mother, cannot behave freely with things daily, taxing the financial situation, tension in the relationship with her husband. (has all kinds of fantasies about relationships with other men .. leaving him and the girl), failure enjoying life.
2. Goals:do not throw objects, do not buy things and keep parallel, start using objects saved, begin to touch most things free, to fulfill her role as a housewife and mother, improving the relationship with husband.

Treatment sessions: 3 session’s diagnosis, 5 exposures, 8 clinical and 5 follow-up sessions.

Breaking the cycle

She got explanations of interfering thoughts, OCD symptoms sequence, assumption and treatment plan, and an explanation of any therapeutic technique.

Positive statements: selection say statements supporting herself as an obsession begins (accepting the obsessive thoughts), to reduce occupation of her thoughts and her feelings as start decreased.

1. Calming breath:use it as obsession begins and often feel physical stress.
2. Practice built-in:daily time for anxiety (Preparatory step for postponement an obsession).
3. Set two split periods a day, each about a quarter of an hour and dedicate them to worry. So that thoughts will start to be boring, get used to them, lose strength and her anxiety will begin to decline.
4. Postponement of obsession:to postpone obsession when begin for a set. When the time comes to postpone it to another time in case she could, other affords to deal with it for a specified period. So she take her obsession out of it’s automatically and start acquires control.
5. Exposures:hierarchy of situations arouses distress on her have been posted. Part of exposures I made with her at home, the others as tasks with tables and hardness scale. Exposures made with her include: looking at and touching the corner of the living room couch, removal a small sticker of fur pillow after one year of avoiding fear yarn could pulled out with it and the pillow damaged. Sticking stickers on a fur blanket and remove them. Cleaning golden bowl after four months of avoiding fear descend from lightning and be damaged using a new kept parents' bed sheets set after a year use the same old set. Using kept blankets for children.

Prevention of rituals (tap washing, wipe the furniture, symmetrical touching) Supporting technique- postponement of performing rituals to practice the sense of distress for a longer duration, lower anxiety, and mastery.

Appeal the premises⁴

Advanced stage was working on her premise, showing how her assumption is- illogical: do not reflect reality because there is nobody perfect. Ineffective: Do let her get what she wants from life? Where did she have it: it may be linked to serious childhood experiences and how have been reworked later? Search Alternative assumptions like "good aim for fitness, but you can't be perfect because the world is not a perfect place."

Working about relationship with husband

Reports at times or situations feel close to her husband, and work on it. Guided Imagery of situation in which she was resigning from her husband and / or family, imagining her life with many daily details. To help her see that it is a fantasy.

After 14 sessions

1. Using new sheets and blankets were reserved without buying parallel.
2. Wore a reserved dress and used handbag, began to dress the girls stored clothes.
3. New defects such as a scratch in a kitchen cupboard, a new pillow left thread, not stuck in her head as before, never felt headaches or breakdown.
4. New glass shelf was placed in a kitchen cupboard after failure of more than one year, for fear that might not come out to match the rest closet shelves. According to her report, now is not worried about the possibility of being different from the rest of the shelves.
5. Cleaning kitchen cupboards alone, after five years of failure afraid finding some fault!
6. Reducing her exits from the house, she is staying at home longer than before.
7. The girls often come straight home from school and she start to help her daughter in homework with a little more patience than ever before.
8. Back cook, wash the dishes mostly at time cleaning floor and objects.
9. There are more emotional closeness and intimacy to husband.

Reducing in rituals

1. Stopped to wash the tap after each use except when this is done automatically.
2. When cleaning table or the kitchen cabinet door started never clean the rest of the tables and the doors belonging to the same corner.

According to her reporting internalize explanations receives in sessions, and they help her to cope with different situations.

Difficulties

Sometimes she has repetitive thoughts on new damaged things already worked on them. In these cases when feeling difficulty doing relaxation exercises or goes into another room.

After her situation improved finds herself in a new reality: responsibility for home and family, daily family tasks that has to continue perform regularly. It began to be requirements of her husband that were not previously as: "Your situation is better now why didn't prepare food"? Decreasing of consideration and help from people around her, falling spoiling, she should do almost everything alone.

New symptoms

At session 16 (a week after dose reduction of seroquel due to the improved situation) she reported: fatigue, depressed mood, angry, lack of motivation, excessive sleep. Session 18 reports new obsessions: food infection and clothes arranging.

Interventions: explanation, exposures and practice.

Session 20 (two weeks after return to the first dose of seroquel): fatigue, excessive sleep, lack of motivation to work at home. Can work but feel constant fatigue.

Interventions:

1. Explanation: habituation of her body to rest. Habituation tohelped and irresponsibility.
2. Daily work program:we set together an appropriate daily activities program.^5‒8
3. Session 21 (after disconnection of 5weeks) reports of fatigue, heaviness and pain in the chest, feeling dizzy and strangling, anesthesia in her hands and legs, sleep 15hours a day, mumps part of the obsessions and throwing objects. At this session the patient announced the completion of care, according to her opinion: her situation is good now, there is no longer need for treatment. In case she need, will come back for more sessions.
4. Fitting dose: At this stage, the patient feels relief and acquires freedom in her life, for the first time since several years. She finds herself in a new reality in which she has to take responsibility for her life and her family and to conduct all kinds of daily tasks, after years of rest, relaxing, pampering, help and consideration. She makes price-profit comparison for interference:
5. Price:suffering, feeling bound deterioration of communication with husband, environmental pressures.
6. Profit:exempt from responsibility, exempt from family demands, support, indulgence, help of others, fantasies (about other man). She reaches to result which meaning: preferring fitting dose of disorder, in which she keeps the profits with reduced pain bearable. And reaches a decision: to stop the treatment.

None.

Author declares there are no conflicts of interest.

None.

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