Captain of the Ship Project – Obsessive Compulsive Disorders Paper

Captain of the Ship Project – Obsessive Compulsive Disorders Paper

“Captain of the Ship” Project – Obsessive-Compulsive Disorders Paper

Walden University NURS 6670, PMH Nurse Practitioner Role II: Adult and Older Adult

Thirty years ago, a diagnosis of OCD was a life sentence in the psychiatry world because it was almost untreatable, but now it is a manageable one (Lack, 2012). OCD is ‘characterized by having intrusive, troubling thoughts (obsessions), and repetitive, ritualistic behaviors (compulsions)’ which takes time and impairs the patients functioning or causes significant distress (DSM-5). These thoughts, feelings, ideas, or sensations (Sadock, 2014) push the patient to be very anxious and elicits certain repeated behaviors to reduce anxiety (Lack, 2012). Men and women are likely to be affected by the mean age of onset, about 22 years, with a 67% lifetime prevalence for major depression (Sadock, 2014).

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HPI and clinical impression of VB

VB is a 41-year-old Caucasian woman who comes in today for her routine follow up.

V.B. has Down syndrome and was diagnosed with OCD in her early twenties. Other diagnoses include depression, intermittent explosive disorder, mood disorder, hyperlipidemia, and hypothyroidism. She is very independent in her activities of daily living. V.B. has a history of physical aggression and property destruction and takes Depakote ER 500mg BID, Haldol 0.5MG BID, Neurontin 100mg TID, and Cogentin 0.5mg BID.

VB works at the local grocery store and lives at home with her mother. She understands prices and can make simple purchases at the store but needs some assistance with her finances. V.B. was married at one point, though divorced now and had no children. She comes in alone today for a follow-up. V.B. has ‘a thing about her bra not on the right’ or the strings in her pants and tries to fix it until she gets it right. Her mother explains that she uses more than an hour to get dressed because she will hook and unhook her bra numerous times before she gets out of her room and then after.

V.B. does not care where she is to set her clothes straight. She can stop in the middle of the mall, lift her dress, and try to fix her bra. In the clinic, she will usually spend about 45 minutes in the bathroom because her bra is not right or her pants strings are not tied a specific way. Her mother tries to encourage her to buy clothes without strings to no avail. And it is better the pant string than stripping in public to get to her bra.

V.B. gets very agitated when asked to hurry up or when told her clothing are fine and will begin to act aggressively towards whoever is saying that to her. She will throw objects, scream, scratch, pinch, and sometimes in extreme cases, induce urinary and fecal incontinence due to her frustration. V.B. has fair insight that her beliefs may or may not be accurate (Sadock, 2014).

Psychopharmacologic treatments for V.B.

People diagnosed with OCD are said to have a lower level of serotonin in the neural synapses; thus, SSRIs are considered first-line medication treatment (Storch, 2006). Studies show that SSRIs benefit adults with OCD (Lack, 2012). V.B. was previously on Zoloft, and it is unclear why she stopped taking it. She states today that she responded well to Zoloft with minimal side effects. The FDA has approved Zoloft for treating OCD, though a higher dose is needed for adequate symptoms control (Sadock, 2014). I will thus start her on Zoloft 50mg and titrate accordingly till her symptoms are reduced. Her maintenance target will be at 150mg daily. Many prescribers augment the SSRIs with Depakote, Lithium, or Tegretol if SSRI alone is unsuccessful, so it is a good thing that V.B. already takes Depakote. The goal of treatment is to reduce V.B.’s current symptoms and continue indefinitely for maintenance (Stahl, 2017)

Psychotherapy choices for V.B.

Behavior therapy is as effective as medications in patients with OCD and has long-lasting effects (Sadock, 2014). Effective behavior therapy for V.B. will include exposure and ritual/response prevention to allow her to form a habit of not needing all her rituals to reduce her anxiety (Goddard, 2014). CBT with exposure and response prevention has been proven to work for both children and adults with OCD (Storch, 2006). Controlled trials in adults have given an 85% response rate with complete remission of symptoms (Storch, 2006 “Captain of the Ship” Project – Obsessive-Compulsive Disorders Paper). This common-sense approach will allow V.B. to confront her fears and teach her ways to cope with the anxiety that will arise and process it without performing any rituals (Goddard, 2014). Having the family involved will help her succeed; most families try to pressure patients to avoid the behavior.

Family therapy will allow the family to reassure V.B and understand the disorder’s delays (Storch, 2006). Supportive psychotherapy, like showing empathy, having a therapeutic alliance, strength support, optimism, explanations about the disease process, etc., benefits all clients (Sadock, 2014), so V.B. can benefit from this type of therapy well.

V. B Medical management needs

V.B. suffered a stroke on 12/31/2011 and has recovered fully. She sees her PCP every 90 days. She takes a slew of medications to include fish oil, Vitamin D, B6, B12, C.Q. 10, Multivitamin, folic acid, Synthroid 50mcg, Lipitor 10mg. Her health is stable at this time, and she has no new medical issues or complications. She has other specialists that she sees annually and follows up as needed. She is compliant with all her medical needs. She sees a nutritionist every year. She is not one to exercise, but she tries to make healthy choices and has kept a healthy weight. Cardiology is every six months to do her EKG – no issues present. Neurology is every year- no medications prescribed. GYN is every two years- no issues found. Mammogram every two years and the dentist every year.

Community support resources for V.B

V.B. has support from her family. Her mother and brother are her surrogate decision- makers though she is her legal guardian. She can think clearly for herself and make good choices. V.B. works with the Division of Rehabilitation Services (DORS) program. This entity help people with disabilities go and succeed at the job site. V.B. has a caseworker who assists her with navigating available resources in the community. V.B. gets worried about her future without her mother or brother and is seeking alternative housing just in case of the inevitable to avoid homelessness. V.B. is in contact with her caseworker once a month. V.B sometimes has a job coach present at the job site to assist. In combination with her medication compliance and psychotherapy, V.B. is living her best life as she usually puts it.

Follow-up plan for V.B

V.B. will follow-up in a week to assess how she is tolerating the new medication. V.B. will be asked to monitor the side effects and call or visit if she has mood swings or suicidal thoughts. Weekly follow up will be for another visit, and if she has no side effects, I will increase the Zoloft to 100mg and have bi-weekly follow ups. I will start her on a routine four-week follow-up when I reach her daily target of 150mg/day with symptoms reduction. V.B. will see her therapist weekly and work on ways to deal with her anxiety and rituals. The therapist and V.B. will decide on the schedule for her visits.

Conclusion

The course of OCD is chronic and unremitting if left untreated as symptoms fluctuate over time and become worse (Storch, 2006). Today OCD is manageable with pharmacological and non- pharmacological treatment that is effective for patients (Lack, 2012). Many patients do not respond to medications alone, so augmenting it with therapy is the most effective option (Storch, 2006). An early and accurate diagnosis will give V.B. and her family a festive look at life.

Reference for Captain of the Ship Project – Obsessive Compulsive Disorders Paper

Diagnostic and statistical manual of mental disorders (5th Ed). (2013). Washington DC: American Psychiatric Association.

Gabbard, G. 0. (2014). Gabbard’s treatment of psychiatric disorders (5th ed.). Washington, D.C.: American Psychiatric Publications.

Lack C. W. (2012). Obsessive-compulsive disorder: Evidence-based treatments and future directions for research. World journal of psychiatry, 2(6), 86–90. https://doi.org/10.5498/wjp.v2.i6.86

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11 th ed). Philadelphia, PA: Wolters Kluwer.

Stahl, S. M. (2017). Prescribers Guide: Stahl’s Essentials Psychopharmacology (6th ed.). New York, NY: Cambridge University Press.

Storch, E. A., & Merlo, L. J. (2006). Obsessive-compulsive disorder: Strategies for using CBT and pharmacotherapy. Journal of Family Practice, 55(4), 329–333.