1. Provisional Diagnosis: Obsessive-Compulsive Disorder
2. Rationale for the diagnosis:
A. Presence of obsession, compulsion, or both:
Obsession: the persistent thoughts of the client and attempts to ignore, suppress or neutralize these thoughts, impulses, or images
---- he feels some foods contain poisonous germs and diseases, any personal hygiene would interfere with his studying, he believes that the special rituals before eating, such as loud hissing, coughing, would allow the food to enter an air-free and sterile environment, he fears that any personal hygiene, such as shaving and showering would make himself contaminated, he thinks placing the objects in a certain way is the method to protect himself and his family from future catastrophe such as AIDS.
Compulsion: behaviors and mental acts, driving the client to perform or to reduce distress
----excessive washing and showering, ceremonial rituals for dressing and studying, compulsive placement of object, narrowing his food intake and doing special eating rituals to reduce the possibility of being contaminated or poisoned even if he knows this is not rational, shuffling and wiping feet while walking, neglect of his personal appearance and refusing to engage in any personal hygiene for fear of study interference and contaminants entering his body. B. Time-consuming or causing clinically significant distress or impairment in important areas of functioning:
Spending excessive time to ensure all things are in the proper place and periodically checking throughout the day(time-consuming), isolation from family and friends and leaving his bedroom infrequently(social dysfunction), refusing meals and getting lost of weight quickly(physiological dysfunction----eating disorder). C. Not attributing to physiological effects or medical condition:
According to text material, it doesn't show that the client have ever taken any medicine or received any physiological treatment. D. Not better explained by other mental disorders: Why not...
a. GAD: The key features of GAD are a persistent worry about a variety of events and activities and presence of other symptoms such as muscle tension and sleep difficulties(these symptoms are not shown in the case). The hallmark of OCD is the presence of specific obsessions and compulsions. OCD typically involves obsessions regarding one or two particular worries or concerns, and compulsive rituals that serve to psychologically “undo” the danger and lower anxiety. In this case, the anxiety is mainly caused by the contamination of germs.
b. Specific Phobia of Contamination: Both of these two disorders are categorized as anxiety disorders, and are similar in that they cause high levels of anxiety. Phobias are initiated by something in the external environment, which if not present does not elicit the maladaptive behavior. OCD is generated internally through thoughts(obsession)that lead to behaviors. In this case, the client thinks that the germs can make him contaminated easily, thus he has to do some ritual things to prevent or to decrease the probability.
c. Social Anxiety Disorder: Social anxiety disorder is an anxiety disorder in which a person has an excessive and unreasonable fear of social situations. Anxiety and self-consciousness arise from a fear of being closely watched, judged, and criticized by others. A person with social anxiety disorder is afraid that he or she will make mistakes, look bad, and be embarrassed or humiliated in front of others. However, obviously, In this case, the client does develop social dysfunction, but it is not because of the fear of social situations.
d. Psychotic Disorder: Although some people with psychotic disorder like schizophrenia also have obsessive-compulsive symptoms, patients with psychosis actually lose touch with reality and their perceptions may become distorted. They have delusions. Their thoughts aren’t based in reality but the person believes the thoughts to be true. Obsessions may involve irrational anxiety, but they are unlike delusions. The symptoms of OCD may be bizarre, but the patient recognizes their absurdity and they can stay in touch with reality in all other areas of their lives. Specifying:
With poor insight----even the client realizes that his ritual behaviors are irrational, he can't stop reducing any chance of contamination. 3.Treatment: Exposure and Response Prevention(ERP)
A. Leaving everything in the client's bedroom chaotically and disorderly and more and more contaminated for a week and prevent the client from cleaning and placing things in the proper place.
B. Let the client to touch something contaminated(such as a tissue with dust and ash)and prevent the client from washing hands for the entire day, then gradually increase the contamination of the objects and repeat this ERP for a whole week.
C. while eating, keep the client from doing ritual behaviors to reduce the probability of being contaminated or poisoned for a week.