1.

INTRODUCTION
1.1 Adolescence
Adolescence is the transition period from childhood to adulthood, a period that brings sometimes
tumultuous physical, social, and emotional changes. Adolescence begins with the onset of
puberty and extends to adulthood, usually spanning the years between 12 and 18. Puberty is the
period during which the reproductive system matures, a process characterized by a marked
increase in sex hormones.
1.1.1 The Anatomical Development of the Adolescent
Adolescent is a stage of development that has some predictable physical milestones. Puberty
involves distinctive physiological changes in an individual’s height, weight, body composition,
sex characteristics, and circulatory and respiratory systems. These changes are largely influenced
by hormonal activity. During puberty, the adolescent develops secondary sex characteristics
(such as a deeper voice in males and the development of breasts and hips in females) as their
hormonal balance shifts strongly towards an adult state. The adolescent growth spurt is a rapid
increase in an individual’s height and weight during puberty resulting from the simultaneous
release of growth hormones, thyroid hormones, and androgens. Because rates of physical
development vary so widely among teenagers, puberty can be a source of pride or
embarrassment.
1.1.2 The psychological development of the adolescent
Adolescent maturation is a personal phase of development where children have to establish their
own beliefs, values, and what they want to accomplish out of life. Because adolescents
constantly and realistically appraise themselves, they are often characterized as being extremely
self-conscious. However, the self-evaluation process leads to the beginning of long-range goal
setting, emotional and social independence, and the making of a mature adult.
Three distinct stages can be identified in the psychological development of the adolescent, even
though there is a great deal of overlap in the stages, and they may not occur during the age span
indicated. During early adolescence (ages 11-13), development usually centers on developing a
new self-image due to their physiological changes. Adolescents need to make use of their newly
acquired skills of logical thinking and ability to make judgments rationally. When they reach the
age of fourteen and fifteen (the period known as mid-adolescence), adolescents strive to loosen
their ties to their parents and their emotions and intellectual capacities increase. The adolescent
becomes adventuresome, and experiments with different ideas. This plays an important role in
finding one’s relations to oneself, groups, and opposite sex. During this time, the adolescent
battles over his own set of values versus the set established by parents and other adult figures.
The adolescent also begins to take on more control of educational and vocational pursuits and
advantages. It is during this time that adolescents’ self-dependence and a sense of responsibility
become apparent, along with their quest to contribute to society and find their place in it.
During late adolescence (ages range from sixteen on), adolescents have a more stable sense of
their identity and place in society. At this stage in life they should feel psychologically integrated
and should have a fairly consistent view of the outside world. Adolescent should, by this time,
have established a balance between their aspirations, fantasies, and reality. In order for them to
achieve this balance they should be displaying concern for others through giving and caring,
instead of the earlier childhood pattern of self-gratification. At the conclusion of late adolescence
they should have had designed or discovered their role in society, have set a realistic goal in life,
and have begun in earnest to achieve it.
1.1.3 Using Developmental Psychology to Understand the Adolescent
Explaining the psychological development of adolescent is difficult due to the lack of empirical
research and the great variety of adolescent behavioral modes. However, developmental
psychologists have formulated theories describing human psychological development which are
useful in understanding adolescents. They demonstrate sequential patterns of development and
make some rough estimates about the ages at which they should demonstrate particular
developmental characteristics.
[Link] Piaget’s Theory of Cognitive Development
According to Piaget’s theory, As children enter adolescence, their cognitive abilities lie
somewhere between Piaget’s third stage of cognitive development—the period of concrete
operational—and the fourth, or last stage—formal operational. During the concrete operational
stage, children begin to understand the concept of conservation. From the Piagetian perspective,
conservation means that children realize that quantities remain the same, even if they are placed
in containers of different shapes and sizes. The adolescent also becomes less egocentric, that is,
he now understands that everyone does not see things in the same way that he does. The
adolescent also becomes capable of reasoning deductively, perform simple operations with
physical objects, and apply logic to arrive at conclusions. Even though adolescents at the latter
part of this stage display some cognitive maturity, they still are incapable of thinking abstractly.
However, once the adolescent enters the last stage—formal operational he/she develops the
ability to test hypotheses in a mature, scientific manner. They can communicate their position on
complex ethical issues, and become capable of thinking abstractly. They can discuss abstract
terms such as freedom or liberty without difficulty.
[Link] Erik Erikson’s Psychosocial Theories
According to Erikson’s theory, individuals proceed through eight stages of development which
begin at birth and conclude at death. If the particular crisis is handled appropriately, the outcome
will be positive. If not, then a negative outcome will be the result. The two stages which involve
conflicts that significantly affect early and late adolescent development is stage 5, puberty and
adolescence (ages 12-18).The fifth psychosocial stage occurs during the ages of 11-18.
Adolescents begin to consider their futures and decide on careers. During this stage they face the
conflict of identity versus role confusion. The child has to learn the roles s/he will occupy as an
adult. It is during this stage that the adolescent will re-examine his/her identity and try to find out
exactly who he or she is. Erikson suggests that two identities are involved: the sexual and the
occupational.
[Link] Kohlberg’s Theory of Moral Reasoning
Lawrence Kohlberg viewed development in terms of different levels of reasoning applied to
choices people make in their lives. This type of moral reasoning occurs throughout a person’s
life and depends on an individual’s social interaction. Kohlberg viewed moral reasoning in three
levels which included six sequential stages. The levels of development range from reasoning
based upon self-gratification (preconventional morality), to reasoning based upon conformity
(conventional morality) to reasoning based upon individual values that have been internalized
(postconventional morality). Kohlberg stressed that the actual decisions people make are not
important, but that the reasoning behind the decisions was important.
 1.1.4 Gender
Gender differences in behaviors or mental processes continue to develop during adolescence.
Research has indicated that experience and learning have a greater impact on such behaviors than
do biological factors. Gender identity develops by age 3. Once they have established gender
identity, children usually try to adapt their behavior and thoughts to accepted gender‐specific
roles. A gender role consists of the behaviors associated with one's gender. Gender‐related
activities help an individual to establish an identity. Sometimes a person adopts gender‐role
stereotypes, beliefs about the “typical” behavior of males and females expected by society.
1.1.5 Peer pressure
Peer pressure, a term used to denote legitimization of activities by a peer group, has been used to
explain many adolescent societal difficulties. Although a peer group rarely forces an adolescent
to try new activities, it may legitimize those activities by indulging in them.
1.1.6 Sexual behavior
During the past few decades, the sexual behavior of adolescents has been heavily investigated.
While the threat of AIDS (acquired immune deficiency syndrome) has changed some behaviors,
many surveys indicate a dramatic increase in adolescent sexual activity through the twentieth
century.
1.2 Obsessive Compulsive disorder
Obsessive-compulsive disorder (OCD) is an anxiety disorder in which individuals have
recurring, unwanted thoughts, ideas or sensations (obsessions) that make them feel driven to do
something repetitively (compulsions).

Obsessions are recurrent and persistent thoughts, impulses, or images that cause distressing
emotions such as anxiety or disgust. Many people with OCD recognize that the thoughts,
impulses, or images are a product of their mind and are excessive or unreasonable. Yet these
intrusive thoughts cannot be settled by logic or reasoning. Most people with OCD try to ignore
or suppress such obsessions or offset them with some other thought or action. Typical obsessions
include excessive concerns about contamination or harm, the need for symmetry or exactness, or
forbidden sexual or religious thoughts.

Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in
response to an obsession. The behaviors are aimed at preventing or reducing distress or a feared
situation. In the most severe cases, a constant repetition of rituals may fill the day, making a
normal routine impossible. Compounding the anguish these rituals cause is the knowledge that
the compulsions are irrational. Although the compulsion may bring some relief to the worry, the
obsession returns and the cycle repeats over and over.
1.2.1 Signs and Symptoms
People with OCD may have symptoms of obsessions, compulsions, or both. These symptoms can
interfere with all aspects of life, such as work, school, and personal relationships.
Common obsessions include:
• Fear of germs or contamination

• Unwanted forbidden or taboo thoughts involving sex, religion, and harm

• Aggressive thoughts towards others or self

• Having things symmetrical or in a perfect order

Common compulsions include:

• Excessive cleaning and/or hand washing

• Ordering and arranging things in a particular, precise way

• Repeatedly checking on things, such as repeatedly checking to see if the door is locked or
that the oven is off

• Compulsive counting

Some individuals with OCD also have a tic disorder. Motor tics are sudden, brief, repetitive
movements, such as eye blinking and other eye movements, facial grimacing, shoulder
shrugging, and head or shoulder jerking. Common vocal tics include repetitive throat-clearing,
sniffing, or grunting sounds.
Symptoms may come and go, ease over time, or worsen. People with OCD may try to help
themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs
to calm themselves. Although most adults with OCD recognize that what they are doing doesn’t
make sense, some adults and most children may not realize that their behavior is out of the
ordinary.
 1.2.2 Risk Factors
OCD is a common disorder that affects adults, adolescents, and children all over the world. Most
people are diagnosed by about age 19, typically with an earlier age of onset in boys than in girls,
but onset after age 35 does happen. The causes of OCD are unknown, but risk factors include:
1. Genetics
Twin and family studies have shown that people with first-degree who have OCD are at a higher
risk for developing OCD themselves. The risk is higher if the first-degree relative developed
OCD as a child or teen.
2. Brain Structure and Functioning
Imaging studies have shown differences in the frontal cortex and subcortical structures of the
brain in patients with OCD. There appears to be a connection between the OCD symptoms and
abnormalities in certain areas of the brain, but that connection is not clear.
3. Environment
People who have experienced abuse (physical or sexual) in childhood or other trauma are at an
increased risk for developing OCD.
In some cases, children may develop OCD or OCD symptoms following a streptococcal
infection which is called Pediatric Autoimmune Neuropsychiatric Disorders Associated with
Streptococcal Infections (PANDAS).
1.2.3 Diagnosis
In DSM-5, Obsessive-Compulsive Disorder sits under its own category of Obsessive-
Compulsive and Related Disorders. Diagnostic Criteria of OCD in DSM V:

A. Presence of obsessions, compulsions, or both

B. The obsessions or compulsions are time-consuming or cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder (e.g.,
excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body
dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder).
Specify if:
With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs
are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
With absent insight/delusional beliefs: The individual is completely convinced that obsessive-
compulsive disorder beliefs are true.
Specify if: Tic-related: The individual has a current or past history of a tic disorder.

1.2.4 Treatment
OCD is typically treated with medication, psychotherapy or a combination of the two. Although
most patients with OCD respond to treatment, some patients continue to experience symptoms.
Sometimes people with OCD also have other mental disorders, such as anxiety, depression, and
body dysmorphic disorder, a disorder in which someone mistakenly believes that a part of their
body is abnormal.

[Link] Medication
Serotonin reuptake inhibitors (SRIs) and selective serotonin reuptake inhibitors (SSRIs) are used
to help reduce OCD symptoms. Examples of medications that have been proven effective in both
adults and children with OCD include clomipramine, and several newer (SSRIs), including:
• fluoxetine

• fluvoxamine
• sertraline
SRIs often require higher daily doses in the treatment of OCD than of depression, and may take 8
to 12 weeks to start working, but some patients experience more rapid improvement. If
symptoms do not improve with these types of medications, research shows that some patients
may respond well to an antipsychotic medication (such as risperidone).

[Link] Psychotherapy
Psychotherapy can be an effective treatment for adults and children with OCD. Certain types of
psychotherapy, including cognitive behavior therapy (CBT) and other related therapies (e.g.,
habit reversal training) can be as effective as medication for many individuals. A type of CBT
called Exposure and Response Prevention (EX/RP) is effective in reducing compulsive behaviors
in OCD, even in people who did not respond well to SRI medication. For many patients EX/RP
is the add-on treatment of choice when SRIs or SSRIs medication does not effectively treat OCD
symptoms. These new approaches include combination and add-on (augmentation) treatments, as
well as novel techniques such as deep brain stimulation (DBS).

1.3 ABOUT THE ORGANIZATION

CSI Rainy Hospital started as a medical dispensary in the campus of Ulaga Meetper Aalayam in
Royapuram in 1888, the hospital moved to its present location in G.A. Road in 1914. Due to the
tireless efforts of Miss. Christina Rainy, an educationist, after whom the hospital is named, the
hospital buildings came into being. The medical work was pioneered by Dr. Alexandrina
Mcphail, between 1888 and 1928, who established an institution primarily to provide medical
care to women and children. Both these pioneers were Missionaries from the Church of Scotland.
Over the years, the institution has grown under the leadership of Overseas and Indian Doctors.
The Church affiliation was taken over by the Church of South India. Today in the 123rd year of
its existence, CSI Rainy Hospital is a Multispeciality Institution providing high quality Medical
care at affordable rates in the field of Medicine, Surgery, Obstetrics & Gynaecology, Paediatrics,
Orthopaedics, ENT, Ophthalmology, Urology, Paediatric Surgery, Nephrology and Neurology.
Inspired by the love and compassion of Jesus Christ, CSI Rainy Hospital provides quality health
services for all, especially the poor and neglected, with particular attention towards the disabled,
terminally ill and elderly. As a teaching and research centre, we offer training opportunities to all
regardless of background, belief or economic status.

2. CASE STUDY

1. Demographic Details

1.1 Initials: A.A

1.2 Age: 15 years

1.3 Gender: female

1.4 Date of birth: 18/09/2004

 1.5 Education: currently studying in 11th standard

1.6 Family type: Joint Family

1.7 Mothers initial: F.S

1.7.1 Occupation: homemaker

1.8 Fathers initial: W.S

1.8.1 Occupation: works in private sector in Saudi

1.9 Economic status: middle class

1.10 Ordinal position: first

1.11 No of sibling: 1

1.12 Informant: mother

2. Diagnosis

2.1 Presenting complaint

The mother F.S was concerned about AA behavior and brought her to the hospital. A.A
presented with the complaint of not being able to pray and spending many hours in washroom at
a stretch for past 3 months.

2.2 Objectives of the case study

• To understand the client

• To understand the difficulties and illness of the client

• To aid the client overcome her difficulties

• To understand the various therapy techniques used

 2.3 Family background

A.A lives in a joint family with her mother, younger brother and paternal grandmother. Her
father works in a private sector in Saudi and comes home to meet everyone every 6 months. Her
mother is a homemaker previously she used to work as a teacher until the second child was born.
A.A has a bad relationship with her father and extended family on his side. Her aunts started
talking behind her about her family’s financial situation which strained the relationship more
between them. A.A has a good relationship with her extended family on mother’s side. She has a
strong emotional attachment to her maternal grandmother as she was brought up by her during
early childhood. A.A has a good relationship with her mother. Mother reported that A.A shares
every piece of knowledge with her. A.A has a good relationship with her younger sibling. She
reported that she loves her brother but he always fights with her over every small thing such as
remote, mobile phone, and food. A.A doesn’t like her paternal grandmother as she doesn’t treat
her mother properly. There is a history of mental illness in the family. A.A’s maternal
grandmother in year 2008 was diagnosed with mania and was treated for 4 years.

Maternal grandmother
with mania

A.A with OCD

2.4 Social background

A.A. is an introverted person and prefers keeping her life private from her friends and relatives.
She doesn’t have many friends and she finds it easier to chat with others online than talking to
them face to face. Although according to the mother, the child is very talkative when interacting
with her at home. She likes to stay at home. AA’s meaning of fun is watching TV serials.
 2.5 Educational Background

A.A. is currently doing her 11th standard commerce stream. She has been in the same school for
the past 13 years. A.A.’s interaction with her friends drastically decreased when her best friend
has moved to another school. At the end of 10th standard AA wanted to take science stream but
no one in her family supported her except her father because of her marks. She doesn’t have any
resentment with her family for not allowing her to choose science stream. She has now decided
to become a Chartered Accountant because her friends told her it is a good paying job. She
hasn’t done any background check on the profession of CA. Her knowledge of different career
options available for her is very minimal. From past 3 months, AA doesn’t like going to her
school as all her friends has shifted to different streams.

2.6 Case History

A.A is the eldest of 2 siblings born to non-consanguineous parents. She grew up with her
maternal grandmother and has intense emotional attachment to her. When A.A was in 1st
standard her great grandmother passed away. A.A. reported that she saw something black flying
around her when she was playing on the terrace alone in her great-grandmother house. During
this period, she started having anxiety spells. At the age of 7, she had crying spells. She used to
cry in the middle of the night. There was a change in her appetite. She had continuous feeling of
hopelessness. She was always tired and had difficulty in concentrating. The mother brought A.A
to the hospital for treatment. She was diagnosed with childhood depression. Precedent factor was
her great grandmother’s death. Her treatment plan included counseling and anti-depressant
medicine. Medicine was given for 1 month. The treatment showed a good response with A.A.

In 5th standard she didn’t wanted to go back to school because her teacher scolded her for
getting very low marks in a test. Her maternal grandmother always defends her from everyone,
family, friends and teachers.

In 2008, her maternal grandmother was diagnosed with mania. Her husband brought her to the
hospital because she wouldn’t come out the house. She had psychotic episodes and believed that
she was able to use black magic. Depression and manic episodes were also seen. 3 years of
intense counseling was given to her to help her get back on her feet.
A.A has always been on her best behavior. She had a good relationship with her father until the
age of 14 when she saw her parent’s marital conflicts.
During the early marriage days, W.S. and F.S. started having conflicts. He wanted her to strictly
follow her religion. He also used to beat his wife. The mother-in-law of the wife during this time
took her son’s side which lead to strained relationship between the mother-in-law and the
newlywed bride. Mother was also asked to leave her teaching job. During this time W.S. got a
job in Saudi which made his beliefs more strong that females shouldn’t work and should be
submissive to the husbands.

A.A conflict with her father also strained more because of her aunts. A.A’s father wanted her to
have a good relationship with her aunts since they are married to rich businessmen. The aunts
used to talk behind her back. On a particular occasion they rejected her saying that A.A. and her
mother are poor people and come to their house when they need anything which led to constrain
relationship of A.A with her aunts. A.A was forced by her father to still maintain a good
relationship with his sisters. She also fought with her father over his consumption of tobacco and
smoking. A.A didn’t talk to her father for 1 month.

At the age of 15, during the month of July, one of her relatives on father’s side passed away at a
young age because of cancer. She was not close to the relative but when she saw her cousin who
just lost her family. She identified with her cousin and again felt the fear of death. During this
time, she also suffered from jaundice and diarrhea.

A.A reported that she also saw a video with sexual content which popped up when she was doing
her homework from internet. She knew it was a bad thing so she told her mother about the
accidental pop-up of sexual content. It was seen that A.A. reasoning skills were good. Watching
the videos resulted in her having distorted thoughts.

She started spending a minimum of 1-2 hours in washroom at a stretch. Her interaction with
everyone around her decreased a lot. She felt that she is not able to pray. Previously she used to
pray for 5 times a day. She constantly felt tearful and had feeling of guilt for not being to pray.
The symptoms also got in the way of AA’s normal daily tasks. Even though she was able to go to
school, her choices may have been swayed by her symptoms. Not only did her symptoms
consume much of her time, but she appeared to be lonely, isolated girl whose quality of life had
been greatly affected.

2.7 Problems identified

It was found that AA has thanatophobia also known as fear of death (obsession) and she was
engaging in repeated grooming rituals, including hand washing, showering, and teeth brushing
(compulsion). It was also identified that AA was having feelings of guilt for watching videos of
sexual content. AA also showed signs of depression.

2.8 Psychological assessment

AA was administered to Yale Brown obsessive compulsive scale also known as CY-BOS. AA
CY-BOS score was 10 which refers to her having mild severity for both obsession and
compulsion.

2.9 Prognosis

The ongoing treatment is helping AA achieve long-term relief from symptoms and return to
normal or near-normal functioning.

2.10 Counseling

Treatment for AA included exposure and response prevention therapy, talking therapy and
medications. A.A was counseled to help breaking her defense of denial.

AA was given exposure and response prevention (ERP) therapy to help her learn how to better
react to these thoughts. She was deliberately subjected to the fearful thoughts (fear of death),
through the use of imaginal exposures, while response prevention involved embracing the
possibility that death will occur. She was encouraged to accept the thoughts without analyzing,
researching or questioning.
She was also encouraged to talking about her concerns to help her feel more in control of her
fear. Her intense emotional attachment with her family especially her maternal grandmother was
also addressed. She has one counseling sessions a week. Family was provided with the
information about the neuropsychiatric source of the symptoms, as opposed to having families
unnecessarily blame themselves for causing the disorder. Clomipramine (Anafranil) were also
prescribed to AA for her depression symptoms. Medications are prescribed for 1 month.

3 References

 James [Link] (1995), Biological Psychology, 5th edition, Brooks/Cole Publishing

Company.
 Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5), 5th edition, CBS
Publishers & Distributors Pvt Ltd.
 Elizabeth [Link], Developmental Psychology a Life-span Approach, 5th Edition, Tata
McGraw-Hill Publishing Company Limited.
 Niraj Ahuja (2011), A Short Textbook of Psychiatry, 7th Edition, Jaypee Brothers Medical
Publishers (P) Ltd.