VIVEK OCD CASE presentation by BRD MEDICAL COLLEGE ON OCD PATIENT

OCD CASE PRESENTATION

1. CASE CONFERENCE PRESENTER - DR. VIVEK SHARMA (JR2) CHAIRPERSON - DR. TAPAS KUMAR AICH (PROFF.& HOD) DEPARTMENT OF PSYCHIATRY BRD MEDICAL COLLEGE GORAK HPUR Reporter ：***

2. Identification Data Enter your title here 01 Enter your title here 02 Enter your title here 03 Sociodemographic Details NAME MR.VP AGE 27 years GENDER Male MARITAL STATUS Unmarried Religion Hindu EDUCATION B.Tech graduate OCCUPATION student TYPE OF FAMILY Nuclear Family SOCIO-ECONOMIC STATUS Uper socio-economic status Address Gorakhpur, UP

3. Informants: Patient himself Father RELIABLE AND ADEQUATE

4. CHIEF COMPLAINTS 8years C/O Repetitive thoughts about good and bad mathematical numbers Stucks in number calculation

5. ILLNESS DETAILS Total duration of illness 8 years Onset Insidious Course continuous Progression Deteriorating Severity Increased since 4 years

6. HOPI Patients persistent and pervasive mood during course of illness - Anxious Du ring episodes Impact of illness on patients attitude – decreased mixing with people, not able to study properly . During illness Biological functions - adequate sleep, appetite regular , bowel and bladder function intact . Activity of daily living & personal care - able to do his daily activities but not with ease & maintained personal hygiene.

7. NEGATIVE HISTORY . No h/o repetitive thoughts of fear something might terrible happens. No h/o repetitive thoughts of contamination. No h/o repetitive cleaning and washing compulsion. No h/o repetitive checking of locks, stove, appliances. No h/o of repetitive thoughts of harming self and others No h/o re-reading or rewriting (repetitive rituals). No h/o repetitive pulling of hair, concern about appearance, excoriation of skin, collecting things. No h/o repetitive forbidden or pervasive sexual thoughts ,images or impulses. No h/o fearfulness about height, darkness, closed spaces, crowds. No h/o ideas of worthlessness, hopelessness, helplessness. No h/o ideas of suicide or act of self harm. No h/o any significant head injury or loss of consciousness or seizure episode . No h/o any substance use.

8. Treatment History 1 st contact( oct 2022)- private psychiatrist took treatment for 15days no records available. Improvement- 30-40% compliance -poor 2 nd contact ( jan 2023)- private psychiatrist took treatment for 20days no records available. Improvement- 40-50% compliance -poor 3 rd contact (may2023) – admitted in BRD Medical college . Tab fluoxitene 40mg 1-x-x Tab fluvoxamine 50mg 1-x-1 Tab risperidone+ THP(2+2) 1HS Tab pantoprazole 1BBF

9. Past history No Past history of any psychiatric illness .

10. ILLNESS GRAPH 2016 Severity of illness increased 2020 2022 Took treatment For 15 days 2023 jan Took treatment for 20 days Admitted in brd medical college may23

11. FAMILY HISTORY 60yrs 56yrs 52yrs 48yrs 50yrs 46yrs 42yrs 27yrs 22yrs t

12. FAMILY HISTORY Patient lives in a nuclear family with father, mother and brother . Head of family is father. Father and mother both work in post office as clerk. Non consanguineous marriage between parents. Patient belong to upper socioeconomic status. No family history of any psychiatric illness reported .

13. PERSONAL HISTORY Birth history :  normal vaginal full term delivery at home , immediate cry without any complication. All developmental milestone achieved at appropriate age. Presence of childhood disorders : no any childhood disorders elicited . Home atmosphere in childhood - no any stress full situation in childhood period elicited Scholastic and extracurricular activities -Age of entry – 5 years ; completed B.tech graduate (2020), average scholastic performance, No any disciplinary and relational problems with peers and authority Occupation - student

14. PERSONAL HISTORY Menstrual History : not applicable Sexual and Marital History : unmarried and sexually inactive Forensic History : No any trouble with police case .

15. Premorbid personality RELATIONS – prefers company , make friend easily, relationships are long lasting, can handles mistakes easily, can tolerate others criticisms. MOOD – mood is stable and cheerful. express the feeling of love, anger, frustration . CHARACTER- reserved and self conscious. Attitude- religious, follow moral standards. HABITS - No substance use. IMPRESSION - well adjusted premorbid personality

16. GENERAL PHYSICAL EXAMINATION PHYSICAL EXAMINATION  - Vitals:  Pulse Rate: 78 beats /min BP: 1 10 /7 mm Hg, RR: 16 breaths /min. Height: 1 68 cm. Weight: 72kg General condition: Alert and Conscious. pallor, icterus, clubbing, cyanosis, lymphadenopathy, oedema was absent .

17. Systemic examination CVS -S1,S2 heard, no murmurs RS – chest bilateral clear GIT- Abdomen soft/ no organomegaly/ free fluid CNS- Gait - Normal Cranial nerves- Normal Motor system- Bulk-preserved; Tone, power- N in all limbs B/L plantar flexor. Sensory system- touch, pain, joint sense, proprioception - preserved in all dermatomes Cerebellar function tests- Normal Skull and spine-Normal

18. MENTAL STATUS EXAMINATION General Appearance : Patient was wearing t-shirt and paint, sat down on stool offered, Average height and built, Well kempt, Normal gait, looking approximate to his age, body hygiene maintained & well dressed and groomed. H aving touch with surroundings . Eye contact present and sustained. Attitude: co-operative, attentive, Manner of relating - tense . Rapport established. Motor Behaviour: normal psychomotor a ctivity. Speech: Audible with normal speed, tone & intensity, soft quality with Normal reaction time and normal productivity, relevant, coherent, goal directed .

19. COGNITIVE FUNCTION 1. Attention and concentration:   Attention aroused and sustained . 2. Orientation: Oriented to time, place and person.   3. Memory: Immediate: Intact Rece nt memory: intact Remote memory: intact

20. COGNITIVE FUNCTION   Abstract thinking: Proverb test: 9-2-11 Hona: Bhag Jana Similarity and dissimilarities test: Chidiya or aero plane me kya antar hai aur kya ek jaisa hai Chidiya living hai or plane non living hai Or dono ud sakte hai IMPRESSION: Abstract Ability conceptualized.

21. MENTAL STATUS EXAMINATION Mood: Qns. Aajkal apka Mann kaisa rhta hai? Ans. Man uljhann me rahta hai. Qns. Aisa kyun hota hai? Ans. man me vichar chlte rhte hai mai usme uljha hua and pareshaan rhta hu. Affect: Anxious , appropriate, communicable with normal range and reactivity. .

22. Thought Stream: Qns. Kya aap saaf saaf soch sakte ho ya apke soch bichar me kisi tarah ki rukawat ya badha ati hai? Ans- nhi koi rukawat nahi aati . Impression - spontaneous . Thought form- no any formal thought disorder elicited.

23. POSSESSION OF THOUGHT: Q- kya kisi tarah ka apko ek hi vichar bar bar dimag ma aata ha ? Ans - haa ata hai. Qns - kon sa vichar baar baar ata hai? Ans- good number bad number ke baare me hi aata rahta hai, 1,3,4,5,7,9,13,16,17 ye saare mere good number hai iske alaawa jo bhi hai wo mere liye sahi nahi hain , toh koi bhi kaam karne se pahle me numbers ko apne liye sahi karne ka vichar baar baar aata hai ,jaise ghr se nikal raha hu toh 1 ya 3 ya 5 logo ke saath nikalna hai ,time dekh kar nikalna hai ki wo mere good no. me aaraaha hai(8.05pm 8+5=13) , khaana khaate time 3 ya 5 roti khaana hai, paani peena hai toh 14 ya 16 ghoont peena hai (1+4=5,1+6=7), paise bhi gin kar kharch karta hu (40,45,50,100). Qns – aise vichar kitni baar ate hai? Ans – aise vichar din bhar ate hai , mai rokna chahta hu lekin rok nhi pata hu , isliye baar baar yahi numbers me uljha hua rahta hu.

24. Qns- kya ye vichar apke apne khud ke hai ya kisi or ke hai or ye vichar apko din me kitni baar aate hai ? Ans - haan ye vichar mere hai , ye vichar din bhar aate hai koi bhi kaam kar raha hota hu ye aate rahte hai jab tak so nahi jaata . Qns - In vicharo ke aane se apko kya pareshaani hai ? Kya aap inhe aane se rouk paate hai? Roukne ke liye kya kya karte hai? Ans – pareshani yahi hai ki me koi bhi kaam time se nahi kar paata , good bad numbers me hi fasaa hua rahta hu, ye vichar jo aate hai unhe rokna muskil ho jata hai , rokne ke liye me calculation karta rahta hu ,numbers ko apne hisaab se sahi kar leta hu tabhi koi kaam aage kar paata hu par ye calculation pure din chalti hai. Impression : obsessions of thought about lucky or unlucky numbers and mental compulsions of number calculation.

25. Qns- kya apko aisa lgta hai ki jabardasti apke mann me vichar dale jate hai? Ans- nhi aisa to nhi lgta hai. Qns- jo vichar apke mann me ate h kya aap unhe sunn sakte hai? Itni uchi awaj ki aas paas khade log bhi unhe sunn sakte hai? Ans- aisa nhi hota hai. Qns- kabhi aisa lgta hai ki jo bhi aap sochte hai wahi vichar awaaj ke roop me dohraaya jata hai ans - nhi Qns –kya aisa lgta hai ki apke dimag se vichar nikal liye gye hai jaise koi bahari takat ya koi admi apke vichar nikal leta hai Ans – nhi Qns – kya bina btaye koi apke mann ki baat jann jata hai? Ans - nhi IMPRESSION : no thought echo, thought withdrawal ,thought broadcasting.

26. Thought content: Q- aajkal apka man kaisa rahta hai? Kya aap in dino udaas rahte hai apko kuch bhi aacha nahi lagta hai? Ans- nahi aisa kuch nahi hai bas vicharo ki wajah se uljhan or chid chidapan rahta hai. Q-apko apna bhavisya kaisa lagta hai ? Aane waale samay ki taraf dekhe toh kaisa lagta hai? Ans- aage ka itna socha nahi hai up police ki padhaai kar raha hu bas ye pareshaani theek ho jaaye toh mai apni padai kar sakunga . Q- kabhi aisa bhi lagta hai jeevan beekar hai , isse accha toh mar jaate ya kabhi mann me marne ka vichar aaya ho ya kosish ki ho? Ans-nahi aisa Nhi nota hai. IMPRESSION – no ideas of worthlessness,hopelessness , and suicide .

27. Content: Qns- kya koi apko janbuchkar nuksan puchane ki koisis kar rha hai? Ans- nahi Qns - kya aisa lgta hai log apki or ishara karke baat karte hai, ya koi bat khas tarike se ki ja rhi h ? Ans - nahi Impression no delusion of persecution and reference.

28. PERCEPTUAL DISORDER Qns- kya aisa hota hai ki jab aap akele hote hai aaspass koi nhi hota hai tab kano me shor ya awaj sunai padthi hai jaise koi apka naam pukar rha hai? Ans- nhi Qns – kya is tarah se kuch chije ya sakle bhi dikkai deti hai? Jab aas pass kuch nhi hota hai. Ans – nhi. Qns – kya chizo ki swad ya mahak me koi ajjeb baat lgti hai? Ya koi farq lgta hai. Ans – nhi Impression – no perceptual disorder elicited.

29. MENTAL STATUS EXAMINATION Judgement : T est : intact Social : impaired Personal : impaired Insight assessment: Question- kya apko lagta hai ki apke vyavhar ya soch me koi badlav aya hai ? Ans : haan ye soch ka dikkat hai. Qns : kya ye soch me dikkat kisi bimari k lakshan ho sakte hai? Ans : haan lag toh raha hai. Qns –kya ye bimari mansik rog ki ho sakte hai? Ans- pahle nahi lagta tha par haan aab malum chala ki mansik hai Impression: Grade 4 insight.

30. DIAGNOSTIC FORMULATION Mr.VP 27yrs old unmarried male admitted with chief complain of repetitive thoughts about good and bad mathematical numbers and stucks in number calculation since 8 yrs with well adjusted premorbid personality with normal general physical examination with MSE showing cooperative ,manner of relating tense, rapport established with normal psychomotor a ctivity with audible speech with normal tone and intensity, soft quality with normal reaction time and normal speed and productivity, relevant, coherent, goal directed with anxious , appropriate, communicable affect having normal range and reactivity with spontaneous s tream with obsession of thought about lucky or unlucky numbers with mental compulsion of number calculation with intact test judgement with impaired social and personal judgement with grade 4 insight. .

31. DEFINITIVE DIAGNOSIS ICD 10 F42.2 Obsessive-compulsive disorder “ Mixed obsessional thoughts and acts” Points in favour - (a)Patient recognized as the individual's own thoughts . (b)Patient thought or act that is still resisted unsuccessfully. (c)the thought of carrying out the act must not in itself be pleasurable. (d)the thoughts, impulses must be unpleasantly repetitive.

32. PLAN OF MANAGEMENT Evaluate the patient with some Baseline investigations like complete haemogram , Random BS, LFT, RFT, Serum electrolytes , Thyroid function test, viral markers . Detailed general and systemic examination of the patient Scale administered- Rating scale 1 ST DAY OF ADMISSION 7 TH DAY Y-BOCS 36 28 HAM-D 10 5 HAM-A 14 8 BPRS 6 4

33. PROGNOSTIC FACTORS- overall bad prognosis GOOD BAD GOOD premorbid social and occupational adjustment MALE A precipitating event Early onset Need for hospitalization Suicide attempt absent Poor compliance Paranoid subtype Family history of mental illness absent Less expressed emotions

34. 2024 THANK YOU ！ FOR YOUR PATIENCE Date ： 17/05/24

35. ACUTE OR SHORT TERM -   The goals of treatment would be To assess the patient & to get a comprehensive history to make a diagnosis To reduce the severity of symptoms . Improvement of functioning . Pharmacological treatment- Cap.fluoxetine 40 mg 1OD Tab. fluvoxamine 50mg 1-x-1 Tab. Risperidone 2mg 1HS Tab .THP 2mg 1-x-x

36. Non Pharmacological Management - Behavioral Therapy ( exposure and response prevention). Repetitive transcranial magnetic stimulation (rTMS) Ensure compliance & regular follow up by psycho-education to family members.

37. Continuation phase Goals: Adherence to medication Recurrence prevention Reduction of mood instability Improvement of functioning Monitoring of side effects Maintenance treatment : I would like to continue the patient on min effective dose with regular follow up for compliance & side effects