Week 5 Assignment 1 Captain of the Ship
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Nurs 5555: PMHNP Role II
Dr. Jack Taa
January 10, 2017
Obsessive Compulsive Disorder (OCD) is represented by a diverse group of symptoms that include intrusive thoughts, rituals, preoccupations, and compulsions (Sadock, Sadock, & Ruiz, 2014). These recurring obsessions or compulsions cause severe distress to the person. An obsession is a recurrent and intrusive thought while a compulsion is a conscious, standardized, recurrent behavior. The purpose of this paper is to explore management strategies of OCD in adult clients. As the PMHNP, I will discuss a case and recommend treatment modalities, medical management, follow-up plan and collaboration in the care of a client with OCD.
History of present illness (HPI) and Clinical Impression
HPI: K. K. a 22 yo CF referred for a psychiatric evaluation by her PCP. Karen reports a complaint of “I need help, I can’t keep a job because of these rituals I have.” She reports that she cannot maintain a job because of her rituals of checking locks. Karen has recurrent thoughts that she had left the door of her apartment and car unlocked. She reports leaving work several times daily to check the locks on both her car and apartment. Additionally, because she often had the thought that she had not locked the door to the car, it was difficult for her to leave the car or apartment until she had repeatedly checked that it was secured causing her to be late for work. She has been fired several times for tardiness and poor attendance however checking the locks decreases her anxiety about security. Karen denies any medical issues and is not currently taking any medications. She also denies the use of any alcohol, tobacco or illicit drugs. Reports a family history of depression in both maternal and paternal grandmothers. Karen recognizes that she is needs help and is eager to begin treatment.
Assessment: A healthy, well-groomed 22yo CF in no acute distress. A, A&Ox4, pleasant and appropriately dressed. Makes good eye contact however mood is depressed with a flat affect; recent and remoter memory are intact. Karen’s thoughts are circumstantial and preoccupied with obsessions and compulsions. Her insight and judgment are fair. Denies SI/HI/AVH.
Clinical Impression: Based on the diagnostic criteria in APA (2013), a diagnosis of OCD is made.
If the patient’s symptoms cause a significant impairment in function or distress, treatment is recommended (Fenske and Petersen, 2015). Based on Karen’s report of losing several jobs because of tardiness and attendance, there is a significant impairment in social and home functionality. Karen also reports that her rituals cause her significant distress. The standard approach is to start treatment with an SSRI or clomipramine and then move to other pharmacological strategies if the SSRI is not effective (Sadock, Sadock, & Ruiz, 2014). I will initiate Prozac 40mg oral daily as it is Food and Drug Administration (FDA) approved for treatment of OCD (Stahl, 2014). I will have the patient return to clinic in week to assess for tolerability and increase to the suggested 80mg oral daily. Higher dosages have often been necessary for a beneficial effect (Stahl, 2014). I prefer to initiate with an SSRI (Prozac) as opposed to tricyclic (Clomipramine) for the less troubling adverse effects associated with Clomipramine. Karen will be informed that she might experience sleep disturbances, nausea, diarrhea, headache and anxiety which are all adverse effects of SSRIs. The desired outcome of pharmacotherapy is to reduce the patient’s intrusive thoughts that cause the compulsions that interfere with her home and work life. Well controlled studies have found that pharmacotherapy, behavior therapy, or combination of both is effective in significantly reducing the symptoms of patients with OCD (Fenske and Petersen, 2015).
Some studies indicate that behavior therapy is as effective as pharmacotherapies in OCD and some indicate that the beneficial effects are longer lasting with behavior therapy (Sadock, Sadock, & Ruiz, 2014). Many clinicians consider behavior therapy the treatment of choice for OCD and also because it can be conducted in both outpatient and inpatient settings. With the prinicpal behavioral approaches being exposure and response prevention, patients must be committed to improvement as Karen is. Behavior therapy will be initiated the same week as pharmacotherapy. The goal of therapy is to change the client’s behavior to reduce dysfunction and to improve her quality of life. A psychotherapist will be consulted to intiate and manage therapy sessions.
I will consult with Karen’s PCP for updates and additional concerns. Since she has been with her PCP for more than 5 years, he has good insight into her life. We will discuss baseline labs such as CBC, CMP, TSH, hepatic panel. Since with SSRIs, nausea, headache dry mouth and diarrhea are common side effects, monitoring the patient’s electrolytes is important. I would also recommend an EKG for baseline and follow up after medication initiation as SSRIs can lengthen the OT interval in otherwise health people (Sadock, Sadock, & Ruiz, 2014). Community resources such as the local chapter of the OCD Foundation will be provided to Karen for support services.
Follow -up Plan and Collaboration
Karen was instructed to follow up in 1 week to monitor tolerability and compliance of medicaiton and dose adjustment. Subsequently, she will return every 4 weeks for medication management. She is also instructed to begin behavior therapy the same week as medication are initiated and to follow up weekly for therapy sessions. I will consult with the therapist weekly for updates and any concerns or questions. I will reiterate and reinforce to both the PCP and therapist the importance of monitoring for suicidal ideations as the patient is taking an antidepressant and abuptly stopping will increase risk of suicide. About one-third of patients with OCD have major depressive disorder, and suicide is a risk for all patients with OCD (Sadock, Sadock, & Ruiz, 2014).
A poor prognosis is indicated by Karen yielding to rather than resisting compulsion or the need for hospitalization. A good prognosis for Karen is indicated by good home, social and occupational adjustment. The importance of an interdisciplinary team including PCP, therapist and other ancillaries will benefit the client for a better quality of life.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Fenske, N. & Petersen, K. (2015). Obsessive-Compulsive Disorder: Diagnosis and Management. American Family Physician, 92(10): 896-903. Retrieved from http://www.aafp.org.afp
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer
Stahl, S.M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.