A CASE PRESENTATION ON

OBSESSIVE-COMPULSIVE DISORDER IN A
PATIENT INITIALLY MANAGED FOR
SCHIZOPHRENIA

BY:
ADEYEMI H.S
RESIDENT, MENTAL HEALTH DEPARTMENT
OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITALS COMPLEX, ILE-IFE
27TH JUNE, 2022

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BIODATA

• The patient is Miss O.I, a 21year old 400 level medical

student of Obafemi Awolowo University (OAU), Ile-Ife, who
lives off campus at Asherifa area, a Christian and of Yoruba
ethnicity
• First seen in our unit via the clinic on 28th January, 2022
• Informant: The Patient

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PRESENTING COMPLAINTS

4 years history of:

Hearing a voice inaudible to others commanding or

discussing her
A belief that an external agent is putting thoughts or images
in her mind

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OTHER IMPORTANT FINDINGS IN THE HISTORY

No persistent Low mood and weeping spells

Energy and interest in pleasurable activities were preserved

No suicidal ideations or attempts

She however had a low self esteem and lost of concentration

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OTHER IMPORTANT FINDINGS IN THE HISTORY

No history of undue happiness or increased energy

No history of unusual beliefs or other abnormality of

thought possessions

Had first MB Exam prior to presentation

Occasional on Tab Olanzapine 2.5mg nocte about 3weeks

prior to presentation
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HISTORY CTD
This was the 3rd exacerbation of symptoms (First episode of
mental illness) when she was first seen at the clinic (on Tab
Olazapine 2.5mg nocte)

The first was in 2017 with similar symptoms: she didn’t seek
hospital care

The second was in 2019 with similar symptoms : She didn’t

seek psychiatric care and didn’t get better in between the
exacerbations
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HISTORY CTD
Managed for with 3 years Hx of Migraine in our facility since 2019 on Tab propanolol 40mg
daily and tab sumatriptan 50mg PRN not more than one (1) dose. Did MRI and MRA which
were normal. Defaulted neurology clinic when symptoms didn’t improve

Diagnosed PUDx in 2016, now on antacid

2nd of 5 children in a monogamous family setting

Father died at 59years when patient was 18 years old (?cause)

Mother is 56year old and runs a business in Ogun state

Family dynamics is cordial

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HISTORY CTD
History of mental illness (Schizophrenia) in 2 paternal uncles

Psychosexual Hx:
LMP was 29/12/2021, menstruate for 4days in a 28day circle, Heterosexual in
orientation, Puberty at 13year , Menarche at 14year, has not attained coitache,
sexually abused by armed rubbers at 14years in 2015 but didn’t lead to rape, not in
any intimate relationship

No history of alcohol/psychoactive drug use/conflict with the law

Described as having few friends, like watching movies, hardworking, likes

reading novels, optimistic and reserved
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MENTAL STATE EXAMINATION

2nd person auditory hallucination, voice commanding or

discussing
Thought insertion
Impaired judgement
Partial insight

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PHYSICAL EXAMINATION

There were no abnormal findings on general physical and

systemic examination
Weight: 86.5kg
Height ?
Blood pressure: 100/60mmHg
Pulse Rate: 75bpm
Respiratory rate: 22cpm

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DIAGNOSTIC FORMULATION

A 21 year old woman, 300 level medical student of OAU with

a 3rd exacerbation of mental illness (first episode)
characterized by 4 years history of hearing a voice inaudible to
others commanding or discussing her and a belief that an
external agent is putting thoughts or images in her mind.
Associated history of mental illness in two(2) paternal uncles
of hers

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DIAGNOSTIC FORMULATION CTD

Items of Phenomenology
2nd person auditory hallucination, voice commanding or
discussing
Thought insertion
Impaired judgement
Partial insight

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DIAGNOSTIC FORMULATION CTD
Axis I:
i. Paranoid Schizophrenia (2nd person auditory hallucination- voice commanding or
discussing, and thought insertion)
ii. Migraine
iii. PUDHx

Axis II: Related disability in Personal care (Moderate), Occupation (Moderate), Family
(Moderate) and Broader social context (Moderate)

Axis III:
i. Predisposing factor : 2nd degree relatives with mental illness
ii. Precipitating: Stressful events, previous exacerbation of symptoms and lack of psychiatric
care
iii. Perpetuating: Lack of psychiatric care
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MANAGEMENT

Short term goals: Achieve resolution of Psychosis and to Psychoeducate Patient and
relatives on nature of illness

Long term goals: Achieve a functional state as close as possible to her premorbid state
i. Focus on functioning
ii. Support from mother for medication and clinic adherence

Biological investigations: E/U/Cr; FBS, 2HPP; FBC+Diff.

Psychological investigation: PANSS- P(13/49), N(10/49), CS: +3, G(28/112),

T(51/210)

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MANAGEMENT CTD

For outpatient care

Tab Olanzapine 2.5mg nocte
To see in 2weeks in clinic with investigations results and
with the mother

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 Prognostic Factors
Overall - Guarded
Favorable Unfavorable
Female Young Age
Predominance of Single
positive symptoms
First episode Student
Good family support Family history of MI
On medication Time of Presentation
from onset of symptoms

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PROGRESS REPORT
After 2weeks (1st follow-up)
Investigation results:
 FBG: 5.6mmol/l
2HPP: 5.9mmol/l

E/U/Cr: Na:135; K: 3.8; HCO-3: 27, Cl-: 102, Urea:3.8 (mmol/l)

Cr: 90umol/l

FBC+Diff: PCV: 37%, PLT: 523000c/mm3,

WBC: 8300c/mm3:
N: 38%
E: 0%
L: 62%
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PROGRESS REPORT CTD

After 2weeks (1st Follow-up)

Seen with mother and both were psychoeducated
Did not do well on Tab Olanzapine 2.5mg nocte
i. Complained of excessive sleep
ii. Irresolution of symptoms

Plan:
D/C Olanzapine
Tab Risperdal 2mg nocte commenced
Planned for depot at next appointment in a week
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PROGRESS REPORT CTD
2nd clinic appointment (A week after the 1st)

The patient was seen alone

Complained of feeling restless
Symptoms not resolving
Will not be able to sustain Risperdal cost in the long run

Plan:
She was switched back to Tab Olanzepine 5mg nocte, then BD after a week
Had IM flupenthixol decanoate 20mg stat
To see in 5 weeks in clinic
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PROGRESS REPORT CTD

3rd Appointment (5 weeks 4days after the 2nd)

The patient could not make it to clinic 4 days earlier

Seen on the ward with the mother
The patient has developed worsening of symptoms

Presented with:
i. A belief that an external agent is putting strange thoughts in her mind
ii. Undue sadness, Loss of interest, Reduced energy
iii. Feeling tired of living and wishing to sleep and not wake up
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PROGRESS REPORT CTD
3rd Appointment (5 weeks 4days after the 2nd)

She said the symptoms have been ongoing for 4years now

Thought of overdosing in relation to inserted thoughts on Tab amitriptyline

when she was placed on it at a peripheral hospital about 3 years ago

Depressive symptoms have been on and off and have been able to function in
between

However, symptoms have increased in severity during this visit

 Denied hallucinatory experiences, unusual beliefs and other abnormality of

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PROGRESS REPORT CTD

3rd Appointment (5 weeks 4days after the 2nd)

MSE:
Depressed
Affect was in keeping with the mood
Thought insertion
Impaired judgement
Partial insight

Physical examination was stable

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PROGRESS REPORT CTD

3rd Appointment (5 weeks 4days after the 2nd)

Differentials
i. Schizophrenia ( Based on one core symptom- thought insertion)
ii. Recurrent depressive disorder, current episode severe with
psychotic symptom (based on core depressive symptoms,
delusion of thought insertion and suicidal ideas)

Plan:
To admit in mental health ward ( Declined because of logistic)
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PROGRESS REPORT CTD

3rd Appointment (5 weeks 4days after the 2nd)

Plan Ctd:
D/C Olanzapine
Patient and mother were psychoeducated
Tab Trifluoroperazine 5mg BD was commenced
Tab Amitriptylline 50mg nocte
Tab Benzhexol 5mg mane
To be seen in the hospital daily to ensure she does not attempt suicide
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PROGRESS REPORT CTD

4th Appointment (Following Decision to be seen daily)

The patient didn’t come the first 2days the decision to be seen daily was made

She came the 3rd day with complaint of seeing image of trees when she closed
her eyes. No hallucination in any sensory modality.

Seen with the mother

She was worried not able to continue with her education because the thoughts are
persistent and distressing despite attempt to ignore it

 Still experiencing persistent thoughts which was described as external

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PROGRESS REPORT CTD

4th Appointment (Following Decision to be seen daily)

MSE:
Depressed
Affect was in keeping with the mood
Thought insertion
Impaired judgement
Partial insight
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PROGRESS REPORT CTD

Plan:
She and her mother were psychoeducated

For medical report to her faculty in order for time off from school

IM flupenthixol decanoate 20mg stat, then 2weekly

Continue other medications

To see on Monday during consultant ward round

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PROGRESS REPORT CTD

5th Appointment (Following Decision to be seen daily)

The patient came the following day after the 4th appointment instead of 3days
later due to worsening of symptoms

Seen with the mother and younger sister

Thought putting in her mind that her mother and younger sister want to kill harm

Regular on medications but symptoms worsened

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PROGRESS REPORT CTD

5th Appointment (Following Decision to be seen daily)

MSE:
Depressed
Affect was in keeping with the mood
Thought insertion
? 2PAH, voice discussing
Persecutory delusion (secondary)
Impaired judgement
Partial insight
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PROGRESS REPORT CTD

5th Appointment (Following Decision to be seen daily)

Differentials:
i. Schizophrenia
ii. Recurrent depressive disorder, current episode severe with psychotic symptom

Plan:
Admit in MHW
Counsel for ECT and take informed consent
Tab TFP 5mg BD
Tab Amitriptylline 50mg nocte
Tab Benzhexol 5mg PRN
For further review
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ADMISSION ON MENTAL HEALTH WARD

Progress Report (3rd day of Admission)

Available Investigations:
FBG: 5.5mmol/l
2HPP: 5.7mmol/l

E/U/Cr: Na:134; K: 4.1; HCO-3: 25, Cl-: 106, Urea:2.7 (mmol/l)

Cr: 69umol/l

FBC+Diff: PCV: 37%, PLT: 324000c/mm3,

WBC: 10000c/mm3:
N: 72%
E: 0%
L: 28%
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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report (3rd day of Admission)

Consult sent to Anaesthesia having taken informed consent

for ECT
Other Care was continued
IV Diazepam discontinued as PRN

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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report (4th day of Admission)

Complained of fever, Headache and cough

MP done was positive for Malaria parasite
An assessment of malaria with URTI was made
Treated with Antimalaria and Oral Augumentin

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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report (5th day of Admission)

1st shot of ECT on account of treatment resistant schizophrenia with

depressive symptoms was commenced with good seizure quality
Other care continued

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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report (6th day of Admission)

Developed urinary retention the following morning after commencent of ECT

Made an assignment of urinary retention 2◦ anticholinergic effect of medications

TFP, Amitryptillin and Benzhexol stopped

Anticholinergic (Artropine/Glycopyrolate) used by the anaesthesia could not be

discontinued

Urinary catheter passed and place on oral flagyl

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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report (7th day of Admission)

2nd shot of ECT given with good seizure quality

Thoughts intruding her mind reduced in frequency and intensity

Consult was sent to Medical Team on Call to review on account of urinary

symptoms: Resolving UTI
i. IVF N/S 1L 8hrly for 24hr
ii. Urinary catheter tip taken for Mcs
iii. IV Levofloxacin 500mg daily commenced by the medical team for 5days
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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report (9th day of Admission)

Thoughts intruding her mind reduced in frequency and intensity

Urinary retention resolving

Had 3rd shot of ECT

D/C TFP, Amitriptylline and Benzhexol

Recommenced on Tab Risperdal 2mg nocte

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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report ( from 11th to 17th day of Admission)

4th session on day 11th of admission had good seizure duration

From the 5th shot of ECT, the machine was not delivery sufficient current with no
seizure activity seen

The same happened during the 6th session necessitating an extra repeated session on
17th day of admission

ECT was discontinued as patient said thoughts have reduced in frequency and intensity

Tab Risperdal 2mg nocte was maintained

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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report ( 3 weeks on Admission)

The patient is overly worried about the persistent disturbing thoughts

During interview on CWR to clarify symptoms as clinical improvement

was not substantial, the patient was able to explain that the thoughts were
not coming from outside

The thoughts come within her

According to her, sometimes, compulsions or rituals follow after the

thoughts which she must obey in order to have her peace
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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report ( 3 weeks on Admission)

Though she believed she can not think in that manner thereby making her belief it can’t be
hers (Must be a false)

Falsity of the experience unlike delusional experiences which the individual always
convincingly hold true

 The thoughts persist despite her effort to exclude them

Her experience is making her depressed and affecting her functionality

 Having suicide ideas (Cutting self)

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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report ( 3 weeks on Admission)

MSE:
Depressed
Affect was in keeping with the mood
Obsessive thoughts
Suicide ideas
Impaired judgement
Partial insight
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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report ( 3 weeks on Admission)

Assignment: OBSESSIVE COMPULSIVE DISORDER

Plan:
Commence Tab fluoxetine 20mg mane
Tab bromazepam 1.5mg nocte for 1 week
Tab Risperdal 2mg nocte

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ADMISSION ON MENTAL HEALTH WARD CTD
• Progress Report ( 22nd day on Admission)
 After commencement of fluoxetine the patient ingested about 3-4 spoons of detergent mixed with
water to end life

 Complained of throat and abdominal discomfort

 Consult was written to MTOC and Chemical pathologist

 She was placed on IVF N/S 1L 8hrly

 1 scoop of activated charcoal 4hly for 24hrs

 IV rabeprazole 50mg 12hrly for 48hrs

 To do LFT and EUCr

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ADMISSION ON MENTAL HEALTH WARD CTD
Progress Report ( 4 weeks on Admission)
Thoughts are still persisting

Tried not arguing with the thoughts

Want to kill self and asking for euthanasia

Having persistent sadness

It is like her head will blow due to the intruding thoughts

Had cog wheel rigidity due to antipsychotic use

 LFT: Bilir Total: 8, Conj. Bilir.: 2, Alk Phos: 126, GTP: 81, SGOT: 26, SGPT: 25 (IU/l), Albm.: 39g/l44
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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report ( 4 weeks on Admission)

Plan:
↓Tab Risperdal to 1mg nocte
↑Tab fluoxetion to 40mg mane
↑Tab bromazepam to 3mg mane for 1/52

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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report ( 5 weeks on Admission)

Thoughts are still persisting

Tried ignoring it but not working

Still having suicide ideas

Having persistent sadness

Complained of migraine
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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report ( 5 weeks on Admission)

Plan:
CT Tab Risperdal 1mg nocte
↑Tab fluoxetion to 60mg mane
CT Tab bromazepam 3mg mane for 1/52
To invite neurology to review:
i. Tab gabapentin 300mg nocte
ii. Catgut 1mg daily
iii. IM diclofenac 75mg stat
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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report ( 6 weeks on Admission)

Not much changes with regard to the thoughts
Tried putting the thoughts under control but failed
Has not be making efforts to change the cognitive distortions from the
thoughts as suggested to her
No more suicidal ideas
More cheerful but the patient denied it
Loss of appetite
Poor sleep (Initiation)
Another review by neurology regarding migraine
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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report ( 6 weeks on Admission)

Plan:
CT Tab Risperdal 1mg nocte
↑Tab fluoxetin to 80mg mane
CT Tab bromazepam 3mg but nocte for 1/52
Tab VitBco II tds
Neurology review: Psychogenic headache
i. D/C gabapentin and catgut
ii. Explore relaxation techniques
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ADMISSION ON MENTAL HEALTH WARD CTD

Progress Report ( 7 weeks on Admission)

The patient mother said the patient looks more lively and cheerful

She interacted with others more

On the thoughts, the patient said they are still there but less
distressing

No suicidal ideas

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ADMISSION ON MENTAL HEALTH WARD CTD
Progress Report ( 7 weeks on Admission)
MSE: Appears stable

Plan:
Discharge home
CT Tab Risperdal 1mg nocte
CT Tab fluoxetion 80mg mane
↓Tab bromazepam to 1.5mg nocte for 1/52
Tab VitBco II tds
For psychotherapy when stable enough- CBT
See in 2 weeks at the clinic for continued care
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2 WEEKS AFTER DISCHARGE

• Progress report
Seen with mother
The patient complained about vomiting and restlessness
The thoughts still persist but reduced in frequency and intensity
Plan:
Tab Fluoxetin was tapered down from 80mg to 20mg, and discontinued
Commenced on Tab clomipramine 25mg nocte for 2weeks, then
increased to 50mg nocte
See in 1month
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PROGNOSIS OF OCD

• Good prognosis
Presence of precipitating events
Episodic symptoms

• Poor Prognosis
Presence of personality disorder
Male gender
Tic related form of OCD
Overvalued ideas
Presence of comorbidity
Onset in childhood
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 Prognostic Factors of OCD in this Patient
Overall - Good
Favorable Unfavorable
Female Overvalued ideas
Presence of Presence of comorbidity
precipitating events
Episodic Symptoms
Absence of TIC form
Absence of personality
disorder
Late presentation

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 THANK YOU FOR LISTENING

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