PMH/501 Week 4: Anxiety, Obsessive-Compulsive and Trauma-Related Disorders, sample paper

Checking the Stove Forty Times Before Leaving for Work: Diagnosing Obsessive-Compulsive Disorder in a 26-Year-Old and Separating It From Anxiety, Perfectionism and Psychosis

[Student Name]

University of Phoenix

PMH/501: Neuropsychiatric Disorders

Week 4 Assignment

[Instructor Name]

[Date]

The patient is a composite written for a model paper.

Ms. R., a 26-year-old medical-surgical nurse, has been late to work repeatedly. She explains that she checks that her stove is off, often 40 times, then returns home to check again because she "can't be sure," fearing her apartment will burn and kill her neighbors. At work, she double- and triple-checks medications beyond the required checks, which slows her down. She knows the checking is excessive but feels unbearable anxiety if she stops. This began two years ago and has worsened. This paper describes the diagnostic evaluation.

Obsessions and Compulsions

DSM criteria define obsessions as recurrent, persistent, intrusive and unwanted thoughts, urges or images that cause marked anxiety, which the person tries to ignore, suppress or neutralize. Compulsions are repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rigid rules, aimed at reducing distress or preventing a feared event, but not realistically connected to it or clearly excessive. The obsessions or compulsions must be time-consuming, taking more than an hour a day, or cause significant distress or impairment. Ms. R.'s fear of causing a fire is an obsession; checking is a compulsion; she spends about two hours a day on it; and it threatens her job.

Rating Severity

Goodman et al. (1989) developed the Yale-Brown Obsessive Compulsive Scale, a clinician-rated instrument measuring time occupied, interference, distress, resistance and control for obsessions and compulsions separately, and demonstrated its reliability. Ms. R.'s total score is 26, in the severe range. The accompanying symptom checklist identifies checking and harm-related obsessions as her main symptoms, with some counting.

The difference between a careful nurse and a nurse with OCD is not how often she checks but whether she can stop when she knows she has checked.

Assessing Insight

DSM specifies insight as good or fair, poor or absent, with delusional beliefs. Ms. R. recognizes that her fears are probably not true: good insight. Insight matters because OCD with absent insight can be mistaken for a psychotic disorder, and because it affects treatment.

Separating OCD From Its Neighbors

Generalized anxiety disorder involves worry about real-life concerns, such as money or health, without rituals. Obsessive-compulsive personality disorder involves perfectionism and rigidity experienced as appropriate, not intrusive, and without true compulsions; Ms. R.'s checking feels unwanted to her. Psychotic disorders involve fixed false beliefs without recognition that they are unreasonable. Trauma-related disorders involve intrusive memories of a real event rather than feared future harm.

How Common Is OCD

Ruscio et al. (2010), analyzing the National Comorbidity Survey Replication, estimated lifetime OCD prevalence at 2.3% and found that most people with OCD had comorbid disorders, especially anxiety and mood disorders, and that onset often occurred in childhood or adolescence. Stein et al. (2019), in a review of the disorder, describe it as a common, often chronic condition associated with dysfunction in cortico-striato-thalamo-cortical circuits, with effective treatments available.

Screening for Comorbidity

Given the high comorbidity, I screen Ms. R. for depression, with a PHQ-9 score of 11, and for other anxiety disorders, tics and substance use. She has mild depression, likely secondary to the burden of OCD. I also ask about suicidal thoughts, which she denies.

Medical and Developmental History

Sudden-onset OCD in childhood after infection raises the question of pediatric acute-onset neuropsychiatric syndrome; Ms. R.'s adult onset does not fit. She has no neurological symptoms.

The Diagnosis

Obsessive-compulsive disorder, with good insight, severe, with comorbid mild depression.

The Role of Avoidance

Many people with OCD avoid situations that trigger obsessions. Ms. R. has stopped cooking at home to avoid using the stove, which reduces checking but narrows her life. Avoidance should be recorded during assessment because it lowers visible compulsions while maintaining the disorder, and because it will become a target of exposure therapy.

Why Reassurance Does Not Help

Family and coworkers often reassure people with OCD that the stove is off or the medication is correct. Reassurance brings brief relief but, like a compulsion, strengthens the cycle. Ms. R.'s partner checks the stove for her at times; I explain that this is common and well-intended but part of what treatment will change.

Stigma and Shame

Ms. R. was embarrassed to describe her rituals and feared being judged as incompetent. Many people hide OCD symptoms for years. Asking specific, matter-of-fact questions about checking, cleaning, counting and intrusive thoughts helps patients disclose, and explaining that OCD is a recognized, treatable brain-based condition reduces shame.

Measuring Change

The Y-BOCS score of 26 serves as a baseline. A reduction of 25% to 35% is often considered a treatment response, and repeated scores will show whether exposure therapy and any medication are working (Goodman et al., 1989).

Onset and Course

Though her symptoms became impairing two years ago, Ms. R. recalls counting rituals as a teenager, consistent with the frequent early onset of OCD. Without treatment, OCD tends to be chronic with fluctuations, which makes early, effective treatment important.

Tics and Related Conditions

I ask about motor and vocal tics, since OCD with a personal or family history of tics may respond differently to treatment; she has none. I also ask about hoarding, skin picking and body dysmorphic concerns, related conditions that often co-occur.

Collateral Information

With her permission, her partner describes the morning routine and confirms the time spent checking, which supports the severity rating and shows how the disorder affects the household as well.

Why Diagnosis Matters

Naming the condition allows Ms. R. to understand her experience as a treatable disorder rather than a personal flaw, and it opens the door to therapy that specifically targets the obsession-compulsion cycle.

Her Goals

Ms. R. says her main goal is to leave home on time without returning to check. This concrete goal will guide the exposure hierarchy and give a clear measure of progress alongside the scale score.

Follow-Up

I will see her in two weeks to review the therapy referral, her mood and her readiness to discuss medication.

Education

I give her written information about OCD and exposure therapy so she can share it with her partner.

Work Implications

Her medication checking at work is excessive, but it is not unsafe. With her permission, I will provide documentation supporting temporary accommodations while treatment begins, without disclosing details she does not wish to share.

First Steps

Stein et al. (2019) describe cognitive behavioral therapy with exposure and response prevention and serotonin reuptake inhibitors as first-line treatments. I refer her to a therapist trained in exposure and response prevention and will discuss medication in a follow-up visit.

Conclusion

Ms. R.'s intrusive fears of causing harm and her time-consuming checking meet DSM criteria for obsessive-compulsive disorder, severe on the Yale-Brown scale, with good insight. Careful questions separated OCD from anxiety, perfectionism and psychosis, and screening found comorbid depression, consistent with epidemiological data. Measuring severity at the start sets a baseline for evaluating treatment.

References

Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., Heninger, G. R., & Charney, D. S. (1989). The Yale-Brown Obsessive Compulsive Scale: I. Development, use, and reliability. Archives of General Psychiatry, 46(11), 1006-1011. https://doi.org/10.1001/archpsyc.1989.01810110048007

Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Molecular Psychiatry, 15(1), 53-63. https://doi.org/10.1038/mp.2008.94

Stein, D. J., Costa, D. L. C., Lochner, C., Miguel, E. C., Reddy, Y. C. J., Shavitt, R. G., van den Heuvel, O. A., & Simpson, H. B. (2019). Obsessive-compulsive disorder. Nature Reviews Disease Primers, 5, Article 52. https://doi.org/10.1038/s41572-019-0102-3