Case Study: Boy with Handwashing and Germs

This case study involves Tyrel, an 8-year-old boy that seems to be having some concerns about germs and handwashing. He has recently been ill and since then has developed what his mother feels an obsession with washing his hands to the point he is missing school and has stopped playing with his friends. His hands are noticeably dry from over washing. He states that he is worried he missed some spots on his hands and is nervous about getting germs on that area. His medical and mental exams are all within normal parameters.

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Decision One

At this time there is a decision to make between three different diagnoses: Generalized Anxiety Disorder, Obsessive Compulsive Disorder, and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. The decision I have chosen is Obsessive Compulsive Disorder, (OCD).

OCD is diagnosed when obsessions and compulsions are time consuming, cause significant distress and interfere with daily functioning in school, social activities, family relationships, or normal routines, (www.psychiatry.org, 2017). Tyrel is describing his hand washing as a compulsion because he is afraid he will get sick if his hands are not washed. He is missing school and not playing with his friends due to the fear of getting sick.

Children with OCD suffer from obsessions and compulsions that distress them significantly enough to interfere with daily functioning and relationships, (APA, 2013). Obsessions are persistent fears or doubts and upsetting thoughts or images that a child cannot ignore or dismiss. Compulsions are repetitive actions or rituals intended to relieve the anxiety caused by the obsessions. The relief is temporary, however, because performing compulsions ultimately reinforces the obsessions, (www.psychiatry.org, 2017). Some compulsions are physical, such as washing, checking doors, tapping, or walking in a certain pattern.

Although there are similarities between OCD and PANDAS, the characteristics that are more seen in OCD are the compulsion of handwashing, with PANDAS the more defining symptoms are urinary frequency, tics or purposeless motor movements, (kids.iocdf.org, 2018). While people with GAD tend to worry a lot, they don’t typically engage in compulsive, ritualistic behaviors to cope with their anxiety. GAD is pervasive and uncontrollable and tends to involve a lot of catastrophizing or other distortions in thinking and decision making, (Goodwin, 2015).

Decision Two

My second decision for the treatment plan would to start Tyrel on Fluoxetine IR 25 mg orally at bedtime. Fluvoxamine has a rapid onset of action and is well tolerated and efficacious for the short-term treatment of pediatric OCD, (Riddle, Reeve, Yaryura, 2001), fluoxetine affects the chemicals in the brain that are not working properly. The dose of sertraline 50mg exceeds the recommended starting dose and could cause more adverse effects.Fluoxetine 100mg in the morning is more than the recommended dose and by giving it in the morning will cause drowsiness and possibly upset stomach.

Decision Three

For my third decision I would be to increase Fluoxetine to 50 mg at bedtime.Since Tyrel is showing some decrease in symptoms since beginning the 25mg dose and no reports of severe adverse effects, increasing the dose to 50mg of the Fluoxetine is the most appropriate choice.

Legal and Ethical Concerns

Ethical decision making is essential in competent clinical care.The provider should monitor and provide care for the patient that will benefit from treatment.Cognitive behavior therapy in conjunction with psychopharmacology to treat OCD will provide a complete treatment.Working along a team of colleagues to create a plan for the ongoing treatment of OCD is important as to maintain communication and ensure that improvement is being made in the symptoms. It is up to the provider to follow the therapeutic guidelines are followed and that the client meets maximum benefit of treatment.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Goodwin, G. M. (2015). The overlap between anxiety, depression, and obsessive-compulsive disorder. Dialogues in Clinical Neuroscience, 17(3), 249–260.

OCD in Kids – For Mental Health Professionals. (2018). Retrieved from https://kids.iocdf.org/professionals/mh/

Riddle MA, Reeve EA, Yaryura-Tobias JA, et al. Fluvoxamine for children and adolescents with obsessive-compulsive disorder: A randomized, controlled, multicenter trial. J Am Acad Child Adolescent Psychiatry. 2001;40(2):222–9.

What Is Obsessive-Compulsive Disorder? (2017, July). Retrieved from https://www.psychiatry.org/patients-families/ocd/w…nur