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Case Study

OCD manifesting as Examination Fear
Dr J P S Bakshi
Dr Ritu Chopra

Summary: What appeared to be a simple case of examination fear was actually a case of classical OCD. Also included a screening test for OCD, interpretation of Rubrics of Mind section of Repertories from the point of view of OCD and Alternative therapies.

Case: One fine morning, a tall and well built, 21 yr old student of B Com (H) final year came to my OPD. He seemed a decent fellow except carried a tense expression and no smile; as if surrounded by thousand worries.

I asked him, 'Yes, young man, what brought you here?' He answered, 'you might find it funny doctor, but my only problem is tension before exams. It has been persisting for 3 years now and I am not able to get rid of it.'
Dr: 'Can you be more specific? What exactly do you feel?'
Pt: 'I feel a lot of pressure on my mind during exams. I study very hard but the day before my exams, I have a lot of anxiety, with restlessness and nausea due to tension. I am not able to concentrate on my studies and cannot even sleep due to this tension'.

He further added, 'I have no confidence that I will remember what I have studied for the exam the next day. I am always in two minds as to whether I would be able to perform well in exams and live upto the expectations of my parents. I am at a constant fight with myself to prove my abilities. My main worry is the my pessimistic attitude, developed over years. 'Initially, it was just anxiety before exams but now it has developed into fear. A fear of forgetting what I have studied. This leads to sudden loss of memory when I start writing my exams.' I am in a vicious cycle from one exam to another and I am not able to come out of it.

These thoughts are constantly on my mind and make me very depressed. On one hand I feel I have the ability to do it and on the other hand I feel I would not able to. This constant fight pulls me apart in two different directions. This thought is present in every breath I take. I feel suffocated. I am not able to live a normal life.'

The agony he was going through was palpable. Further questions were asked to complete the case, the case was repertorised using following rubrics.

  1. Mind; Fear; examination, before
  2. Mind; Anxiety, fear with
  3. Mind; Will; contradiction of
  4. Mind; Concentration; difficult
  5. Mind; Thoughts; persistent
  6. Mind; Confidence; want of self
  7. Mind; Memory; weakness of; read, for what he has, just

The result of the repertorisation was a given under-
Anac17/7 Sil11/6 Ph-ac 9/6

Final choice was Anacardium 1M, given on 21st April- 1dose was given with Sac Lac for 15 days. The patient came after 15 days. He entered the chamber and sat as before. His expression was also quite the same.

Dr: 'How are you feeling?' Pt 'Just the same. No change at all'.
This got me thinking: what went wrong here? There seemed to be a persistence of the same thoughts. While planning my next move, I saw him take out a paper out of his pocket, read it, keep it back, take it out again and read it. I asked for it and read it. There were 4 pages and on questioning he told that whatever he studied he used to write on paper. But it was a most peculiar thing: exactly the same notes were written 5 times.

Dr: 'Why have you written them so many times?'
Pt: 'I am in the habit of writing again and again because I tend to forget what I just read.'
I had my clue. I should use my knowledge of disease to view this case from a different angle.
Dr: 'Do you do anything else so repeatedly?'
He could not understand the question so I reframed the question 'Do you do any other task again and again'.
Pt: 'Yes, as a matter of fact, whenever I have to give money to somebody or take money from somebody I tend to count it at least 5-6 times. This has became a habit. Actually I tend to count everything again and again.'
The diagnosis of OCD became clear. To help him uncover this aspect of his personality, he was given the screening test for OCD and further symptoms were elicited.

Dr: 'How particular are you about things in your life?' He said 'Doctor, you have asked me a very good question. I am very particular about the no 3. I tend to never do anything 3 times. It will be done either 2 times or 4 times. Even if I am serving food I never serve 3 times.'
'If the door is half-open and I do not notice it, it does not make a difference but the oment I notice it, I cannot sit comfortably; I have to either open it fully or close it fully. I tend to write everything in points and if the order is broken, I tend to write it gain to make sure it is written perfectly. I am suspicious relating to the choices I make, constant insecurity about doing the right thing. I have developed a tendency of creating an imaginary sort of fear for anything I cannot achieve or is beyond my control".

While he was narrating all his problems, another patient came in. An irritation passed over him.
I asked him later. 'Something wrong?'
He said 'Not really"
Dr: 'Still. You did not seem to like something'
He said, 'Actually, I did not like the colour of her dress'
Dr: 'What was wrong? It was so bright.'
He said, 'That's it. I have a strong dislike for bright colours.'
Dr: 'OK, one last question. How particular are you about cleanliness?'
He said, 'Doctor, I am surprised. Do you know everything about me already?'
'I have a mania for cleanliness. I tend to clean things, put them in order even if it is sparkling clean. My family and friends are sick and tired of me.After I have my food I have to wash my hands at least 10-15 times to get rid of the smell of food from my hands.'
I told him to collect the medicine the next day.

I repertorised the case, taking the following rubrics into consideration-

  1. Mind; Ideas; abundant; same idea repeated
  2. Mind; Thoughts: persistent
  3. Mind; Thoughts; repetition of
  4. Mind; Compulsive; repetition of
  5. Mind; Repeats; same things
  6. Mind; Washing; always; hands, her
  7. Mind; Colour; aversion to; bright
  8. Mind; Counting; continually
  9. Mind; Washing; cleanliness; mania for
  10. Mind; Fear; examination, before
  11. Mind; Will; contradiction of
  12. Mind; Concentration; difficult
  13. Mind; Thoughts; persistent
  14. Mind; Confidence; want of self
  15. Mind; Memory; weakness of; read, for what he has, just

The result of repertorisation was as under-
Sil 15/9 Anac 14/6 Lach 10/6 Nat-m 10/6 Sulph 10/6 As 9/7

I finally selected Silicea as the remedy which was coming 2nd after Anacardium in the 1st case taking and was neglected thinking it to be a case of examination fear rather than OCD.

(Editor: Difficult to understand this. Silicea is a very commonly prescribed remedy for exam fear! In fact Sil is more commonly used than Anacardium. If the author's experience is otherwise, we would be grateful if he could give statistics of 20-50 cases of exam fear with percentage of remedy distribution.)

I finally prescribed Sil 1M/ 1 dose followed by Sac Lac for 15 days. After 1 week, he called saying he was much better and had successful exams. This confirmed my diagnosis and selection of the remedy.

Conclusion: The handling of this case clearly demonstrates importance of the proper knowledge of disease from which the patient is suffering as this helps not only in selecting the right similimum but in advicing anxious families. In certain cases it also helps in involving the family in the healing process.

Another aspect: it demonstrates the richness of our repertories with their huge collection of fine human emotions in the form of rubrics. For maximum benefit, rubrics from the mind section of 'the Phoenix Repertory' as interpreted from the view point of OCD and as given in the Manual of Psychiatry are listed below.

Obsessional Thinking:
Obsession for words, ideas and beliefs, recognized by the patient as his own, that intrude forcibly into his mind.

Mind; Ideas; abundant; same idea repeated
Mind; Thoughts; persistent
Mind; Thoughts; repetition, of

Compulsive Behavior, Obsessional Rituals:
Rituals which include both mental activities, such as counting repeatedly in a special way or repeating a certain form of words and repeated but senseless behaviors, such as washing the hands 20 or more times a day.

Mind; Answer, answering, answers; question; repeats; over and over, in a singing tone until interrupted by another, which he repeats like the first
Mind; Break things, desire to; bright objects
Mind; Break things, desire to; pins
Mind; Break things, desire to; possession, parent's most prized
Mind; Break things, desire to; sticks
Mind; Break things, desire to; windows
Mind; Busy; tying shoes, fumbling in pockets, picking threads
Mind; Collects many things
Mind; Colours; aversion to; black
Mind; Colours; aversion to; blue
Mind; Colours; aversion to; bright
Mind; Colours; aversion to; green
Mind; Colours; aversion to; maroon
Mind; Colours; aversion to; red
Mind; Compulsive
Mind; Compulsive; ritualistic
Mind; Counting; continually, things in the room
Mind; Counting; continually
Mind; Counting; pins
Mind; Fills pockets with everything
Mind; Gestures, makes; actions, repeated
Mind; Music; repetition of, even when out of humor
Mind; Religious affections; mania; praying all the time
Mind; Repeats same things
Mind; Sits; breaks pins, and
Mind; Talk, talking, talks; repetition of same phrases
Mind; Talk; sufferings, troubles, constantly of his
Mind; Touch things, impelled to ( Corrected upto here)
Mind; Washing; always, hands, her
Mind; Washing; always; face, her
Mind; Washing; always; underwear, her
Mind; Washing; bathing, mania for
Mind; Washing; cleanness, mania for

Obsessional Ruminations:
It is an internal debate in which arguments for and against even the simplest everyday actions are reviewed endlessly.

Mind; Thoughts; persistent, occurrences of the day at night, of the
Mind; Thoughts; persistent, persons who have offended him
Mind; Thoughts S; persistent, recurred to his mind, expressions and words heard

Obsessional Impulses: 
It is an urge to perform acts, usually of a violent or embarrassing kind, for example leaping in front of a running car, injuring a child or shouting blasphemies in church.

Mind; Kill, desire to; barber wants to kill his customer
Mind; Kill, desire to; child, her own
Mind; Kill desire to; everyone he sees
Mind; Kill, desire to; knife, with a
Mind; Kill, desire to, loved ones
Mind; Kill, desire to; parents, in a child
Mind; Kill,, desire to; person that contradicts her
Mind; Kill,, desire to; sudden impulse to
Mind; Kill,, desire to, threatens to
Mind; Thoughts; persistent, homicide
Mind; Thoughts; persistent, murder, fire and rats

Obsessional Phobia:
A small number of obsessional patients are afflicted by extreme obsessional slowness that is out of proportion to other symptoms. It is partly for this reason that obsessional thoughts with fearful content (such as thoughts about knives) have been called obsessional phobias.

Mind; Thoughts; persistent, hedgehogs, of
Mind; Thoughts; persistent, unpleasant subjects, haunted by

Alternative Therapies:

It has been noted that obsessive- compulsive disorder runs a fluctuating course and may improve eventually whatever treatment is given. Until recovery, supportive interviews can benefit patients by providing continuing hope.

Art Therapy
Helpful in enabling a patient to 'let go' some of the underlying fear, TENSION and anger, which lead to ritualistic behavior. The resulting work of art, however simple, provides a channel for communication and an outlet for deeply repressed anger. Using modeling clay, or other malleable materials, can be particularly helpful in the safe release of emotion.

Behavioral Therapy
Repeated thoughts and actions are seen as short-term ways of dealing with fear and anxiety. The therapist aims to teach the sufferer to manage his anxiety in more productive ways- for instance, by relaxation training. Response prevention is also part of the treatment; the client is encouraged not to repeat the thought or action, so discovering that nothing bad or untoward will happen and his irrational fears do not come true.

Autogenic Training
Obsessional conditions are usually difficult to overcome, but autogenic training has a lot to offer. In the hands of an experienced practitioner, great progress occurs in many cases.

Colour Therapy
The practitioner may find that old, unresolved difficulties are at the root of the problem, and very careful counselling is required to go over and try to break through the patterns formed in the mind of the client. This may be difficult, since the obsessive- compulsive behavior is often rooted in the subconscious.

It may manifest itself in small, stupid, harmless actions at which most people might laugh- or, at the other end of the scale, as serious crime. Counseling with colour has, it is claimed, shown that a soft magenta, along with relaxation, given by an experienced professional practitioner, can turn what may be a vicious circle into a spiral of growth. Tactful recognition of the self- through the counselor- is vital. Relaxation, color, music and counseling all help.