Case files: A psychodynamic formulation of a case of Obsessive Compulsive Disorder (OCD)

Briefly, obsessive compulsive disorder (OCD) is a mental illness characterized by unwanted, intrusive, and repetitive thoughts or images(obsessions) that can have accompanying rituals or other behaviors/acts (compulsions) that a patient feels they must engage in to alleviate the anxiety brought on from the obsessions.  You can still have OCD if you have obsessions without compulsions or more rarely, compulsions without obsessions.

These symptoms must also cause significant distress or dysfunction in your life to qualify as an illness.

I do not see many patients with OCD in my practice, and so I am not as familiar with the treatment of OCD as I am with other more common illnesses that come my way.  I know the national guidelines on how to treat OCD and what the textbooks say, but this kind of exposure and education to OCD pales in comparison to the richness, diversity and challenges of treating these patients in the real world. Here is an example:

I recently assessed a 32 year old pediatrician who presented with alarming intrusive thoughts that she was harming her infant patients when she did physical exams where she needed to take the child's clothes off.  Her obsessions revolved around being a pedophile and the fear that she was sexually abusing them on some level.  As a result, she was constantly asking for consent from parents and her patients multiple times during an examination or procedure to the point where the parents complained to her clinic manager.  In addition, she had found herself avoiding physical exams which is not possible to do her job.

Simple enough case of OCD, I had thought.  My training and textbooks tell me to start an antidepressant because OCD responds particularly well to this class of medications.  In a perfect world, she would also have access to OCD -specific therapy that would have her challenge her thoughts as well as acclimatize her to the obsessions so they lose their potency.  This is all fine and good, until...

This pediatrician tells me about a memory she has had for as long as she can remember that is so vivid, it is as if it happened yesterday.  She is reluctant to tell me because she can not verify with anyone whether or not it actually happened.  In this memory, she is 5 years old.  She is with an uncle who is telling her that he must look at her genitalia for a rash and that he was instructed to do this by her parents.  She remembers feeling very uncomfortable with this and knowing on some level that what he was doing was wrong.  She remembers him insisting that it was for her benefit, that he was trying to make sure her genitalia were healthy and that he did this out of care and concern.

I too do not know whether this memory has happened or not.  But I also can not ignore its significance to the insecurity she has of harming her patients.  In this memory, she is confused by how something supposedly therapeutic could feel so bad.  As a pediatrician, she, like her uncle, tells children and their parents that she needs to touch and examine their bodies for their own benefit, in ways that may be uncomfortable and intimate.  Is this not the source of her OCD fears?  Further eroding her confidence, her reality is the uncertainty she has of her memory and of the truth.  What would it mean for this patient if it did not actually happen?  What would it mean if it did?