PSYCHOTHERAPY REPORT

Department of Clinical Psychology

CENTRAL INSTITUTE OF PSYCHIATRY, RANCHI
Ministry of Health and Family Welfare
Govt. of India

UHID NO: 20230010043 CRF No: 2306124/A

Name: Piyush Saurabh Occupation: Unemployed
Education: Graduation Age: 25 years
Marital status: Single Sex: Male
Socio-economic status: Middle Residence: Jharkhand

Referral Purpose: Psychological Management

Chief Complaints:

● Repetitive thoughts of asymmetry followed by acts to correct them Past 3-4

● Distress followed by irritability on trying to control thoughts years

BACKGROUND INFORMATION AND CASE SUMMERY:

Source of information: Patient, parents, patient’s case record
file
Mode of onset- Insidious
Course of illness- Continuous
Progress- Deteriorating
Reliable and adequate

Index patient was maintaining better 4 years ago when his guardians noticed that he started
complaining of unwanted thoughts which were his own. These thoughts seemed senseless and would come
and intrude his daily living. They were recurrent in nature and he reports that he is unable to control them
even when they cause him a lot of distress and she really wants to get rid of them. These thoughts keep
running in her mind for 4-5 hours and compels him to do acts like correction of asymetry. These actions
by itself take 4-5 hours of the day and he reports that he does not feel satisfied if he performs the behaviour
only once. Hence, he has to do it 3-4 times which relieves his anxiety for some time but then again, these
thoughts come back and the cycle repeats.
He reports feeling better after that and that is how these thoughts came uninvited and resided his mind
almost whole day. Most of the time the anxiety he feels by chest pain, perspiration, palpitations is so much
that even when he wants to control he is unable to do so and instead has to correct them as only that gives
her transient relief.
 He reports being distressed by such thoughts and more by the repeated behaviours which seems his
own yet very illogical. He feels guilty after wasting the whole day preoccupied by them and does not feel
like doing any chore. He reports that he feels lethargic and worried when he is asked to do something and
have no confidence in himself about the successful completion of activity without giving in to his habit or
getting distracted by but therefore losing a lot of time. Hence, he asks his family members to support him
now and when they don’t listen to him, he become irritated and aggresses towards them. He throws things
in impulse and say bad things to them. Thus for the pasat 2-3 years there have been multiple fluctuating
episodes of low mood and crying when his demands were not met. He reports that he has been feeling
defeated by his illness and his own thoughts. He is unable to regulate the irritability and sudden impulse
to quite his life. He is unable to plan his future and hope for change.
Persistent and pervasive mood: Dysphoric mostly
Biological functions: Disturbed sleep
Role functioning: Impaired
Activities of daily living: Intact
Personal Care: Impaired
Negative history:
• No history of episodes of elevated mood, excessive talk, tall claims, increased energy.
• No history of intense fear of any specific object or place, panic attacks, free floating anxiety,
nightmares, episodes of dissociation etc.
• No history of fearfulness and suspiciousness.
• No history of thoughts being inserted, withdrawn, broadcasted or controlled by external agency.
• No history of seeing people, hearing voices or any other sensory experience in any other modality.
• No history of disorganised and disinhibited behaviour
• No history of seizures, significant head injury, prolonged illness, etc.
• No history of seizures, epilepsy and fits.
• No history of substance use and dependence.

Mental Status Examination:

General appearance – kempt, tidy, eye contact not maintained, looks appropriate to
stated age; Attitude: cooperative, rapport established, relaxed manner of relating; Motor
Behaviour – normal; Speech – soft, normal reaction time, normal productivity, coherent,
relevant, goal-directed; Cognitive Functions – intact; Affect –dysphoric, normal reactivity,
communicable; Thought –possession: obsession of asymmetry; perceptual disorder- NAD,
judgment- intact; grade-III insight.

Management Goals:
1. Reduce the frequency of compulsive behavior of Asymmetry.
2. Reduce obsessive thoughts linked to negative something happened.
3. Diminish the anxiety and fear and frequent anger outburst.
4. Breaks down his beliefs concerning elevated responsibility appraisal and lack of self-esteem.

Mode of Therapy: Cognitive behavior Therapy for OCD.

Techniques used:
Behavioral Experiments and ERP
Cognitive restructuring (Socratic questioning and guided
discovery) Pie Chart and Pink elephant exp.
 INITIAL PHASE:

No. of sessions : 4

Target: Conducting assessments, identification of problem and defining target behavior:

Detailed history was collected from parents about the patient. The necessary assessments were
conducted (Y-BOCS). Rapport building process was initiated with the patient by discovering his
interest areas. The patient started to become comfortable with the therapist.

Identification of the Target Behaviors: Based on observation, interview with parents, and
psychological assessments, maladaptive Behaviors and negative appraisal were identified as:

Excessive concern for asymmetry and ordering things

Frequent anger outburst on trivial issues

PROCEDURES:

Initial two sessions are targeting to rapport building and conducting assessment and case
formulations. Before the assessment trainee psychoeducated regarding the importance of
psychological assessment however, during the assessment, anxiety also observed regarding
whether answer is correct or not observed. After that next two session targeted to educating
about the OCD and its Cycles. Informing about Case formulation and mode of therapy, number
of sessions, homework assignment, and mother as a co-therapist discussed.

Psychoeducation of OCD
After the evaluation session, trainee moved to the discusses the patient’s illness. What is
Obsession, Compulsion covered on the following points:

Obsessions:
Obsessions are repetitive and persistent thoughts, images, or impulses that, at some point, are
considered intrusive and inappropriate and cause marked distress: they are not worries about
real-life problems: they are accompanied by attempts to ignore, suppress, or neutralize (i.e.,
subjective resistance); and they are acknowledged as a product of the person's mind.
Here index patient’s obsessions are
• fear will be responsible for something else terrible happening,
• fear of might self-harm, fear harm will come to others.
• Excessive concerns with illness or diseases.
• Concerns with dirt, germs, certain illness (e.g.
AIDS)

Compulsions:
Compulsions are repetitive behaviors or mental acts that the person feels compelled to perform
 in response to an obsession or certain rigidly applied rules, and the function of the behaviors
or mental acts is to prevent or reduce distress or some dreaded event or situation. The rituals
either are not connected in a realistic way with what they are intended to neutralize or are
clearly perceived as excessive.

Here index patients’ compulsions are

• need for symmetry,
• checking that did not/will not harm others,
• need to do things (arrange or touch until it feels just right).

OCD Cycle:

The cycle of OCD is an experience loop of four components: an obsession, feelings of

overwhelming anxiety, a compulsion that neutralizes distress, and temporary relief. When
intrusive thoughts return, the cycle begins anew. This was diagrammable explained how his
obsessions (fear will be responsible for something else terrible happening, fear of might self-
harm, fear harm will come to others.) create anxiety which reduced temporarily by compulsions
(need for symmetry, checking that did not/will not harm others, need to do things (arrange or
touch until it feels just right.), which is reinforce the obsessive thoughts. Along with model of
Inflated responsibility appraisal also explained.

Frequent anger outburst on trivial issues

ABC analysis of Anger Outbursts

Patient’s Name: Piyush Saurabh Observer: Mother Environment: Home

environment

Triggering Antecedents Problem Behaviors Maintaining Consequences

When mother do not listen,tolerate his Anger outburst Mother satisfies his demands and
demands, and listens to him
when mother tell him to go to work irritability, not
eating
food and remain
outside for long
time.
PROCEDURES:

Session has been done with mother and educates regarding the patients presenting
issues. Case formulation and management informed, invites as a co-therapist, proxy
compulsion and maintaining factors informed. Regarding frequent anger outburst, contingency
management, differential reinforcement concept explained.

MIDDLE PHASE (INTERVENTION PHASE)

No. of sessions : 12

Targets:

• Detailed identification and self-monitoring of obsessional thoughts and appraisal.

• Record of dysfunctional Thoughts
• Introducing self-soothing techniques.

PROCEDURES:

To IDENTIFYING MISINTERPRETATIONS and DYSFUNCTIONAL THOUGHT,

thought record chart has been provide to the patient.

Situation in Intrusive What the Beliefs Discomfort What Strength of

which thought, intrusion rating for when neutralizing urge to
intrusion images, or meant to you significanc intrusion response neutralize it
occurs and impulse (the negative e (0-100) occurred (0-100)
any significance (0-
triggers attached to 100)
which set it it)
off.
Mother told Thoughts I will harm 80% 65% I go out side 75%
me of self- either of the home
somethings harms and myself and and not
but I disagree other other. involved in
any type of
activity
Tried to Thoughts Being not to 85% 80% Write and 85%
focus a of control it erase it,
work but somethings actually focuses on
didn’t focus will terrible happened symmetry
on it happened and I will of table
responsibility

Also, Socratic Questioning and Guided Discovery techniques are used in subsequent sessions
to identify appraisals. Following faulty appraisals are found
 • Inflated Responsibility
• Overestimation of threats
• Need for control
• Neutralization beliefs.

Cognitive Restructuring Strategies:

Pie chart Techniques: Patient and the therapist putting an example of having an accident and
giving weightage of possibility of causes, with real-life evidences, at end summarizing the to
personal responsibility of it. Following percentages given by possible factor

• Careless driving 30%

• Careless driving: others- 30%
• Poor Skills 10%
• Drunk Driving 10%
• Sudden Distraction 10%
• Self 10%

Pink Elephant Exp: Exercise targeted to explain who avoidance or trying to suppressing a
event leading to frequent occurrence of it.

Exposure and Response Prevention:

Therapist obtained the rating of degree of distress and anxiety, urge to engage in compulsion
and Subjective Unit of Distress (SUD) for both obsession and compulsion made. Rational has
been given for the exercise. Before it was explained the physiological changes in state of
anxiety graphically and activity of sympathetic and parasympathetic NS in Flight and Fight
responses. Explained through a simple example of performance anxiety in class, how the heart
rate, sweating, heavy breathing increased and after a pick it reduces by facing it and through
repeated practice it no longer able to cause significant distress.

Subjective Unit of Distress (SUD) Rating of level of anxiety and avoidance in the 1st
and 7th session.

Sessions 1 1 7 7

Rating Rating of urge to Rating Rating of

of level do of level urge to do
of Compulsion/Avoi of Compulsio
anxiety d anxiety n
1. Make asymmetry of object /study 80% 75% 50% 40%
materials while staying

2. If touched, then both lands or 55% 45% 30% 20%

legs need to touched in same
manner

Targets:
• Provide supportive therapy
• Realistic treatment expectation and treatment prognosis of OCD.
 • Home-work

monitoring PROCEDURES:

Trainee graphically presenting the prognosis of OCD, and provide supportive

psychotherapy to patient and mother. Regarding the anger outburst Contingency management
also discussed during the sessions.

FINAL PHASE (TERMINATION AND RELAPSE PREVENTION)

Number of sessions: 4

Techniques used: Sharing percent improvement

Objective: Reviewing progress in follow-up

session

Feedback was taken from the patient whereby he was requested to note down. The
patient also reported that now he was more aware of his problem and better equipped to manage
the on their own by using the techniques that he had learned. The sessions were recapped and
he was motivated to continue his therapy as well as adhere to the pharmacological management.
Patient also encouraged to be vigilant for any urge to slip back into the “control mentality”
when re- experiencing an obsessional thinking, provide triggers and high-risk situations.

POST- INTERVENTION EVALUATION

At the end of therapy when the patient about to discharge post test has been done. Mother
reported improvement in his daily functioning and repetitive behaviors. The feedback by
corroborated both objectively as well as subjectively where there was marked improvement on
the following test scores:

Pre- Post-
intervention Intervention
Total score- Total score-
Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) 18 12
(Moderate) (Mild)

Future plan
To continue with Cognitive Behavioral Therapy on OPD basis.

Therapist: Urbi Chakraborty Supervisor: Sunny Kumar Sharma

Signature: Signature:
Date: Date: