How should a psychiatric nurse practitioner assess obsessive‑compulsive disorder during a follow‑up visit, including patient age, gender, comorbidities, current medications, prior OCD treatment, symptom changes, severity using Y‑BOCS or OCI‑R, functional impact, safety screening, medication adherence and side‑effects, and engagement in exposure‑and‑response‑prevention therapy?

Assessing OCD in a Follow-Up Appointment as a Psychiatric Nurse Practitioner

At every follow-up visit, administer the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to quantify current symptom severity, assess medication adherence and side effects, screen for suicidal ideation and comorbid psychiatric conditions, evaluate functional impairment in work/social/relationship domains, and document engagement with exposure and response prevention (ERP) therapy. 1, 2

Structured Severity Assessment Using Y-BOCS

• Administer the Y-BOCS at each follow-up visit to track symptom trajectory over time; this 10-item clinician-rated scale quantifies time spent on obsessions/compulsions, distress level, and functional interference, with scores ranging 0-40. 1, 3
• Interpret scores using the following thresholds: 0-7 subclinical, 8-15 mild, 16-23 moderate, 24-31 severe, ≥32 extreme OCD. 3
• Recognize that avoidance behaviors can artificially lower Y-BOCS scores, leading to underestimation of true severity; directly inquire about situations the patient avoids to prevent triggering obsessions. 1, 3
• Score obsessions (items 1-5) and compulsions (items 6-10) separately, as each subscale contributes up to 20 points; patients with only obsessions or only compulsions can still have severe OCD if their subscale score ≥14. 1

Symptom Dimension and Insight Assessment

• Document the primary symptom dimension(s): contamination/cleaning, harm/checking, symmetry/ordering, or unacceptable/taboo thoughts (aggressive, sexual, religious obsessions). 1, 4
• Assess level of insight using DSM-5 specifiers: good/fair insight (recognizes OCD beliefs are probably not true), poor insight (thinks beliefs are probably true), or absent insight/delusional (completely convinced beliefs are true). 1
• Note that absent insight/delusional OCD requires augmentation with an atypical antipsychotic in addition to SSRI and ERP. 4

Comorbidity Screening

• Screen systematically for the most common comorbidities: anxiety disorders, major depressive disorder, impulse-control disorders, substance use disorders, and tic disorders, as 90% of OCD patients meet criteria for at least one other lifetime psychiatric disorder. 1, 2
• Distinguish ADHD symptoms from OCD: ADHD inattention is ego-syntonic and not anxiety-driven, whereas OCD compulsions are ego-dystonic rituals performed to neutralize specific obsessions. 2
• Assess for comorbid schizotypal personality disorder, as this predicts significantly worse long-term outcome and treatment resistance. 5
• In patients with sexual orientation obsessions (SO-OCD), avoid misdiagnosing as sexual identity crisis or paraphilia; these are intrusive ego-dystonic thoughts that cause marked distress, not genuine sexual desires. 1, 4

Safety and Suicide Risk Evaluation

• Screen for active suicidal ideation at every visit using direct questioning; OCD is associated with increased mortality risk. 1, 4
• If suicidal ideation is present, assess for psychotic features (auditory hallucinations, paranoia) that would necessitate immediate hospitalization and antipsychotic augmentation. 4
• Never rely on "no-suicide contracts" as their protective value is unproven and creates false reassurance. 4

Medication Review

• Verify adherence to SSRI therapy and confirm the patient has been on the maximum tolerated dose for at least 8-12 weeks before declaring treatment failure. 4
• Assess for common SSRI side effects: gastrointestinal upset, sexual dysfunction, activation/insomnia, weight changes, and emotional blunting. 4
• Document current SSRI dose and compare to OCD-specific dosing: sertraline 150-200 mg/day, fluoxetine 40-80 mg/day, or equivalent; depression-level doses are inadequate for OCD. 4
• If augmentation with an antipsychotic is prescribed, monitor for metabolic side effects (weight gain, glucose/lipid abnormalities) and extrapyramidal symptoms. 4

ERP Therapy Engagement and Barriers

• Confirm the patient is actively engaged in ERP therapy, the gold-standard psychological treatment for OCD; ask specifically about frequency of sessions and homework completion. 2, 4
• Inquire about specific exposure exercises practiced between sessions and whether the patient is resisting compulsions during exposures. 4
• Identify barriers to ERP adherence: therapist availability, cost, transportation, fear of exposure exercises, or misunderstanding of the ERP rationale. 4
• For patients not in ERP, provide psychoeducation that combining SSRI with ERP produces superior outcomes compared to medication alone, and refer to an OCD-specialized therapist. 2, 4

Functional Impairment Assessment

• Quantify impairment in three domains: occupational/academic functioning, social relationships, and family/intimate relationships using the Sheehan Disability Scale or similar tool. 1, 3
• Ask about days out of role in the past month due to OCD symptoms; severe OCD is associated with an average of 45.7 days out of role per year. 1
• Assess family accommodation behaviors (family members participating in rituals, providing reassurance, modifying routines to avoid triggering obsessions), as these maintain OCD symptoms and predict worse outcome. 3, 4

Treatment History and Predictors of Outcome

• Document duration of illness (DOI) and duration of untreated illness (DUI): longer DOI and shorter DUI paradoxically correlate with increased current severity, suggesting more severe cases prompt earlier treatment-seeking. 6
• Record response to initial SSRI trial: patients who responded to their first SSRI have a 31% remission rate at 10-20 year follow-up, compared to 12% for partial responders and 0% for non-responders. 7
• Note age at onset: earlier onset (especially <18 years) predicts worse long-term outcome and higher likelihood of comorbid tic disorders. 1, 2, 6
• Track symptom dimension stability: 58% of OCD patients experience qualitative symptom changes over decades, so reassess primary dimensions at each visit. 8

Longitudinal Course Monitoring

• Recognize that OCD typically follows a chronic waxing-and-waning course: only 20-38% of patients achieve full remission even with adequate treatment, and 60% of those who remit subsequently relapse. 7, 5
• For patients in remission (Y-BOCS ≤8), continue treatment for 12-24 months before considering medication taper, given high relapse risk. 4, 7
• Identify treatment-resistant OCD (failure to respond to 3 adequate SSRI trials including clomipramine, 2 augmentation strategies, and 20 hours of ERP over 5 years with Y-BOCS ≥28) for consideration of advanced interventions. 1

Common Pitfalls to Avoid

• Do not mistake compulsions for ADHD impulsivity: compulsions are anxiety-driven rituals performed to neutralize specific obsessions, whereas ADHD impulsivity is ego-syntonic and not ritualistic. 2
• Do not accept patient self-report of "no compulsions" at face value: many patients perform mental compulsions (silent counting, mental reviewing, reassurance-seeking) that are not observable. 9
• Do not overlook the multiple functions of compulsions: 85% of compulsions serve more than one purpose (anxiety reduction, achieving "just right" feeling, preventing feared outcomes, automatic habit), and identifying these functions informs ERP targets. 9
• Do not declare SSRI failure before 8-12 weeks at maximum tolerated dose, as OCD requires longer trials and higher doses than depression. 4, 5