Today we will cover elements of the mental status exam that are particularly important in obsessive compulsive disorder (OCD). These are important clues that will help you with diagnosis as well as gauge treatment response. Let's get started.
Today's Content Level: Beginner; Intermediate
REMINDER OF THE MENTAL STATUS EXAM COMPONENTS
•Appearance
•Behavior
•Speech/Language
•Mood
•Affect
•Thought process
•Thought content
•Perceptual Disturbances
•Cognition
•Insight
•Judgement
•See our introduction to the mental status exam here
APPEARANCE & BEHAVIOR
•Write this section with the goal of later being able to reconjure the person's most salient features on physical appearance and their behavior.
•There is no one-size-fits-all when it comes to appearance and behavior of patients with OCD. Many patients with OCD are suffering on the inside but still able to present themselves as well-kept and presentable. On the other hand some patients with debilitating OCD may lack the focus and energy to bathe or properly groom and dress themselves or appear disheveled.
Parallels can be made to the mental status exam of patients with anxiety disorders and depressive disorders since there is significant co-occurence.
Some patients may have comorbid anxiety and present with "psychomotor agitation" associated with feelings of inner tension (hand wringing, hair pulling, pulling of clothes, pacing, fidgeting, hand or voice tremor, and inability to sit still).
Some patients may have comorbid depression and present with "psychomotor depression" which can be seen as generalized slowing of movements and speech (stooped posture, minimal spontaneous movements, downcast gaze, minimal eye contact with interviewer). Also observe for evidence of self-harm such as cut marks, burns, or scars.
•During the interview you may or may not observe compulsions (ex: checking, counting, tapping, hand sanitizing, ordering) or certain consequences of compulsions (ex: dry cracked hands from frequent hand washing)
•Observe for vocal or motor tics. Up to 30% of individuals with OCD have a lifetime tic disorder. This is most common in males with onset of OCD in childhood. 1
SPEECH / LANGUAGE
•Speech and language tends to be less affected in OCD compared to other conditions such as psychotic, bipolar, or depressive disorders. Pay attention to rate, tone, volume, and rhythm.
•Patients with severe anxiety may have difficulty speaking such as stammering or a vocal tremor. Patients with comorbid depression may have decreased rate and volume and variation in tone of speech (slow, soft, and monotone).
MOOD / AFFECT
•Patient's with OCD are typically very distressed/bothered by their symptoms, so their stated mood can be frustrated, anxious, afraid, worried, exhausted, tense, irritable, hopeless, depressed, worthless, guilty, miserable, etc.
•Obsessions and compulsions and related anxiety are the core clinical features, however it is important to realize that some patients primarily choose to discuss a particular somatic complaint, consequence of their compulsions, or depressed mood as their primary symptom.
•Other patients may deny any problems and may not appear to be particularly anxious at first glance. Family members or employers may suggest they come in for treatment due to their observations of obsessional thought patterns, witnessing repetitive behaviors, avoidance, or the consequences of their symptoms (ex: constantly showing up late to work due to time-consuming rituals).
•The emotional range can vary. Some patients may be blunted or restricted which are a reduction in the range and intensity of emotional expression. They may also be guarded, which means filtering their emotional expression and using caution in disclosing information. Others may be show more lability and higher emotional expression when experiencing acute anxiety.
THOUGHT PROCESS / THOUGHT CONTENT
•Disorders in thought process relate to the way in which ideas and languages are formulated and organized. OCD alone does not typically cause a disorganized thought process.
If appropriately questioned, patients with OCD will reveal their obsessions and compulsions.
Obsessions = thoughts/urges/images that are recurrent/intrusive/undesired and cause distress/anxiety.
Compulsions = repetitive behaviors/mental rituals that the individual feels driven to perform (often in response to obsessions) aimed at preventing or reducing anxiety/distress.
•As mentioned in an earlier lesson, common themes include contamination, symmetry, doubt/safety, violence/sexual, and morality/religion.
•Patients with OCD, like depressed patients, sometimes have negative views of themselves and the world.
•If present, clearly describe in your documentation the extent of their suicidal (and homicidal) thoughts and include their specific thoughts, their intent, plans, research, preparatory actions, etc. This will weigh heavily in your risk assessment and safety plan. Risk assessments are discussed in detail here and here.
PERCEPTUAL DISTURBANCES
•Perceptual disturbances are not associated with OCD alone, but keep in mind that at first glance an intrusive image/urge may be initially confused as psychosis unless further clarified. Grandiose/bizarre/persecutory delusions can lead to obsessive thoughts and compulsive behaviors in some patients with schizophrenia that may resemble an OCD pattern with poor/delusional insight.
COGNITION
•Commonly obtained through a general sense of cognitive functioning obtained through conversation, however additional tests (MMSE, MoCA) can expand this exam if needed.
•Severe OCD symptoms and associated anxiety can lead to difficulty concentrating and may also lead to confusion. Significant obsessional thought patterns may lead to difficulty focusing on anything other than their anxious ruminations.
INSIGHT / JUDGEMENT
•OCD is typically ego-dystonic. In this context this means that most patients often have good insight into the fact that their obsessions and compulsions are irrational or out of proportion to the actual threat. This does not make it any easier, however, to control their symptoms.
•Some patients, however, have varying degrees of insight about the accuracy of the beliefs that underlie their OCD symptoms. You should specify whether patients have good, fair, poor, or absent insight / delusional beliefs (<4%) 2.
•Judgment is best assessed by reviewing patients' actions in the recent past and their behaviors during the interview.
CONCLUSION
Nice work today. We covered some important factors regarding the mental status exam in patients with OCD. Next lesson will be a review quiz before we proceed to treatment of OCD.
Resources used today include Kaplan and Sadock's Synopsis of Psychiatry, The Psychiatric Interview, and Pocket Psychiatry.
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