Cognitive Therapy of Obsessive Compulsive Disorder with Chronic Tic Disorder
On 2-9-2009, 27-year-old male, who got graduation in M Sc. in computer science, employed regularly, presented with complaint of purposefully going into toilets or rooms (to avoid people noticing) and talking to self while tensing his body since 2 years but increase markedly over few months. These episodes occurred several times a day and each episode lasted for 10 min to 2 h. Self-talk varied from faint muttering to loud yelling. During these times he was making movements forcefully, like, blinking, opening eye lids, and deviating eye balls; tensing scalp, abdomen, limb and chest muscles. Sometimes he pressed, banged or lifted his breast area, mentally visualizing his chest to be of male (not having gynecomastia). At times he held his breath and increased the pressure in the chest.\nPatient had several unacceptable sexual thoughts about relatives with sexual arousal, aggressive images (dead bodies of relatives), doubts about appearance and acceptance from friends and relatives; and need to remember perfectly. When these thoughts appeared he was consoling and convincing himself by self-assurances, rationalizations, analyzing them till his mind was accepting his view about those issues. He tried to recall information till he is satisfied. It was a struggle to convince own mind against intruding thoughts, which were unacceptable. During this struggle, the self-talk (spoke the content of thoughts loudly) and tensing the body accompanied.\nDuring adolescence he was treated briefly for washing compulsions and improved. He had intermittent concerns over balding, shape of his chin, having gynecomastia, getting swine flu or scrotal cancer over a period of few months. He had anankastic and borderline personality traits.\nA diagnosis of OCD with chronic tic disorder with anankastic and borderline traits was made. Fluvoxamine and clomipramine were titrated to 200 mg and 100 mg respectively and talking to self-tics and body tensing were improved. Addition of risperidone did not benefit him. His residual symptoms were preoccupation with gynecomastia, complex tics, several obsessions, mental compulsions and ruminations (but without talking to self). He was referred to a qualified psychologist to undergo cognitive behavior therapy (CBT) and in 20 sessions preoccupations with breast shape and tics improved but obsessions persisted. Perusal of his past CBT treatment notes revealed that therapy had focused on preoccupation on gynecomastia and tics (habit reversal) but obsessions remained untouched.\nDuring follow-up, after 2 years, author offered him cognitive therapy (CT) for his persisting obsessions and patient consented. Main schematic beliefs were need to control and over importance of thoughts (moral thought action fusion). He believed that just presence of sexual thought made him a bad person and failure to control his mind might lead to overt sexual (womanizer) behavior. He aspired for mental purity. Unless he recalled information perfectly, he thought, he will not retain information usefully (low cognitive confidence). Initially patient was reluctant to allow the bad thoughts in the mind without responding them. He was motivated to do this by advantage and disadvantage analyses. Normalization of intrusive sexual thoughts was achieved by self-disclosure and internet search. Futility of thought suppression was demonstrated by suppression of an image of elephant for 1 minute. He was told that non-acceptance and resistance offered to mental events and avoidances results in excessive unwanted intrusions. Thought action fusion was corrected with behavioral experiments. He was told to allow sexual thoughts freely for 1 day and observe for any change in his behavior. Gradually he was more confident and stopped mental compulsions in response to sexual thoughts. He was told to look at ladies (he was avoiding) or imagine and masturbate as much as he wanted lead to reduction in avoidance of sexual issues. He was told to stop doing repeated recall of information for 1 day and see any deterioration in his memory or functioning. He learnt that there was no need to take care of his memory and those compulsions improved. He wanted an ideal friendship in every friend in every occasion. This splitting or polarized thinking was corrected. At the end of therapy he told that friendship pricks him only once in ten times compared to past.\nSurgical opinion confirmed the presence of grade II true gynecomastia. Patient decided to undergo surgery at a later date for the need of money. With this new hope his concern and obsessions over gynecomastia improved. Along with improvement in OCD, tics and muscle tensing also improved. Over 2 months (with 10 sessions of therapy) medications were tapered and stopped and patient reported good improvement and was quite happy. Monthly three more booster sessions were given and patient is maintaining improvement.