I Can’t Stop 1

Running Head: I CAN’T STOP WASHING
















I Can’t Stop Washing and Cleaning

Jeriel L. Music

ST. Martin’s College

Psychology 345




















                              I Can’t Stop 2

Abstract

Washing and constant cleaning, an obsessive-compulsive disorder (OCD). OCD often goes

undiagnosed. Patients obsessively wash, check something or hoard things to relieve themselves

of an overwhelming anxiety, and are fully aware their behavior is abnormal. This research

studies a 23-year-old married woman who sought treatment for a severe washing and cleaning

problem and how the patient was treated. I will discuss how the patient was diagnosed,

and treated with a form of cognitive behavioral psychotherapy or CBT (exposure and response

treatment) and what medications can be used for treatment.





























I Can’t Stop 3

I Can’t Stop Washing and Cleaning

Vickie, a 23 year-old married woman arrived with the company of her husband. Vickie had

a problem with severe had washing and cleaning. She would wash her hands up to 30 times a

day for at least 5 minutes each time. She always had the feeling that her hands were not really

clean, she might touch the side of the sink after she rinsed her hands and then think they were

dirty again. She also took two showers a day for up to 50 minutes or until all the hot water was

gone. Other things she did to make herself feel clean is use alcohol to wipe things down that she

would come into contact with, like her car seat before she set in it. She has been unable to seek

employment as a Licensed Practical Nurse (LPN) due to her symptoms. I conducted four initial

sessions, session one and two were to seek information about the history of her symptoms,

obsessional content, including external and internal fears cues, beliefs about consequences, and

information about passive avoidance patterns and types of rituals (Levenkron, 1991). I also

requested Vickie before our next session to record all washing and cleaning that she did,

including wiping things with alcohol. She recorded every time she washed, how long she

washed, what made her wash, and how anxious she was before she washed. This kind of record

will help us identify any sources of contamination she may have gotten and we can also use it to

measure her progress during treatment; the third session was devoted to personal and family

history; the fourth session was devoted to treatment planning. During the first three therapy

sessions Vickie talked about her experiences of recurrent and persistent ideas, thought, impulses,

images that were intrusive and senseless. One example; her repeated impulses to wash her hands

or wipe down everything she came into contact with using alcohol for no apparent reason

(Levenkron, 1991). Vickie recognized that the obsession was the product of her mind.

I Can’t Stop 4

After taking all the information gathered in the three initial therapy sessions and referring to

diagnostic and statistical manual of mental disorders (DSM-IV-TR) which states Obsessions:

recurrent and persistent thoughts, impulses, or images that are experienced, at some time during

the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.

Compulsion: repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g.,

praying counting, repeating words silently) that the person feels driven to perform in response to

an obsession, or according to rules that must be applied rigidly as a definition for obsessive-

compulsive disorder (DSM-IV-TR, 2000, p. 462). Now with the disorder defined, during the

fourth session the patient and myself compose a treatment plan, and a commitment to follow my

instructions is secured. My first step in treating her for OCD was educating her and her family

about OCD and its treatment as a medical illness. This is crucial in helping Vickie and her

family learn how best to manage OCD and prevent its complications. Its important that Vickie

and her family become an experts on her illness, since OCD could come and go many times

during her life, this will help her get the best treatment and keep the illness under control

(Obsessive-Compulsive Foundation). Over the last 20 years, two effective treatments for OCD

have been developed: cognitive-behavioral psychotherapy (CBT) and medication with a

serotonin reuptake inhibitor (SRI) (Obsessive-Compulsive Foundation). We decided on 20

treatment sessions, using exposure and response-prevention treatment, which falls under the BT

in CBT behavior therapy. Behavior therapy will help her learn to change her thoughts and

feelings by first changing her behavior. Behavior therapy for OCD involves exposure and

response prevention. Just a little bit about exposure and response-prevention treatment, the

exposure part of the therapy involves actually confronting the source of the anxiety and/or

I Can’t Stop 5

Discomfort (Jenike, 1999a). For example a person afraid of contamination from public

bathrooms will be asked to go with the therapist to a bathroom and touch some “contaminated”

item in the bathroom. The response prevention part of the therapy occurs when the patient does

not wash his/her hands while feeling contaminated, until an item no longer produces anxiety or

discomfort. Exposure is generally more helpful in decreasing anxiety and obsession, while

response prevention is more helpful in decreasing compulsive behaviors (Jenike, 1999a). In

order to prepare for an exposure program in which objects are presented hierarchically with

respect to their ability to provoke discomfort, Vickie was asked to rank her major contaminants.

We made a list of the main things that upset her. I asked her how uncomfortable she would be

on a scale from 0 – 10 if she touched the things I named. Zero indicates no discomfort at all and

10 means you’d be extremely upset. Once we came up with a list of 10 to 20 items we put them

in order from low to high in preparation for treatment by exposure. The other part of CBT is CT

cognitive therapy we added it to E/RP to help reduce the catastrophic thinking and exaggerated

sense of responsibility often she was feeling with her OCD (Obsessive-Compulsive

Foundation). We held our sessions on weekdays for a period of four weeks along with Vickie

and her husband conducting four-hour exposure therapy treatment at home touching whatever we

worked on during the therapy session. During the 5th week I visited her twice for four hours

each time at her home. This type of treatment will expose her and her spouse to imagination and

reality to the things that bother her. We will also limit her washing. The scenes she will be

exposed to will concentrate on the harm that you fear and the actual exposures will focus on the

things that contaminate you. Restricting her washing will teach her how to live without washing.

During these visits I contaminated her home and exposed her to objects that provoked discomfort

I Can’t Stop 6

at home and in her neighborhood. Thereafter weekly follow-up sessions were instituted to ensure

maintenance of progress and to address any other issues of concern to her. Treatment began with

exposure to moderately difficult items and progressed to the most disturbing ones by the

beginning of the second week. The major feared items were repeated during the remainder of

the 2nd and 3rd week (Engler & Goleman, 1992). Before each therapy session I checked to see

if Vickie was doing her assignments from the previous day to verify that she had completed it

and has not engaged in avoidance. This provided an opportunity to reinforce efforts at self-

exposure. We also went over her self-monitoring of rituals list, so we could measure her

progress during treatment. Exposure to contaminants during the home visit was conducted about

the same as the in office visit but for a longer time until all dirty items are touched and cleaned

places are contaminated. After 10-15 sessions Vickie reported anxiety levels had decreased

considerably and at the 16th her anxiety level was at an expectable level, but still needed follow-

up sessions because her anxiety level was still high and to ensure gains were maintained. We

decided on monthly treatment plan for six months so that we could monitor her symptoms. If all

goes well we will have yearly follow-ups after that. Regardless of scheduled appointments if she

has signs of recurrent or OCD symptoms she will notify me.

To summarize Vickie’s treatment plan and diagnosis. After my first couple therapy sessions I

determined that Vickie had a milder case of obsessive-compulsive disorder. She showed no

signs of depression or any signs of other psychiatric disorders that might resemble obsessive-

compulsive disorder. She sought help and treatment for her own problem. Vickie and myself

selected a form of cognitive-behavioral psychotherapy (exposure and response treatment)

if we could confront the source of her problem along with monitoring her response to the

I Can’t Stop 7

problem over time and with repeated sessions, the discomfort should diminish until the

containment item no longer produces anxiety or discomfort. We decided not to use any form of

medication since she had a milder form of the disorder and showed no signs of needing it.

Both cognitive-behavioral therapy and medication methods of treatment are effective, and

each has its own strengths and weakness. Drug treatment is relatively easy to administer and

does not cause significant patient discomfort. Behavior therapy, on the other hand, eliminates

concerns about medication side effects and produces results that may be better maintained after

medical treatment is terminated.

I did not need the use of medication for Vickie, but the majority of the drugs that help OCD

are classified as antidepressants. Depression commonly results from the disability produced by

OCD, and that doctors can treat both the OCD and depression with the same medication.

Research clearly shows that the serotonin reuptake inhibitors (SRIs) are uniquely effective

treatments for OCD. These medications increase the concentration of serotonin, a chemical

messenger in the brain. There are six drugs that have been shown to be effective for OCD they

include: fluoxetine (Prozac), fluvoxamine (Luvox), citalopram (Celexa), sertralin (Zoloft),

paroxetine (Paxil) and clomipramine (Anafranil). The choice of agent depends on your clinical

preference and subtle differences in patient presentation and preference. Fluoxetine, for example,

tends to be slightly energizing, whereas fluvoxamine tends to be slightly calming. Clomipramine

is a nonselective SRI, which means that it effects many other neurotransmitters beside serotonin.

As a general rule, it appears that for most people high dosages of these drugs are required to

obtain anti-obsessional effects. Studies done to date suggest that the following dosages may be

necessary: Luvox (up to 300 mg/day), Prozac (40-80 mg/day), Zoloft (up to 200 mg/day), Paxil

I Can’t Stop 7

(40-60 mg/day), Celexa (up to 60 mg/day), and Anafranil (up to 250 mg/day), (Jenike, 1999b).











































I Can’t Stop 8

References


American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders

(4th ed.). Washington, DC: Author

Engler, J. & Goleman, D. (1992). The authoritative guide for making informed choices about all

types of psychotherapy. The Consumer’s Guide to Psychotherapy. New York, NY: Simon &

Schuster/Fireside

Levenkron, S. (1991). Treating & Understanding Crippling Habits. Obsessive-Compulsive

Disorders. New York, NY: Warner Books.

Jenike, J. (1999a). How to select a Behavior Therapist. Obsessive-Compulsive Foundation.

Available: http://www.ocfoundation.org/ocf_0003.htm

Jenike, J. (1999b). OCD medication: Adults. Obsessive-Compulsive Foundation. Retrieved

November 18, 2001, from http://www.ocfoundation.org/ocf1050a.htm

Obsessive-Compulsive Foundation: How is OCD treated. Retrieved November 14, 2001, from

http://www.ocfoundation.org/ocf1030a.htm