Case Study

Obsessive-Compulsive Disorder (OCD) with Comorbid Social Anxiety

Presenting Problem
RA, a 26-year-old male software engineer, sought therapy after struggling with obsessive
thoughts about contamination and compulsive handwashing behaviors. He reports spending
several hours daily engaged in rituals, such as repeatedly washing his hands, cleaning his
workspace, and avoiding public spaces for fear of exposure to germs. Additionally, RA also
reported having social anxiety signs, such as excessive fear of being judged or humiliated in
social or professional settings. These issues have significantly impacted his productivity at
work and his ability to maintain relationships.
Demographic Details
• Name: RA
• Age: 26
• Sex: Male
• Educational Qualification: Bachelor’s degree in computer science
• Marital Status: Single
• Employment Status: Employed as a software engineer at a multinational firm
• Family Type: Nuclear family
Psychosocial History
RA grew up in a nuclear family with a history of strict behavioural expectations and a strong
emphasis on hygiene and orderliness. He recalls being scolded frequently as a child for
making mistakes, contributing to his perfectionistic tendencies. RA developed obsessive-
compulsive behaviors during his teenage years, but these worsened during his new job. Social
anxiety symptoms began during college, where he feared speaking in public or interacting
with authority figures such as teachers, lecturers. Stressors in his current environment include
demanding work deadlines, a competitive work culture, and the fear of making errors in his
job performance which could cause humiliation.
Mental Status
Appearance: Neat and clean; overly preoccupied with adjusting his clothing during the
sessions. He kept fixing his shirt while talking especially when discussing family issues.
Behavior: Anxious and fidgety, with visible discomfort when discussing his obsessions.
Speech: Clear and logical but hesitant when discussing social interactions.
Mood and Affect: Anxious mood with a restricted affect.
Thought Process: Rigid and focused on intrusive thoughts about contamination.
Perception: No hallucinations or delusions.
Insight and Judgment: Partial insight; RA recognizes the irrationality of his compulsions
but struggles to control them.
History of Presenting Illness (HOPI)
RA’s obsessive thoughts and compulsive behaviors began during adolescence, around the age
of 15. He recalls being particularly distressed by intrusive thoughts of contamination due his
family’s emphasis on cleanliness, which led to repetitive handwashing and cleaning rituals.
Initially, these behaviors were infrequent but escalated significantly over time, interfering
with his daily life and social functioning.
During the COVID-19 pandemic, RA’s symptoms became more pronounced. The heightened
societal focus on hygiene and cleanliness exacerbated his fears of contamination, leading him
to engage in compulsive handwashing for up to 20 minutes per instance and cleaning his
workspace multiple times a day. These behaviors disrupted his ability to concentrate on work
tasks and prolonged his daily routine significantly.
In addition to his OCD symptoms, RA developed social anxiety in his early 20s, particularly
during his college years. He experienced intense fear of being judged or criticized amongst
his peers, which led him to avoid presentations, group discussions, and social gatherings.
This avoidance continued into his professional life as well, where he became anxious about
interacting with colleagues, participating in team meetings, or asking for help from
supervisors. As a result, he often isolates himself at work, which contribute to feelings of
loneliness and self-doubt.
RA reports experiencing overwhelming distress when unable to perform his rituals or when
faced with situations that challenge his compulsions. For example, he described an incident at
work where he accidentally touched a doorknob without sanitizing afterward due to work
commitments. This led to an episode of intense anxiety and panic, during which he
experienced heart palpitations, excessive sweating, and a sense of impending doom. He
admitted to leaving work early that day to wash and sanitize himself thoroughly, further
disrupting his professional responsibilities.
RA acknowledges that his obsessive-compulsive behaviors and social anxiety are irrational,
but he feels powerless to control them. He often describes a cycle of intrusive thoughts
leading to compulsive actions, followed by temporary relief, only for the thoughts to return
shortly after. This pattern has caused significant frustration and feelings of hopelessness, as
RA fears that his condition will continue to impede his personal and professional growth.
RA’s struggles are combined by the lack of emotional support from his family. While his
parents are aware of his behaviors, they dismiss his struggles as exaggerated and fail to
provide encouragement or understanding. This dismissive attitude has led RA to avoid
discussing his mental health challenges with his family, further contributing to his sense of
isolation.
RA’s presenting illness is characterized by a tireless and unbearable cycle of obsessive
thoughts, compulsive behaviors, and social anxiety. These symptoms have intensified over
time, significantly impacting his emotional well-being, professional performance, and ability
to form meaningful social connections. His condition is further preserved by environmental
stressors, a lack of familial support, and his internalized sense of helplessness.
Family History
Mother: Exhibits traits of obsessive behavior but has not sought professional help.
Father: Has a history of alcohol dependence and struggled with anger management issues.
Sibling: Younger sister with no known mental health concerns.
Assessment
RA’s clinical presentation is consistent with the symptoms of obsessive-compulsive disorder
(OCD) and Social Anxiety Disorder (SAD). His obsessive thoughts of contamination and
compulsive cleaning behaviors significantly impair his daily functioning, while his avoidance
of social interactions and fear of judgment align with social anxiety.
Psychometric tools such as the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) revealed
a severe level of OCD symptoms, with high scores for distress caused by intrusive thoughts
and the time spent on compulsions.
RA’s obsessive-compulsive symptoms are maintained through a reinforcement cycle where
compulsive behaviors temporarily alleviate anxiety caused by intrusive thoughts, thereby
strengthening the compulsion. Similarly, his social anxiety persists due to avoidance of feared
situations, which prevents opportunities for corrective experiences and reinforces his negative
beliefs about social interactions.
The contributing factors to RA’s condition include a predisposition for anxiety disorders,
environmental triggers such as the COVID-19 pandemic, and a lack of familial support. His
obsessive-compulsive tendencies appear to have emerged in adolescence, while his social
anxiety became more pronounced during his college years, suggesting a combination of
genetic vulnerability and environmental stressors.
Diagnostic Impressions
Based on DSM-5 criteria, RA meets the diagnostic criteria for:
Obsessive-Compulsive Disorder (OCD): Marked by persistent intrusive thoughts of
contamination and repetitive cleaning rituals that cause significant distress and impairment.
Social Anxiety Disorder (SAD): Characterized by intense fear of social analysis and
avoidance of social interactions, significantly impacting his professional and personal life.
RA’s condition requires many different treatment approaches, including psychoeducation,
behavioural interventions, and cognitive therapy, to address the core symptoms and their
underlying cognitive distortions. The treatment plan will also incorporate strategies to
improve emotional regulation, build social skills, and enhance family support to promote
long-term recovery.

Intervention Plan and Goals

Interventions:

1. Exposure and Response Prevention (ERP): To reduce obsessive-compulsive

behaviors by exposing RA to feared situations without allowing formalized responses.
2. Cognitive Behavioural Therapy (CBT): To address cognitive distortions that fuel
his obsessive thoughts and social anxiety in very specific cases.
3. Social Skills Training (SST): To help RA improve his communication skills and
manage social interactions effectively.
4. Relaxation Techniques: To manage anxiety during exposures and social situations.

Goals:

1. Gradually reduce the frequency and intensity of compulsive behaviors.

2. Challenge and modify RA’s maladaptive beliefs about contamination.
3. Build confidence and reduce avoidance in social and professional settings.
4. Develop healthy coping mechanisms to manage anxiety and stress.

Diagnostic Impressions
According to the DSM-5, RA’s symptoms are indicative of obsessive-compulsive disorder
(OCD), which are characterized by intrusive thoughts about contamination and compulsive
cleaning behaviors. These symptoms significantly impact his daily functioning and quality of
life. Additionally, his presentation also aligns with Social Anxiety Disorder (SAD), that is
marked by a persistent fear of social interactions and avoidance behaviors. The comorbidity
of these conditions, combined by environmental stressors, highlights the need for a
comprehensive and sustained intervention plan. RA also exhibits vulnerability to chronic
anxiety due to his long-standing struggles with social and familial stressors.
Skills and Challenge Areas of Session
Skills Utilized: Psychoeducation to help RA understand the nature of OCD and social
anxiety. Guided exposure and response prevention to reduce compulsive behaviors.
Active listening and empathy to create a safe therapeutic environment.
Challenges: RA exhibited significant resistance to ERP initially due to fear of contamination
which also manifested during treatment His rigid thought patterns required frequent
reinforcement of cognitive restructuring techniques.
Conclusion
RA’s case highlights the challenges of managing OCD with comorbid social anxiety in a
high-functioning individual. Over the course of therapy, RA demonstrated progress in
reducing his compulsions and gaining confidence in social interactions. Through ERP, CBT,
and social skills training, RA has begun to regain control over his life and improve his overall
functioning. Continued support and follow-up sessions are recommended to maintain his
progress and address any future challenges.
References
Abramowitz, J. S. (2006). Understanding and Treating Obsessive-Compulsive Disorder: A
Cognitive-Behavioral Approach. Routledge.
Clark, D. A., & Beck, A. T. (2010). Cognitive Therapy of Anxiety Disorders: Science and
Practice. Guilford Press.
Heimberg, R. G., & Becker, R. E. (2002). Cognitive-Behavioral Group Therapy for Social
Phobia: Basic Mechanisms and Clinical Strategies. Guilford Press.
American Psychiatric Association. (DSM-IV). Diagnostic and Statistical Manual of Mental
Disorders (Fourth Edition). Washington, D.C.: American Psychiatric Association, 1994.
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