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OBSESSIVE-COMPULSIVE DISORDER - Coggle Diagram
OBSESSIVE-COMPULSIVE DISORDER
Diagnosis
Dermatological symptoms -Excessive washing, genital or anal symptoms ( obsessive checking/washing) general stress or doubts about getting HIV
Screen for symptoms of Depression/anxiety/alcohol or substance misuse body dysmorphic disorder, eating disorder
Ask - Do you wash or clean a lot? Do you check things a lot? Is there any thought that keeps bothering you that you like to get rid of, but cannot? Are your daily activities take a long time to finish? Are you concerned about putting things in a special order, or are you upset by mess?
Do these problems trouble you? A positive response to any of these questions suggest the need for more detailed assessement.
Where confirmed diagnosis - assess risk of self harm and suicide, consider comorbid conditions and psychosocial aspects which may contribute to risk.
Diagnostic and Statistical Manual-5 (DSM-5) criteria for OCD)
Differential Diagnosis
Obsessive-compulsive personality disorder - preoccupation with orderliness, details, rules, organisations or schedules to the degree that point of the activity is lost with obsessions but may involve discomfort if things not done completely.
Body Dysmorphic Disorder - perceived defect in physical appearance
Somatic Symptom Disorder
Illness Anxiety Disorder - hypochondriasis / Anxiety Disorder /Depression
Delusional Disorder
Autism Spectrum Disorder /Asperger's syndrome
Hoarding Disorder. Trichotillomania
Excoriation Disorder. Olfactory Reference Disorder
Assessment
Assess degree of distress and functional impairment as mild/moderate and severe
Management options guided by severity, gather info from initial responses to the six screening questions OCD diagnosis
Ask re impact on work/school/relationships/social life/quality of life.
Establish how much time is taken by obsessive thoughts or compulsive behaviours each day.
Establish how much distress is caused by obsessive thoughts how hard the person tries to resist them and how much control they have over them.
Consider using a severity scale Y-BOCS. Be aware that OCD my exist with other mental health disorders e.g. depression/anxiety/substance misuse/ eating disorder.
For those diagnose with OCD, assess their risk of suicide and self harm.
Assess for safeguarding concerns for children or vulnerable adults in their care
Management
Assess severity/risk of suicide/consider comorbidity and safeguarding issues.
Refer for specialist assessment for people assessed having severe OCD.
Those considered at risk of suicide /risk to life due to OCD symptoms.
Refer same day to crisis team if person at high risk of suicide/ severe self neglect. Those with significant substance misuse, severe depression, anorexia or schizophrenia. Initial treatments not led to an adequate response. Those under age of 18.
Follow local policy when referring to specialist mental health services with urgency
Adults - mild functional impairment, recommend a psychological intervention by referring or self referral to NHS TALKING THERAPIES. CBT/Exposure response prevention ERP may be offered
Adults - moderate functional impairment, offer self referral to NHS TALKING THERAPIES or SSRI medication.
Consider prescribing clomipramine if preference or person had previous good response to it or SSRI is contraindicated
Adults - Severe functional Impairment, refer to secondary care mental health team for assessment. Consider offering combined treatment with SSRI and CBT whilst waiting. Consider prescribing clomipramine as an alternative . SSRI e.g. fluoxetine, fluvoxamine, paroxetine and sertraline licensed for OCD treatment.
Be aware that in minority of people under 30 years age, SSRI's associated with increased risk of suicidal thinking and self harm.
Monitor people on Clomipramine for psychiatric symptoms or suicidal ideations.
Management in Pregnancy - Consider seeking specialist advise in perinatal mental health
Current advice includes - no robust evidence to suggest one SSRI is safer than another
Management in Pregnancy - Small risk of foetal cardiovascular malformation associated with SSRI treatment in pregnancy.
Risk of neonatal withdrawal syndrome if mother is taking SSRI in weeks prior to delivery
Management in Pregnancy- Risk of persistent pulmonary hypertension in new born if SSRI exposure beyond 20 weeks of gestation.
There may be an increased risk of postpartum haemorrhage where SSRI used in month prior to delivery.
Lowest effective dose of SSRI should be used.
Manufacturer of Clomipramine does not recommend for use in pregnancy or women of childbearing age not using contraception.
Management in Children/Young People - Refer to child and adolescent mental health services (CAMHS).
Those with mild OCD - offer self -help guides.
Moderate to severe functional impairment of whom guided self hep not effective or refused, offer CBT/ERP involving family and carers if appropriate.
SSRI used if treatment is declined or ineffective. Only prescribed SSRI following assessment and diagnosis by child/adolescent psychiatrist.