CASE CONFERENCE ON OBSESSIVE COMPULSIVE DISORDER.pptx

CASE CONFERENCE
Presenter – Dr Avinash Kumar (PG1)
Moderator – Dr. Arish Khan (SR)
Chairperson–Dr. S.Jena(Consultant)
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DEMOGRAPHIC DETAILS :
• Mr Kapil Dev, 19 year old unmarried hindu male,studied till class 12th,
currently unemployed,Resident of Ghaziabad,Uttar Pradesh, belongs to middle
socioeconomic status.
• Informants :
1)Patient himself
2)Patient’s mother
Information provided by them are adequate and reliable

CHIEF COMPLAINTS:-
3
According to Patient
गंदे गंदे विचार और वचत्र वदमाग में आते है
अपने मन में विचार ं क र क नह ं पाता हूँ
न ंद काम आत हैं
According to Informants
बह त ज़्यादा वचड़वचड़ा ह गया है
विद्द ह गया है काफ
5 years

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COURSE SPECIFIERS :
• Total duration of illness – 5 Years
• Onset – Insidious
• Course – Fluctuating
• Progression - Deteriorating
• Predisposing factor – Nil elicited
• Precipitating factor – Nil elicited
• Perpetuating factor – Poor compliance to medications
• Protective factor – Good family support and Good insight

5
HISTORY OF PRESENTING
ILLNESS
Patient was apparentely well 5 years ago when he was studying in class eighth.One day
Family members noticed that patient would walk over stairs repeatedly and was looking
very distressed and was muttering in self which was not audible and was associated with
sudden anger outburst.He would climb 4-5 times on a single stair before moving to other
stairs and when asked about the reason behind he told that he is getting repeatitive thoughts
which would enter in his mind all of a sudden about doing the same which when patient
tries to resist, he would feel like his heart racing, feels vibration sense in his upper limbs
and feels like churning sensation in his upper abdomen region with feeling of warmth in
his entire body leading to develop fear of something abnormal going on in body. So,to
avoid this he would do these acts and feel relaxed.On further probing he told that he gets
similar repetitive thoughts of switching on and off the switchboard and also repetitive
thoughts of touching any object to avoid any undesirable circumstance like developing
some disease or failing in exam or meeting with RTA or Gas cylinder bursting in house.
These thoughts would spontaneously enter into his mind anytime in a day and he finds it
very unwanted and unnecessary causing him irritability. Gradually,over time patient
started getting repetitive thoughts of his hand getting contaminated with dirts whenever he

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Acc to mother,they have to fill the water tank thrice in a day due to excessive uses by the patient.Patient would feel
very shy in sharing these things to family members,causing him to feel more distressed with these unwanted
thoughts. Gradually,over months this ritual of hand washing has increased in severity from mild to moderate and
now patient would wash his hands for more than 20 times a day and would spend almost 3 hours in doing so.
After a year,patient started to notice that whenever he sees any female member in his family like sister,mother or
any school friend,he would get their nude images in his mind which lately would be more detailed and vivid having
sexual intercourse in which male member is generally any of his friends or father or patient himself. Initially,he felt
very distressed and guilty about the same and did not have the courage to share it with his family members. So, to
relieve his ghabrahat, he would imagine similar family member of his friend doing the same act to feel that both the
families are undergoing similar acts.This act of neutralising compulsion would decrease his ghabrahat and patient
felt very relaxed after this.Patient also started being overprotective about his mother and sister and would advice
them to not to go to a certain place and not to meet with certain peoples as they had bad intentions.These fear patient
started to develop as he started getting thoughts and imaginations of his sister being harassed by certain group of
people and so causing him to imply restrictions on his sister and mother. Initially,he would feel guilty of all these
and generally used to avoid seeing any female members of family and wouldn’t make eye contacts with
them.so,mother noticed it and asked reason behind it .On further probing it was noticed that initially when he would
get these sexual content as thought and images,he would feel very guilty and would try to resist but later on ,he
would feel very excited after compairing the same with his friend’s sister leading to compulsive masturbation. Acc
to patient,He would tell sorry to his friend’s sister in his mind after the act of masturbation to relieve his guilt.
Sometimes, sexual content also involved childrens and homosexualiy.so, patient was taken to GBPH,Psychi dept
and medications were started .Patient felt much improvement in 2-3 weeks but never touched baseline as acc to
mother for a week pt would not do the repetitive acts like washing ,touching but when asked about these sexual
thoughts and images,it would persist all the time

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Gradually,mother started to get complaints from school that patient is becoming week in studies as he would repeat
writing the same line in his copy by cutting it and reading the same line multiple times and wouldn’t cope up with other
classmates.He would also suffer from repetitive fights with his classmates as his threshold for irritability has been
decreased and mostly he would be preoccupied with his own thoughts. Mother also noticed that patient would mutter
while sleeping also about the events occurred in the day and would complaint of not feeling fresh in the day time.
He also started getting abusive content in his mind whenever he sees any picture of god and would develop an imagery
in which he sees stool have been sticked on the god’s face.He would feel very bad about his thoughts and would also
pluck his hairs to decrease the associated ghabrahat and sometimes,also would hit himself with slaps.
He would also get thoughts of developing any chronic illness like cancer,AIDS whenever he wouldn’t do the acts which
he usually do. So,in fear of developing these illness,he would repeatedly touch the objects multiple times in a day.He
would also check the mobile phones multiple times as to check if it didn’t remained open.He would also repeat the same
video which he sees in youtube until he feel relaxed.He would also get thought of lucky and unlucky numbers as like
whenever he sees 32 number written anywhere he would get thought of failing in exam as passing mark is 33. So,he
would intentionally open 33 number in mobile phones to decrease associated ghabrahat.Acc to patient,he would feel
strong urge to unbox something which is packaged in closed box infront of him and also gets urge to confess something
immediately.He would also be afraid in going to Public gatherings as he had fear of doing something embarrassing like
shouting any abusive words or hitting some girl with bad intention as he would get these urges after seeing them. so,he
started avoiding going to any public places and if in his school he gets these thoughts,he would rush to washroom or
pinch himself for getting distracted.

Gradually,mother noticed behavioural change in patient like he became very stubborn as whenever he
would demand something,irrespective of time,place,money he would need the same thing in front of
his eyes within few hours and upon non fulfillment ,he would throw and break all the household
items and would also shout on them.Acc to him,whenever he feels to meet with his friend,he would
call them at anytime and would demand for meeting them irrespective of any situation and if they
would deny,pt feels ghabrahat episode and would emotionally blackmail them to meet him
instantly.So,gradually his friends also noticed some changes in him and requested him to meet some
psychiatrist. He also started facing difficulties in concentration in his studies as whenever he would
start studying,he would get these unwanted thoughts,images,impulses and he would get distracted
very soon.
From last one year,pt started occasional feeling of sadness of mood,decreased interest in talking to his
family members,watching his favourite movies and also feeling of whole body weakness and easy
fatiguability upon doing minor household works like making tea also and he would lie on bed most of
the times.He would also feel helpless as he is not getting improvement by medications and would
repeatedly check new advancement in treatment of OCD on internet and would discuss with his
mother.
His academics performance also declined since last one year as he would skip classes and would lie
on the bed mostly.He couldn’t maintain 75% attendance for sitting for examination. He also got
compartment in his 11th class examination as he couldn’t perform well. So,patient was admitted in

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• One month back, patient gave his 12th board exams whose results are awaited but acc to
him,he couldnot perform well in his exams as he would find very difficulty in sustaining his
attention for more than a hour for studying and in exams,he would complete his paper 1.5
hours early and would get out of the examination hall as he would get these unwanted
thoughts,images in his mind causing him to feel very irritable and distressed. So,after
completion of board exam,he requested his family to get him admitted in GBPH,Psychiatry
department ward 2 for getting imaging of his full brain as what he saw in some youtube
video about the disease.
Sleep – Decreased [ Patient goes to sleep around 10 PM and falls asleep 2-3 hours late than his
premorbid state and doesn’t feels fresh during daytime]
Appetite- Normal
Self care- Normal
Role functioning - Decreased

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NEGATIVE HISTORY :
• No history of any other obsessional thoughts,images,impulses or any
involuntary repetitive muscle movements or any sounds.
• No history of any sore throat or acute febrile illness before the onset of
disease.
• No history of any self harm episodes.
• No history of persistent and pervasive sadness of mood or free floating
anxiety.
• No history of any head trauma,LOC, ENT bleeds or any abnormal body
movement.
• No history of suspiciousness or hearing of any voices.

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TREATMENT HISTORY
SNO. DRUG DOSE DURATION RESPONSE & COMPLIANCE SIDE EFFECT
1. CAP FLUOXETINE 40-80mg 28.3.2022 – TILL
NOW
Good compliance and minimal
improvement in symptoms
None
reported
2. TAB CLOMIPRAMINE 100-150
mg
28.3.2022 – TILL
NOW
Dry
mouth
and skin.
3. TAB RISPERIDONE 2 mg 23.5.2023 –
20.8.2023
None
reported

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PAST HISTORY
• Patient is a known case of Dyslipidemia since 2 years and is on treatment
[T.Atorvastatin 20mg HS]
• Patient is a known case of Chronic sinusitis since 15 years and underwent
surgery for maxillary sinus 6 yrs back.
• No past history of any Psychiatric illness present.

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FAMILY HISTORY
• Patient lives in a nuclear family with Parents and 2 siblings and is 3rd by order[1 sister
and 1 brother]
• Financial Head:- Father
• Emotional head:- Mother
• Father is a known case of Coronary atery disease [underwent CABG 2 years back]
• Mother is a known case of Type 2 Diabetes Mellitus and Hypothyroidism and is on
traeatment for the same.
• No any Psychiatric illness present in family members.
• Family’s attitude towards patient is supportive and caring.
• Family’s attitude towards the illness is that now they consider it as a mental
illness and understands the nature of the illness that it will take time for his
recovery.

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PERSONAL
HISTORY
• Birth history: uneventful antenatally, was born full term , normal vaginal
delivery at home with no history of NICU visits.
• Developmental history : all milestones attained at appropriate age.
• Scholastic history : started schooling at the age of 5yrs, was an above
average student in academics till class 8th but deteriorated due to his illness
but had managed to clear all the classes till 10th in single attempts with
marginal passing scores and got compartment in multiple subjets in class
11th.
• Substance abuse : No history of any substance abuse present.

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PREMORBID TEMPERAMENT
Activity level- Patient was moderately active and used to prefer outdoor energetic and noisy
games like football, Volleyball.
Attention and concentration – Patient used to shift from one work to another and was not
able to concentrate on any particular work. Like while he would be studying, if he would
hear noises from adjacent room,he used to go and get involved in that and parents used to
get similar complaints from school of patient not sustaining attention in class as he used to
roam and talk with his mates during classes.
Adaptability – Patient used be moderatelty difficult to adapt with changes in his environment
like when his school was changed initially he used to complain to parents of not being able
to mixed up with boys and would try to resist going to school but gradually he would mix
up with other boys and would make new friends.
Rhythmicity- Patient was regular in his biological functions like he used to sleep,eat at a
particular time and was regular in his excretory functions. So,his sleeping and eating pattern
was very predictable.

Intensity of Reaction – Patient used to show intense reaction when his demands were not
fulfilled of food,things like new bicycle, toys and was very rigid and stubborn. If he liked
something and parents would deny buying it, he was very sensitive and would cry unless
he gets it.
Threshold level – Patient was moderately sensitive to noise, heat, cold, smell, touch and
used to get bothered by changes in it.
Quality of Mood – Patient’s predominant mood was cheerful but was very prone to crying,
getting irritable if his demands are not fulfilled.
Hobbies and Interests – Patient used to like watching cartoons, playing outdoor games and
hanging out with his friends.
[ IMPRESSION – Slow to warm Temperament ]

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GENERAL PHYSICAL EXAMINATION
• Patient was alert, oriented to time, place and person.
• BP – 110/80 mmHg, PR- 78/min, RR – 14/ min
• Height –175cm , weight – 80kg , BMI- 26.30kg/m2
• No pallor/ icterus/ cyanosis/clubbing/lymphadenopathy/pedal
edama.
• Bilateral postural tremors present in hands.
• No any marks of self harm seen on body.
• No any signs of dehydration present.

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SYSTEMIC EXAMINATION
• Respiratory system : B/L air entry equal, no adventitious sounds heard
• Cardiovascular system : S1, S2 heard with no audible murmur
• Per abdominal : soft, non tender, no organomegaly , normal bowel
sounds heard .

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CNS EXAMINATION:
CRANIAL NERVE EXAMINATION:
• Olfactory nerve – intact
• Optic nerve – B/L pupillary reflex (direct and indirect) normally present.
• Oculomotor, trochlear and abducens nerve – extraocular movements present
normally in all 6 gazes.
• Trigiminal nerve- sensory: intact
motor : no restriction in jaw movement
• Facial nerve - no facial deviation , no restriction of facial expression
• Vestibulocochlear nerve – vestibular component: no nystagmus , cochlear
component : no hearing impairment.
• Glossopharyngeal nerve gag reflex present
• Vagus nerve
• Spinal accessory nerve – B/L shoulder shrugging present against resistance
• Hypoglossal nerve – no tongue deviation on protrusion
}

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• MOTOR –
• Bulk: B/L symmetrical in all 4 limbs
• Power : 5/5 in all 4 limbs
• Tone : normal in all 4 limbs
• DTR: bicep, triceps, knee and ankle : +2 bilaterally
• Plantar reflex : B/L flexor response
• SENSORY –
• Pain- equally and symmetrically percieved in all dermatomes bilaterally
• Fine and crude touch- equally and symmetrically perceived in all
dermatomes
bilaterally
• Vibration sense – intact
• Joint position sense- intact
• CEREBELLAR SIGNS –
• Ataxia and nystagmus-absent
• Dysdiadochokinesia – absent
• Finger nose test- intact
• Heel shin test – intact
• Rhomberg’s test - negative

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MENTAL STATUS
EXAMINATION
GENERAL APPEARANCE AND BEHAVIOUR :
Patient is an adult male of good built and nourishment looking as
of his stated age, was lying down on the allotted bed when
approached for interview. Entered Interview room with Normal Gait
and sat on chair after wishing. During Interview,he was expressing
his helplessness about his illness and was about to cry doing the
same.During interview,he stood for hand washing as by mistake he
touched his slippers with his hand and returned back after10
minutes and was looking very distressed .He was well kempt and
cooperative during entire interview.
Rapport: established and sustained
Eye to eye contact : established and
maintained

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• Psychomotor activity : Normal
• Speech : rate / tone / volume/reaction time – Normal [
Decreased tone at times]
• Mood : बेचैन ह त है
• Affect : Anxious, Reactive and congruent w.r.t thought

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E- नमस्ते कवपल क
ै से ह आप ?
P- नमस्ते ठ क नह ं हूँ
E- क् ं क्ा ह गया आपक ?
P-परेशान हूँ अपने विचार से थक गया हूँ अबत ह
E- क् ं क्ा हुआ क
ै से विचार आते हैं ?
P- बहुत गंदे गंदे इतना क शेयर भ नह ं कर सकता अपने ह माूँ बहन क
े बारे में आते हैं बहुत ज्यादा बुरा
लगता हैं क्ा मैं कभ ठ क नह ं ह सकता क्ा , अब ऐसा लगता है पुरे लाइफ मैं ऐसे ह अक
े ला रह जाऊ
ं गा
मम्म पापा भ वकतना ह हेल्प करेंगे मेरा
E- हाूँ आप जरूर ठ क ह सकते ह , इसक
े अलािा क ई और भ परेशान हैं क्ा ?
P- नह ं बस मेरे विचार मेरे कण्ट्र ल में आजाए मैं वबलक
ु ल ठ क ह जाऊ
ं गा
E- क्ा आपक ऐसा महसूस ह ता है क आपक वकस बाहर क शक्ति ने अपने िश में कर रखा है ?
P- नह ं ऐसा नह ं लगता
E- क्ा आपक ऐसा लगता है क ल ग आपक
े बारे में बात करते है या ल ग आपक और इशारे करक
े बाते
करते हैं ?
E- क्ा आपक ऐसा लगता है क ई आपक जानबुझ कर नुक्सान पहुचाने क क वसस कर रहा है या क ई जहर
देने या मार देने क क वसस कर रहा है ?
P- नह ं ऐसा क
ु छ नह ं हैं IMPRESSION- Normal Form, Flow.
Content- Worry about his illness

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Possession-
E-अच्छा आप क्ा बता रहे थे अपने विचार क
े बारे में जड़ा विस्तार से बताएगे ?
P- मुझे गंदे गंदे विचार आते रहते हैं वजससे मैं बहुत परेशान ह गया हूँ
E- थ ड़ा विस्तार से बताइये विचार क
े बारे में ?
P- मुझे अपने वसस्टर और मदर क लेकर गंदे गंदे सेक्सुअल थॉट्स और वपक्चसस आते रहते है वजसमे
उनक
े साथ बहुत गलत गलत काम ह रहा ह ता है और घबराहट ह ने लगत हैं
E- अच्छा क्ा आप इन्हे र कने क क वशस करते हैं ?
P- हाूँ बहुत बार कर हैं लेवकन नह ं रुकते है खुद से कभ भ आजाते हैं और कभ भ चले जाते हैं जब
क वशस करता हूँ र कने क त ह घबराहट ह ने लगत हैं और वदल में अि ब सा टेंशन ह ने लग जाता हैं
हाथ ं में कम्पन जैसा लगता हैं इसवलए अब मैं क वशस ह नह ं करता हूँ
E- अच्छा घबराहट कम करने क
े वलए क्ा करते ह ?
P- मैं अपने वकस द स्त क बहन क उस वसचुएशन में स च लेता हूँ और तब मुझे लगता हैं चल द न ं
क
े साथ ऐसा ह रहा हैं तब मुझे शांवत वमल जात हैं
E-क
ु छ सिाल थ ड़े वनज ह सकते है लेवकन हमे ऐसे ब मार में पूछना ह ता है क्ा आप मन में उत्तेजना
भ महसूस करते हैं जब ऐसे गंदे विचार और फ ट मन में आते हैं ?
P- हाूँ वपछले क
ु छ मह ने से जब भ मुझे ऐसे विचार या फ ट आते हैं और जब मैं वकस और लड़क क
ऐसे न्युड स चता हूँ तब मुझे सेक्सुअल फ वलंग्स आते हैं और मैं मास्टरबेशन करलेता हूँ और इससे
पछतािा ना ह इसवलए मैं मन में उस लड़क से माफ़ भ मांग लेता हूँ

26
E- क्ा ये विचार आपक
े अपने ह ते है या क ई बाहर से डाल रहा ह ता है ?
P- नह ं ये मेरे अपने विचार ह ते हैं वजससे मैं पूर तरह से परेशान ह गया ह
E- क्ा आप अपन सफाई पर बहुत ज्यादा समय लगते हैं जैसे बार बार नहाना या हाथ ध ना ये जानते
हुए भ क आप साफ़ है क्ा आप च ि क सजाने सिारने में भ बहुत समय लगाते हैं ?
P- हाूँ मैं हाथ ध ता रहता हूँ मुझे लगता हैं मेरे हाथ में गंदग लग हुई है इसवलए मैं 15-20 बार ध ता ह
और 1-2 घंटे तक नहाता रहता ह क्ूक मुझे अंदर से संतुवि नह ं वमलत क मैं साफ़ हं
E- क्ा ऐसा ह ता है क आपक च ि क बार बार चेक करना पड़ता है यह जानते हुए भ क आप
पहले ऐसा कर चुक
े है ?
P- हाूँ मुझे म बाइल क लेकर ऐसा ह ता है मुझे लगता है मेर म बाइल खुल रह गय है और मैं उसे
ऑन और ऑफ करता रहता हूँ जबतक मुझे संतुवि नह ं वमल जात
E- क्ा इसक
े अलािा क ई और विचार वचत्र बार बार आते हैं ?
P- हाूँ मुझे क ई भ च ि टच करना बार बार या क ई भ क्तिच ऑन और ऑफ करना या लक ,
अनलक नंबर ये सब विचार आते रहते है और लगता है अगर मैंने नह ं वकआ त मेरे साथ क
ु छ गलत
ह जाएगा या मुझे क ई क
ैं सर एड्स जैयस ब मार ह जायेग और मुझे बंद च ि क ख लने क भ
बहुत इच्छा ह त है इसवलए मेरे आसपास क ई भ च ि बंद नह ं रह सकत , इसक
े अलािा मुझे
भगिान क लेकर भ मन में गाल आत है जब भ मैं उनका फ ट देखता हूँ, अब मुझे ऐसा लगता है
मेर ये ब मार एड्स क
ैं सर जैस ब मार से भ ज्यादा ख़राब है
IMP- Obsessional thoughts regarding contamination,Blasphemy,Sexual thoughts and

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E- क्ा ऐसा ह ता है जब आप अक
े ले ह ते है और आसपास क ई नह ं ह ता है तब कान में श र या
आिािे सुनाई पड़त है कभ कभ ऐसा लगता है क्ा क ई आपका नाम पुकार रहा है ?
E- क्ा इस तरह से क
ु छ च िे या शकले भ वदखाई देत ह जब आसपास क ई नह ं ह ता त भ
इस तरह क क ई और अज ब बात हुई है त बताए ?
P- नह ं ऐस क ई बात नह ं हुई है
[ IMPRESSION : No Perceptual
abnormality]
PERCEPTION

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HIGHER MENTAL FUNCTION
• Attention and concentration :
• Digit forward test : upto 5 digits
• Digit backward test : upto 4 digits
• 100-7 : could continue upto 5 substractions
• Days in a week in reverse order :was able to say
IMPRESSION : aroused and sustained
• Memory :
• Immediate :intact by digit forward test
• Recent : could recall last day meal intake
• Remote :- was able to tell DOB & SCHOOL NAME

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• INTELLIGENCE :
General fund of knowledge
1) PM of India: modi
2) 5 rivers : Ganga, Yamuna, Saraswati,Narmada,Brahmaputra
3) capital of UP : Lucknow
4) 5 Leader name:-Rahul Gandhi,Amit shah,modi,Mayawati,Sonia Gandhi
Comprehension
Could point on door /light/sofa /table when pointed
Arithmetic
could perform simple calculations with addition, substraction as well as
multiplication both verbally and written
[IMPRESSION : good fund of general information, intact comprehension
and arithmetic skills]

30
ABSTRACT ABILITIES :-
1] PROVERBS-
 9-2-11 ह ना - भाग जाना
 पेट में चूहे क
ू दना- भूख लगना
 आूँख ं का तारा ह ना- दुलारा ह ना
 ड
ू बते क वतनक
े का सहारा - विप्पवत में थ ड़ा साहरा वकस काम का नह ंह ता
 दह हथेल पर नह ंजमत - नह ंपता
2] SIMILARTIES
 शलजम और फ
ू लग भ -द न ं सब्ज है
 डेस्क और टेबल- द न ं लकड़ क
े ह ते है
 कार और एर प्लेन- द न ं से एक जगह से दू सर जगह जाते है
 प एम और नॉिेल - द न ं पढ़ते है
 हॉसस और एप्पल - नह ंपता
[IMPRESSION- INTACT ABSTRACT ABILITY]

31
• JUDGEMENT:
1. TEST JUDGEMENT : ( fire test)
E : agar ghar par aapke aag lag jaye to kya karoge ?
P : paani daalunga,mitti dalunga,nhi bujhi toh aag wle ko call krunga
IMPRESSION : test judgement intact
2.PERSONAL JUDGEMENT :
E : abhi aage kya plan hai aapke ?
P : Agar mai theek hogya toh doctor banne ki tyari karunga.
IMPRESSION : Intact personal judgement
3. SOCIAL JUDGEMENT :Intact through history & MSE

32
• INSIGHT :
E- क्ा आपक लगता है आपक
े व्वयहार में क
ु छ बदलाि आए है वपछले क
ु छ वदन ं में ?
P- हाूँ बहुत वचड़वचड़ा ह गया हूँ अपने विचार क
े चलते
E- अच्छा त आपक लगता है ये क ई ब मार ह सकत है
P-हाूँ मुझे पता है ये ब मार है ,ये एक मानवसक ब मार है
E-क्ा आप इसक
े वलए क
ु छ बदलाि करना चाहते है अपने लाइफ में ?
P- हाूँ, मै दिा य ग सब करू
ूँ गा और आपल ग ज ब लेगे सब करू
ूँ गा
[IMP- 6/6 INSIGHT]

33
DIAGNOSTIC FORMULATION :
Patient Mr Kapil Dev ,19 year old Hindu Unmarried Male,studied till class 12th,resident of
Ghaziabad,UP belongs to middle SES of Urban background,presented with reliable and adequate
information of TDI of 5 years,insidious in onset ,Fluctuating course,Deteriorating in
progression,perpetuated by poor compliance to medications and protected by good family support
and illness is characterised by Repetitive intrusive thoughts of contamination,Fear of acquiring some
chronic disease,sexual thoughts and images ,Blasphemy thoughts,Fear of doing something
embarrassing ,concern that something wrong will happen if acts are not done
accordingly,obsessional thoughts of need to know,touch,tap and lucky unlucky numbers and
compulsive acts of handwashing ,bathing,tapping,touching,checking,climbing stairs,Rereading and
rewriting,compulsive self mutilating behaviours,compulsion of need to tell,ask or confess,decreased
sleep and increased irritability with past history of dyslipidemia since 2 years and on tab
Atorvastatin 20mg with history of chronic sinusitis since 15 years and underwent Maxillary
sinusectomy 6 years back with family history of Father being known case of CAD and mother being
known case of T2DM and hypothyroidism on tt and with slow to warm Premorbid temperament.
GPE is suggestive of Bilateral Postural tremors in both hands with MSE suggestive of Irritable
Mood, anxious affect with thought content suggestive of ideas of guilt,helplessness,worry about his
illness and thought possession suggestive of obsessional thoughts regarding
contamination,blasphemy,sexual thoughts and images,compulsive washing,bathing,checking with
insight 6/6.
PROVISIONAL DIAGNOSIS ACCORDING TO ICD -10 :

34
Points in favour of the diagnosis :
• The thoughts,images or impulses are unpleasantly repetitive and
intrusive.
• These thoughts,images are ego-dystonic and unpleasurable.
• These are patient’s own thoughts and is unable to resist them
successfully.
• These obsessions and compulsions are interfering with the patient’s
social and individual functioning.

35
PLAN OF MANAGEMENT
Patient was Admitted on 15th April 2024 in ward 2 of Psychiatry department,GBPH as
patient was not having improvement with the drugs inspite of good compliance.
Following admission his condition was assessed and basic investigations Like CBC, Blood
sugar, LFT,KFT, Lipid profile, Serum electrolytes, TFT ,ECG , CXR PA were done which are
within normal limits.
YBOCS Symptom checklist and Severity scale was applied which came out to be 30/40
[Severe OCD].
Patient was then started on oral medications :-
1] T. FLUOXETINE 80mg/day.
2] T. CLOMIPRAMINE 150mg/day.
3] T.CLONAZEPAM 0.5mg/day.
4] T.ATORVASTATIN 20mg/day.
Presently ,the Plan is to taper and switch to other SSRI as patient is not responding well to
the present one after adequate trial. Further,Non Pharmacological Treatment like Exposure
and response prevention therapy are to be done.

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