The document discusses the management strategies for obsessive-compulsive disorder (OCD) in adult clients, focusing on a case study of a 22-year-old woman named Karen. It outlines her symptoms, diagnostic assessment, and proposed treatment plan, which includes pharmacotherapy with an SSRI (Prozac) and behavior therapy. The document emphasizes the importance of collaboration with the patient's primary care physician and therapist, along with a follow-up plan to monitor progress and manage side effects.

1. Week 7 Assignment 1 Captain of the Ship
Obsessive Compulsive
Kamp University
Nurs 4582: PMHNP Role II
Dr. Hohn Doe
March 18, 2016
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.

2. 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.
Psychopharmacology
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

3. 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).
Psychotherapy
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.
Medical Management
I will consult with Karen’s PCP for updates and additional

4. 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).
Conclusion
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.

5. References
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
/2015/1115/p896.html
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.