medical cases- obsessive compulsive disorder

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Refer your cases in to mount carmel hospital in Valletta, Malta.( The whole case study should be in Malta)
Find a related topic about obsessive compulsive disorder
I’II upload my friend assignment which was perfectly done by him last year.
You can see my friend assignment and please please make my case study, obsessive compulsive disorder, in the same approach and pattern he did, but not the same person in his assignment, starting from:

Introduction and demographic data
History of Presenting Complaint
Past Psychiatric History
Past Medical History
Drug history
Family Psychiatric and Medical History
Social Situation
Personal History
Early life and development
Education history
Occupational history
Relationship history
Collateral history
Mental State Examination
Differential diagnoses
And so on… (please don’t miss anything)

Case 3: obsessive compulsive disorder

Domiciliary visit: yes

Discussion of Emotional Impact or Burden: yes

Introduction and demographic data:
Mrs. MG is a 50 year female, unemployed, from msida, who was visited in her home on the 22/10/2013; she is single and lives alone. She was diagnosed previously with obsessive compulsive disorder for which she was admitted to Mount Carmel for, and is now being followed up regularly.
History of Presenting Complaint
The patient explained that the first time she remembers having problems was when she was about thirty three years of age, when she began having thoughts that she wasn’t clean enough during washing, at this time she remembered that it was around the same time her mother was at hospital after suffering a stroke, for which she felt sad about and it kept her up nights thinking. Overtime these thoughts began to develop into compulsions, such as washing herself several times a day as well brushing her teeth, and cleaning the floor. She states that now, she cleans the floor about 100 times a week, as well as rearranging her apartment multiple times. She admits that these acts to not make any sense to her and they in fact waste a lot of her time, however if they are not performed she feels very bad after it. After she performs these actions she starts feeling guilty for doing them and ponders a lot about what she did, but she says she has no power over herself when these thought come to her mind. She tries to avoid these actions by reading her recipe books, but she attributes her medication to be the best way to block these thoughts. .She also explained that prior to the first she had these thoughts, she had also been recently hospitalized at Mount Carmel for problems regarding her behavior, as she would quarrel with her mother and become violent and agitated and proceeded to bang chairs and door, as well swear a lot, which led to her mother taking her to hospital. She also explained that she had always been a nuisance to her family; she had behavior problems as a child, which continued into her adulthood. She doesn’t know why she had these episodes and did not have control over herself. Her actions have led her to become alienated from everyone around her especially her mother for whom she is very close, and this causes her to feel very depressed and cry a lot. She also says that ideas of illness and death cross her mind daily, and she often wastes time thinking about them and becomes less productive and does not accomplish anything. She admits to having a fear of death and regularly gets panic attacks and experiences symptoms of shortness of breath, sweating and trembling; depending on how much she thinks.
During the time of the visit, the patient was experiencing depressive symptoms that included: anhedonia, as she feels that she is not enjoying doing her hobbies lately, as well as early waking, and guilt feeling, mostly due to her constant quarreling with her mother. However she says that her OCD has been under control lately and has been feeling much better.
Past Psychiatric History
–    At age seven, she was taken to a psychiatrist after a suIDen behavioral change and began throwing tantrums, and becoming physically abusive to her family. She received Ativan and became much better.
–    Had an EEG performed at age thirteen, but doesn’t recall for what reason, and states that the results were good because she nothing followed after that.
–    Was forcefully admitted to mount camel hospital for four weeks when she was twenty one years old, after an episode of agitation. She received psychological therapy and was better.
–    During her late twenties she frequented villa Chelsea, after her mother couldn’t bear living with her.
–    In 2009, she was admitted to Mount Carmel hospital voluntarily, after she had an episode of agitation at work.
Past Medical History
–    Eczema as a baby.
–    Rheumatic fever at age seven.
–    Suffered an episode of acne in her thirties, which became infected and had to be hospitalized, she said that she almost died from this experience.
–    Hypercholesterolemia.
–    She has no known drug allergies.
Drug history
Flueoxetine 20mg 3 – 0 – 0
Rivotril (Clonazepam) 2mg   ½ – 0 – ½
Nodiril (risperidone) 2mg    2 – 1 – 2
Family Psychiatric and Medical History
When Mrs. MG was 43 her father died at the age of seventy seven. Her mother is alive and aged seventy eight; she suffers from hip problems, and has been suffering from anxiety since 2011 and is receiving treatment. She also has three siblings who are well and are very supportive of her. Her mother and older sister live across the street from her. There are no other known psychiatric illnesses in the family.

Social Situation
Mrs. MG lives in apartment by herself, for which she owns. The apartment consists of two bedrooms and one bathroom, and a spacious living area. It is very well kept and organized, especially her collections of calendars that she has collected from the year 1991 till 2013. The patient does not have any pets. She does not currently have any financial problem, as she is helped with budgeting by a social worker who visits her regularly. She used to live with her mother up until ten years ago, but had to move out because of constant fighting. She still remains close with her mother, who frequently visits her along with the Mr. MG’s sister. She says that her mother and sister offer her emotional support, even though they often fight. There is no history of gambling.
Personal History
Early life and development:
The patient was born through normal vaginal delivery with no complications pre- or perinatal. She did however suffer from eczema as an infant which caused great distress to her family. When she was seven years old she suffered from rheumatic fever that she remembers very well, the experience affected her a lot. During her childhood, the family lived in a house of two stories; they did not have any financial difficulties as her father was an accountant, while her mother was a housewife. Her parents were happily married and there were no problems at home. She did not suffer from any childhood abuse.
Education history
Mrs. MG had a troubled educational history, as she would never listen to what she was told. She attended a private school, and was expelled once due to behavioral issues with teachers, and she would always create panic when she was at school. She did not complete her GCE’s and quite school at the age of sixteen. Therefore she never learned to write In Maltese, however she did learn to write in English. She never suffered from any bullying, and had few friends at school.
Occupational history:
After leaving school, Mrs. MG stayed at home for a few years until the year 1987, where she began working at hotel in the filing department. She still works in that position till this day, and her condition has never affected her work performance, except on one occasion where she had an episode of agitation for which she was sent to Mount Carmel hospital.
Relationship history:
Mrs. MG has never been in a romantic relationship. She says that she does not keep close friends, as she tends alienate those around her, and her closest friend is her mother.  She stated that she always had problems with her mother growing up, as her mother could not tolerate her behavior at many times, and this has led to her mother developing anxiety issues later on. The patient feels guilty for causing her mother such stress.  Nevertheless, she states that her mother loves her and is still very close with her despite everything. Mr. MG was never close with her father, and she feels guilty for not having a good relationship with him and admits that sometime she cries about this subject. The patient says that she is very close with her three siblings; however it was not always the cause. Growing up, her siblings were very offended by her behavior, and were not very close with her. She states that ever since she was admitted to Mount Carmel hospital, their attitude changed drastically and they began to offer her a lot more support, although occasionally they still have arguments.
Substance abuse
She does not drink alcohol or smoke cigarettes, and has never used any illicit drugs.
Forensic history
The patient has never been convicted for crimes or offences.
Hobbies and ADLS’s
She keeps herself busy throughout the day by doing house work. She enjoys reading books, listening to music, and walking.
Premorbid Personality
Mrs. MG says that she has always been the same, and has always been called by others as stubborn. When asked about her life prior to her OCD, she says that she was much happier and had a better relationship with her mother and siblings, but since then it has been very tremulous.
Collateral history:
The collateral history was collected from the patient’s mother and older sister, after asking the patient politely to leave the room. They discussed how Mrs. MG’s condition has caused great distress to the family. Her mother described when her daughter was growing up, how tiring it was caring for her. As she would tend to fight with everyone, especially in public places. This caused her mother suffer from a lot of anxiety issues, because she would be afraid that her daughter would cause another problem.  Her mother also discussed the issue of them living together and how in recent years it was becoming unbearable, especially after her husband died. Therefore she asked her daughter to move out, but to live close by in order to still be in touch with her, and she still stays with her on weekends. Her sister explained how she sympathizes with her sister’s condition, and she is more tolerant than her mother, especially when her sister was hospitalized and she knew that her sister was suffering from a psychiatric condition. Despite all that, she recalled an incident that caused great distress to the family and caused her to be less sympathetic. It was her sister’s weIDing, and Mrs. MG was going to be her bridesmaid. However, the patient misbehaved in such a manner that caused her to be kicked out of the weIDing. Despite of everything, they say that their relationship with her is improving and her condition is getting better, as she rarely has any more incidents like those which occurred in the past.
Mental State Examination
Appearance: Mrs. MG is of petite build, and seems younger than stated age. She has a wound on the dorsal side of her hand as result of excessive brushing when washing herself. She is appropriately dressed, with no psychomotor agitation or retardation noted. The patient managed to maintain eye contact throughout the interview, and it was easy to establish rapport with her.
Speech: the patient speech remained mostly normal in rate, tone and volume. However, when the subject of her mother was brought up, she would get excited and her tone would get high.
Thought form:  the patient experienced some flight ideas at times.
Mood: when asked about mood the patient she was feeling fine, however objectively she was euthymic.
Affect: reactive.
Thought process:  ruminations were noted in the patient’s though content, as she had preoccupations about illness and death, which she brought up frequently during the interview.
When asked suicidal ideations, she denied having any suicidal thoughts, plans, or intent.
Perception: normal as there were no signs to suggest that the patient was suffering from any delusions or hallucinations.
Cognition: the patient was alert during the interview. She was oriented in time, place, and person. There was no impairment in concentration or memory; therefore no further formal testing for cognition was conducted.
Insight: The patient is aware of her condition and is taking her medication regularly in order to get better. She also hopes that with time, her relationship with her family can improve further.

Differential diagnoses:

Obsessive compulsive disorder: the most likely diagnoses as the patient has both obsession( not being clean enough ) and compulsions ( excessive hand washing and cleaning) which are time consuming, as they sometime last her all day. It is noted as well that the patient observes these obsessions as absurd (ego dystonic) and she tries to suppress them.
Anakastic type personality disorder: This diagnosis could be considered as well as it is noted that the patient does exhibit symptoms of rigid of thinking, excessive cleanliness and orderliness. However it is less likely to be the cause as she does not observe the obsessions as rational and desirable.
Antisocial type personality disorder: it less likely, however her symptoms of impulsivity, irritability, and incapacity to maintain relationships, it may be a possible diagnoses.
Depression: this diagnoses should be brought into consideration, as the patient exhibits many symptoms of depression especially anhedonia, early waking, as well as guilt feelings.
Panic disorder: the patient complained of recurrent attacks of panic where sweats, and has difficulty breathing, however this most likely to be coexistent with her OCD.

Management:

The first aspect of management involves risk assessment for the patient’s self and others around her. Since her past history does include episodes of agitation towards members of her family, she could be of risk of harming others. It is therefore crucial to keep evaluating this aspect as a change in the patient’s circumstances can lead to a change in the mental state. Most importantly, it should be noted if there is any discontinuation of her prescribed medication, any recent stressful life events, or use of recreational drugs. (At a glance, 2012) In this case, there seems to be no risk of harm to others as she does not exhibit any of the previous conditions. Also, her mental state exam does not suggest that she is suffering from any delusions or has any violent intentions.
Since the patient’s symptoms most likely suggest Obsessive compulsive disorder. The patient can be managed by tackling the following aspects using the biopsychosocial approach:
Biological treatment: treating with a selective serotonin reuptake inhibitor (SSRI) such venlafaxine or a serotonin-noradrenergic reuptake inhibitor (SNRI) like fluoxetine however it is noted that these are most optimal in the absence of depressant symptoms. It also may take up to 12 weeks to observe any effect; therefore the patient should be advised to remain compliant throughout that period. It should be noted that when discounting antidepressants they should be tapered down slowly in order to avoid withdrawal symptoms. (NICE, 2005)

Psychological treatment: cognitive behavior therapy is the first line treatment for obsessive compulsive disorder, and can be performed as group or individual therapy. Therapy can also involve exposure-response prevention, where they are exposed to a situation that involves their compulsive behavior, and they are urged to resist it. (NICE, 2005)

Social: in Mrs. GM case, it is crucial for her to have a regular follow up with a social worker, to help her financial issues such as budgeting, as well as resolve family issues.

Discussion of management:
Biological:
It is customary to treat OCD patients with a 5-HT reuptake inhibitors, most commonly a SSRI’s (fluoxetine, sertraline) or clomipramine. Even though these drugs are sometimes used in isolation, it almost impossible to achieve a complete remission with seratogenic treatment alone.( Greist, 1995) Extensive research has been conducted into the use of glutametergic agents like (memantine or riluzole) in order to treat resistant cases of OCD, although the direct mechanism of action has not been established, they have been shown to produce swifter results with regards to improving symptoms.(Coric et al, 2005)( Greenberg et al, 2009) The use of atypical antipsychotic such as risperidone has also been known to aid in treatment of resistant ocd, and is standard to use it when there are multiple comorbid conditions like panic disorders and depression.(Bloch et al, 2006) Recent studies suggest that the combination of both SSRI’s along with noradrenaline reuptake inhibitors can lead to great improvement the clinical condition of the patient.(Denys et al, 2006) it is therefore important in pharmacological treatment to take note of co-morbidities as they can hinder treatment, and in the case of resistant treatment, the use combination therapy such the agents mentioned previously could therefore lead to a better clinical outcome. (APA, 2000)

Psychological:
Cognitive behavioral therapy is considered the gold standard in treatment of OCD. Especially when conducted by a competent psychotherapist, it can produce substantial results.(NICE, 2005) Studies show that when compared to treatment with SSRI’s, results are similar or even better; therefore it has gained popularity as a treatment modality as it can rid patients of the side effects caused by medication.( Kobak et al, 1998) The use of exposure response therapy has also been implanted in the behavioral treatment of OCD, as it has been shown to be the best method for allowing patients to become more aware of their irrational thoughts, which the psychotherapist can then teach the patient to counter them with more rational thoughts. (APA, 2007) A new approach to behavioral therapy combines the use of ERP for OCD and that of eating disorders, as patients with OCD receive a supervised eating plan along with their medication and social support. The results show reduction in both OCD and eating disorders simultaneously.(Simpson et al, 2013) when treatment modalities have been exhausted, a different approach can be used that includes reinforcing a patient’s attitude by allowing to accept their uncertainty of living with obsessional ideas by preparing for any modified situations that they may face.( Grayson, 2004)
References:

1.    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.
2.    American Psychiatric Association Work Group on Obsessive-Compulsive Disorder. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry. July 2007;164(suppl):1-56.
3.    Bloch MH, Landeros-Weisenberger A, Kelmendi B, Coric V, Bracken MB, Leckman JF. A systematic review: antipsychotic augmentation with treatment refractory obsessive-compulsive disorder. Mol Psychiatry. Jul 2006;11(7):622-32.
4.    Coric V, Taskiran S, Pittenger C, Wasylink S, Mathalon DH, Valentine G, et al. Riluzole augmentation in treatment-resistant obsessive-compulsive disorder: an open-label trial. Biol Psychiatry. Sep 1 2005;58(5):424-8.
5.    Denys D, Van Nieuwerburgh F, Deforce D, Westenberg H. Association between the dopamine D2 receptor TaqI A2 allele and low activity COMT allele with obsessive-compulsive disorder in males. Eur Neuropsychopharmacol. Aug 2006;16(6):446-50
6.    Grayson J. Freedom From Obsessive Compulsive Disorder: A Personalized Recovery Program for Living With Uncertainty. New York: Berkley Publishing Group; 2004.
7.    Greenberg WM, Benedict MM, Doerfer J, Perrin M, Panek L, Cleveland WL, et al. Adjunctive glycine in the treatment of obsessive-compulsive disorder in adults. J Psychiatr Res. Mar 2009;43(6):664-70.
8.    Greist JH, Jefferson JW, Kobak KA, Katzelnick DJ, Serlin RC. Efficacy and tolerability of serotonin transport inhibitors in obsessive-compulsive disorder. A meta-analysis. Arch Gen Psychiatry. Jan 1995;52(1):53-60
9.    Kobak KA, Greist JH, Jefferson JW, Katzelnick DJ, Henk HJ. Behavioral versus pharmacological treatments of obsessive compulsive disorder: a meta-analysis. Psychopharmacology (Berl). Apr 1998;136(3):205-16.
10.    National Institute for Health and Care Excellence, 2005, Obsessive compulsive disorder, CG31.
11.    Psychiatry at a Glance, 5th Edition, Cornelius Katona, Claudia Cooper, Mary Robertson July 2012, ©2012, Wiley-Blackwell
12.    Simpson HB, Wetterneck CT, Cahill SP, Steinglass JE, Franklin ME, Leonard RC, et al. Treatment of obsessive-compulsive disorder complicated by comorbid eating disorders. Cogn Behav Ther. Mar 2013;42(1):64-76.

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