A holistic psychotherapeutic approach for the management of obsessive-compulsive disorder with poor insight

Ritu Raj Gogoi; B Surchandra Sharma

doi:10.4103/jmhhb.jmhhb_56_20

CASE REPORT

Year : 2021 | Volume : 26 | Issue : 1 | Page : 78-82

A holistic psychotherapeutic approach for the management of obsessive-compulsive disorder with poor insight

Ritu Raj Gogoi, B Surchandra Sharma
Clinical Psychologist, LGB Regional Institute of Mental Health, Sonitpur, Assam, India

Date of Submission	11-Jun-2020
Date of Decision	18-Jul-2020
Date of Acceptance	10-Apr-2021
Date of Web Publication	30-Jul-2021

Correspondence Address:
Ritu Raj Gogoi
Clinical Psychologist, LGB Regional Institute of Mental Health, Tezpur, Sonitpur - 784 001, Assam
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jmhhb.jmhhb_56_20

Abstract

An individual with obsessive-compulsive disorder (OCD) and poor insight has a significant impact on the person, thinking clearly about his obsessive thought and compulsive behavior. Cognitive-behavior therapy is an evidence-based therapy for the treatment of OCD patients. However, the need felt to incorporate other therapeutic approaches such as supportive, mindfulness-based therapy to treat OCD. This case study tried to discuss the efficacy of a holistic intervention approach in an individual with OCD who had poor insight. The result showed that the holistic approach decreased distress, intrusive thought and reassurance-seeking behavior and improved his insight. At the end of the psychotherapy session, the Y-BOCS score decreased to 15.

Keywords: Cognitive-behavior therapy, mindfulness, obsession-compulsion, poor insight, supportive therapy

How to cite this article:
Gogoi RR, Sharma B S. A holistic psychotherapeutic approach for the management of obsessive-compulsive disorder with poor insight. J Mental Health Hum Behav 2021;26:78-82

How to cite this URL:
Gogoi RR, Sharma B S. A holistic psychotherapeutic approach for the management of obsessive-compulsive disorder with poor insight. J Mental Health Hum Behav [serial online] 2021 [cited 2023 Jun 4];26:78-82. Available from: https://www.jmhhb.org/text.asp?2021/26/1/78/322826

Introduction

Obsessive-compulsive disorder (OCD) is the fourth most common psychiatric disorder. It features by obsessions and compulsions.^[1] OCD symptoms are known by the patients as irrational and ego-dystonic.^[2] However, there is growing recognition of the extent to which insight into symptoms varies in OCD individuals.^{[3],[4],[5],[6],[7]} Some OCD patients do not regard their symptoms as unreasonable or excessive. Their ideas can be explained as overvalued or delusional.^[5],[6] Indeed a subtype of “poor insight” has been introduced into the DSM-IV criteria for OCD.^[8] It presumed that OCD patients have good insight, convinced that their thoughts are senseless and irrational. Newer studies found that some of the patients are not convinced about the irrationality of their thinking. They recognized that thought may or may not be true, and such patients tend to have fair to poor-insight.^[9] Insight is a continuum, whereas good-insight patients tried to resist their thoughts and so are more distressed. On the opposite end, poor-insight patients do not recognize their symptoms as senseless and attempt less to accept and control their thoughts and behavior.^[10],[11] Studies reveal that insight also varies among different symptom dimensions of OCD.^[12] The diagnosis of OCD may be difficult in patients who relinquish the struggle against their symptoms that appears to shift from unwanted and distressing intrusion to psychotic delusion.^[13] OCD patients with poor insight may have a different treatment response or course than patients with better insight.^[14] The poor insights of patients accommodate their symptoms and take more time to seek treatment. Poor insight associate with a longer duration of illness or longer time without treatment. These all are negative predictors for the therapeutic process of OCD. OCD with poor insight is associated with a higher nonresponse rate to treatment and poorer prognosis.^[9]

Case Report

Mr “V. S.,” a 41-year-old, male patient had attended to general psychiatry OPD. The patient had chief complaints of distress feeling, disturbed sleep, inattentive, repetitive thought of having HIV, and excessive reassurance-seeking behavior from the past 8 months. The onset of illness was sudden, the course was episodic, and progress was static. The patient reported triggering factors of a single episode of having protective sexual intercourse with a sex worker in 2004 and one of his colleagues diagnosed with HIV positive in his workplace in 2017. The precipitating factors increased his preoccupation with the ruminative thought of having HIV infection. He started to think about the HIV window period, again and again. He consulted with several doctors for his repetitive thoughts. The doctor advised him that the window period of HIV is 3 months, but he worried about the window period of HIV. He underwent with numbers of medical test for HIV, but all the report indicates HIV negative. However, his ruminative thought remains the same and increased his reassurance-seeking behavior in the form of compulsion.

Further, it leads to an impact on his attention and occupational life in the workplace. He used to ask his colleagues about HIV infection and gradually, he refused to do his assigned duties. Finally, his colleagues brought him for further psychiatric consultation in 2018 and he admitted on the same day. After the 2 months of admission, the concerned psychiatrist referred to a clinical psychologist for psychological management. In the intake session, the patient was hard to convince that his repetitive thought is the symptoms of OCD. It was difficult to convince him that his obsessional thoughts and reassurance-seeking behaviors were unreasonable or excessive. His obsessive thoughts were overvalued and expressed that he cannot resist it. He felt like his body doesn't exist.

The history of the patient suggested that in the year of 2004, he had a similar episode. He frequently went to the doctor and done the medical test of HIV 4–5 times within a span of 3 months to assure him. He does not take any medication for the last episode. His symptoms subsided, ensuring by the doctors about HIV infections and the window period. In between 2004 and 2009, there were no prominent symptoms of OCD. After that, in an incident, one of his colleagues commented on his height and then he started to checked his height again and again and asking others whether he is abnormally tall or not. However, there was no significant clinical condition of O. C. symptoms since 2009 to 2015, he was quite well but always preoccupied with some unnecessary thoughts. Then, in one incident, he argued with an officer because of some duties. After that, he started his repetitive intruding thoughts of “Guilt,” why he confronts the officers. He used to feel very offending and disturbed. Then, he went on leave and Consulted with a psychiatrist. After joining his duty, they referred to a psychiatrist for fitness certificate.

Since this incident he developed his anxious thought that they might be declarer his as an unfit. Because of these symptoms of apprehension he was diagnosed as suffering with OCD and declared as incompetent. After the declaration, his nature duty was changed. From that time onward, had been under the psychiatric consultation and went for regular follow-up, once in every 6 months. Later on, he declared as medically fit. Then, he had continued repetitive apprehension and thought of losing his job and asked about his health conditions to every officer he met. He repeatedly came to the unit doctor to clear his doubts. The patient's treatment details were not able to elicit, of this period. In 2016, he was under the medication of risperidone 2 mg and fluvoxamine 200 mg for OCD. However, he had poor medication compliance and gradually refused to perform his duty in the battalion and not obey orders. He was admitted to the unit hospital for few days on observation. After that, he got discharged from the hospital and rejoined his duty. Then in 2017 August, he met with HIV positive colleague in his unit that triggered his thought that once he had protective sexual activity with a sex worker, now I also might have HIV. After this, he consulted with several doctors; they advised him to do HIV tests and reports were negative every time. However, his doubts remain the same. Hence, intrusive thoughts were present for the last 8 months; because of these reasons, the patient referred by the unit Hospital to the LGBRIMH for further treatment. He was admitted in the same day and continued the following medicine, fluvoxamine 100 mg, risperidone 2 mg, and zolpidem 12.5 mg.

Regarding family history, there is no significant history of psychiatric illness from the paternal and maternal sides. The patient has a cordial relationship with the family members.

The patient's personal history suggests that he maintained systematic and cleanness in childhood. Premorbidly, he was apprehensive, self-conscious, systematic, perfectionist, and self-preoccupied with unnecessary thoughts. In the mental status examination his affect was dysphoric, anxious, and apathetic. He had ideas of having HIV, with poor insight (as the patient does not recognize his symptoms as senseless, unreasonable, or excessive and overvalue the thoughts). Clinical history was suggestive of O. C. symptoms, premorbid personality indicates obsessive-compulsive like personality traits. The mental status examination findings suggestive of affective disturbance and ideas of HIV infection with poor insight, along with the psycho-diagnostics finding suggests O. C. traits diagnosed as “Mixed Obsessional thoughts and acts” (ICD-10, F-42.2) with poor-insight.^[15]

After the patient's admitted at LGBRIMH, the psychiatrist was started with fluvoxamine 200 mg up to 250 mg for 3 weeks. After that tab, fluvoxamine stopped, the patient received tablet clomipramine 50 mg/day and increased up to 150 mg/day. After around 4 weeks of treatment tablet, risperidone added, with tab clomipramine. The patient was given tablet clomipramine 150 mg/day and tablet risperidone 4 mg/day for 4 weeks. In the next tab, clomipramine stopped, tablet fluoxetine 20 mg started and increased up to 60 mg/day. In the last 8 weeks, the patient received tablet fluoxetine up to 60 mg/day and tablet risperidone 6 mg/day. After the pharmacotherapy, no significant response to the medication and the patient's clinical condition deteriorating with suicidal ideation. Later on, he kept on close observation and planned for electroconvulsive therapy (ECT). The patient did not show significant improvements in ECT. Then, the patient referred to the clinical psychologist for further psychological intervention [Figure 1].

Figure 1: Cognitive-behavioural formulation

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Psychotherapeutic process

Case formalized through cognitive-behavioral formulation. The psychotherapeutic procedure followed the cognitive-behavioral approach with supportive therapy and mindfulness.

Clinical psychologist planned two sessions per week, each of approximately 45 min. The patient explained the aim of psychotherapy to reduced repetitive thought and reassurance-seeking behavior. Initial five sessions centered on baseline assessment, psychotherapeutic formulation, rapport building, building a therapeutic alliance, and providing psycho-education. In the baseline assessment score of Y-BOCS 37 indicates an extreme level of obsession and compulsion. The somatic-obsession of excessive concern with illness and miscellaneous compulsions needs to tell, ask, confess, and observe in Y-BOCS assessment. The interventions of psycho-education, supportive psychotherapy, and Jeffrey M. Schwartz's “Four-step self-treatment-method” explained. The psychotherapy sessions started with psychoeducation of informative model and explained the pattern of illness, progress of the disease, and medication adherence and implication of the psychotherapy procedure.

The patient excessively ruminated about the window period of HIV infection and sought reassurance in each session. Hence, he was psycho-educated the window periods of HIV infection, with the reference of World Health Organization guidelines.^[16] After that, the supportive psychotherapy of reassurance and externalization of interests' techniques applied to treat his concern issue. He was reassured and conciliate that he is neither hopeless nor ultimate insanity. It tried to make him understand the problem and reduce the distressed state.

The patient was also lying down on the bed in the day time without engaging in any activity. Hence, the externalization of interest's techniques was applied to resolve the problem. He had encouraged to be attained at the entertainment club and take part in play activities. He takes part in play-act like played caroms, watching T. V. and take part in the yoga exercise. The patient had also suggested practice evening walk in the indoor campus. This technique helps him to reduce disturbing thought time being.

The four-step self-treatment-method of Jeffrey applied with the purpose of to explain the role of the internal thought process. This technique tried to organize a mental and behavioral response to the internal thought process. It helps to improve his insight and alter cognitive dissonance. The patient was able to make sense that reassurance-seeking behavior increased because of obsessional thoughts. At the end of five sessions, the patient gets aware of his problem behavior and gradually improved insight.

The next six sessions focussed on faulty thought appraisal and belief systems, applying through empirical hypothesis testing and cognitive restructuring procedure. In the exposure-response-prevention exercise, the patient suggested neither analyzing the thought nor practising in a stereotyped way. This technique helped him to adapt adaptive appraisal by confronting his thoughts. During ERP practice, the obsessive thought process record through a self-monitoring record sheet. The behavioral experiments applied to test the faulty thought appraisal through inflated significance practice. The patient had an inflated significance of thought appraisal, might infect with HIV. Hence, he asked to rate the impact of obsessive thought after the shortest trial and lengthy trial. After practising the session's technique, he understood that prolonged preoccupation with thoughts could increase worries. He had encouraged to practice the inflated significance techniques. In the next session, he reported that the above procedure helped him to alter his irrational thought process.

The cognitive restructuring procedure tried to change the erroneous appraisals and beliefs. This procedure applied down-ward-arrow and thought-action fusion techniques. The down-ward-arrow technique addresses the obsessive thought of having HIV infection. This technique probe with questions to make aware of how the thought process overestimating the risk. The thought-action fusion exercise performs to modify the erroneous view of the obsessions of a feared outcome. He had asked to generate an alternative thought appraisal and explained that having obsessive-thoughts of HIV positive does not mean that it is sure. The patient had assured that he was safed because medical test findings indicate no HIV infection. This procedure was monitored through unwanted intrusive thoughts and appraisal record sheet. The practice of thought-action fusion technique helped him to reduced his irrational thought process, restlessness, and distress level. His reassurance-seeking behavior also came down, but some ambivalent thoughts still present [Table 1].

Table 1: Psychotherapeutic Reflections

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In the last five sessions introduced the mindfulness approach with the cognitive-behavioral approach. The mindfulness approach tried to focus on the evaluative thought process and reassurance-seeking behavior. This approach applied nonjudging and acceptance techniques and psycho-educated about the mindfulness techniques. The therapist explained the judging process, how our mind evaluates our experiences, compared them with other experiences, or held them up against expectations and standards. The not judging process says about having thought of HIV infection, let be as it is, without attempting to evaluate it as “good” or “bad.” He had said that whatever thought came to your mind, recognize it without condemning it. The same way the mindfulness technique of acceptance explained, to accepting means accepting that thought is a part of yours. This technique helped him to allow though to go through rather than getting stuck with you. The sitting meditation demonstrated to the patient and suggested to practice it for 20 min every day. He had reported that meditation enhanced his attention regulation, from moment to moment and not to more attentive toward intrusive thoughts. He had encouraged and tried to builds his motivation to practice meditation regularly. In the last two sessions, it was reviewed by all the therapeutic techniques applied.

At the end of 16 sessions, the mental status examination, Y-BOCS scale, and psychotherapy monitoring sheet re-assessed. The MSE and assessment findings showed that the affect, self-efficacy, and insight improved. As well as reassurance-seeking behavior and distress level also reduced. The Y-BOCS score was decreased at the end of the psychotherapy sessions. In the intake session, the Y-BOCS score was found 37, which shows an extreme level of obsessions and compulsions. Whereas at the end of the psychotherapy sessions, the Y-BOCS score was found 15 indicates a mild level of obsessions and compulsion in the patient.

Discussion

OCD with poor insight is highly distressful for the individual. They have difficulty of thinking clearly about obsessional-thoughts. The application of cognitive-behavior therapy (CBT) with OCD and having poor-insight and the premorbid issue of O. C. traits is a challenging task. This case report tried to evaluate the efficacy of the holistic psychotherapeutic approach in patients with OCD. The holistic approach examines the impact of OCD with poor-insight, whose not sufficiently response to CBT or adequate response to medication. The holistic psychotherapeutic approach brought a positive change of thought appraisal, and belife system. It also enhances the nonjudgmental ability, attention functions, and ego-functions. A study elucidated the benefits of Mindful-Based Cognitive Therapy for OCD patients who did not sufficiently benefit from CBT.^[17] The mindfulness training increased willingness to experience difficult thoughts, feelings, and body sensations.^[18] The mindfulness approach might help question metacognitive styles and beliefs that maintained OCD, such as thought-action fusion^[19],[20] and thought control.^[21] CBT recommends for OCD patients who have failed to respond to approved medications. After received CBT, OCD severity decreased significantly. However, patient having poor insight shows low effort into CBT. CBT is a useful treatment for OCD patients who have failed to respond adequately to multiple serotonin reuptake inhibitor medications. Patients with a long history of inadequate response to the treatment may have poor insight or not put sufficient effort into treatment. These factors are likely to diminish treatment outcomes.^[22] This case study highlights that OCD patients with poor insight not sufficiently benefit from conventional CBT and other treatments that need a strong urge to find additional treatment or complementary treatment options. Hence, it wants to shed light on the role of holistic therapeutic approach in the management of OCD with poor insight.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Acknowledgment

This case report would not have taken its shape without the support of the various individuals and institutions. Colleagues contributed valuable comments and suggestions in the case report. I would like to thank all of them who have helped me in completing this case report at different levels and through various means. I acknowledge my gratitude to case that give his consent to published the case work as case report in Journal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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