Case Vignette

Lisa is a 32-year- old Caucasian bank teller. She has been married for five years and has a 3-year-old daughter. Lisa's job requires her to interact with customers on a daily basis. Her work involves processing routine bank transactions including cashing checks and depositing and exchanging money. Lisa is constantly fearful of coming into contact with anything that might be contaminated. Concerned about bacteria and viruses from the money she handles, Lisa hurries to the bathroom to wash her hands after each teller transaction. She has convinced the bacteria on her hands will cause an illness, serious or fatal, eventually leading to her inability to take care of her family. Lisa spends up to ten minutes each time in the bathroom. This has caused delays in getting her work done. Despite spending a significant part of her day washing and using hand sanitizer, Lisa constantly doubts her cleanliness. If she accidentally touches something she believes is dirty, she immediately washes her hands. This has resulted in bleeding and skin abrasions. Lisa showers twice daily and systematically wash each body part starting with her head and working down to her feet. This often takes her one hour each time. After showering, Lisa "  drip dries" so that her bath towel does not spread germs. To avoid spreading germs at home, she excessively uses Lysol on household objects, sanitizes dishes using several wash cycles, and even uses her elbow to flip light switches. Lisa's husband often assists with the daily cleaning to reassure her that the house is clean. Based on your reading of the vignette, discuss the possible diagnoses you considered when thinking about the client's presenting issues.


1. What diagnosis would you make?


2. What is your rationale for how the client meets all of the specific DSM-5 diagnostic criteria for the mental disorder you have selected?


3. What other information would you need if your client does not meet all of the criteria?


4. What are some examples of current medications being used to treat this diagnosis?


• What are the benefits the client might receive from taking medication, and what are the potential side effects?


• What other issues or concerns would you want to address when considering the use of medication with this client?


5. How is the impact of the larger social system (family, school, work, and community) important to consider when assessing and diagnosing the client?




Diagnosis of the patient


This patient is suffering from obsessive- compulsive disorder. This is a mental state in which the patient behaves strangely. The patient is highly equipped with obsessive thoughts which make him/her behave strangely. Excessive cleaning and hygiene is a part of this disorder.


DSM-5 and its relatedness with Lisa’s disorder


DSM-5 stands for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). This manual is the diagnostic tool used by American Psychiatric Association. In this manual, details of all mental disorders with their symptoms, treatments, and recommendations are present. This manual also contains the recommended payment criteria which should be used up by health care providers in the treatment of the particular disorder.


Obsessive-compulsive disorder is a totally separate chapter in DSM-5.


This client meets all the DSM-5 diagnostic criteria for the obsessive compulsive disorder. The entire diagnostic criteria can be explained pointwise.


First, the patient is having recurrent thoughts about an unwanted act. Such thoughts are termed as obsessions in the medical dictionary. In the present case, the patient is having an obsession for excessive cleanliness and hygiene that includes hand washing.

Second, in OCD, the patient performs a particular behavior repeatedly and compulsorily. Here repetition has been observed for hand washing, cleaning, taking bath twice etc.

Third, the behavior or act performed reduces the anxiety of the patient; same is happening in the case of Lisa.

Fourth, all obsessions and compulsions are time- consuming. Here, in the case of Lisa, all of her unwanted acts are consuming a lot of time.

Fifth, none of the symptoms observed in the patient should be due to effects of any substance like a drug.

Lastly, all symptoms should not be a result of any other mental disorder.

Other information needed (if your client does not meet all of the criteria)


Here the client meets the entire requisite criterion, therefore other information is not required.


Current medications for Lisa


Presently FDA has recommended antidepressants for this disorder. Different medications have been approved for different age groups. The medicines include:


For ages 7 and above: Fluoxetine (Prozac)

For ages 8 and above: Fluvoxamine

For ages 10 and above: Clomipramine (Anafranil)

For adults only: Paroxetine (Paxil, Pexeva)

It is important to note that there is no cure for the obsessive compulsive disorder. The above medications bring temporary relief to the patient, and symptoms come under control. It is noteworthy that a patient suffering from obsessive compulsive disorder (in this case, Lisa) should continue medications throughout her lifetime.


Benefits of medications


Symptoms of the disorder come under control

The patient can lead a completely normal life if the proper and timely prescription is observed on a compulsory and regular basis.

Side-effects of these medicines


Most anti-depressants encourage suicidal thoughts in the patient’s mind. These thoughts are more in children than in adults. So, it is necessary for a patient suffering from OCD to have emotional contact with a friend, relative or acquaintance. In the present case, the care provided by Lisa’s husband is commendable.

The effect of antidepressants becomes severe if the patient is taking some other medicines. Most anti-depressants react with other medications, showing toxic effects.

Treatment of OCD continues the whole lifetime.

So, the patient will take anti-depressants for whole life. But these are drugs, and the patient will become addict to these drugs on prolonged usage. This is one of the most serious side effects of OCD medicines. The patient, if accidentally stops usage of medicines, symptoms of the disease will relapse. In medical terminology, such relapse of symptoms is known as “discontinuation syndrome”.

Other considerations related to Lisa’s treatment


Instead of medication, it would be better to treat the patient with Psychotherapy. The most common type of psychotherapy exercised in the case of OCD is CBT or cognitive behavioral therapy. In this, the patient is exposed to his/her obsession repeatedly, but slowly. First, the patient is exposed to the obsession for short time intervals then the object is exposed for longer periods of time. Gradually, the patient may get rid of the syndrome, though not completely. Generally, doctors perform a combination of this treatment with antidepressants. The dosage of antidepressant is lowered to a great extent by the use of CBT.


Impact of social system on the patient


An impact of the larger social system is very important in diagnosing such a client. This is so because this patient is diseased, not mad. So, he/she cannot be kept out the society. He/she has to be treated within the system itself.


Lisa is 32-yearar lady, a bank teller, and the mother of a 5-year-old. She has her social responsibilities. The society is dependent on her besides her diseased state.


Larger social systems generally consider such patients to be mad and make fun of them when present in groups. This type of behavior of the society deprives the patient of complete treatment. As stated above, in the side-effects section, the patient is seduced towards suicide in many cases. The social system, which includes family members, friends, colleagues etc., should treat such a person as normal because their impact on the patient would be remarkable.




Sica al (2016) “Not just Right experiences, as a psychological endophenotype for obsessive-compulsive disorder: Evidence from an Italian family study” Psychiatry Research, 245:27-35.

Gordon al. (2016) “Anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder”, Medicine, 44(11): 664-71.

Poppe, al. (2016) “Pharmacotherapy for obsessive-compulsive disorder in clinical practice-Data of 842 inpatients from the International AMSP Project between 1994 and 2012”, Journal of Affective Disorders, 200: 89-96.