DMS-5 Treatment of Obsessive Compulsive Disorder, Case Study Example

Introduction

In the film “As Good as It Gets” Jack Nicholson depicts a character by the name of Melvin Udall, a secluded writer who suffers from a severe case of obsessive-compulsive disorder. The film provides a perfect window into characteristics of the illness. Obsessive-compulsive disorders are a category of anxiety disorder. Patients with anxiety disorders have the tendency to become aroused in anticipation of a particular event, issue, or problem. When this happens, cognitive, physical, and emotional symptoms are incited from feelings of apprehension, which can lead to trembling, increased heart rate and respiration or intense sweating.  Some cognitive symptoms entail loss of concentration, preoccupation with a particular action or event, and rumination.  The problem with anxiety disorders is that they have the ability to adversely influence the functioning of the parasympathetic nervous system, which represents aspects of the nervous system that are controlled without thought, such as heart beat or breathing.

DSM-5 Diagnosis Criteria and diagnostics of the patient.

Step 1: The differential diagnosis process is broken down into four core steps. The first step entails identifying whether the individual being diagnosed is sincere about their condition, specifically in regards to the symptoms and severity of those symptoms. This step is carried out during an interview process between the social worker and the patient. During the interview, the patient is asked a set of questions and the responses are cross checked against historical data and responses. The expertise of the social worker/ psychiatrist interviewing the patient also plays a significant role in the accuracy of the diagnosis.

Step 2: This step entails ruling out substances as the primary cause of the disorder. For example, a side effect of narcotic use, or obsessive alcohol use, could cause anxiety or depression. If the patient is a habitual user of these substances, it might be difficult to identify the true cause of their symptoms. It would be premature to diagnose these symptoms too early.

Step 3: The third step involves determining whether the symptoms are caused by a medical condition. In the case of a patient with obsessive compulsive disorder, there are many emotional and psychological triggers that manifest themselves physically in the form of panic attacks, often the result of severe anxiety. These panic attacks can adversely impact the respiratory system causing symptom very similar to many medical conditions, so it is important to assure the patient is not suffering from any common medical problem.

Step 4: The final step entails identifying the primary disorder. Especially with a condition like obsessive-compulsive disorder, which can have a variety of symptoms, it can often be difficult to distinguish the primary cause of those symptoms. Often this leads to duel diagnosis, which isn’t necessarily bad but it is essential that the core cause of the problem be isolated so that it can be addressed in treatment.

Psychopharmacology for Obsessive Compulsive Disorder

Fineberg & Gale (2005) identify clomipramine SRIs to be the primary first-line pharmacotherapy for obsessive compulsive disorder.  During the 1960s, clinical trials of clomipramine proved the medication to be more effective in treating OCD than other tricyclic antidepressants like imipramine (Tofranil) (Goodman, 2013). In addition to clomipramine, there are a variety of other SRIs that have been proven to be effective such as fluoxetine (Prozac), fluvoxamine (Luvox), and paroxetine (Paxil), sertraline (Zoloft) (Goodman, 2013). Authors note however, the drug is not without its side effects in that it’s very similar to other tricyclic antidepressants, which cause urinary retention, dry mouth, and constipation. Clomipramine SRI is also characterized as causing many of the side effects common among other SRI medications, like tremors and nausea. Goodman (2013) observed many patients who reported having failed or delayed orgasms, weight gain, and fatigue.  The author further noted that, “safety concerns with clomipramine include adverse effects on heart conduction and seizures. The risk of seizures increases significantly at doses more than 250 mg daily” (Goodman, 2013).This is largely why overdoses of the medication can have lethal results, but the drug is still considered to have a superior efficacy compared to other anti-obsessionals  agents and anti-depressants like monoamine oxidase inhibitors.

A Tentative Social Work Treatment Plan

Overall Goals of the Treatment

The overall goal of the treatment is to cure the patient of the symptoms plaguing him and interfering with his ability to live a normal life.  Some of the fundamental factors to consider when treating OCD are that, Comorbid conditions can create unintended complications in treatment. Having a greater understanding symptom profiles can enhance treatment effectiveness.  The practitioner must also take into account all treatment possibilities that fall into psychotherapy treatment methods, pharmacologic treatment, and deep brain stimulation or neurosurgery treatment methods (Fineberg et al., 20120). In Melvin’s case, he exemplifies a variety of symptoms that could potentially be obsessive compulsive disorder, or they could be cause by some other form of physiological, psychological, or emotional issue. Through implementing the four major steps of DMS-5, the primary goal of curing the patient’s symptoms can be reached by narrowing down the causes and identifying the disorder.

Search Process and the results

The search process involves identifying whether or not the patient responds to distinct emotional and psychological triggers and then prescribing him medication for the obsessive behavior. Statistically behaviors that are uncommon, situations where individuals have cognitive inability to adapt, are situations where the individual is at odds with social norms.  Main search criteria involves assessing some key questions, such as, “what is defined as psychopathology” (Koran, 2010). Researcher breakdown this classification as those characteristics that differ from standard societal norms. This means the characteristic can change over time based on changes in culture. Essentially when searching for OCD symptoms, one is searching for psychopathological traits (Koran, 2010).

DSM-5 Definition of Mental Disorder:

The DSM-5 definition of a mental disorder is a syndrome identified by disturbances that impact an individual’s emotion regulation, or behavior. Usually this dysfunction results in forming issues that impact one’s “mental development, biological development, or even their psychological development” (American Psychiatric Association, & American Psychiatric Association, 1994). Mental disorders tend to arise from substantial distress, occupational activities or other important actives. It’s key to note that when individuals mourn over the loss of a loved one, this is standard response within common culture and should not be viewed as a mental disorder (Lee et al., 2010). When identifying mental disorder it is also keen to note that social behavior which deviates from the common standard practices such as devout religious, political, or sexual behavior is also not considered a mental disorder unless that behavior in some way results in the mental dysfunctions previously mentioned.

Intervention and Rationale for Intervention

Intervention must be based on identifying the disorder that is the core cause of the patient’s symptoms. Specifically in regards to DMS-5, the symptoms composed within the diagnostic criteria sets do not represent a comprehensive overview of underlying disorders. These symptoms include emotional, physiological, cognitive, and behavioral processes that can be far more complicated to define within a [DSM-5] summary (American Psychiatric Association, & American Psychiatric Association, 1994). The Director of the University of Dorpat in Livonia, Kraepelin established an in depth documented analysis of patients, which resulted in his first psychiatric breakthrough.  Authors note that, before Kraepelin came along, the disorder known as dementia praecox as well as manic depression and schizophrenia were all viewed as being collective disorders with the same pattern of symptoms.  They state that, “Kraepelin was able to separate these symptoms and distinguish the difference between them” (Fineberg et al, 2012).  He discovered that manic-depression was intermittent while dementia praecox was deteriorating.  These findings are helpful in understanding the necessary interventions to treat OCD. He discovered that dementia praecox is a deteriorating disorder while manic-depression is intermittent.  These findings are helpful in understanding the necessary interventions to treat OCD. Kraepelin utilized medical models to identify that symptoms can occur across a range of disorders.

Mataix-Cols, do Rosario-Campos, and Leckman (2005), provide a model of obsessive compulsive disorder that takes a multidimensional approach to the illness. As obsessive compulsive disorder (OCD) is heterogeneous condition, which means it encompasses a diverse set of symptoms. This means that clinical trials, neuroimaging, genome scans and natural history studies can all be obscured making it more difficult to diagnose the disorder. The authors implemented a multidimensional study through the use of factor analytic studies devised from manual and computerized literature on the topic. In a twelve factor analytic study the authors examined more than 2,000 patients with symptoms like hoarding,  symmetry/ordering obsession, obsession checking, and contamination/cleaning. They found a collection of overlapping symptoms that could possibly “1) coexist within a range of conditions, 2) be an aspect of any obsessive-compulsive disorder and 3) and reach beyond the traditional limitations of obsessive-compulsive disorder” (Mataix-Cols, do Rosario-Campos, and Leckman, 2005). While there are dimensional structures of obsessive-compulsive symptoms that are not easily identifiable, research shows taking a quantitative approach to the disorder  can be the best way to treat the disorder. It also proves to provide a path towards advancing understanding about OCD(Mataix-Cols, do Rosario-Campos, and Leckman, 2005).

Conclusion

In sum, In the case of Melvin, it is clear that he suffers from a severe case of Obsessive compulsive disorder through many of his interactions in the film. He has issues with cleanliness, taking showers far longer than the average person, he keeps a daily routine and when that routine is changed by external forces, he can’t rest until he has restored his routine to normal. This can be seen in the fact that he uses the same waitress daily and when she has to take off because her child is sick, he goes out of his way to cure the child just so he can get her back to work to serve his breakfast.  The irony of the film is that he develops a relationship with her, but in real life this is a habit prevents OCD patients from functioning in daily life. The above mentioned criteria and treatment protocols represent the ideal way to treat Melvin’s issue using DMS-5.

References

American Psychiatric Association, & American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (DSM). Washington, DC: American

psychiatric association, 143-7.

Fineberg, N. A., Brown, A., Reghunandanan, S., & Pampaloni, I. (2012). Evidence-based pharmacotherapy of obsessive-compulsive disorder.International Journal of Neuropsychopharmacology, 15(8), 1173-1191.

Fineberg NA, Gale TM (2005). Evidence-based pharmacotherapy of obsessive-compulsive disorder. International Journal of Neuropsychopharmacology 8, 107–129.

Goodman, W.K. (2013). Medications for OCD. Psych Central. 1-3.

Koran, L. M. (2010). Treatment of Patients With Obsessive-Compulsive Disorder.

Lee KU, Lee YM, Nam JM, Lee HK, et al. (2010). Antidepressant-induced sexual dysfunction among newer antidepressants in a naturalistic setting. Psychiatry

Mataix-Cols, D., do Rosario-Campos, M. C., & Leckman, J. F. (2005). A multidimensional model of obsessive-compulsive disorder. American Journal of Psychiatry.