top of page

PUID: 62 || PLAB 2 Mock 2 :: Psych Misc 6: OCD


Summary

A first-year medical student reports difficulty completing work due to anxiety-driven hand-washing and repeated door-checking. The presentation is consistent with Obsessive–Compulsive Disorder (OCD) with contamination fears and checking compulsions, exacerbated by exam stress. The task focuses on safe, structured data-gathering, explaining a working diagnosis, and outlining evidence-based management (ERP-focused CBT ± SSRI), with risk assessment and clear safety-netting. NICE+2nhs.uk+2



Key Points


Presenting Problem & Core Phenomenology (OCD)

  • Obsessions (intrusions): recurrent, unwanted thoughts about contamination; intrusive doubts about doors being left open.

  • Compulsions (responses): repetitive hand-washing; repeated checking of doors/taps/locks; done to reduce anxiety or prevent feared harm.

  • Course/Triggers: recent escalation around exam period suggests stress-related exacerbation.

  • Functional impact: time consumption; interference with studies, sleep, social life. NICE


Differential Diagnoses to consider briefly (rule out/alongside)

  • Generalised or performance anxiety disorder; depression (esp. low mood/anhedonia); OCD (most likely); adjustment disorder; medical contributors (e.g., thyroid dysfunction) to anxiety symptoms. (Use focused screening & vitals/baseline tests pragmatically.) NICE


Red Flags (must ask)

  • Suicidal ideation/self-harm risk (thoughts, intent, plan, protective factors).

  • Severe functional impairment (e.g., absent from placements/exams), self-neglect, or risk to others. NICE


Consultation Style Reminders (PLAB 2)

  • Do not assume the case from the first line; read the task and start with open questions (“Can you tell me more about what’s been happening?”).

  • Listen and avoid stock phrases; use patient-friendly language; keep a logical structure (PC → Hx → ICE → impact → risks → PMH/meds/substances/family/SH → exam/obs → explain → plan).

  • Manage time; be relevant; show rapport without over-rehearsed empathy; safety-net and follow-up. nhs.uk



Important Considerations

  • Name the pattern clearly: OCD = obsessions + compulsions causing distress and impairment.

  • Normalise without trivialising: many students experience stress, but OCD is a treatable mental health condition.

  • Explain treatment expectations: ERP-focused CBT is first-line; SSRIs may be added for moderate/severe cases or poor response/preference; benefit may take 8–12 weeks (often 4–6+ weeks at a therapeutic dose before clear improvement).

  • Setting-appropriate prescribing: In primary care, SSRIs (e.g., fluoxetine, sertraline, citalopram, paroxetine, fluvoxamine) per NICE; arrange/stimulate access to NHS Talking Therapies (self-referral possible) and university supports.

  • Confidentiality & consent to share with university wellbeing/disability services rests with the patient; offer to provide a medical note if they agree. NCBI+3NICE+3nhs.uk+3



Diagnostic Approach


Step-by-step Data Gathering (focused, structured)

  • Open the consult: confirm identity/age/role; open question about difficulty coping/finishing work.

  • Elaborate PC (OCD mapping):

    • Triggers and content of thoughts (contamination? “not safe?”).

    • Frequency, duration, intensity of obsessions; distress level.

    • Compulsions: what, how often per day, total time spent; ability to resist/delay (what happens if they delay 1–2 minutes?).

    • Functional impact: studies/placements, sleep, relationships, self-care.

  • ICE: ideas, concerns (e.g., “am I going mad?”), expectations (help with coping, exams).

  • Screen comorbidity: anxiety, depression core (low mood & anhedonia), concentration, appetite, energy; substances/caffeine.

  • Risk: self-harm/suicide (Sx/plan/means), safeguarding concerns; protective factors.

  • Background: PMH/psychiatric history; family history of OCD/Anxiety/Depression; medications; thyroid symptoms.

  • Focused exam/obs if indicated (vitals; consider TFTs where clinically appropriate).

  • Summarise & signpost next steps; check understanding. NICE



Management


1) Explain the Working Diagnosis

  • “Your symptoms fit Obsessive-Compulsive Disorder — unwanted, intrusive thoughts (obsessions) that drive you to perform repetitive actions (compulsions) like washing or checking to reduce anxiety.”

  • Emphasise treatability; outline options and shared decisions. NICE


2) First-line Treatment

  • CBT with Exposure and Response Prevention (ERP): collaboratively face triggers without ritualising, in a graded, supported way, to break the obsession–compulsion cycle. Provide a clear, non-technical description. PMC+1

  • Accessing therapy: refer/signpost to NHS Talking Therapies; many areas allow self-referral; consider university counselling/wellbeing in parallel (with consent). nhs.uk+1


3) Medication (when indicated)

  • Offer an SSRI if symptoms are moderate–severe, therapy alone is insufficient, or patient prefers combination. Discuss common choices (e.g., fluoxetine, sertraline, citalopram, paroxetine, fluvoxamine) per NICE. Set expectations: response typically 8–12 weeks, often 4–6+ weeks at therapeutic dose before clear benefits. Monitor side-effects and adherence; review at 4–6 weeks. NCBI+3NICE+3nhs.uk+3


4) Self-help & Lifestyle

  • Delay/response-prevention homework: start by delaying the hand-wash for 1–2 minutes, then extend; keep a thought/ritual log.

  • Stress reduction: regular sleep, exercise, structured study plan, reduce caffeine/stimulants.

  • Trusted resources: OCD-UK, Mind, NHS pages for psychoeducation and guided self-help. OCD-UK+2Mind+2


5) Risk Management & Safety-Netting

  • Agree a follow-up in 4–6 weeks (earlier if worsening).

  • Urgent help: if overwhelmed or experiencing self-harm/suicidal thoughts, seek immediate support via GP/111 or Emergency/A&E; crisis lines as per local area.

  • Document risk assessment and give written safety-net advice. nhs.uk


6) Study/Placement Support (with consent)

  • Offer to write a medical note for the university to facilitate reasonable adjustments (deadline extensions, exam arrangements, fewer clinical exposures that trigger rituals during therapy). Patient chooses what is shared. nhs.uk

What not to do: Avoid stimulants like methylphenidate (for ADHD, not OCD). For OCD, use ERP-focused CBT ± SSRI per NICE. NICE


Communication Skills

  • Start open; don’t assume the scenario; listen and respond to what the patient says; avoid over-rehearsed phrases.

  • Plain, non-judgmental language; check understanding; share decisions (therapy vs therapy+SSRI).

  • Validate distress (“This sounds exhausting”) while keeping the explanation clear and accurate.

  • Structure the consult and manage time; prioritise risk/safety-netting over leaflets if time is short. nhs.uk



Ethical Considerations

  • Confidentiality and consent to share with university or family; discuss benefits of disclosure and respect choice.

  • Capacity & shared decision-making; present options including doing nothing; be honest about uncertainties and timelines.

  • Work within competence; refer appropriately; use resources proportionately. nhs.uk



Additional Resources

  • NICE CG31: OCD & BDD — assessment and management (adults & young people); last reviewed 11 July 2024. NICE

  • NHS: OCD treatment page; NHS Talking Therapies (self-referral information). nhs.uk+1

  • Evidence for ERP & combined therapy: peer-reviewed reviews/meta-analyses. PMC+1

  • Patient organisations: OCD-UK, Mind (access pathways & practical tips). OCD-UK+1

Comments

bottom of page