Research Article
Abstract
This article presents the detailed case of a 27-year-old man who began to suffer from intrusive imagery after watching a brutal scene in the TV series Game of Thrones. The content of the intrusive imagery included images of people with enucleated eyes and was initially accompanied by anxiety about sharp objects. The patient’s mental distress was assessed by the Yale-Brown Obsessive Compulsive Scale and the Impact of Event Scale—Revised, and the patient was diagnosed with obsessive-compulsive disorder (OCD). Eye movement desensitization and reprocessing (EMDR) therapy was provided to treat related distressing memories and the intrusive imagery. As treatment progressed, more complex and layered aspects of the symptom presentation became evident, and EMDR was integrated with other treatments. These included psychodynamic psychotherapy to address his complicated relationship with his father, exposure and response prevention (ERP) therapy to reduce avoidance of sharp objects, and cognitive therapy (CT) for aggressive violent thoughts toward others. The article identifies the various clinical decision points and discusses theoretical conceptualizations and related factors. This clinical case report provides additional support for the body of knowledge on the relationship between traumatic events and imagery in OCD. Therefore, trauma-focused treatments, such as EMDR therapy, which concentrates specifically on those experiences, might be especially effective.
Obsessive-compulsive disorder (OCD) is an often disabling and chronic psychiatric disorder, which causes interpersonal relationship problems, social withdrawal, and loss of income and occupational function (Calvocoressi et al., 1995; Jacoby, Leonard, Riemann, & Abramowitz, 2014; Murray & Lopez, 1996). OCD is a major cause of disability in young to middle-aged adults (Markarian et al., 2010), and the World Health Organization (2011, 2013) listed this disorder in the top 10 most disabling illnesses. Its comorbidity with other psychiatric disorders is quite high (Torres et al., 2006), with 1.6% of the world population suffering from this mental disorder (Kessler et al., 2005).
Obsessions and compulsions may have many forms, and the new edition of the Diagnostic and Statistical Manual of Mental Disorders includes a whole chapter on the OCD spectrum to distinguish them from anxiety disorders (American Psychiatric Association [APA], 2013). OCD is a complex condition characterized by the presence of obsessions, compulsions, or both. Obsessions are recurrent and persistent images, impulses, thoughts, and urges that are experienced as intrusive and unwanted. Those disturbing impulses, thoughts, and urges provoke anxiety and distress, and the individual may try to suppress them or neutralize them by performing an action (APA, 2013). The actions or the behaviors performed to prevent or reduce the anxiety are termed compulsions, and there is often no realistic connection between the obsession and the compulsion. Compulsions are repetitive behaviors which may be excessive and take many forms (APA, 2013).
Although persistence of images is one of the criteria of OCD, the issue of mental imagery does not receive much attention in the literature. In the few empirical studies which did examine it, most of the patients with OCD not only reported mental images but also complained about significant suffering which accompanied those images (Lipton, Brewin, Linke, & Halperin, 2010; Speckens, Hackmann, Ehlers, & Cuthbert, 2007). OCD imagery is often seen from a field perspective and in high frequency, with the predominant content of the images being unacceptable harm to others. In addition, individuals who suffer from such images perceive themselves as being dangerous (Ferrier & Brewin, 2005; Lipton et al., 2010; Rachman, 2007). Intrusive images in OCD have been related to past memories (Speckens et al., 2007), and the sensory modalities were described as being similar to those in posttraumatic stress disorder (PTSD; Ehlers et al., 2002; Hackmann, Ehlers, Speckens, & Clark, 2004). The majority of images are visual in nature, and some patients report that they also have auditory, gustatory, and olfactory qualities (de Silva, 1986; Speckens et al., 2007). In another study, only 15% of the patients considered that their intrusive image was similar to a memory of a past event (Lipton et al., 2010), but a major limitation of that study is the small number of OCD imagery patients (n = 21).
An interesting question which arises about this intriguing phenomenon is whether the essence of this symptom is actually elaborative cognitions without any clear link to an autobiographical memory and, as such, should be treated with rescripting (Lipton et al., 2010) or if it is a trauma-related symptom which should be treated with a trauma-focused approach. Interestingly, a few case studies described an association between traumatic events, imagery, and the development and the course of OCD (de Silva & Marks, 1999, 2001; Lipinski & Pope, 1994; Pitman, 1993).
Most of the psychotherapeutic treatment methods in those cases are different variations of cognitive-behavioral treatment, and no psychological treatment specifically directed at OCD imagery has been described in any literature review. In contrast, there is extensive empirical support for OCD treatment, exposure and response prevention (ERP), and cognitive-behavioral therapy (CBT; Ponniah, Magiati, & Hollon, 2013; Rosa-Alcázar, Sánchez-Meca, Gómez-Conesa, & Marín-Martínez, 2008). Psychodynamic therapy has not received much empirical support, and motivational interviewing, satiation therapy, and eye movement desensitization and reprocessing (EMDR) therapy were described as having some efficacy as adjacent interventions to other treatments (Ponniah et al., 2013).
EMDR Therapy and Obsessive-Compulsive Disorder Treatment
EMDR treatment of OCD has received less attention in the EMDR literature in comparison to other mental disorders, such as PTSD. However, the studies that investigated EMDR treatment of OCD, all using different EMDR protocols, reported interesting results. In a randomized trial, patients who received 12 sessions of EMDR therapy were compared to those who received pharmacological treatment (citalopram). Although both treatment methods led to symptom reduction, EMDR therapy was significantly more effective in improving OCD symptoms (Nazari, Momeni, Jariani, & Tarrahi, 2011). In another study, three patients who received EMDR therapy combined with ERP reported on a significant symptom reduction (Böhm & Voderholzer, 2010).
Keenan, Keenan, Ingham, and Farrell (2014) used the standard EMDR protocol to treat eight patients who had been previously treated with CBT but who were still presenting with OCD symptoms. The targets of the treatment were either past aversive life experiences or intolerance of uncertainty for those participants who did not identify aversive life experiences. All patients reported significant improvements at 3-month follow up (Keenan et al., 2014). Marr (2012) reported successful treatment of compulsions and obsessions using adaptations to Shapiro’s (2001) phobia protocol, which involves the patient first targeting current triggers. Marsden (2016) used the same protocol to treat three patients with OCD, who complained of checking behaviors.
Case Description
Presenting Complaint
Sam (name and details changed to maintain confidentiality), a 27-year-old bachelor who worked as an engineer, presented for treatment because he had suffered for 8 months from what he called “disturbing thoughts.” When the therapist queried about the content of those disturbing thoughts, Sam asked the therapist if he watched the TV series Game of Thrones. The therapist answered positively, and he asked if the therapist remembered a scene in which there is a fight between a gigantic man and a smaller person that ended as the huge man extracted the eyes of the other figure. Sam talked about the eighth episode of the fourth season, “The Mountain and the Viper,” which was also quite shocking. He said, “Well, ever since I viewed that scene, I started to see people around me with their eyes plucked out, including my girlfriend.”
History
Sam was the oldest of three brothers. His father worked as an accountant in a large company and his mother as a computer programmer. He denied any developmental problems and described himself as a friendly person and as a good student. He was a mischievous child until the seventh grade and sometimes annoyed other students in class. On one occasion, he broke some of their equipment, and his father had a serious talk with him (in his words: “My father strengthened me.”), after which he became a straight-A student. During his childhood, Sam reported many occasions when his desires were considered unacceptable by his father. When asked about any anger he may have toward his father, Sam replied that his father always said that all of his actions were done in Sam’s best interests. However, he mentioned an incident when he was 17 years old in which he argued with his father and imagined an arrow flying through the window and hitting the father. Back then, this image bothered Sam only for the next few days.
When he was 18, he was drafted into (obligatory) military service and served for 3 years without any problems. At age 21, he was demobilized and started studying engineering. He worked for 3 years in the same company and was considered a good worker by his managers. Sam described several relationships with women as “normal,” in contrast to his current relationship, in which he described his girlfriend as jealous of his relations with other girlfriends.
Eight months had passed since he saw the episode on television and he suffered from intrusive images of people with missing eyes throughout this time. His girlfriend was one of those people, and he feared that his impulses might lead to an actual violent action against her. He also suffered from intrusive thoughts about violent injuries during the workday, and felt some anxiety when he passed next to sharp objects, such as scissors and pencils, because he imagined them stuck in his colleagues’ eyes. Lunches in his workplace turned to distressing situations because his attention was constantly focused on knives and on the possible harm they could cause. When those thoughts had intensified, he felt sick or experienced panic attacks and started to miss days at work. Sam added that the violent thoughts and images had worsened when he was not busy and he looked for distractions to keep them at bay.
Sam reported that he did not have any other obsessive thoughts or compulsions. He did not fear any contaminations or did he check or wash his hands frequently following distressful thoughts. He missed many days at work and stopped his usual participation in sports activities. After 6 months of mental distress, he turned to psychological treatment, which focused on the relationship with his girlfriend. After 10 sessions, he felt some relief because the severity of the symptoms had lessened, and the psychologist said that he will now have to live with those thoughts and images. At that point, Sam thought to himself that this is the best possible situation and that he would have to learn how to cope on a daily basis with the symptoms.
However, a few days after the treatment ended, Sam walked next to sharp pencils and the intrusive thoughts and images reappeared with even greater intensity. He became more anxious and immediately searched the Internet for appropriate treatment for intrusive images. During this search, he read about EMDR as an evidence-based treatment for intrusive symptoms and contacted this therapist.
Diagnosis
Sam’s frequent and intense obsessive thoughts and images pointed to a diagnosis of OCD. He tried to suppress those thoughts with limited success for 8 months and was often occupied in distracting himself to avoid the anxiety that accompanied the threatening stimuli.
The whole course of Sam’s disorder was not the typical one of OCD. For example, the mean age at OCD onset is 19.5 years (APA, 2013). In addition, OCD has a gradual onset, and Sam stated clearly that the whole mental distress had an acute and very specific onset. Sam’s symptomatology included the invasive images, the invasive thoughts, the hyperarousal state around sharp objects, the avoidance from encounters with threatening stimuli, and the avoidance from viewing war movies which he had enjoyed throughout his whole life. The similarities to subjective experience of a PTSD patient were evident. As in the criteria for defining PTSD, the patient suffered from reexperiencing, hyperarousal, and avoidance symptoms from the time he was exposed to horrific images on television. Sam’s case was reminiscent of the reports on PTSD onset after 9/11 (Ahern, Galea, Resnick, & Vlahov, 2004), and he might have indeed been diagnosed as having PTSD before May 2014. However, the DSM-5 clearly states that that traumatic experience that conforms to a PTSD diagnosis must be firsthand and not through media, pictures, television, or movies (APA, 2013).
Assessment
The following questionnaires were administered at the beginning of the treatment, at the end of the treatment, 6 months posttreatment, and 1 year after the end of treatment.
The Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al., 1989) is regarded as the “gold standard” in the measurement of OCD symptom severity and treatment response (Moritz et al., 2002; Steketee, 1994). The Y-BOCS includes five rating dimensions for obsessions and compulsions, and each item is scored on a 4-point scale from 0 = no symptoms to 4 = extreme symptoms. The total sum of the first five items comprises the severity index for obsessions, and the total sum of the last five items is the index for compulsions. Sam scored 19 on the obsessions scale (indicative of moderate OCD) and 0 on the compulsions scale.
The Impact of Event Scale—Revised (IES-R; Weiss & Marmar, 1997) is a measure which assesses self-reported PTSD symptomatology experienced in the past 7 days. It consists of 22 items that are rated on a 5-point Likert scale, which ranges from 0 (not at all) to 4 (extremely). This tool is composed of three subscales, which reflect the different posttraumatic stress symptomatology clusters—intrusion, avoidance, and hyperarousal. The IES-R has a high degree of intercorrelation (Creamer, Bell, & Failla, 2003) and high levels of internal consistency (Creamer et al., 2003; Weiss & Marmar, 1997). Test–retest reliability, which was collected across a 6-month interval, was also high and ranged from .89 to .94 (Weiss & Marmar, 1997). At the beginning of the treatment, Sam’s total score was 66 (intrusion = 24, avoidance = 26, hyperarousal = 16). An IES-R score ≥33 indicates PTSD.
EMDR Treatment Conceptualization and Treatment Plan
Although CBT is usually the first treatment of choice for OCD, EMDR was chosen as the first therapeutic intervention for Sam because the intrusive images had been his most disturbing complaint and because the symptoms started after a specific event which was very traumatic to him. EMDR has a high level of efficacy in reducing vivid and emotional imagery (Andrade, Kavanagh, & Baddeley, 1997; van den Hout, Muris, Salemink, & Kindt, 2001), and it is an empirically validated psychotherapy approach in which a structured approach is used to address past, present, and future aspects of disturbing memories (Shapiro, 2001). EMDR is an evidence-based treatment (Bisson & Andrew, 2007; Bradley, Greene, Russ, Dutra, & Westen, 2005) which is identified as a first line of treatment for PTSD in many countries (National Collaborating Centre for Mental Health, 2005; U.S. Department of Health and Human Services, 2011). EMDR relies on the adaptive information processing (AIP) model, which contends that mental disorders result from unprocessed memories of earlier life experiences. Those experiences can cause high arousal levels and are thought to be stored in memory with the original emotions, physical sensations, and cognitions (Shapiro, 2014). The AIP model views various manifestations of intrusive symptomatology as symptoms resulting from the triggering of these unprocessed memories (Shapiro, 2014) and argues that sufficient processing of those traumatic memories may bring about adaptive resolution and functioning.
According to the AIP model, Sam’s intrusive images can be understood as stemming from the inability to process the scene he viewed on television, as well as from earlier unprocessed traumatic experiences. Because Sam’s symptomatology had evident similarity to PTSD, and because there is not a specific or a recommended EMDR protocol for obsessive imagery, the therapist decided to use the EMDR standard eight-phase protocol (Shapiro, 1995, 2001) for processing of past events and present triggers. The therapist considered combining EMDR therapy for the obsessive imagery with CBT for the intrusive thoughts about violent injuries or with ERP for exposure to sharp objects. However, because the therapist’s clinical experience shows that the EMDR work on intrusive imagery significantly reduces intrusive thoughts and the overall anxiety, the therapist decided to use the standard protocol for the obsessive imagery and to follow-up with CBT if needed.
Provision of EMDR Therapy
EMDR therapy is administered according to an eight-phase protocol (Shapiro, 1995, 2001). The first phase includes client history and treatment planning. In the next phase, preparation, the patient receives explanation about the treatment and is also taught self-relaxation techniques which will help him in self-regulation during and between sessions (Shapiro, 1995, 2001). Reprocessing occurs during Phases 3 through 7. During the third phase (assessment), the client identifies a snapshot image which represents the disturbing experience, articulates a negative cognition (NC) about the self related to the incident and a preferred positive cognition (PC), and rates the PC using the Validity of Cognition (VOC) scale where 1 = not true, and 7 = totally true. The patient then identifies emotions and body sensations related to the image and provides a score on the Subjective Units of Disturbance scale (e.g., 0–10 in SUD) where 0 = no disturbance and 10 = worst disturbance imaginable (Shapiro, 1995, 2001).
In the desensitization phase, the patient is instructed simultaneously to focus on the disturbing incident and to engage in bilateral stimulation (BLS) such as alternating eye movements, tapping, or tones. After each set of BLS, the therapist elicits associated material, asking what the patient has noticed. This phase ends when the SUD score has reached 0 or 1. In the fifth phase, installation, the PC is paired with the distressing incident during BLS, following standard procedures until VOC = 7. Next, in the sixth phase, the patient is asked to scan his body, and if any somatic response arises, it is processed. Closure is the seventh phase in which the patient is instructed to keep a record of any disturbing material which arises between the sessions, so it can be reprocessed. Phase 8 begins the subsequent session and focuses on reevaluation; the therapist and the patient examine the progress made so far and continue to target past events, current triggers, and any anticipated future events related to the target event (Shapiro, 1995, 2001).
EMDR History-Taking Phase: Sessions 1–2
During the history taking, Sam was asked about disturbing events in both the present and in the past, and a hierarchy of the disturbing images was built according to those events.
1 An event when he was 12 years old and got into a fight with two schoolmates (SUD = 5).
2 Sam sat across his girlfriend in his living room and began to see her with enucleated eyes (SUD = 7).
3 Sam experienced a panic attack during vacation with his girlfriend after an intrusive imagery of himself plucking out her eyes (SUD = 8).
4 Viewing the scene from the television series Game of Thrones (SUD = 10).
EMDR Preparation Phase: Sessions 2–3
The preparation phase included psychoeducation about OCD and an explanation about EMDR treatment. Sam was also taught a relaxation technique which he was asked to practice on a daily basis. For the BLS, Sam chose to use eye movements.
EMDR Reprocessing: Sessions 3–4
The first targeted memory was the fight at the age of 12 years (Table 1). Sam ranked this memory as SUD = 5, and the NC associated with this memory was “I’m afraid.” The PC was “I’m safe.” At the end of the desensitization phase, the levels of the distress had been reduced to SUDS = 1. Interestingly, the picture which had represented the hardest moment was the look in the attackers’ eyes, which Sam interpreted as contempt and as an indication of victory.
Session Number | Treatment | Focus of Treatment | SUD Score for Images | |
---|---|---|---|---|
Start of First Session | End of Last Session | |||
1–3 | EMDR | History taking, preparation | 10 | 10 |
4 | EMDR | Reprocessing of childhood fight | 5 | 1 |
5–6 | EMDR | Reprocessing of current trigger | 8 | 0 |
7–8 | EMDR | Reprocessing of current trigger | 8 | 1 |
9–10 | EMDR | Reprocessing of current dream | 1 | 1 |
11 | EMDR | Reprocessing of memory of TV scene | 6 | 9 (stopped) |
12–14 | Psychodynamic | Work on relationship with father | ||
15 | EMDR | Reprocessing of memory of TV scene | 3 | 1 |
16–17 | Psychodynamic | Relationship with new girlfriend | ||
18 | ERP | Exposure to knives | 1 | 8 (stopped) |
19 | EMDR | Reprocessing of childhood memory of knife injury | 8 | 1 |
20 | ERP | Exposure to knives | 3 | 0 |
21–22 | ERP+CT | Exposure to knives | 8 | 2 |
23 | ERP+CT | Exposure to scissors | 8 | 1 |
24 | ERP+CT | Exposure to scissors | 6 | 1 |
25 | EMDR | Reevaluation and Conclusion |
Note. SUD = subjective units of disturbance; EMDR = eye movement desensitization and reprocessing; ERP = exposure and response prevention; CT = cognitive therapy.
EMDR Reprocessing: Sessions 5–6
The second targeted memory was an invasive memory image which was bothering Sam on a daily basis. In that situation, Sam had sat across his girlfriend and saw her with hollowed-out eyes. During the desensitization phase, Sam described this image as becoming blurred and, at the end of this phase, he reported being surprised that he could no longer see the image. The work on this disturbing image continued in the next session according to the eight-phase protocol at the end of which he reported that it no longer disturbed him. During a follow-up phone call on the following day, Sam related that he woke up without any anxiety or any aggressive thoughts for the first time in many months. He noted that he had felt some anxiety when he passed near sharp objects but that the discomfort lasted for only a few minutes and not for hours as in the previous months.
EMDR Reprocessing: Sessions 7–8
At the next session, Sam reported that both the intrusive imagery of the TV scene and the aggressive thoughts had decreased during the last week. Interestingly, during the period between the two sessions that focused on eye removal, Sam reported that he had started dreaming “strange but normal dreams” again. He was quite surprised because he reported that he usually did not dream or occasionally had nightmares. Meantime, Sam and his girlfriend broke up for reasons unrelated to the OCD imagery. The next targeted memory was that of a vacation in which Sam experienced a panic attack after seeing an image of his girlfriend with no eyes. Sam’s NC was “I am afraid of myself” and the PC was “I can cope with it.” During the two sessions which focused on this event, the frightening image blurred until Sam reported that he can no longer see it in spite of his efforts to summon it. In the following week, he reported that he felt very calm, and his friends had told him that he “returned to himself” and said that he looked less stressed out. He explained that he participated more in conversations and that he started to be funny like the “old Sam.” Sam reported noticing that he coped better with stress at work and did not get annoyed from petty things as he did before. When asked about what happened when he now passed next to sharp objects, he said, “It does not bother me as before.”
EMDR Reprocessing: Sessions 9–10
According to the treatment plan, the next targeted memory should have been the Game of Thrones TV scene, but Sam reported that he recently had a dream and that he only remembered his father in the dream. He remembered that he woke up anxiously in the middle of the night with itching thumbs and sat on the bed for 5 minutes until he calmed down. The next two sessions were dedicated to that recent dream because it was related to the original traumatic memory from his childhood.
EMDR Reprocessing: Session 11
At the 11th session, the targeted memory was the Game of Thrones scene and the image which represented the worst part of the memory. The NC associated with this memory was “I’m helpless,” and he gave this memory a SUD score of 6 (in contrast to 10 SUD score at the beginning of the treatment). The PC was “I’m safe” and the VOC was 2. During the desensitization stage, Sam reported that as he visualized the scene, he was paying attention to other aspects in it that he had not thought about before. In a subsequent set of bilateral stimuli, Sam suddenly said, “I saw my father but as the smaller guy in the scene.” After the next set of bilateral stimuli, he said, “I see my father in the scene . . . he’s wounded . . . I’m afraid to continue.” The session was paused for a few minutes to let Sam practice a relaxation technique.
The treatment then continued, and the associations which came up were related to various childhood fears that his father would be killed in various ways, including a memory from age 17 years in which Sam imagined that his father was shot by an arrow. The associations went on to different scenes from various movies or series which included brutal killings and body mutilations. In one of them, Sam remembered a specific scene from a movie in which a man was being threatened that he would be castrated. Sam reported that he was too afraid to continue watching the scene and turned off the television.
Clinical Decision Point and Conceptualization From Psychodynamic Psychotherapy Perspective
At this point of the treatment, the therapist decided to stop the EMDR treatment and turn to psychodynamic psychotherapy. Psychodynamic psychotherapy views psychic tension as the result of conflicting forces in the psyche and unconscious and past experience as affecting the present (Gabbard, 2004). A main aim of this therapy is to help the patient acknowledge conscious and unconscious motives which influence his behavior. The therapeutic relationship is a crucial element in the therapy because it enables the patient, through transference–countertransference relations to understand interpersonal difficulties and maladaptive behavioral patterns. Free associations, dream analysis, and interpretation of dreams are additional techniques used in psychodynamic psychotherapy for symptom relief and uncovering disavowed aspects of the personality (McWilliams, 2004).
Despite the belief that this treatment method lacks empirical support or scientific evidence, empirical evidence not only supports the efficacy of psychodynamic therapy, but effect sizes for this psychotherapy approach are as large as those reported for other therapies that are considered “empirically supported” and “evidence based” (Shedler, 2010). In addition, a prominent finding which arises from independent meta-analyses shows that the benefits of psychodynamic therapy increase with time (Abbass, Hancock, Henderson, & Kisely, 2006; Anderson & Lambert, 1995; Leichsenring & Rabung, 2008).
The rationale for integrating this therapeutic method stemmed from Sam’s free associations which included raw aggression toward the father coupled with enormous fear from the consequences of this aggression. Those associations and the fear in reaction to the TV scene which involved castration hinted at an unsolved oedipal complex which, according to the psychodynamic approach, laid the base for Sam’s OCD symptomatology. The Oedipus complex is a major cornerstone in Freud’s (1924) psychosexual developmental model. It relates to the child’s desire to have sexual relations with the parent of the opposite sex, meaning, boys are attracted to their mothers, and girls are attracted to their fathers.
The oedipal drama occurs at the phallic stage (5–6 years of age) because it is in this phase that the boy is attracted to his mother and yearns for intimate closeness to her. The child wants to take the father’s role as the mother’s spouse, but he fears that the powerful father will hurt him in his most vulnerable place. In other words, the child fears that his wishes for intimate proximity with his mother and his aggressive fantasies toward the father will end in a colossal failure and in his castration by the father (Freud, 1956). The therapist thought that the frightening scene from the TV series Game of Thrones was so intimidating because it is a symbolic representation of an unsolved Oedipus complex.
In the psychodynamic conceptualization, Sam’s different repressed and unexpressed impulses, the fantasies, and the ambivalent emotions which Sam felt toward the father during his life were significantly related to his OCD symptomatology. The murderous fantasies, the impulses, and the ambition to take the father’s place were understood to provoke guilt, with resultant anxiety. The therapist’s premise was that the Game of Thrones scene in which “the mountain” brutally killed “the viper” raised the unconscious conflict to the conscious level. According to this psychodynamic formulation of Sam’s disorder, the defense mechanisms whose role was to keep this instinctive struggle unconscious and allow Sam to carry on with his life without awareness of the inner struggle could not fulfill their task as efficiently as they had in the past. Consequently, the aggressive impulses had risen, but they were still displaced toward other people in Sam’s world because of the fear of the father.
Provision of Psychodynamic Psychotherapy: Sessions 12–14
The therapist asked Sam to describe his relations with his father throughout the years, and Sam described a strict father who always wanted his children to succeed in life but who did not attend to their emotional needs. During his childhood, Sam used to pull pranks on other children whose parents did not approve, and they reported Sam to his father who punished him. In addition, Sam reported that the father placed harsh limitations on Sam hanging out with his friends during puberty so that any attempts toward rebellion during this period were quickly ended. The father also insisted that Sam study engineering although Sam was reluctant to do so.
When asked if he felt anger toward his father, Sam first answered in the negative, but after a few moments of silence, he said that he did. The therapist explained to Sam that he thought that the next sessions should be dedicated to a joint investigation of his relations with his father, and Sam agreed. Sam and the therapist chose major incidents in which Sam felt anger toward the father but did not express it. Sam was encouraged to talk openly about those incidents with his father and to explain to his father the different emotions he had felt toward him during different periods of his life.
At the 14th session, after three-and-a-half sessions dedicated to focused dynamic treatment, Sam reported that during the previous week, he had talked to his father as the therapist had recommended and that he now saw his father in a completely different light. The father explained that the family had financial difficulties during most of Sam’s childhood and that those problems had constantly worried him. The father also said that he was a war veteran who did not receive any treatment, and he now believed that much of his harsh behavior toward Sam and the other family members stemmed from unresolved memories of horrific war experiences. The father said that he was sorry for what Sam felt, but, at that time, he believed that he was doing his best. He added that he saw Sam as the most talented of his children. Sam reported to his therapist that he had never heard his father talk in such emotional manner and that although he still felt considerable anger toward his father, he now was also compassionate toward and more understanding of the father’s intentions.
Provision of EMDR Therapy
Reprocessing: Session 15
In the subsequent session, the work on the Game of Thrones TV scene was continued with EMDR as Sam rated the horrifying image with an SUD score of 3. The NC was “I’m shocked” and the PC was “I can cope with it,” and the VOC of this cognition was 4. At the end of the session, the SUD ratings had decreased to 1, and the VOC was 7. Sam reported that he no longer suffered from intrusive imagery and said that the aggressive thoughts “come and go sometimes” but they do not disturb him as they had before treatment.
Clinical Decision Point and Psychodynamic Psychotherapy Treatment for Relationship Issues
At this point, it appeared that EMDR therapy was complete, as past traumatic memories and present triggers were resolved. Sam asked to continue with therapy but with a change in focus to address his interpersonal relations with his new girlfriend. Although the EMDR future template protocol has not been administered, Sam reported significant symptom relief, and this new problem seemed more urgent. Both he and the therapist expected that the intrusive symptoms would no longer disturb Sam, but they were wrong.
Psychodynamic Psychotherapy: Sessions 16–17
The treatment now focused on Sam’s current relationship. He made numerous efforts to keep his girlfriend happy and wanted her to think that he was “perfect.” A discussion about his efforts to portray an image of being flawless elicited thoughts about his behavior with different people during his life. In the same session, he added that during the past week, he had felt pervasive anxiety when he passed next to sharp objects, such as knives and scissors, and he feared that those objects would hurt his colleagues. He feared to admit that he had obsessive thoughts about causing possible harm to others. Sam’s anxiety was conceptualized by the therapist as indicative of an additional unconscious conflict—the wish to be loved by everyone versus the fear of rejection. An earlier example of this was his many efforts to please his girlfriends and his constant worry that if he did not do enough, his girlfriends might leave him.
In addition, Sam had decided to tell his girlfriend that he suffered from obsessive thoughts with aggressive contents, without specifying the contents. Sam was at the beginning of the relationship with the current girlfriend and this decision heightened his anxiety because Sam was afraid that his girlfriend would decide to end their relationship. Another source of growing anxiety was intrusive thoughts of knives and scissors being stuck in his colleagues’ bodies that bothered him during the last week. Every lunch with his coworkers or any exposure to scissors and pencils turned to dreadful experience that made him fear his own potential aggression.
Clinical Decision Point and Exposure Response Prevention Treatment for Obsessive Thoughts
This was a clinical decision point. The therapist had been using psychodynamic conceptualization to understand the unconscious processes that influence on Sam’s behavior in his relationship with his girlfriend. The therapeutic crossroad was to decide whether to continue with psychodynamic psychotherapy toward discovery of the unconscious sources of his aggression and broader analysis of Sam’s personality structure or to use ERP. Because the intrusive aggressive thoughts were Sam’s main complaint, the therapist chose to treat Sam with an evidence-based treatment for obsessive thoughts—ERP.
Exposure Response Prevention for Obsessive Thoughts: Session 18
ERP is a form of behavioral therapy that involves repeated exposure to disturbing situations or cues, such as objects perceived to be contaminated, while preventing rituals or repetitive behaviors, such as hand washing that are used to dissipate the anxiety related to the obsessive preoccupation (Abramowitz, Deacon, & Whiteside, 2011). ERP has received significant empirical support from numerous studies, and the American Psychiatric Association recommends this treatment for OCD (Koran, Hanna, Hollander, Nestadt, & Simpson, 2007).
The therapist gave Sam a detailed explanation about ERP, and together they created a hierarchy of feared situations which triggered gradually increasing amounts of distress. Sam was presented with the following situations:
1 Obsessive thoughts about a utility knife cutting people (SUD = 3).
2 Obsessive thoughts about a large kitchen knife cutting people (SUD = 7).
3 Obsessive thoughts about scissors stuck in people (SUD = 10).
Sam was asked to imagine himself holding a utility knife in great detail. His homework assignment for the first day of the in vivo exposure was to hold the knife for only 10 minutes to provide an opportunity for habituation to occur (Osgood-Hynes, n.d.) and because the therapist wanted him to experience success on his first actual practice. After each home assignment, he was instructed to write his thoughts and feelings and to rate the difficulty of the daily home assignment. On the first day, he reported that during the assignment, he thought of the utility knife cutting a stomach and then this thought disappeared and returned. Then he remembered that he had played with such knife and cut himself when he was in the second grade. He was reluctant to continue the exposure, so it was decided to target that memory with EMDR in the following session.
Provision of EMDR Therapy: Session 19
The targeted memory for the EMDR work in the following session was the memory from the second grade. At the beginning of the session, Sam rated the image with 8 SUDS, and at the end of the session, the SUDS ratings had decreased to 1. Following the session, Sam was ready to continue with ERP.
ERP Treatment: Session 20
In the following days, he held the knife for 30–45 minutes and felt a significant reduction in the frequency and the intensity of the aggressive thoughts. Interestingly, an image of a knife cutting a penis had appeared on one of those days.
Sam felt successful after this week and wanted to continue to the next feared situation. The behavioral treatment was accompanied with major cognitive components because Sam suffered both from aggressive thoughts as well as pervasive thoughts about himself.
Clinical Decision Point: Integrating Cognitive Therapy With Exposure and Response Prevention
Sam told himself that his having frequent aggressive urges and frightening thoughts must be meaningful. He read in the newspapers about murderers and about situations in which people without any criminal record performed aggressive actions and wondered if he was liable to act in such a way as well. This self-talk reflected Sam’s fear of his own aggression and his view of himself as a dangerous man. Therefore, to challenge these negative cognitions (NCs), the author had chosen to combine cognitive therapy with ERP.
Cognitive therapy (CT) for OCD relies on the ideas of Beck (1976) and Salkovskis (1985), and it targets dysfunctional beliefs considered to be central to this disorder, such as overestimation of danger. Patients treated with CT show the same rate of OCD symptom reduction as patients treated with ERP (Cottraux et al., 2001; van Balkom et al., 1998; van Oppen et al., 1995). In some of these studies in particular and in CBT treatment of OCD in general, variants of CT include behavioral experiments, which has some similarities to exposure techniques, and variants of exposure therapy include some CT techniques. In clinical practice, these two forms of treatment are often combined (Koran et al., 2007), as it was in Sam’s treatment.
Cognitive Therapy and ERP: Sessions 21–24
The therapist provided psychoeducation about the “normality” of aggressive thoughts among large part of the population and explained the difference between assertiveness and aggression. Another cognitive intervention was to challenge cognitions associated with dangerousness by presenting arguments, such as “Many people have aggressive thoughts—does that make them dangerous?” Sam read about aggressive thoughts on the Internet and realized that this phenomenon is prevalent among nonclinical populations. He became even more convinced that if a person has an aggressive thought, it does not mean that he or she intends to perform a violent act. The cognitive interventions were integrated into the ERP treatment not only to challenge some of Sam’s cognitions but also to reduce the impact of the unproductive self-talk. The therapist presented him with questions, such as “Does merely holding a sharp object make you a dangerous man?” “Do you see yourself, a well-respected person, going on a killing spree?”
The ERP treatment continued for the second feared situation. When he held the knife during cooking, he felt anxious and had images of this knife cutting people. Sam was instructed to hold the knife for 40 minutes each day and then to rate how distressful those situations were and describe his feelings and thoughts in writing. On the first day of this home assignment, he reported a SUD score of 8 and a passing image of the knife making scratches on various body parts, including the penis. On the following day, he held the knife and reported that there were fewer frightening images and aggressive thoughts. On the next days, Sam felt quite bored and the SUD decreased to 2. At the next session, when he reported on boredom during the home assignment, the therapist asked him to look at the sentence “Holding a knife is dangerous,” and to comment on it. The next lines describe the conversation.
Sam: “No, not necessarily. It is boring.”
Therapist: “So you are saying that holding a big kitchen knife is boring?”
Sam: “You know, at some stage during the assignment, I started playing with the knife.”
Therapist: “Really? You actually played with the knife?”
Sam: “Yes. At the beginning of the week, I felt anxious, but then for most of the time later on, I thought to myself that what I’m doing is ridiculous.”
Therapist: “What exactly is ridiculous?”
Sam: “Holding a big knife is ridiculous. I mean, why would someone simply hold a kitchen knife? If it is being used for cooking, fine. But otherwise, I don’t see any reason to hold it.”
The aim of the cognitive intervention was to challenge cognitions associated with danger and to assist Sam in identifying the cognitive distortions typically related to a faulty assessment of danger (Foa, 2010). This provides an opportunity to create adaptive cognitions concerning the encounter with the sharp object. In addition, the frequent mentioning of words which elicit anxiety during the conversation helps in the desensitization of the distorted beliefs and teaches the patient that talking about sharp objects is not dangerous. Encouraged by his success, Sam approached the most feared situation—scissors. He reported that the sight of the scissors in his office triggered images and thoughts of their being stuck in his colleagues’ bodies. As such, he kept the scissors in a bottom draw of his desk and did not use them.
The instructions for this assignment were to put the scissors on his desktop for 30 minutes a day. At the subsequent session, Sam noted that he worked during the past few days without paying any attention to the scissors which had remained on his desk the entire day. His next assignment was to occasionally hold the scissors, leave them on the table, and to use them if necessary. Sam followed those instructions on the first day and did not find the assignment distressful. On the next day, he decided to place the scissors in front of him and to keep looking at them for an hour. During that week, Sam decided independently to hold the scissors for more than an hour each day.
During Session 24, he explained his attempt to immerse himself into the feared situation and stay in it with curiosity and self-confidence. He said that the previous successes enhanced his self-confidence and he wanted to test whether he was strong enough to cope with the threatening situation. In essence, Sam had chosen to perform flooding and it led to significant symptom reduction. Since then, the scissors have remained on his desktop, and he reports that he does not feel uncomfortable as before, nor does he need to hide them. Sam was worried that those thoughts appear and asked to get rid of them, and the therapist told him that such thoughts are much like sneezing—something that one cannot predict but simply comes and goes (G. Agassi, personal communication, March 8, 2016).
The last session dealt with the end of the treatment and with Sam’s current relationship, because he and his new girlfriend decided to break up because of incompatibility. A major moment in those sessions was when the therapist said to Sam that despite his fear that his thoughts would cause the separation, the relationship ended because of a completely different reason. Sam was quite surprised by this comment and said that he had not thought of it in that way. This comment provided support for the idea that Sam had already read about—that people can and do live with aggressive thoughts. In other words, people can have serious relationships and work productively with aggressive thoughts that occasionally come and go.
Follow-Up Assessments
At the end of treatment, Sam’s total score on the Y-BOCS was reduced to 3 from his pretreatment score of 19. His total score on the IES-R was 5 (intrusion = 3, avoidance = 1, hyperarousal = 1), reduced from pretreatment scores of 66 (intrusion = 24, avoidance = 26, hyperarousal = 16). A 6 months and 1 year follow-up assessment showed the same results. These scores indicate subclinical OCD and minimal symptoms of posttraumatic stress (Figure 1).
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Discussion
Treatment Implications
This article presented a case of a patient who suffered from OCD imagery, obsessive thoughts about aggression, and avoidance of sharp objects after watching a brutal and violent scene on TV. The onset of these symptoms was sudden and acute and caused the patient much mental distress, damaged his interpersonal relationships, and led to significant functional impairment of his work. The patient’s most prominent complaint was recurrent and disturbing imagery, an OCD symptom which receives less attention in professional literature than compulsions and obsessions. Intrusive images in OCD have been distinguished from those in other anxiety disorders by their greater frequency (Lipton et al., 2010).
As previously mentioned, there is much similarity between most PTSD symptom clusters and OCD, as both are characterized by intrusive contents. The subjective experience of the patient is also quite similar. There is intrusiveness (images, dreams) in both diagnoses, and the patient feels powerlessness because he often cannot predict when the frightening imagery will appear. In PTSD, a patient who underwent a road accident might avoid the place of the accident or driving altogether. In OCD, a patient who suffers from aggressive thoughts of harming other people may avoid an underground train because of the fear of pushing people in front of the oncoming train. The hyperarousal in PTSD is related to the patient’s cognition that the world is a dangerous place. In OCD imagery, when the patient has aggressive thoughts and images, he believes that he has a “dangerous self” and that he may harm others (Lipton et al., 2010). In both cases, there is hyperarousal related to the fear of unexpectedly encountering the threatening stimulus or when actually encountering it.
Trauma-focused treatment may prove beneficial to such patients, and although one of the evidence-based treatments for both PTSD and OCD is CBT (Bisson & Andrew, 2007; Koran et al., 2007), in this case, the therapist chose EMDR therapy to treat the intrusive imagery for several reasons.
First, EMDR therapy has proven efficacy in reducing intrusive symptomatology in different mental disorders and emotional problems (de Jongh, Ernst, Marquesc, & Hornsveld, 2013; Puk, 1991; Shapiro & Forrest, 2004; Silver, Brooks, & Obenchain, 1995). Second, Sam was suffering from an acute problem which had already lasted for a significant period and which was impeding his interpersonal relations, his functioning in work, and his life quality. Previous treatment had failed and he was looking for relief. Third, I believe that as therapists, we are obliged to act with professional integrity, recommending to our patients the most efficient treatments for their problems. Therefore, based on my colleagues and my own personal experience with treating patients who suffered from disturbing images, I chose EMDR therapy for Sam. I expected it to reduce the intrusive symptomatology and lessen his anxiety. For the same reason, I subsequently chose to treat the intrusive aggressive thoughts with the most efficient treatment for this symptom that the professional literature suggests—CBT.
Contribution of EMDR Therapy
The contribution of EMDR therapy to the patient’s subjective experience and life quality was enormous. First, the intrusive imagery stopped bothering him. Second, after the processing of the first memory, the SUD scores of the next memories dropped. For example, the TV scene was rated with an SUD score of 10 at the beginning of treatment; then, when EMDR therapy was first provided for this image (Session 11), the SUD score had already dropped to 6; and it had dropped again to a score of 3 at the last session dedicated for processing this disturbing image. Third, after the beginning of EMDR therapy, Sam reported a significant decrease in the distress level associated with intrusive thoughts, although these started to bother him again after 4 months in treatment (Sessions 16–17). Fourth, during the first 10 sessions of EMDR therapy, Sam’s interpersonal relations and his social and occupational functioning had improved significantly.
These promising results suggest that future EMDR therapy protocol for OCD should be based on the “three-pronged” (past, present, and future) approach (Shapiro, 2001) and include processing of past memories, present triggers, and future situations. In the case of OCD aggressive imagery, therapists could use the future template to help the patient visualize successful management of an anticipated future event, such as sitting in a family dinner with knives on the table or standing on the pavement next to another pedestrian and not pushing him toward the traffic.
Böhm and Voderholzer (2010) also reported on the efficacy of EMDR in the treatment of a patient who had suffered from aggressive and sexual obsessions since the age of 14 years. However, those authors did not elaborate on the patient’s aggressive thoughts or aggressive images or the thought that was the focus of treatment. Therefore, after a literature review that failed to yield comparable reports, this case appears to be the first description of EMDR treatment of OCD imagery in general and of OCD imagery focused specifically on aggression.
Contribution of Psychodynamic Psychotherapy
Psychodynamic psychotherapy was used when Sam feared to continue with EMDR treatment in the session that focused on the most disturbing image and in sessions that focused on his relationship with his girlfriend. Although it is difficult to measure the unique contribution of psychodynamic psychotherapy in this case, the sessions which focused on Sam’s relations with his father, and especially the covert talking about the aggression and the anger toward him, contributed to creating a more open dialogue and improved the father–son relations. In addition, the application of psychodynamic treatment led to the continuation of the EMDR work on the most disturbing memory.
Contribution of CBT Treatment
CBT was used for three main reasons. First, psychoeducation was provided to normalize Sam’s aggressive thoughts. Second, cognitive interventions were used to challenge Sam’s cognitions about his dangerousness or about any other possible hazards in any imagined or real encounter with sharp objects. Third, ERP was used to help the patient stay in contact with situations which trigger obsessive and aggressive thoughts. This intervention helped to change his maladaptive beliefs and from week to week, Sam’s avoidance was reduced and his sense of self-efficacy was enhanced. The accumulative successes of ERP treatment led to his independent attempt to perform flooding and to confront his fear.
Recommendations
This article provides additional support for the body of knowledge on the relationship between traumatic events, imagery, and the development and the course of OCD (de Silva & Marks, 1999, 2001; Janet [as reviewed in Pitman, 1987]; Lipinski & Pope, 1994; Pitman, 1993; Speckens et al., 2007). Speckens et al. (2007) had already suggested that the cognitive-behavioral treatments that are used in PTSD treatment, such as imaginal reliving and restructuring of meanings, or imagery modification of childhood memories, might prove efficient in treating OCD imagery. The efficacy of EMDR in the treatment of OCD imagery lends support for the AIP model and for the premise that the images which those patients experience are related to traumatic and unprocessed memories. Therefore, it is suggested that randomized controlled trials of EMDR be conducted among patients who suffer from OCD imagery. Such trials should use appropriate assessment tools for measuring invasive images.
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Acknowledgment
The author would like to thank his Thursday evening supervision group for the opportunity to learn from their experience.
Figures
Tables
Session Number | Treatment | Focus of Treatment | SUD Score for Images | |
---|---|---|---|---|
Start of First Session | End of Last Session | |||
1–3 | EMDR | History taking, preparation | 10 | 10 |
4 | EMDR | Reprocessing of childhood fight | 5 | 1 |
5–6 | EMDR | Reprocessing of current trigger | 8 | 0 |
7–8 | EMDR | Reprocessing of current trigger | 8 | 1 |
9–10 | EMDR | Reprocessing of current dream | 1 | 1 |
11 | EMDR | Reprocessing of memory of TV scene | 6 | 9 (stopped) |
12–14 | Psychodynamic | Work on relationship with father | ||
15 | EMDR | Reprocessing of memory of TV scene | 3 | 1 |
16–17 | Psychodynamic | Relationship with new girlfriend | ||
18 | ERP | Exposure to knives | 1 | 8 (stopped) |
19 | EMDR | Reprocessing of childhood memory of knife injury | 8 | 1 |
20 | ERP | Exposure to knives | 3 | 0 |
21–22 | ERP+CT | Exposure to knives | 8 | 2 |
23 | ERP+CT | Exposure to scissors | 8 | 1 |
24 | ERP+CT | Exposure to scissors | 6 | 1 |
25 | EMDR | Reevaluation and Conclusion |
Note. SUD = subjective units of disturbance; EMDR = eye movement desensitization and reprocessing; ERP = exposure and response prevention; CT = cognitive therapy.
Period | Abstract | Full | Total | |
---|---|---|---|---|
Jan 2025 | 7 | 11 | 0 | 18 |
Dec 2024 | 8 | 4 | 0 | 12 |
Nov 2024 | 9 | 3 | 0 | 12 |
Oct 2024 | 13 | 4 | 1 | 18 |
Sep 2024 | 16 | 3 | 1 | 20 |
Aug 2024 | 81 | 6 | 2 | 89 |
Jul 2024 | 13 | 4 | 1 | 18 |
Jun 2024 | 13 | 11 | 0 | 24 |
May 2024 | 49 | 5 | 0 | 54 |
Apr 2024 | 15 | 26 | 6 | 47 |
Mar 2024 | 10 | 4 | 0 | 14 |
Feb 2024 | 7 | 15 | 3 | 25 |
Jan 2024 | 17 | 12 | 3 | 32 |
Dec 2023 | 27 | 10 | 4 | 41 |
Nov 2023 | 20 | 9 | 3 | 32 |
Oct 2023 | 14 | 9 | 2 | 25 |
Sep 2023 | 17 | 8 | 7 | 32 |
Aug 2023 | 54 | 3 | 1 | 58 |
Jul 2023 | 63 | 7 | 1 | 71 |
Jun 2023 | 26 | 9 | 3 | 38 |
May 2023 | 17 | 3 | 1 | 21 |
Apr 2023 | 39 | 11 | 4 | 54 |
Mar 2023 | 26 | 19 | 6 | 51 |
Feb 2023 | 14 | 26 | 10 | 50 |
Jan 2023 | 23 | 37 | 17 | 77 |
Dec 2022 | 12 | 17 | 2 | 31 |
Nov 2022 | 12 | 39 | 3 | 54 |
Oct 2022 | 14 | 24 | 5 | 43 |
Sep 2022 | 13 | 15 | 2 | 30 |
Aug 2022 | 9 | 9 | 2 | 20 |
Jul 2022 | 19 | 9 | 4 | 32 |
Jun 2022 | 22 | 12 | 7 | 41 |
May 2022 | 22 | 4 | 2 | 28 |
Apr 2022 | 19 | 14 | 7 | 40 |
Mar 2022 | 28 | 10 | 4 | 42 |
Feb 2022 | 15 | 10 | 9 | 34 |
Jan 2022 | 20 | 26 | 8 | 54 |
Dec 2021 | 11 | 15 | 8 | 34 |
Nov 2021 | 21 | 10 | 2 | 33 |
Oct 2021 | 16 | 10 | 3 | 29 |
Sep 2021 | 10 | 10 | 5 | 25 |
Aug 2021 | 12 | 5 | 2 | 19 |
Jul 2021 | 6 | 10 | 4 | 20 |
Jun 2021 | 8 | 29 | 2 | 39 |
May 2021 | 13 | 17 | 6 | 36 |
Apr 2021 | 17 | 20 | 6 | 43 |
Mar 2021 | 34 | 27 | 5 | 66 |
Feb 2021 | 21 | 29 | 4 | 54 |
Jan 2021 | 25 | 21 | 4 | 50 |
Dec 2020 | 25 | 23 | 4 | 52 |
Nov 2020 | 35 | 15 | 5 | 55 |
Oct 2020 | 23 | 15 | 1 | 39 |
Sep 2020 | 16 | 5 | 2 | 23 |
Aug 2020 | 16 | 7 | 2 | 25 |
Jul 2020 | 6 | 5 | 1 | 12 |
Jun 2020 | 20 | 15 | 5 | 40 |
May 2020 | 21 | 22 | 4 | 47 |
Apr 2020 | 21 | 23 | 4 | 48 |
Mar 2020 | 22 | 18 | 3 | 43 |
Feb 2020 | 23 | 17 | 1 | 41 |
Jan 2020 | 15 | 5 | 5 | 25 |
Dec 2019 | 16 | 13 | 7 | 36 |
Nov 2019 | 7 | 11 | 5 | 23 |
Oct 2019 | 15 | 10 | 2 | 27 |
Sep 2019 | 16 | 11 | 4 | 31 |
Aug 2019 | 3 | 12 | 8 | 23 |
Jul 2019 | 1 | 10 | 4 | 15 |
Jun 2019 | 28 | 12 | 1 | 41 |
May 2019 | 8 | 8 | 7 | 23 |
Apr 2019 | 4 | 8 | 5 | 17 |
Mar 2019 | 3 | 7 | 3 | 13 |
Feb 2019 | 4 | 9 | 6 | 19 |
Jan 2019 | 11 | 23 | 0 | 34 |
Dec 2018 | 7 | 2 | 1 | 10 |
Nov 2018 | 7 | 0 | 0 | 7 |
Oct 2018 | 46 | 1 | 2 | 49 |
Sep 2018 | 21 | 0 | 0 | 21 |
Aug 2018 | 9 | 0 | 2 | 11 |
Jul 2018 | 6 | 1 | 1 | 8 |