Successful treatment of refractory obsessive-compulsive disorder

A case study is presented of a 40-year-old man with obsessive-compulsive disorder (OCD). He had been treated with long-term institutional placement, electroconvulsive therapy, exhaustive pharmacotherapy, and psychodynamic and cognitive-behavioral psychotherapy. Nothing had relieved his excessive hand washing and door checking. Records from previous treatment revealed a diagnosis of dissociative identity disorder (DID). This information led to reconceptualization of the OCD symptoms as manifestations of the patient's ego fragmentation. When his fragments were catalogued and addressed, all overt OCD symptoms abated within weeks. It is believed that the patient's most anxious ego fragment communicated dread from the background of the patient's psyche, the executive component only being aware of the anxiety and not the triggering stimulus. The patient was taught to address this fragment verbally to elicit its cooperation, whereupon the fragment stopped sounding alarm, creating anxiety and driving the patient to check and recheck, wash and rewash. Symptoms have returned only when the patient has suspended his announcing behavior and have abated when this was resumed. Connections between OCD and DID are addressed.

Patients exhibiting refractory OCD symptoms should be assessed for dissociative symptomatology.