The purpose of this paper is to provide a client recovery-focused treatment plan for a client with a cluster C personality disorder, obsessive compulsive disorder.
Assessment
The role of the psychiatrist and health professional includes assessing whether OCD is of disability severity, in which case it may be necessary to write on behalf of the patient to government agencies, publicly financed health care or other agencies to assist the patient in daily functioning and care of needs (APA, 2010; 2013). In this case, the WHODAS score suggest the patient may have up to a 50 % level of disability, which may increase with age (APA, 2010). Explaining to family members the need for continuing support, whether from family or caregivers will prove critical to the long-term efficacy of treatment methods presented to the patient.
The patient has lived at home for the last 30 years, with regular support and visitation from family members include a brother (two years senior). This suggests at present the client/patient may be capable of continuing outpatient/home care.
Diagnosis/Differential Diagnosis
The patient exhibits classic features of Cluster C personality disorder Obsessive Compulsive Disorder. OCD diagnosed patients tend to focus on rules, regulations and the general orderliness of their environment. They may devote to work more so than social or personal relationships, and exhibit perfectionist tendency, drive to get their work right. Many OCD patients get lost in details and can’t see the bigger picture; they can be rigid or inflexible, and incapable of delegating tasks because of a fear that tasks will be completed to a less perfect quality than would be if they completed the work themselves. Money is often rigidly controlled.
Differential diagnosis for this patient is major depressive disorder with anxiety/panic disorder (APA, 2013). Patient rating scales suggest a family history of major depressive disorder, although the primary diagnosis remains OCD. The patient admits to engaging in daily ritualistic behaviors to reduce anxiety and feelings of panic. Further, behaviors supporting diagnosis include the patient’s need to control their environment, frequent obsessions and idealizations over conversations, activities, and daily needs. The patient washes hands in excessive of four times per hour, as part of their daily behaviors and ritualistic activities.
Comprehensive Initial Treatment Plan
The primary needs of the patient include rating the severity of current OCD symptoms and any co-occurring symptoms. This can be achieved via use of Yale-Brown’s OCD scale, (APA, 2007; 2000; Fireman, Koran, Leventhal & Jacobson, 2001). The treatment plan focuses on addressing the patient’s primary diagnosis with attention to the need for comprehensive psychotherapeutic approaches to address the potential for comorbid disorders. The treatment plan described below addresses the patient comprehensive needs, including a need for psychotherapy, pharmacotherapy, and ongoing assessment and support from health professionals.
Primary/Secondary/Tertiary Prevention Activities
Primary prevention activities include assessing and accurately diagnosing the patient. Prevention activities moving forward will include assessment for compliance to pharmacotherapies regimens, and compliance to psychotherapeutic approaches. Prevention measures will include providing education to family members, who in the past may have enabled ritualistic activities or behaviors out of concern or care for the patient. Teaching patient family members to avoid enabling activities, including helping the patient to identify habitual or ritualistic behaviors and identifying the cause or need for them, may help promote greater quality of life and reduce the risk for enablement of negative behaviors in the home.
Safety & Legal Concerns
To provide for the patient’s safety, a full assessment of compulsive rituals and past aggressive behavior is needed. Patients that fear loss of control may have extensive rituals to avoid symptom breakthrough; OCD may come with suicidal tendencies or aggressive tendencies (APA, 2007). If co-occurring disorders exist, then treatment for these is also needed. Further safety measures may include treatment of any co-occurring medical disorders that may contribute to symptoms. These may include head trauma, seizures or loss of consciousness (APA, 2007).
The patient is older than 18, thus parental consent is not needed. The patient may have limited capacity to understand the implications of his disorder; as such, full consent, and working with family members may prove critical to providing for the patient in the best manner possible.
Genomic Considerations
Patient presents with a family-history of major depressive disorder and panic disorder, both considered comorbid considerations among patients with OCD (APA, 2010). Assessing the patient for comorbid conditions include depression is relevant to overall care for the patient.
Psychotherapy (Individual, Family, Group)
Psychotherapies proven effective for treating OCD include Cognitive behavior therapy, to help augment treatment outcomes. Group and multifamily behavioral treatment are also helpful in managing these systems.
Pharmacotherapy
Commonly, serotonin reuptake inhibitors are prescribed to increase serotonin among patients with OCD. Commonly utilized SSRIs include fluvoxamine, fluoxetine and paroxetine (APA, 2010; 2013). Additionally, pharmacotherapy for this patient may include treatment with a benzodiazepine PRN to help reduce panic attacks (APA, 2010; 2013; Schmeck, Schulter-Muller, Foelsch, & Doering, 2013). The introduction of fluoxetine into the patient’s daily routine will first be attempted, based on patient self-reports of the successful use of daily treatment with fluoxetine in the past to control symptoms. Compliance with medication recommendation may be an ongoing challenge, given patient self-reports of moderate compliance with previous pharmacological intervention.
Complementary & Alternative
Complementary and alternative therapies commonly prescribed to treat OCD include deep brain stimulation and transcranial magnetic stimulation (APA, 2010). These treatments may help the patient on a deep level. Other complementary and alternative treatments that may prove relaxing or comforting for the patient may include use of sensory therapies including massage therapy to help the patient reduce adjunct symptoms including stress and anxiety.
Treatments (Community Interventions)
The relevance of identity problems in modern society is critical to understanding and assessing personality pathology (Schmeck, Schulter-Muller, Foelsch, & Doering, 2013). Common features of personality disorders including obsessive compulsive disorder is instability of mood or personality traits, lack of “synchrony” approaching treatment, and similarity among patients (Schmeck, Schulter-Muller, Foelsch, & Doering, 2013). The American Psychological Association decided not to alter its diagnostic criteria significantly for assessing patients with OCD from the IV to the V manual (Schmeck, Schulter-Muller, Foelsch, & Doering, 2013). Rather, a dimensional approach is provided, suggesting that patients may have varying levels of functional ability, and that patients may exhibit symptoms of a comorbid disorder requiring complete assessment and diagnosis (APA, 2013).
- American Psychiatric Association, (2010), Practice guideline for the treatment of patients with obsessive-compulsive disorder, VA: APA, Retrieved from: http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm.
- American Psychiatric Association, (2013), Diagnostic and statistical manual of mental disorders
V, VA: APA. - Hoermann, S., Zupanick, C., & Dombeck, M. (2013). DSM-5 the ten personality disorders:
cluster C, MentalHelp.net, Retrieved from: https://www.mentalhelp.net/articles/dsm-5-the-ten-personality-disorders-cluster-c/ - Fireman, B. Koran, L.M., Leventhal, J.L., & Jacobson, A. (2001). The prevalence of clinically
recognized obsessive-compulsive d
isorder in a large health maintenance organization, American Journal of Psychiatry, 158:1904-10. - Schmeck, K., Schulter-Muller, S., Foelsch, P.A. & Doering, S. (2013), The role of identity in the
DSM-5 classification of personality disorders, Child and Adolescent Psychiatry in Mental Health, 7:27, Retrieved from: https://capmh.biomedcentral.com/articles/10.1186/1753-2000-7-27
