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You are a FY1 doctor on a community psychiatry placement. You have been asked to take a focussed history from Dee Veetee, a 23 year old woman who was referred by her GP with a problem with her thoughts. She has a history of anorexia nervosa and takes no regular medications.

Please take a history from Dee and perform a mental state examination. You will then be asked to discuss the case with the examiner.

You are Dee Veetee, a 23 year old woman who has been experiencing unwanted thoughts.

HPC: For the past 3 weeks you have been extremely worried that everything is covered in “superbug” bacteria. It started after you a news report on antibiotic resistant strains of bacteria and you became extremely worried that everything in your house and office might be covered in this bacteria. You are terrified that you become contaminated every time you touch something and have to go and wash your hands every time you touch a door handle or a table.

Because your hands don’t feel clean enough after just one wash, you have to do it four times over each time you wash. It takes about fifteen minutes and you scrub each finger individually and really scour around the fingernails, to the extent that your hands have become cracked and sore. After you have washed your hands in this way, the worry subsides a little. You have also started cleaning the kitchen and any surfaces in the house down with bleach, which you do two times a day.

You are aware that the thoughts are unreasonable but you know they are your own. You cannot resist the need to wash your hands; you have tried to stop yourself by breathing deeply and trying to calm down but you can’t. This is extremely frustrating and stressful for you: you have always considered yourself to be a sensible (and actually quite cynical!) woman, and this behaviour is so unlike you. Unfortunately, you just can’t help yourself – this brings you to tears in your kitchen on most days.

Despite this, you generally do not think you have felt particularly low in mood and you have not felt anxious about anything other than the bacteria.

You have been able to go to work as normal, although you have been very careful not to touch anything and have had to run off to the bathroom to wash your hands several times a day. You think that your colleagues might have begun to notice this because it has started taking up a significant portion of your day. Your work has begun to suffer – you work as a graphic designer – and you’re falling behind on deadlines, which again is not like you at all. Your work boasts a ‘pastoral’ service, which is supposed to look after people with problems, however your friend Harry was recently fired after confiding in that group, so you don’t want to tell them anything!

You went out for drinks with friends last week and felt that you were okay as long as you didn’t touch anything, which you managed with only one time where you needed to go and wash your hands.

PMH/PPH: You are normally fit and well. You suffered from anorexia nervosa as a teenager for which you were admitted to a unit for refeeding but you have since managed to overcome that through behavioural therapy.

DH: You take no medications and have no allergies. FH: Your father died in a car accident when you were 9 years old because he wasn’t wearing his seat belt. You were in the car at the time and it was a very traumatic experience.

You have no family history of psychiatric illness or other relevant medical illnesses.

SH: You live alone in a small house close to the estate agents where you have worked for the past five years. You normally enjoy your job and you have a close circle of friends who live nearby. Your mother lives close by with your 17 year old brother, they have always been very supportive, especially when you were having your issues with anorexia.

You rarely drink alcohol as you don’t like the taste, you do not smoke and you have never taken any illicit drugs. You have never had any contact with the police.

ICE: You have heard a little about OCD on TV and in magazines and you are worried that you might have this. You are extremely worried because you constantly feel terrified about this bacteria and you can see this getting out of control like your anorexia did. It has started to have an effect at work and people have started to notice your sore hands. You would like to know what help is available for you.

Observe the student take a focussed history from the patient and ask the student to present an MSE for the patient, there may not be many positive findings but it is useful to run through.

Ask the student to present their differential diagnosis which should include obsessive compulsive disorder.

Topics for discussion: - What is the ICD-10 criteria for obsessive compulsive disorder? - How would you assess this patient further? - What management is available for this patient? - What risk factors does this patient have for obsessive compulsive disorder?