Case Studies of John Murtagh(52)
——A Perfectionist and Anxious Nurse

，

1 Forewords

The obsessive compulsive disorder is common mental health problem.In US study，the 12 month prevalence is 1.2%，and life time prevalence is 2.3%.A recent epidemiological survey in Beijing suggests 12 month prevalence 0.90% and life time prevalence 2.50%[1].The obsessive compulsive disorder is one of anxiety disorders which the most common mental problem in population.General practitioners need to have knowledge of the disorder and also cooperate with mental health specialists for patient management.

2 Background

Kim Kong is a 30 year old nurse who works in the surgical ward of a major hospital.She is married to a surgeon from the same hospital and has two children aged 1 and 4 years.

3 History

She presented to the clinic in a distressed state after being verbally abused by her husband who claimed that he had been driven to frustration by the weird habits of Kim.He accused her of being ′a crazy woman′ and ′off her head′.In fact he called her a schizophrenic and said that she needed anti-psychotic medication!

Kim was ushered into a separate cubicle and questioned about her problem.Her demeanor was that of a very anxious and depressed person who was shocked by the sudden outburst from her husband.

This particular episode developed after she was worried that she had acquired ′warts′ in her work as a nurse.She had consulted other doctors who could not find evidence of any specific wart virus infection.However she has been experiencing frequent intrusive thoughts that she has picked up an infection from a patient who had warts.She feels fearful that she could pick up the infection and cause her to be seriously ill and pass it onto her children or patients.She has excoriated hands from numerous hand washings each day-sometimes up to 25 times.She cleans the kitchen， toilets and bathroom three times a day.She wears plastic gloves when handling patients and often around the home.In the past two days she was fearful of going to work and took sick days off work.

In the past she said that she has always been a ′perfectionist′ and always wanted the house to be tidy.While studying at high school and university she ensured that her work was perfect and became very anxious around exam time but was always a high achiever.She said that she worries about the health of her children and concerned about them catching ′germs′ from herself or other children.She worries about her four-year old child at kindergarten and keeps him home with even the slightest sign of a cold.

She finishes the interview with the comment ′Doctor I realise and know that my behaviour is not normal but tell me I′m not mad or going crazy′.

4 Questions

4.1 What is your provisional diagnosis?

4.2 How would you counsel the patient about the diagnosis and understanding of the problem?

4.3 How would you manage this situation?

5 Suggested answers

5.1 Provisional diagnosis Obsessive compulsive disorder(OCD) is likely the provisional diagnosis[2].The key feature of OCD is the presence of obsessions and/or compulsions.Obsessions are recurrent intrusive thoughts that cannot be ignored， resisted or reasoned away.Compulsions are repetitive actions that are performed in a stereotyped way and that are excessive and inappropriate.Compulsive acts temporarily reduce the anxiety caused by the obsessions.Individuals with OCD often also exhibit marked avoidance of objects or situations that may trigger the obsessional thoughts.

5.2 Counsel the patient It is important to handle the situation with compassion and diplomacy.After speaking to Kim in a calm and reassuring manner it would be appropriate with her permission to see her husband and explain the problem.

Inform the patient that she has OCD which is a feature of people with a perfectionist personality[3].

·Explain that OCD is an anxiety disorder.

·Reassure her that she′s not going crazy，but that she is very anxious which is a common human problem.

·Explain normal anxiety and relevance as an adaptive response.

·Explain that anxiety disorders are when anxiety becomes so severe that a person′s functioning is affected.

·Explain that obsessions are recurrent and persistent thoughts， impulses or images that are inappropriate and cause marked distress and that compulsions are repetitive behaviours or mental acts that a person feels driven to perform in response to an obsession or according to rules that must be rigidly applied and that the acts are aimed at preventing or reducing distress， or preventing a dreaded situation.However they are not realistically connected.

·Explain that the anxiety about the well being of her children has found expression in fear of infection or contamination.The fear has no basis in reality but is not psychotic or delusional because she is aware that is irrational.

·Reassure her that with treatment her anxiety and functioning are likely to improve.

5.3 Management plan The principles of management are as follows.

·Tell the patient the diagnosis.

·Establish the patient′s knowledge of the diagnosis.

·Establish the patient′s attitude to the diagnosis and management.

·Educate the patient about the diagnosis without using jargon.

·Develop a management plan in collaboration with the patient.

She needs ongoing counselling and referral to a mental health specialist -psychologist or psychiatrist for therapy and medication.Therapy will be based on relaxation strategies， cognitive behaviour therapy for obsessions and exposure and response prevention for compulsions Reassure her that medication with SSRI anti-depressant medication is an effective option[3-4].

1 劉肇瑞，黃悅勤，陳曦，等.北京市社區(qū)人群心境障礙、焦慮障礙及物質使用障礙的現(xiàn)狀調(diào)查[J].中國心理衛(wèi)生雜志，2013，27(2):102-110.

2 Blashki G，Judd F，Piterman L.General Practice Psychiatry[M].New South Wales:McGraw Hill，2007.

3 Muratgh J.Murtagh′s General Practice[M].New South Wales:McGraw Hill，2011.

4 Better Health Channel，Obsessive compulsive disorder[EB/OL].http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Obsessive_compulsive_disorder_explain.