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1. Establish and maintain a therapeutic alliance.

  • Tailor communication style to the patient'€™s needs and abilities.

  • Allow patients with excessive worry or doubting time to consider treatment decisions. Repeat explanations if necessary.

  • Attend to transference and countertransference, which may disrupt the alliance and adherence.

  • Consider how the patient'€™s expectations are affected by his or her cultural and religious background, beliefs about the illness, and experience with past treatments.

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2. Assess the patientâ??s symptoms.

  • Use DSM-IV-TR criteria for diagnosis.

  • Consider using screening questions to detect commonly unrecognized symptoms (Table 1).

  • Differentiate OCD obsessions, compulsions, and rituals from similar symptoms found in other disorders (Table 2).

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Table Reference Number
TABLE 1. Example Obsessive-Compulsive Disorder Screening Questions
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Table Reference Number
TABLE 2. Symptoms of Other Psychiatric Disorders to be Differentiated From the Obsessions, Compulsions, and Rituals of Obsessive-Compulsive Disorder (OCD)
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3. Consider rating the patientâ??s symptom severity and level of functioning.

  • Recording baseline severity provides a way to measure response to treatment.

  • A useful symptom scale is the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which is available on web sites such as http://healthnet.umassmed.edu/mhealth/YBOCRatingScale.pdf.

  • Useful self-rated depression scales include the Patient Health Questionnaire (PHQ-9), the Beck Depression Inventory–II (BDI-II), the Zung Depression Scale, and the patient versions of the Inventory of Depressive Symptoms (IDS) or the Quick-IDS.

  • A useful disability rating scale is the Sheehan Disability Scale (SDS).

  • A useful quality-of-life scale is the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) or the more detailed World Health Organization Quality of Life Survey (WHOQOL-100).

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4. Enhance the safety of the patient and others.

  • Assess for risk of suicide, self-injurious behavior, and harm to others.

  • Collateral information from family members and others can be helpful.

  • Take into consideration factors associated with increased risk of suicide, including specific psychiatric symptoms and disorders (e.g., hopelessness, agitation, psychosis, anxiety, panic attacks, mood or substance use disorders, schizophrenia, borderline personality disorder) and previous suicide attempts. See APA'€™s Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors.

  • Evaluate the patient'€™s potential for harming others, either directly or indirectly (e.g., when OCD symptoms interfere with parenting).

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5. Complete the psychiatric assessment.

  • See APA'€™s Practice Guideline for the Psychiatric Evaluation of Adults.

  • Assess for common co-occuring disorders, including mood disorders, other anxiety disorders, eating disorders, substance use disorders, and personality disorders.

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6. Establish goals for treatment.

  • Goals of treatment include decreasing symptom frequency and severity, improving the patient's functioning, and helping the patient to improve his or her quality of life.

  • Reasonable treatment outcome targets include less than 1 hour per day spent obsessing and performing compulsive behaviors, no more than mild OCD-related anxiety, an ability to live with OCD-associated uncertainty, and little or no interference of OCD with the tasks of daily living. Despite best efforts, some patients will be unable to reach these targets.

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7. Establish the appropriate setting for treatment.

  • In general, patients should be cared for in the least restrictive setting that is likely to be safe and to allow for effective treatment.

  • Outpatient treatment is usually sufficient. More intensive settings (e.g., hospitalization, residential treatment, or partial hospitalization) may be needed by patients who have significant suicide risk, pose a danger to others, are unable to provide adequate self-care, have co-occurring psychiatric and general medical conditions, or need intensive treatment or monitoring.

  • Home-based treatment may be needed by patients who are unable to visit an office or clinic because of impairing fears or other symptoms.

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8. Enhance treatment adherence.

  • Recognize that the patient'€™s fears, doubting, and need for certainty can influence his or her willingness and ability to cooperate with treatment and can challenge the clinician'€™s patience.

  • Provide education about the illness and its treatment, including expected outcomes and time and effort required.

  • Inform the patient about likely side effects of medications, inquire about side effects the patient may be unwilling to report (e.g., sexual side effects), respond quickly to concerns about side effects, and schedule follow-up appointments soon after starting or changing medications.

  • Address breakdowns in the therapeutic alliance.

  • Consider the role of the patient'€™s family and social support system.

  • When possible, help the patient to address practical issues such as treatment cost, insurance coverage, and transportation.

Table Reference Number
TABLE 1. Example Obsessive-Compulsive Disorder Screening Questions
Table Reference Number
TABLE 2. Symptoms of Other Psychiatric Disorders to be Differentiated From the Obsessions, Compulsions, and Rituals of Obsessive-Compulsive Disorder (OCD)

References

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