Chief Complaint/History of Present Illness
Despite being a mental health issue that can lead to potentially life-threatening scenarios, Obsessive-Compulsive Disorder (OCD) continues to be substantially underdiagnosed and undertreated. Among the key reasons for OCD to be so profoundly ignored, one should list the issues of healthcare accessibility and health literacy (Gagné et al., 2018). Therefore, building awareness about OCD, its threats, and the importance of diagnosing the disorder in a timely fashion should be prioritized. In the case under analysis, the inclusion of anti-depressants (Gagné et al., 2018) for minimizing the feeling of anxiety combined with exposure therapy and individual CBT-based interventions with a therapist should be considered as the first line of treatment.
The patient (Chloe) is a 32-year-old Asian American middle-class woman. Chloe addressed the healthcare facility due to the continuous and uncharacteristic loss of weight, as well as the persistent need to repeat specific mental acts, such as certain phrases and physical actions. According to the patient, without the specified routine, she feels particularly vulnerable to possible accidents (“I feel like something awful is going to happen if I don’t repeat these words”). Alongside the specified factors, the patient mentioned constant intrusive and unwanted thoughts (“I don’t want to think these things, but they come to mind anyway”). In addition, the patient reports uncharacteristic weight loss and frequent insomnia.
Past Psychiatric History
According to Chloe, the symptoms described above appeared when the pandemic and the following economic and political issues occurring in the U.S., as well as globally, caused her to become increasingly concerned about her economic well-being. Along with the specified concerns, the symptoms in question emerged. Since the eruption of the pandemic, Chloe has developed repetitive actions and intrusive thoughts, specifically those related to health concerns and the possibility of developing COVID-19 symptoms. Even after the vaccination, Chloe has been feeling anxious and experiencing intrusive thoughts. Furthermore, after the threat of COVID-19 had subsided, Chloe started experiencing other fears, particularly the idea that an unknown threat may emerge if she did not take her routine actions.
Substance Use History, Past Medical History, Family History
Chloe explained that intrusive thoughts and the related issues that she has been suffering recently used to be a minor problem when she was a child, yet the described phenomenon gradually subsided as she grew older. According to the patient, she never complained about the specified issue to her parents, which was why she was not diagnosed at the specified stage of the disorder development. The process of self-isolation that she underwent after having received the vaccine exacerbated Chloe’s fears, leading to increased compulsion to take routine actions such as arranging items at home and in her workplace. Additionally, intrusive thoughts, such as the fear of being pushed in front of a car by a passerby, have been affecting Chloe’s mental well-being.
The issue of substance use should also be addressed as one of the possible factors that may have exacerbated the patient’s sense of anxiety and prompted the aggravation of her OCD. The patient admits to having been binge-drinking and being an active smoker. Chloe also reported that smoking and drinking supposedly help her cope with the sense of anxiety. However, the patient has never used the services of a healthcare provider to address the substance misuse issue due to the heavy stigma associated with substance misuse in the Asian American community. Therefore, additional therapeutic measures for supporting the patient on her way to overcoming the drug misuse issue must be integrated into the intervention.
Apart from the health issues mentioned above, Chloe has not had any major health concerns. She has never had a surgical intervention and has never developed any major health complication that would have required a prolonged hospital stay. The patient admits to having experienced the symptoms that could be explained as hypertension several times, yet she did not seek health support to address the issue. However, the specified phenomenon should be associated not only with the patient’s health status but also with the culture of her community, which she admits to having a negative perception of meticulous management of one’s health. Being driven by her career aspirations, Chloe claims to have never been able to afford enough time to address her health issues fully.
Chloe mentioned that substance misuse issues ran in her family, where her father would engage in binge drinking quite often. Furthermore, Chloe’s mother has been experiencing anxiety and is currently developing symptoms of what could possibly be defined as early-onset Alzheimer’s disease.
Medications and Allergies
Currently, the patient is not taking any medications that could possibly intervene with the proposed treatment. Therefore, introducing SSRIs into the list of treatments that Chloe should take in order to address the current issue of OCD should not represent any concerns for her health. However, it should also be kept in mind that the patient needs to be informed thoroughly about the possible outcomes of mixing medications, as well as provided with a list of medicine that is incompatible with SSRIs. Specifically, Chloe must be warned about the danger of mixing SSRIs and non-steroidal anti-inflammatory drugs (NSAIDs), namely, the threat of developing gastrointestinal problems and, in the worst-case scenario, intracranial hemorrhage (Lee et al., 2020).
It should also be noted that the patient does not have any known allergies. Despite the specified information, the patient needs to be informed about the possible allergic reaction that the consumption of SSRIs may entail (Lee et al., 2020). Specifically, the possibility of developing a rash or a similar skin condition as a response to the intake of SSRIs should be considered. Consequently, the patient should be encouraged to report an instance of a supposed allergy so that the problem can be addressed immediately and that the threat to the patient’s well-being can be eliminated.
Social History
The patient has a rather robust social history. Chloe is currently employed as a manager in a local company and deals primarily with administrative issues and tasks related to business planning. Though the patient was reluctant to admit it, the current workload has placed her under noticeable pressure, which appears to have aggravated her condition to an extent. Specifically, Chloe admits that she experiences higher anxiety rates on her workdays as opposed to her days off. Furthermore, Chloe communicates with her colleagues, family, and friends actively. The patient is single and has a very supportive mother.
Risk Assessment and Vital Signs
Currently, the risk levels that the patient’s condition poses to her well-being are moderate, yet there is an evident threat of her mental health deteriorating rapidly in the future. While Chloe complains about increasing fatigue and intrusive thoughts for the most part, the fact that she mentions developing insomnia, loss of weight, and the increasing failure to control her anxiety levels, as well as the intrusive thoughts in question, she needs an active and immediate intervention (Gagné et al., 2018). It is presumed that, without due therapy and medications introduced as soon as possible, the patient may develop comorbid mental health disorders such as depression (Gagné et al., 2018). The patient denies visual or auditory hallucinations.
Presently, the patient’s vital signs are comparatively normal. Her current blood pressure is 130/85 mm Hg, which is indicative of the presence of hypertension. The pulse is 75 bpm, which is within the existing norm, and her breathing is 15 bpm, which also aligns with the set standards for the specified age range. Currently, the key risks that the patient is facing are defined by the rapidly developing OCD (Gagné et al., 2018), as well as the possible mental health issues that typically accompany it, including severe anxiety (GAD-7 13) and moderate depression (PHQ9 11/27).
Review of Systems (ROS)
According to the information reported by the patient, she has not experienced any instances of hearing loss or any problems swallowing. Likewise, no changes in the patient’s perception of smell have been noticed. However, Chloe did mention the fact that she has lost her appetite, which has led to a subsequent loss of weight. Chloe attributes the specified phenomenon to the increasing anxiety that she is feeling.
Furthermore, the patient has not had any instances of fever, chills, or night sweats. However, the patient did mention noticeable weight loss, which can be attributed to anxiety caused by OCD (Gilbert, 2019).
Currently, the patient has minor respiratory concerns, such as dry mouth due to constant smoking, yet no shortness of breath has been registered. As far as the cardiovascular issues are concerned, since the patient has not addressed an expert, diagnosing issues with blood pressure does not seem reasonable, yet Chloe did mention the symptoms that could be attributed to increased blood pressure.
Similarly, no gastrointestinal concerns have been mentioned during the conversation with Chloe. Finally, according to the patient’s complaints, certain neurological issues, such as fatigue, have been observed after particularly stressful instances in her life.
Neurobiology
Remarkably, very little is currently known about the neurobiology of OCD. Specifically, Olsen et al. (2020) explain that understanding the nature of the disorder, as well as the neurobiological mechanisms behind it, requires thorough and profound research (Gagné et al., 2018). However, the recent studies addressing the subject matter are generated through the cortico-striatal-thalamo-cortical (CSTC) pathway in a patient’s brain (Gagné et al., 2018). For instance, Olsen et al. (2020) posit that the damage to the specified areas of the brain causes OCD to develop in most cases. According to the research, the destruction of CSTC pathways affects the processing of emotional and cognitive inputs, generating a feeling of unease once a specific trigger is introduced (Olsen et al., 2020).
Assessment
Based on the available evidence, one may conclude that the patient is suffering from a case of obsessive-compulsive disorder (300.3 (F42)) (OCD). Specifically, according to the definition offered in the DSM-V manual, the observed symptoms align quite clearly with the symptoms and core characteristics of OCD: “OCD is characterized by the presence of obsessions and/or compulsions” (American Psychiatric Association, 2014, p. 235). Moreover, according to the definition offered in the DSM-V text, “Obsessions are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted” (American Psychiatric Association, 2014, p. 235). The described characterization of OCD aligns perfectly with Chloe’s experiences since she has been having obsessive thoughts about her well-being. Moreover, the DSM-V definition of compulsion is also in line with the actions that Chloe has been taking to address these intrusive thoughts: “Compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response” (American Psychiatric Association, 2014, p. 235). Therefore, the established definition of OCD fits the symptoms that the patient has been demonstrating.
Furthermore, there is a possibility of general anxiety disorder (GAD) also being present due to the increasing amount of anxiety that the patient has been experiencing. Specifically, the GAD-7 score indicates the likelihood of the GAD (300.02 (F41.1)) being present in the patient. Indeed, according to the SDM-V criteria, the presence of GAD is marked by the following symptoms: “excessive worries about […] social performance,” even though the manual also specifies that nonsocial performance worries are also symptomatic of GAD (American Psychiatric Association, 2014, p. 206).
Overall, assessing the patient’s current performance rates and the extent to which the disorders have progressed, one may conclude that the symptoms observed in Chloe align with the GAD and OCD disorders. The presence of OCD is particularly apparent in the patient since the complaint concerning intrusive thoughts, numerous ritual actions, and anxiety resulting from failing to follow the rituals in question represent the chief complaint. Therefore, the problem of OCD must be addressed first as the primary reason for concern.
Obsessive-Compulsive Disorder (OCD) and Generalized Anxiety Disorder (GAD) CriteriaOverall, assessing the patient’s current performance rates and the extent to which the disorders have progressed, one may conclude that the symptoms observed in Chloe align with the GAD and OCD disorders. The presence of OCD is particularly apparent in the patient since the complaint concerning intrusive thoughts, numerous ritual actions, and anxiety resulting from failing to follow the rituals in question represent the chief complaint. Therefore, the problem of OCD must be addressed first as the primary reason for concern.
References
American Psychiatric Association. (2014). The diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.
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