Amiya Ranjan Behera is an 18-year-old male student who was admitted to the hospital with a diagnosis of obsessive compulsive disorder. He reports symptoms of palpitations, breathlessness, repetitive behaviors like hand washing for 15 minutes and checking things an even number of times. On examination, he appears anxious but is oriented with intact cognition. He reports obsessions about contamination and compulsions to perform behaviors in an even manner. The document outlines his history, mental status exam, physical exam and provides context on obsessive compulsive disorder including potential etiological factors and definitions.

1. Obsessive Compulsive
Disorder

2. Identification Data
• Name - Amiya Ranjan Behera
• Age - 18yr
• Gender - male
• Marital status - Unmarried
• Religion - Hindu
• Education - +2 Science
• Occupation - Student
• Address - At- Panchapada, Bhadrak, Odisha
• Date of admission – 23/10/2018
• Diagnosis – Obcessive Compulsive Disorder
• Ip no:- -- 181022128

3. • .INFORMANT’S NAME – Saudamini Behera
• Relationship with the patient - Mother
• Reliability of the information - Reliable

4. Chief complaint
• According to patient
• I am having palpitation since 1 year
• I feel like breathlessness most of the time.
• If I do something I feel like I should do it again. I do everything for even
times.
• I do my hand wash upto elbow for about 15 minutes since 1year.
• I am facing difficulty in swallowing since 4 days.
• I think that if people get to know about my condition they may mock at
me so I keep myself isolated.
• I feel like dryness of mouth since 4 days.
• I check everything even time before doing.

5. • According to Informants
• My son was washing his hands frequently.
• He was checking everything for twice.
• He was sitting alone.
• He always become anxious.
• If I advice something he always ask questions frequently related to
that matter.
• He suspects every thing.

6. • According to observer
• He is checking everything for twice or more even times
• He was checking side and also walking like in square shape( he stops at the
point of changing direction while walking then walk straight.)
• He checks his his side and way while walking.
• He checks bed before sitting.
• He has some particular position for particular work, if he don’t do that work
according to his position he became anxious.
• He thinks that if he write something in others paper his knowledge may be go
away.
•

7. HISTORY OF PRESENT ILLNESS
Patient was apparently alright before 1 ½ year back.
He had fight with his step brother. Some family disturbance was also
there due to his fathers 2nd marriage.
He joined +2 Science college, as he was a Odia medium student , he
faced difficulty in understanding his subjects, he got very less marks
in class tests in the coaching centre.
He was feeling stressed for the study. He used have palpitations,
breathlessness whenever he got stressed.
He had excessive sweating during these episode.

8. • Later he keep himself away from the friends. Because he was feeling that they
may mock at him.
• He started suspecting in everything.He had repeated thoughts of
contaminations of hand so he was washing his hands for 15 mins
• . He was checking 6-10 times before eating in hostel.
• He was feeling that he may get harmed if he does not carry out the thoughts
repetitively.
• His friends started laughing at him.
• This was continued for 4-5 months,. Then his coaching centre informed to the
family member regarding his condition.
• His family member consulted a local doctor he gave some medications.
Although patient was not fully cured as he was continuing his daily activities
his family members thought that gradually the behaviour will change.

9. •Before four days back patient did not took any food , he was
complaining something is there in his throat.
•He was feeling difficulty in breathing . so his family
member brought him to the IMS and Sum hospital now he
is admitted in ward-1.

10. Treatment history
• He was taking medication for the mental illness from a
local doctor.
• He was taking following medications
• Exam(300) 1 tab. BD (Amisulpride,)[Atypical
antipsychotics],
• Kerad(5) 1 tab.BD(Diazepam)[Anti anxiety],
• Lurastar(40) 1 tab. BD (Lurasidon) [Antipsychotic],
• Zymocat 1 tab. OD (Pancreatin+Dimethicon)[Digestive aids]

11. Personal history
• (A) Perinatal history
• No history of any infection or exposure to radiation during
antenatal period. His mother has no habits of takingany alcohol and
smoking. Amiya was born with normal delivery. He was cried
immediately after birth. There was absence of any birth defect.
According to his informant he was given all the vaccines according to
the schedule.

12. • (B) Childhood history
• Amiya’s primary caregiver was his mother. He was given breast milk
upto 4-5 months and gradually he was given semisolid diet. He had
achieved all the developmental milestone appropriately. He was not
mixing with his friends at first, but when anyone approach to him he
became friend with them. He had general diseases like fever, sinusitis
etc. Once he was drowned in a pond from that incident he had some
fear regarding pond and river.

13. • (C) Educational history:
• Amiya had started his schooling at the age of five years. He was a
good student and secured positions among top three. He has not got
any extracurricular achievement. He had a good relationship with the
teacher and teacher also love him. He had no conduct disorders like
stealing. He had no school phobia, he loves to study. He is continuing
his study and currently he is in 12th standard.

14. • (D) Play history
• He played cricket, and carrom with his friends.
• Very good relationship was there among his playmates.
• (E) Emotional problems during adolescence
• Sometimes he could not handle stress, he cries whenever he faces
some problem.

15. • (H) Occupational history
• He is still dependant on his family members.
• (I) Sexual and marital history
• He is unmarried.

16. (J) Premorbid personality
• Amiya is an introvert. He had a good relationship with his family
members especially hwith his mother, but he did not like his father as
he had marriage for the 2nd time. He spends his leisure time by
watching television and roaming with friends. His mood changes
according to the situation. He become depressed in stressful
situation. He had a positive attitude towards self and others. He does
his homework perfectly but sometimes he get stressed. He believes in
god. He is looking forward to become a teacher. He sometimes
hesitate to eat. Normal elimination pattern. Sometimes he could not
sleep because of his thoughts. Ho has never used any drugs or
alcohol.

17. Family History
• Patients grandfather had history of diabetes and patients
father has high blood pressure. But there is no family history
of any mental illness.

18. Mental Status Examination
• Appearance:
• Patients height is 170cm and weight is 66 kg.
• He has thin body built. His grooming was appropriate to the
time of the day.

19. Behavior:
• He Well behaved and followed the command.
• He has normal motor activity. But he follows a definite pattern
for every action.
• For eg. He checks his shoes before wearing , he wear shoes and
remove it , and continue it for 6-8 times till he became satisfied.
• He checks both sides and road before walking. He checks
medicine for even times and take it in particular direction.

20. • Attitude
• When I first interviewed him he was very anxious . After
sometime he was very open, cooperative and friendly.
• Level of consciousness:
• He was Conscious and alert as patient is answering to the
question appropriately.

21. •Orientation:
•He is fully oriented to time, place and person.
•Speech and Language:
•The patient was talking normal speed with adequate
volume and there was fluctuation in speech.

22. Mood
• Subjective
• Student nurse : How are you feeling?
• Patient : I feeling tensed
• Student Nurse : Why do you feel tensed.
• Patient : Various thoughts are coming to my mind like I am feeling
some thing is there in my throat, to clear it I have to cough for 4-6
times, if I don’t do this I feel something is going to happen to me.
• objective : Patient is looking anxious.

23. Affect
•Quality : Dysphoric
•Fluctuation : Elevated
•Range : Broad
•Appropriateness : Appropriate
•Congruency : Congruent

24. Thought
• Stream
• Student Nurse : How much you love your mother?
• Client : She is my best friend I love him very much.
• Form
• Student Nurse : what do you do when you feel stressed?
• Client : When I feel stressed that problem come to
my mind repetitively and suddenly my heart started beating
faster.

25. • Content
• Student nurse : Why do you check before eating
anything?
• Client : I suspect that something may mix
with the food if I don’t check it I may lost my life.

26. Inference of thought
• Thought stream is Normal, goal-directed, no thought block, circum-
stantiality, tangentiality, perseveration, flight of ideas or stereotypy.
F
• Form is Well-structured, understandable, no loosening of
association, is seen.
• Possession Recognizes his thoughts as his own.
• Patient gets obsessions about checking everything and compulsions
about performing some acts in even times. Content Ideas of
persecution are present.

27. Perception
• Hallucinations
• Student Nurse : Sometimes some of the people listen
various sounds and visualize the things when they are alone
which are not recognized by others, do you have any of the
problem like those?
• Client : No I don’t listen or visualize the things like you
said..

28. •Illusion
•Student Nurse: if this type of thing happens to you that,
you saw a material but another person told you that your
thought is wrong regarding this material. For e.g. you saw a
snake but another person told you that it was a rope.
•Client: No this type of thing never happen to me.
•Derealization
•Student Nurse: Have you felt that your soul has come out of
your body and observing your body from outside.
•Client: Laughed, No this also never happen to me.

29. • Cognitive Functions
• Orientation
• Person
• Student Nurse : Who is sitting near by you?
• Client : My mother
• Student Nurse : Who are you?
• Client : I am Amiya Kumar Jena.
• Student Nurse : What do you do.
• Client : I am a student and studying in Class 12th.
• Place
• Student Nurse : Where are you now?
• Client : At Hospital
• Inference: Patient is oriented to time place and person.

30. • Attention
• Student Nurse : Can you say 5 words in English which starts with T.
• Client : Tiger, Time, Timber, Truck, Tractor.
• Student nurse : Can you say 1-5 in backward?
• Client : told correctly
• Concentration
• Student Nurse : Name the months in backward?
• Client : Told correctly.
• Memory
• Immediate
• Student Nurse : Repeat the word what I say bucket, Pen, mobile, ball,
soil.
• Client : Pen, mobile, ball, soil.
• Remarks : Immediate memory intact.

31. • Recent
• Student Nurse : Have you taken your morning medication?
• Client : Yes I have taken.
• Remarks : Patient’s Mother said that he has taken medication. So
Recent memory intact.
• iii. Remote
• Student Nurse : Who was the previous prime minister?
• Client : I don’t know
• Student Nurse : Can you name some of your school friends of
childhood?
• Client : Raja, Samir, pawan, kailash, Jatin.
• Remarks : Remote memory intact.

32. •Abstraction
•Student Nurse : What is the similarity and dissimilarity
between bird and Aeroplane.
•Client : Both can fly , Bird has life but aeroplane has no
life.
•Student Nurse : Can you identify meaning of odia
proverb “ Gaan Kania Singani Naki.”
•Client: : People do not value qualities of their own
people.
• Remark : Abstraction is appropriate to
socio educational status.

33. •Insight:
•Student Nurse : Do you accept your illness and
require treatment?
•Client : Yes I am having repetitive thoughts in my
mind , I require treatment.
•Remark : Grade 5 insight.

34. • Judgment:
• Test:-
• Student Nurse : What will you do if there is fire in this room?
• Client : I will poor water.
• Personal test:-
• Student Nurse :what will you do after discharge?
• Client:- :I will go to my home.
• Social:-
• Student nurse :what will you do when a marriage party is there in
your neighbor.
• Client :I will go there and eat food.
• Remarks :judgment is intact.

35. • Amiya Kumar Behera is a 18 year old male patient. He
was well groomed.
• He well behaved and followed command. He is open
and cooperative. He was conscious and alert.
• He is oriented to time place and person. He was
talking normal spped with adequate volume and there
was fluctuation in speech.

36. • Patient was looking worried and anxious while talking.
• He has broad range, dysphoric, and congruent affect with the mood.
• Thought stream is Normal, goal-directed. Form is Well-structured,
understandable, no loosening of association, is seen.
• Possession Recognizes his thoughts as his own. Patient gets obsessions
about checking everything and compulsions about performing some acts
in even times.
• Content Ideas of persecution are present.
• The patient has no hallucination, illusion, derealization, depersonalization.
Concentration and memory is intact with the patient.
• Insight of the patient is grade-5.
• Abstraction is according to socio educational status. Judgement is also
intact with the patient.

37. Physical examination
• Patient is well nourished with moderate body built.
• He looks healthy and active. He was anxious.
• His scalp was clean.
• Normal visual acuity.
• There was absence of any redness and any sign of jaundice in sclera.
• his hearing was also normal and absence of perforation of tympanic
mebrane.
• Normal bowel movement no dischare or impaction of cerumen in the
ear.
• Symmetrical chest expansion.
• All the joints are movable .

38. Neurological examination
•Patient was conscious and alert.
•He was able to smell perfectly.
•Visual acuity and visual field examination was also found
normal.
•Pupil reacted to the light and both the pupil size was
equal.
•corneal and facial reflex was present.
•mandibular strength was adequate.
•No abnormality was found in facial expression.

39. • Gag reflex was present.
• Normal tongue movement was found.
• No abnormality was found in sensory motor assessment.
• Patient was not able to maintain balance during tandem
walk test.
• Assessment in reflexes was found normal.
• No abnormality was found in deep tendon reflex.

40. Definition:
•Obsessive-compulsive disorder (OCD) is
represented by a diverse group of symptoms that
include intrusive thoughts, rituals,
preoccupations, and compulsions.
•These recurrent obsessions or compulsions cause
severe distress to the person. The obsessions or
compulsions are time-consuming and interfere
significantly with the person's normal routine,
occupational functioning, usual social activities,
or relationships. A patient with OCD may have an
obsession, a compulsion, or both.

41. Etiological Factor:
Book Pictures:
• Neurotransmitters
• SEROTONERGIC SYSTEM.: The many clinical drug trials that
have been conducted support the hypothesis that
dysregulation of serotonin is involved in the symptom
formation of obsessions and compulsions in the disorder.
• NEUROIMMUNOLOGY. Some interest exists in a positive
link between streptococcal infection and OCD. Group A/3-
hemolytic streptococcal infection can cause rheumatic
fever, and approximately 1 0 to 30 percent of the patients
develop Sydenham's chorea and show obsessive-
compulsive symptoms.

42. • Genetics
• Relatives of probands with OCD consistently have a
threefold to fivefold higher probability of having OCD
or obsessive compulsive features .

43. Behavioral Factors
• According to learning theorists, obsessions are conditioned
stimuli.
• A relatively neutral stimulus becomes associated with fear or
anxiety through a process of respondent conditioning by being
paired with events that are noxious or anxiety producing.
• Thus, previously neutral objects and thoughts become
conditioned stimuli capable of provoking anxiety or
discomfort.
• Compulsions are established in a different way.
• When a person discovers that a certain action reduces anxiety
attached to an obsessional thought, he or she develops active
avoidance strategies in the form of compulsions or ritualistic
behaviors to control the anxiety.

44. Psychosocial Factors
• Personality Factors:. OCD differs from obsessive-
compulsive personality disorder, which is associated
with an obsessive concern for details, perfectionism, and
other similar personality traits. Most persons with OCD
do not have premorbid compulsive symptoms, and such
personality traits are neither necessary nor sufficient for
the development.
• Even though the symptoms of OCD may be biologically
driven, psychodynamic meanings may be attached to
them. Patients may become invested in maintaining the
symptomatology because of secondary gains.

45. Psychoanalytical Theory:
• In classic psychoanalytic theory, OCD was termed obsessive-
compulsive neurosis and was considered a regression from the
oedipal phase to the anal psychosexual phase of development.
• When patients with OCD feel threatened by anxiety about
retaliation for unconscious impulses or by the loss of a
significant object's love, they retreat from the oedipal position
and regress to an intensely ambivalent emotional stage
associated with the anal phase.
• The ambivalence is connected to the unraveling of the smooth
fusion between sexual and aggressive drives characteristic of
the oedipal phase. The coexistence of hatred and love toward
the same person leaves patients paralyzed with doubt and
indecision.

46. Patient Picture
• Behavioral Factors
• Patient is repeating his behaviour to reduce anxiety.
• He had also stress factors like studying and
disturbance with his siblings.

47. Diagnostic Criteria:
•Book Picture:
•Mental Status examination
•Psychoanalysis
•Presence of obsessions, compulsions, or
both

48. Patient Picture:
•Mental status examination
•Psychoanalysis
•Presence of obsessions and compulsions.

49. Clinical Features:
•Book Picture:
•Sign of obsessons
•Fear of contamination
•Repeated unwanted ideas
•Aggressive impulses
•Persistent sexual thoughts
•Thoughts that you might cause others harm

50. Sign of compulsion
•Constant checking
•Constant counting
•The repeated cleaning of one or more items
•Repeatedly washing hands
•Constantly checking the stove or door locks
•Arranging items to face a certain way

51. Emotional symptoms:
•Signs of depression
•Excessive worry
•Extreme tension
•Constant feeling that nothing is ever
right

52. Patient pictures
• He is checking everything for twice or more even times
• He was checking side and also walking like in square shape( he
stops at the point of changing direction while walking then
walk straight.)
• He checks his his side and way while walking.
• He checks bed before sitting.
• He has some particular position for particular work, if he don’t
do that work according to his position he became anxious.
• He thinks that if he write something in others paper his
knowledge may be go away.

53. Management
• Book picture
• Pharmacotherapy
• SSRIs, Sodium valproate, Lithium, Carbamazepine,clonazepam,
antipsychotics
• Psychosocial therapy
• Behaviour therapy
• Psychotherapy
• Electro convulsive therapy
• Deep brain stimulation
• Nursing Management

54. Patient picture
• Pharmacotherpy
• Antipsychotics
• Anti depressants
• Psychosocial therapy
• Psychotherapy
• Behaviour therapy
• Nursing management

55. Nursing Management
• According to book:
• Anxiety related to obsessive thoughts as evidenced by patients
verbalization.
• Disturbed thought processes physical environment
• Social isolation related to lack of faith on others.
• Impaired verbal communication related to lack of interest.
• Disturbed family process related to disease process

56. According to patient
• Anxiety related to perceived threat to biological integrity as evidenced by
patients facial expression
• Fear related to perceived threat to life as evidenced by acknowledge and
discuss of the fear by patient.
• Ineffective coping related to obsessional thoughts as evidenced by ritualistic
behaviour.
• Social isolation related to threat of being mocked as evidenced by patient sit
alone on his bed and never talk with other patient or family members.
• Disturbed family process related to mental disorder of a family member as
evidenced by knowledge deficit regarding health care support.

57. Anxiety related to perceived threat to biological
integrity as evidenced by patients facial expression
• Patients family members of other patients are adviced to stay one
attendant with one patient.
• Staff members are adviced not to force the patient to do anything
• While discussing the client accept the symptoms of patient.
• Client thought process is given priority with rational approach.
• Staff members are adviced to keep eye on the patient.
• He is taught various relaxation techniques to apply when levels of
anxiety are high.

58. Fear related to perceived threat to life as
evidenced by acknowledge and discuss of the fear
by patient.
• Safety security provision of the ward is discussed with the client and he was
reassured.
• Client is helped to understand that his perception of fear is unreal by exploring
his thoughts.
• Thought stopping technique is taught to the client and adviced to substitute
positive thoughts whenever he is getting any negative thoughts in his mind.
• Client is encouraged to share his perceived threat and feelings so that others
can help him to get out of that situation.
• Systematic desensitization approach is applied to reduce his fears

59. Ineffective coping related to obsessional thoughts
as evidenced by ritualistic behaviour.
• Hamilton score was 23 which indicates moderate anxiety.
• Various situations are identified and listed down which increase
clients anxiety and ritualistic behaviour.
• Client his helped to recognise his obsessional thoughts and apply
thought stopping as well as relaxation techniques.
• Client is allowed to go outside for some time as a reinforcement to
non ritualistic behaviour

60. Social isolation related to threat of being mocked
as evidenced by patient sit alone on his bed and
never talk with other patient or family members.
• Ward incharge is adviced to plan a group activity with other patient.
• Staff members are adviced to be with the client as group activity may
increase patient anxiety.
• Staff members are adviced not to give anny false promise like discharge will
be done today to the client as it may decrease trust on them.
• Client is adviced to use relaxation and thought stopping techniques
whenever he feels anxious.
• Student nurses are adviced to use laugh and cautiously

61. Disturbed family process related to mental
disorder of a family member as evidenced by
knowledge deficit regarding health care support.
• Family members knowledge is assessed through questionnaire.
• Family coping ability is identified (e.g., experience of loss, caregiver
burden, needed supports).
• Information is provided regarding bipolar disorder according to family
members understanding.
• Information is provided on client and family community resources for
the client and family after discharge: day hospitals, support groups,
organizations ,psychoeducational programs,

62. Home care and follow up
• Client is adviced to use relaxation and thought stopping techniques
whenever he get anxious.
• Patient is adviced to talk with the friends and family members.
• He is encouragde to share his feelings.
• Improve the self care needs (personal hygiene) independently.
• Sleep hygiene techniques.
• Instruct to use relaxation technique when getting aggressive.
• Taught about the positive coping methods.
• Advice to do meditation.
• Patient and his family member is adviced not to stop medication without
consulting doctor.
• Advice the patient for regular checks up and follows up.

63. References:
• Sadock Benjamin james, Synopsis of psychiatry,Virginnia, , Wolters
Kluwler, 2015
• https://www.mentalhealth.com/home/dx/ocd.html] cited on
November 10 2018
• [https://psychopharmacologyinstitute.com/antipsychotics/risperido
ne/mechanism-of-action-pharmacodynamics-risperidone/]cited on
November 10, 2018
• https://www.ncbi.nlm.nih.gov/pubmed/2418652 [Cited on
November 10 2018]