Identifying OCD and understanding how sufferers think

Obsessive-compulsive disorder signs physical therapists, occupational therapists and medical case managers may see and how overcome OCD.

Cheryl, an occupational therapist, is visiting Kari who became depressed and housebound after losing her 15-year office manager position. She was impeccable but slow in finishing her work. Her company lost an account because she missed a deadline; she needed to be certain that there were no mistakes in the contract. She worried she would be held liable for a contract that misstated the terms.

Cheryl is accustomed to seeing people’s homes in myriad levels of tidiness, or lack thereof. But she notices that Kari’s household is disorganized, dusty, and neglected. She has unpaid bills and is at risk of being cut off from utility services. Cheryl is there to assist Kari with putting order back in the house and to supervise Kari while she pays her bills. Kari is resistant to Cheryl’s help, but she finally agrees it is needed.

They agree that paying the bills is the immediate priority. Kari gets her checkbook from her purse, sits down, and looks at the electricity statement showing she is three months behind. Kari is financially stable but, nonetheless, seems overwhelmed in performing this task. Cheryl prompts her to start writing out the check so it can be mailed before the shutoff date.

Kari seems stuck while reading the statement and is having trouble moving on. Cheryl asks if there’s something Kari doesn’t understand on the statement, and Kari shushes her because she has been interrupted and starts rereading the statement again.

After a long silence, Cheryl reminds Kari that they only have 20 minutes left to get the bills paid. Kari hesitates but starts to fill out the check. She keeps looking back at the statement to make sure she is paying the right amount, which takes up more of the remaining time. Cheryl prompts Kari to stay focused on finishing the check. Knowing that depression can interfere with concentration, Cheryl is concerned about how slow Kari is in her task completion. Kari wonders if there may be something else going on.

In order to assess the situation, Cheryl asks Kari about her behavior.

“I need to be absolutely sure that I fully understand the statement and pay accurately,” Kari says. Kari also fears she will unintentionally write profane words as she fills out the check. She looks to make sure she has not acted on the fear. Cheryl tries to reassure Kari that she has done no such thing, but Kari is still anxious about it.

Cheryl asks permission from Kari to contact her psychiatrist, Dr. Nelson, to share her observations. Kari provides consent, and Cheryl leaves with the envelope addressed to the electric company to put in the mail. Cheryl places a call to Dr. Nelson and describes her observations via voice mail. Dr. Nelson calls her back and asks a series of questions that result in a scheduled appointment for Kari to be assessed. Dr. Nelson mentions a possible diagnosis of OCD based on Cheryl’s assessment.

During Kari’s next appointment, Dr. Nelson will administer the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), considered the gold standard measurement tool (and can be accessed by anyone). The scale first asks five questions about obsessions:

Why was OCD identified as a working diagnosis?

1. Kari was perfectionistic in her behavior but now had gone to the other extreme; she no longer could maintain that perfect standard and simply gave up.

2. She was slow and too methodical in reviewing the bill. The bill was in arrears because every time she went to pay it, she doubted what she read and was worried she’d write something inappropriate and embarrassing on the check.

3. Kari was essentially avoiding her obligations because she was unable to achieve complete certainty that she was doing things “right.”

Calling Dr. Nelson was the most helpful intervention under these circumstances. If the OCD diagnosis was confirmed, she could begin a course of medication (SSRIs) and be referred to a behavior therapist who specializes in treating OCD.