OBSESSIVE COMPULSIVE DISORDER.

OBSESSIVE COMPULSIVE DISORDER.
SOAP ANALYSIS

1. Case presentation on
Obsessive–compulsive
disorder(OCD)

2. DEFINITION:-
•Excessive thoughts (obsessions) that lead to repetitive behaviors (compulsions).
•Obsessive-compulsive disorder is characterized by unreasonable thoughts and fears
(obsessions) that lead to compulsive behaviors.
TYPES OF OCD:-

5. SOAP ANALYSIS
PATIENT DETAIL:
AGE:-42 yrs. old
SEX:-female

6. SUBJECTIVE EVIDENCE
CHIEF COMPLAINT:-
•she was getting a vaginal yeast infection and She was convinced that here had been faecal
contamination of her vagina after a recent bowel movement.
•She also felt that she talked too much and made relationships difficult to maintain by driving
people away with her nonstop chatter.
•The patient stated that she had washed and checked the vulvar area several times but was
still convinced that faeces had entered her vagina.
•She has complaints of depression and anxiety too.

7. PAST PSYCHIATRIC HISTORY:-
•Her initial complaints were depression and anxiety
•Her depression was initially thought due to amphetamine withdrawal, since she had been
using diet pills for 10 years .She stated that at first she took them to lose weight , but
continued for so long because people at work had noted that she concentrated better and
her job performance had improved.
•Her past doctors had all commented on her limited ability to change and her neediness,
insecurity, low self-esteem, and poor boundaries.
•In addition, her past doctors had noted her promiscuity.

8. PAST PSYCHITRIC EVALUATION:
•Neurological testing during her initial evaluation had shown the possibility of non-dominant
parietal lobe deficits.
•Previous Testing showed." problems in attention, problem in recent visual and verbal memory,
abstract thought , cognitive flexibility, and visual analysis.
•A possibility of right temporal dysfunction is suggested.
" IQ testing showed a combined score of 77, which indicated borderline mental retardation.
PAST PSYCHITRIC MEDICATION HISTORY:-
•Phenelzine for depression and anxiety.
•History of chronic dieting, and although extremely thin, she continued to be obsessed with not
gaining a single pound. This was a patient who took diet pills for 10 years.

9. PSYCHOSOCIAL HISTORY:-
•Her father was morose and he has said, " I don't like my children." One of the patient 's
earliest memories of was being told by him that her " butt was too big." Her father was
physically and verbally abusive throughout her childhood ..
•K. described her mother as the family the glue that held the family together. She stated that
she was very close to her mother.
•She had a best friend through grade school whom she stated "deserted" her in high school.
•She remained a virgin until her marriage at 19 years old which lasted less than one year. Her
husband left her while she was pregnant with her son.
•The husband was abusive and had not a role in their lives since the divorce. After the
divorce, K. moved back to her parents' home with her son. She currently works as a file
clerk.

10. FAMILY HISTORY:-
•K.' s mother had two serious suicide attempts at age 72 and was diagnosed with major
depressive disorder with psychotic features and OCD. She also had non-insulin dependent
diabetes mellitus and irritable bowel syndrome.
•K.'s brother was treated for OCD.
MEDICAL HISTORY:-
She suffered from gastroesophageal reflux and was maintained symptom free on a combination
of ranitidine and Omeprazole.
SOCIAL HISTORY:-no history of abuse of alcohol or street drugs.

11. OBJECTIVE EVIDENCE
MENTAL STATUS EXAM
•She had difficulty sitting still and fidgeted constantly in her chair
•Her speech was rapid, mildly pressured, and she rarely finished a sentence.
•She described her mood as "anxious."
•Her thought processes showed mild circumstantiality and tangentiality.
•Her inability to finish a thought as exhibited by her incomplete sentences.
•Her thought content was focused upon sexual themes, worry over vaginal cleanliness.

12. •When K. was questioned about her phone messages she stated, " I always repeat calls to
make sure my message is received. "
•The patient checked all locks and windows repeatedly before retiring. She checked the iron a
dozen times before leaving the house. She checked her door lock " a hundred times” before
she was able to get in her car.
•The patient washed her hands frequently. She carried disposable wash cloths in her purse" so
she can wash as often as she need to." She said people at work laugh at her for washing so
much.
•This was what she always referred to as " talking too much ." In sessions it was observed that
K.'s anxiety, neediness and poor boundaries over issues of misplacing things in her purse and
insurance forms that were incorrectly filled out.

13. -Finding of soft neurological deficits.
•The patient‘s neuropsychological testing suggested problems with visuospatial functioning
and visual memory, attentional difficulties and low IQ.
•Right hemispheric dysfunction, specifically difficulties in visuospatial tasks, associated with
OCD
•The patient's history of an attention deficit that was confirmed by neuropsychological tests.
•Eating disorders are viewed by some clinicians as a form of OCD.
•she was started on a trial of methylphenidate.
•Although she showed a good response by slowing down enough to finish sentences and
focus on conversations, she could not tolerate the side effects and refused to continue
taking the medication.
•The patient missed many sessions of CBT because of bad weather.
•Her dose of fluoxetine was increased to 40 mg a day but discontinued because of severe
restlessness and insomnia.

14. ASSESMENT
DIAGNOSIS:-
•Case with multiple diagnosis: borderline mental retardation, attention deficit disorder,
borderline personality disorder, a history of major depressive disorder and obsessive
compulsive disorder(OCD).
-ETIOLOGY:-
•Genetic.
•Environment.

15. Standard
Algorithm..

16. ASSESMENT OF CURRENT THERAPY:
a)Tab.fluoxetine 20 mg OD
Category: selective serotonin reuptake inhibition(SSRIs)
Indication: to treat depression, obsessive-compulsive disorder.
MOA: Fluoxetine exerts its effects by blocking the reuptake of serotonin into presynaptic
serotonin neurons by blocking the reuptake transporter protein located in the presynaptic
terminal.
ADR: nervousness, anxiety, difficulty falling asleep or staying asleep, nausea, diarrhea, dry
mouth, heartburn, yawning.
DI: buspirone, fentanyl, Duragesic, lithium, Lithobid, tryptophan, amphetamines, or some pain or
migraine medicines (eg, rizatriptan, sumatriptan, tramadol).
Contraindication: diabetes, low amount of sodium in blood, manic behavior, suicidal thoughts,
manic depression.

17. Results: Data, based on a group of 9087 patients, who were included in 87 different randomized
clinical trials, confirms that fluoxetine is safe and effective in the treatment of depression from
the
first week of therapy. Fluoxetine's main advantage over previously available antidepressants
(TCAs)
was its favourable safety profile, that reduced the incidence of early drop-outs and improved
patient's compliance, associated with a comparable efficacy on depressive symptoms. In these
patients, Fluoxetine has proven to be more effective than placebo from the first week of therapy.
Fluoxetine has shown to be safe and effective in the elderly population, as well as during
pregnancy.
Fluoxetine has demonstrated to be as effective as chlomipraminein the treatment of Obsessive-
Compulsive-Disorder (OCD).
Conclusion: Fluoxetine can be considered a drug successfully used in several diseases for its
favourable safety/efficacy ratio.
Reference: http://www.general-hospital-psychiatry.com/content/3/1/2
Justification:

18. b) Tab.Clomipramine 25mg OD :
Category: serotonin reuptake inhibitor (SRIs)
Indication: To treat people with obsessive-compulsive disorder.
Dose range: 25 mg orally once/day initially. Gradually increase to 100 mg/day (divided with
meals) over 2 weeks, THEN. May increase further to 250 mg/day maximum; may give a single
daily dose at bedtime once tolerated.
MOA: reducing the re-uptake of norepinephrine and serotonin in the central nervous system,
thereby enhancing the effects of these neurotransmitters.
ADR: drowsiness, dry mouth, nausea, vomiting, diarrhea, constipation, nervousness, decreased
sexual ability.
DI: Monoamine oxidase inhibitors such as selegiline, and drugs such as linezolid, methylene blue,
fentanyl, tramadol, lithium, buspirone, and St.
contraindication: neuroblastoma, pheochromocytoma, overactive thyroid gland, manic-
depression, suicidal thoughts, alcoholism, serotonin syndrome, closed angle glaucoma.
*She felt "more relaxed " and had less anxiety.

19. ResultsSix (21%) of 29 patients randomized to receive intravenous (IV) clomipramine vs 0 of 25 patients given
IV placebo were responders after 14 infusions (df=1,P<.02). Dimensional ratings after infusion 14 revealed
significant (P=.007) improvement on the National Institute of Mental Health–Obsessive-Compulsive Scale and
the Clinical Global Impressions Scale (P=.03), but not the Yale-Brown Obsessive Compulsive Scale. One week
later, all dimensional measures of OCD showed significant improvement. At 1 week post-IV, 9 (43%) of 21
patients initially randomized to IV clomipramine and treated subsequently with oral clomipramine were
responders, whereas 0 of 18 patients initially randomized to receive IV placebo and treated subsequently with
several days of open-label IV clomipramine responded (df=1,P<.002). Of the 31 patients assessed 1 month
after IV infusion (treatment not controlled), 18 (58.1%) were responders. Intravenous clomipramine treatment
was safe with no serious adverse consequences.
ConclusionsIntravenous clomipramine is more effective than IV placebo for patients with OCD with a history
of inadequate response or intolerance to oral clomipramine.
Reference: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/204286.
Justification:

20. PLANNING:-
General goal:
Patient specific goals of treatment:
•To improve her checking rituals.
•To limit her handwashing ritual.
•To decrease the anxiety and depression.
•Marked clinical improvement, recovery, and full remission
•Decrease symptom frequency and severity, improve the patient's functioning, and help
the patient improve QOL
•Enhance the patient's ability to cooperate with care
•Anticipate stressors likely to exacerbate OCD and help the patient develop coping
strategies
•Educate the patient and family about OCD and its treatment.

21. Point to physician:
•N/A
Point to patient:
•Do not miss the CBT sessions.
•Self monitoring of rituals.
•Exposure hierarchy development.
•Practice confronting obsessional thoughts.

22. •Tab.fluoxetine 20 mg OD, Tab.Clomipramine 25mg OD for 12 months.
•At the end of the 12-month period if recovery is maintained the person can be
discharged to primary care
•If relapse -see as soon as possible
Discharge medication

23. Reference:
•https://jdc.jefferson.edu/jeffjpsychiatry/vol12/iss2/5
•https://www.drugs.com/fluoxetine.html
•https://www.webmd.com/drugs/2/drug-1305/clomipramine-oral/details

24. Thank you