Case Study Of Melvin Udall In the Film: As Good As It Gets (1997).
This is a term paper for PSYC 305 Abnormal psychology. The case study is from a movie “As good as it gets”. There is a patient with Obsessive-Compulsive Disorder in this film. We take the position of therapist to counsel with the character in the movie, and delineate the assessment, the symptoms and diagnosis, causes, and treatments in this paper.
OCD, Obsessive-Compulsive Disorder is a kind of mental illness. People with OCD will engage in obsessions or compulsions. We will identify Melvin Udall, the character Jack Nicholson plays in AS GOOD AS IT GETS (1997) as the patient who is in the process of therapy. The purpose of this paper is to take OCD as a case study for assessment, diagnose and treatment of a type of disorder.
Summary of Video
Melvin Udall, a successful author (played by Jack Nicholson), who lives the life of a kind of isolation. The movie depicted him as an unfriendly person toward other people. He throws a dog into a trash can to avoid dirty and immediately washes his hands very hard after he returns to home. That’s the episode of his obsessive-compulsion disorder. Besides, he gets used to be alone and does his job at home all the time. He won’t need to communicate with outside world and therefore doesn’t show any polite to his neighbors, especially the gay one who is the owner of the dog.
As for the daily life outside the apartment in which he only stays, he goes to the same restaurant every day with his own plastic wear. His behaviors are so weird because of his disorder episode. No one could stand his bad manners except the waitress (played by Helen Hunt). She is a mother of a sick boy however she is very patient for Melvin Udall. One day, the waitress doesn’t show up in the restaurant because her son has a great illness. This is a crisis for Melvin Udall. His unchanged life now has been destroyed and this event forces him to see his counselor again. Later, he solves the problem by asking a physician to help the sick boy to get well. Thus, the waitress may come back to work for him again.
After a serious of experiences of helping other people, he has changed a lot. He takes care of a dog for his wounded neighbor and has a very good relationship with the pet. Then he takes in charge of a tour for the painter, who is the gay neighbor to see his parents for financial reason. In this trip, he also invites the waitress to participate. And then they fall in love. Although he suffered the symptoms of mental disorder, he is still willing to accept change of life just for love.
At the end of the movie, Melvin Udall is very happy to have a date with the waitress. Meanwhile, he can walk on the cracks where he usually skips his step finally.
Introduction of Obsessive-Compulsive Disorder (OCD)
The lifetime prevalence of OCD is 1%-2% in the general public, twice that of schizophrenia or panic disorder. (Szechtman, Henry, Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton,Ontario, Canada & Woody, Erik, Department of Psychology, University of Waterloo, Waterloo,Ontario, Canada, 2004)
OCD are equally common in both male and female. (Fals-Stewart, William, Department of Psychiatry, University of California,San Diego, Alpha House Substance Abuse Treatment Facility, Ithaca,New York, & Lucente, Steve, California School of Professional Psychology,San Diego, California, 1994)
Age of onset
OCD often begins when very young. Children can suffer OCD but they often hide their symptoms. For male, the peak age of onset is between 6 and 15 years; for female, the peak age on onset is between 20 and 29 years of age. (Nolen-Hoeksema, 2004) The average age of seeking treatment is 27. (Obsessive compulsive disorder OCD - course and prognosis.2006)
Course of disorder
OCD often takes place at a young age, and tends to be a chronic disorder if left untreated. Depression, panic attacks, phobias, and substance abuse could along with OCD. (Nolen-Hoeksema, 2004) OCD is associated with excessive attention to the body and distorted perceptions and therefore induce other kinds of disorders. About 13% of OCD patients will suffer from eating disorders, 15% suffer from trichotillomania , which is the irresistible urge to pull out one’s own scalp, facial, or body hair. About 10% to 15% people with OCD experience Tourette’s syndrome, which causes involuntary muscle movements and tics, and repetitive uncontrollable speech that is often disruptive and profane. (Obsessive compulsive disorder OCD - course and prognosis.2006)
Types of tools
Melvin Udall was assessed with an unstructured diagnostic interview in the beginning then a psychiatric test is needed after.
Unstructured interview: The interview may initiate with a few questions that are open-ended, such as “Tell me about your self.” (Susan, 2004) We may also ask him about his interpersonal relationship, what happened when he tried to control the compulsions. We can get information from this interview to know many of his abnormal behaviors. Meanwhile, through the open questions, the relationship between his obsessive thoughts and compulsion habits can be revealed.
Clinical test, questionnaire and inventory: These tools can assist to evaluate the symptoms aroused by obsessive-compulsive disorder (OCD) as well. One comprehensive self-report for OCD is The Obsessive-Compulsive Inventory (OCI). There are 42 items rated on two kinds of 5-point scales. One is for measuring the frequency of symptoms and the other is for evaluating the distress caused by the symptoms. Those 42 items are from seven subscales, which are based on symptom categories as Checking (9 items), Washing (8 items), Obsessing (8 items), Mental Neutralizing (6 items), Ordering (5 items), Hoarding (3 items), and Doubting (3 items).(Foa, Edna B., Center for the Treatment and Study of Anxiety,University of Pennsylvania et al., 2002)
After gathering information about symptoms from above interview questions and tests, we can synthesize the data and make an accurate assessment with above aid.
Symptoms & Diagnosis
OCD is Obsessive-compulsive disorder. Obsessions are intrusive or recurring thoughts, ideas, or behaviors that the person tries to eliminate or resist. Compulsions are thoughts or actions that provide relief; they are used to suppress the obsessions. Compulsions can be seen as behaviors whose purpose is to get rid of obsessions. People with OCD have symptoms of obsession focusing on contamination, aggressive impulses, sexual thoughts or impulses against one’s moral code. Most of the patients of OCD engage in compulsions to erase the unwanted thought by repetitive behaviors and temporarily reduce the anxiety. Compulsions usually fall into two categories: checking behaviors and cleaning rituals. Checking behaviors can be annoying; cleaning rituals can be hazardous. (Getzfeld, 2004)
DSM IV-TR Criteria
Based on Axis I of DSM IV, obsession & compulsion are defined as following features:
1. recurrent and persistent thoughts, impulses, or images that are experienced as intrusive
and inappropriate and that cause anxiety or distress
2. thoughts, impulses, or images that are not simply excessive worries about real-life
3. thoughts, or impulses, or images that the person attempts to ignore suppress or to
neutralize with some other thought or action
4. obsessional thoughts, impulses, or images that the person recognizes are a product of
his or her own mind
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g.,
praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing distress or
preventing some dreaded event or situation; however, these behaviors or mental acts
either are not connected in a realistic way with what they are designed to neutralize or
prevent or are clearly excessive. (Source: APA, 2000)
Symptoms of Melvin Udall
Melvin Udall is a male who is 45 years old around. He is a popular novelist who always stays at home and to be alone. He shows his mental disorder in many different ways. He doesn’t keep a relationship with other people and is irritable. He eats every day at the same restaurant; he insists to sit at the same table, and insists to have the same waitress (Helen Hunt) to serve him. His life is all the same and won’t allow any accidental circumstances. The most obvious mental illness for him is his obsession for cleanliness and check.
To expel the anxiety aroused by the obsession thought of contamination and check, he has to behave compulsive behaviors repetitively. For the aspects of contamination, he always wears gloves when he is outside, he washes his hands with hot water along brand new soaps spontaneously, he wipes off door handles before opening doors, always wears his gloves to drive, and he brings his own paper-wrapped plastic wear to eat in the restaurant, he also carefully walks on the street to avoid stepping on cracks, For the aspect of check, every time he went home, he needs to lock the door 5 times and he has to turn on the lights in the same way, too.
Melvin Udall suffers from OCD very prevalently in his life. No matter he is at home or outside, he has the unwanted obsession thoughts of contamination all the time, and therefore engages in many different kinds of compulsion behavior. It is not easy to assert his age of onset. However, we know his occupation is writer who works at home and he has lived alone for many years. Probably the symptoms of OCD showed up since he began his novelist career or maybe his symptoms happed earlier during his young adulthood or adolescent even childhood.
He had seen a counselor two years ago. Therefore he is aware of his own mental illness for more than two years for sure.
According to DSM-IV-TR classification, the person must show either obsessions or compulsions, which he or she recognizes are excessive or unreasonable. On the basis of above information of assessment, Mr. Udall was diagnosed as Obsessive-Compulsive Disorder which is a kind of anxiety disorder. His repetitive behaviors which we call compulsions are the results from his obsessive thoughts.
Defense of diagnosis
His symptoms are fit the criteria of DSV-IV. On one hand, he has an obsessive thoughts and he recognizes that is generated from his own mind, such as he has to go to the restaurant and must have the same table and the same waitress. On the other hand, his repetitive behaviors of hand-washing and checking are the typical model of compulsions. He applies the rules very rigidly in his daily life. As long as he meets one of the symptoms defined in DSM-IV either obsessions or compulsions, he is diagnosed as obsessive-compulsive disorder (OCD).
Obsessive-compulsive disorder (OCD) is a model related with both biological disorder and psychological disorder.
For the biological part, the diathesis component of this model is the biological vulnerability to experience anxiety. Recently, Biological theory has become a dominant theory and view OCD as a neurological disorder. People with OCD have the dysfunction in their circuits in the brain. And this may cause the disabilities to regulate primitive impulses or to turn off the execution of the stereo type. For example, people with OCD will let the impulse of fearing of dirt keep arising even when the behaviors are not necessary to be taken. OCD is very possible formed because of the deficiencies in serotonin.
For the psychological part, more anxiety developed by OCD patients than normal people when experiencing stressful life events. “The negative perceptions of obsessive thoughts may often take the form of exaggerated assumptions about whether actual harm can result from the intrusive thoughts themselves (e.g., a thought about something can cause it to happen) and about the degree of personal responsibility for preventing harm to oneself or other (e.g., failure to prevent harm relating to the thought is just as bas as causing the harm directly).” (Brown & Barlow, 1997)
In Melvin Udall’s case, we apply two kinds of therapy for OCD treatment. One is exposure and ritual prevention (ERP); the other one is the SSRI drug therapy. ERP has an evidence that 90% of patients who experiences this treatment show substantial improvement by the end of the program. (Brown & Barlow, 1997) Meanwhile, about 60% of individuals who have OCD benefit from taking SSRIs. (Getzfeld, 2004) So we administer these two methods for treatment to Mr. Udall at the same time.
The most useful treatment for obsessive-compulsive disorder (OCD) is exposure and ritual prevention (ERP), (Abramowitz, Foa, & Franklin, 2003) The ERP has been proved in the last two decades that it’s features and delivery have a great contribution to optimize the therapy toward OCD. (Hood, Alderton, & Castle, Jun2001)The primary purpose for ERP is to expose the OCD patients to a situation deliberately that would set off obsessive thoughts. It is a kind of treatment of behavior. This method is used to treat OCD with response prevention.
We arrange Mr. Udall to confront those fear cues, especially the issues of contamination and repetitive check by exposing him to the feared thoughts (obsessions) and cues that trigger his fear to engage in compulsive behaviors, such like fear of germs when touching the door.
During the first session, we can get a long list of triggers from Mr. Udall. This information is very important for the development of EPR exercises. We emphasized the factors of her compulsions over time then we ask Mr. Udall to extend the interval of his ritual taking place by using the imagination for the feared triggers. (Brown & Barlow, 1997)
. For example, we focus Mr. Udall’s obsession about contamination and a washing compulsion. We can model rubbing dirt on his hands and ask him not wash his hands during the session of therapy. When the obsessive thought arises, we encourage him to get his hands dirty and use relaxation techniques to control the anxiety.
Besides, a self-monitoring form is very helpful. It could help him to generate daily records. For example, the frequency and intensity of symptoms could be listed down clearly to let us know his progress and to be a tracking tool in the later treatment. The ERP would be delivered in a graduated way.
Serotonergic medications have emerged with ERP as the standard and effective treatment of OCD. (Hood et al., Jun2001) We can prescribe Prozac to Mr. Udall. Prozac is an antidepressant. Prozac is one of the Selective Serotonin Reuptake Inhibitor (SSRI), which means it acts more selectively on serotonin receptors. Prozac will partially block the reuptake of serotonin. They slow the synaptic vacuuming up of serotonin; excess serotonin in synapse enhances its mood-lifting effect.
Medication should be initiated at a moderate dose with gradual increases. It has been suggested that that patients should be treated for a period (ex. 10 weeks) of time before concluding that the medication is ineffective. Therefore we will observe the progress of Mr. Udall after he takes Prozac to decrease his symptoms.
At the same time, we should be aware of the side effect of Prozac. The possible side effects are dry mouth, weight gain, hypertension, dizzy spells or decreasing sexual appetite, .etc. Moreover, even 40 or 50 percents of patients can reduce the symptoms of OCD by Prozac, they tend to relapse if stop using drugs.
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