The assessment will focus on a patient with Obsessive-Compulsive Disorder (OCD) and analyze various aspects that are necessary when dealing with the patient. The evaluation will evaluate the history of the patient to identify measures that would be implemented to create a treatment plan for the patient.
Background Information
Cate is a 33year old female banker, who was diagnosed with Obsessive Compulsive Disorder at the age of 9 years. Throughout the years, Cate has successfully managed the condition with medication, which has been part of her life. Following significant transitions in her life over the past six months, Cate began experiencing recurrent OCD symptoms despite taking her medication as prescribed. During this time, Cate did not have control of her OCD, thus prompting her to seek therapy. The fact that Cate had separated with her husband of 8 years was an issue that created an emotional toll resulting in the new OCD symptoms. Additionally, the issue of separation created a significant issue on the patient, considering that she was worried about her daughter.
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Presenting Problem
The present condition of the patient exhibits symptoms associated with increased anxiety, sleeping problems, insecurity, and mood changes. The development of the recurrent OCD symptoms is attributed to the significant transitions experienced in her life within the six months.
History of Present Illness
An analysis of the history of the illness indicates that Cate began exhibiting the symptoms of OCD at a tender age, where she required a high standard of order for her to feel safe in her environment. During this time, the parents and teachers of Cate focused on maintaining a specific routine, considering that any change would result in extreme agitation and anxiety.
Past Psychiatric History and Medical History
At the age of four, a psychologist performed a battery of test to the patient but was hesitant to make conclusions on the diagnosis of OCD. The psychologist, in this case, provided provisional diagnosis citing probable OCD. However, at the age of nine, Cate was diagnosed with OCD and was placed under medication, which she would use for the better part of her life.
Developmental History
Further evaluation of the patient indicated that there was no history of substance use in her entire life. There was no family psychiatric and psychosocial history, thus no possible link with the current condition of the patient. Although the condition may contain hereditary aspect, there was no information indicating that Cates’s OCD was hereditary considering that no one in the family history was diagnosed with the condition.
Physical Assessment
The physical assessment of the patient was initiated by the move to seek intervention for her obsessive thoughts and compulsive actions. The evaluation involved the analysis of the occurrence of significant symptoms associated with OCD and identifying the level of consistency of the symptoms. The significance of physical assessment is to rule out other conditions that may present symptoms similar to those of OCD.
Diagnosis
To engage in the proper differential diagnosis, it is essential to focus on undertaking a mental status examination to understand the underlying factors that may be attributed to the condition of the patient (Hirschtritt, Bloch, & Mathews, 2017). The first step in the mental status exam includes the analysis of General appearance and behaviour. The second important aspect of the mental status exam is an evaluation of speech and mood presented by the patient. Other factors that are necessary to consider during the mental status exam include perception of the patient, attention, orientation, and personal judgment (Öst, Havnen, Hansen, & Kvale, 2015). The physical assessment and mental status examination of the patient led to the conclusion that the patient has OCD. The diagnosis is attributed to numerous tests and examination that evaluates the signs and symptoms presented by the patient.
Treatment Plan
The treatment plan that is appropriate for the client involves talk therapy and medication. A clinical psychologist and a psychiatrist would have a significant role in the development of a treatment plan that would suit the patient to help in creating a lasting solution for the condition (Dayan, Berger, & Anholt, 2017). The different types of therapies that are relevant for the patient include cognitive behavioural therapy, psychotherapy, group psychotherapy, and aversion therapy. The implementation of the mentioned therapies would play a significant role in providing the patient with the ability to overcome the condition by dealing with the symptoms presented concerning the condition. Additionally, the severity of the condition may require the use of medication to help in overcoming the condition. The prescribed medication for the condition would include selective serotonin reuptake inhibitors (SSRIs), which helps in easing symptoms associated with depressed mood and anxiety (Riesel, Endrass, Auerbach, & Kathmann, 2015). Other medications may include Anxiolytic and antidepressants, which help in managing the condition.
Part 2: Family Genogram
The family genogram provides a striking display of family relationships, which may help in the analysis of the hereditary aspects associated with the OCD condition of the patient (DeMaria, Twist, & Weeks, 2017). In this case, the genogram indicates the three generations in Cate's family from her maternal grandparents to her daughter.
References
Dayan, A., Berger, A., & Anholt, G. E. (2017). Enhanced action tendencies in obsessive-compulsive disorder: An ERP study. Behaviour research and therapy , 93 , 13-21.
DeMaria, R., Twist, M. L., & Weeks, G. R. (2017). Focused genograms: intergenerational assessment of individuals, couples, and families . Routledge.
Hirschtritt, M. E., Bloch, M. H., & Mathews, C. A. (2017). Obsessive-compulsive disorder: advances in diagnosis and treatment. Jama , 317 (13), 1358-1367.
Öst, L. G., Havnen, A., Hansen, B., & Kvale, G. (2015). Cognitive-behavioural treatments of obsessive-compulsive disorder. A systematic review and meta-analysis of studies published 1993–2014. Clinical Psychology Review , 40 , 156-169.
Riesel, A., Endrass, T., Auerbach, L. A., & Kathmann, N. (2015). Overactive performance monitoring as an endophenotype for obsessive-compulsive disorder: evidence from a treatment study. American Journal of Psychiatry , 172 (7), 665-673.
