Four-session cognitive behavioral therapy for the management of obsessive-compulsive disorder using a metaphor for conceptualization: A case report.

Sir,

Cognitive behavioral therapy (CBT) is one of the effective psychological interventions for obsessive–compulsive disorder (OCD), which usually involves 10 or more sessions.[1] Here, we present a case of OCD which was treated with four sessions of CBT based on case conceptualization (CC) through the use of a metaphor for the facilitation of easier understanding and adherence to the exposure exercises.

CASE PRESENTATION

A 25-year-old graduate male reported with a 12-month history of having intrusive thoughts and images of him harming his relatives while batting, using sharp objects and watching action movies, parents lying dead, and images of having sex with relatives while watching sexually intimate scenes in movies.

He was coping by avoiding movies, using knives, fork, bat, and other objects by which one can easily injure others, face-to-face interaction with parents and by reassuring himself of parent's wellbeing by making phone calls to them. He was trying repetitively to replace an image of the “loved ones” with of others, climbing up and down, switching on and off the plugs to prevent any harm to them by him or by accident. He did not want to take medications worrying about the side effects, especially drowsiness as he was preparing for competitive examinations.

Psychological intervention

Four sessions of 1-h CBT were provided on the 1st, 2nd, 4th, and 6th week. In the first session, tailored CC was done using the following narrative as a metaphor.

“One day a boy started to have severe itching while he was in one corner of his room. He interpreted that it was the 'corner of the room' which perhaps got him 'itching.' He could not entertain any other explanations at that time. Next day while he was in the corner of that room he felt distressed, as soon as he left the area his distress decreased. He avoided going there. 'Avoidance' of the corner became his major coping mechanism. Later, even the thought of going there increased distress. He started asking his brother to get things from the corner or he started using other means like sticks when no one was around to get things from the corner. He coped this way as he was not having 'itching.'”

After this, the patient was asked to reflect whether by these coping behaviors, the boy's concern that corner contributed to itching is decreased; and if not, what would he do to deal with the concern. The patient replied that these behaviors helped reduce fears only temporarily, but “he should have gone to the corner, once again, to experiment.” It was acknowledged that exposure was the appropriate answer with further discussion on the role of repeated exposure in reducing distress and misinterpretation.

Through this metaphor clinical translation of his problems, role of feared objects (knives, bat, intimate scene and railway track), feared consequences (harm to parents by him or accident and inability in reducing distress until he engages in neutralizing acts), role of neutralizing and safety behaviours in maintaining feared consequences and importance of 'exposure' were conveyed and discussed.

With the help of his own reflection, an exposure session of witnessing a railway track in a video was conducted in the first session. Mutually, a list of homework sessions with increasing difficulty was prepared, for example, to hold knives and rate his distress level every five minutes; seeing/reading intentionally violence clips/news; to use knives in front of loved ones; using such sharp objects in many situations other than home; not to try replacing “negative image;” and to delay in calling parents seeking reassurance. While performing these, he was asked to check his distress level and expectancy of feared consequences. From second to fourth session, revision of homework and learning from it were discussed; further assignments of exposure exercises were given, which he adhered.

Outcome

Yale-Brown obsessive–compulsive scale[2] scores and quality of life (QOL) based on the WHOQOL-BREF[3] at baseline, posttreatment (6 weeks), and follow-ups after 1 and 12 months are given in Table 1. OCD symptoms decreased from “severe” to “mild” at post and follow-up stages. QOL also showed progressive improvement.

Table 1

Scores of Yale-Brown obsessive-compulsive scale and WHO quality of life-BREF at different time

	Pretherapy	Posttherapy	Follow-up at 1 month	Follow-up at 12 months
YBOCS	32	15	11	7
WHOQOL-BREF*
Overall perception of QOL	2	3	3	4
Overall quality of health	1	4	4	4
Physical	10	14	14	15
Psychological	9	14	15	16
Social relationship	4	8	8	12
Environmental	9	13	14	17

*Transformed scores in range 4-20. YBOCS – Yale-Brown obsessive-compulsive scale; QOL – Quality of life

DISCUSSION

In the present case, four-session CBT showed reductions of OCD symptoms in contrast to the reported average of 14.7 sessions.[1] This was probably achieved through the use of a lucid narrative for easier understanding that helped adherence to the interventions and homework. In addition, CC helped in tailoring individual-specific appropriate interventions.[4]

There are many challenges in the management of OCD including nonresponse,[5] besides the feasibility issues in India considering inadequate workforce for the provision of psychotherapy. Although 12–14 CBT sessions may be ideal for OCD, these may not be possible in most cases. This case report suggested that CBT may be effective in fewer sessions. Controlled studies using four-session approach are required for further confirmation.

Consent

The patient provided written informed consent for publication of this report.

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 understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.