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Patient describes extreme discomfort when placed in outdoor settings. He fears dirt, germs, insects, and pollen. He becomes extremely distracted by these fears when he is outdoors. Patient also reports that he feels the need to open and close each door through which he enters or leaves a room three times while counting out loud (often in a language other than English). He reports extreme anxiety at the thought of his home being anything less than perfectly clean and is plagued by constant thoughts of cleanliness. Patient fears shoes on the carpet of his home and is at times overwhelmed by anxiety if in fact someone walks on the carpet with shoes on. Patient reports muscular ticks in his face, neck and head in certain situations. These often become prominent when he is nervous, outdoors, or in a new or unfamiliar setting.

History of Present Illness:

Patient reports that he has noticed his symptoms and has attempted to self-medicate utilizing illegally obtained prescription drugs. He does not know the name of this medication. Symptoms seem to have been present for at least fifteen years but may stretch as far back as adolescence. Patient reports that on one occasion he felt suicidal because of his overwhelming feelings about his symptoms but that fear of staining his carpet prevented him from taking his own life with a handgun.

Past Psychiatric Illness, Treatments, Outcomes:

No known history

Medical History:

Patient reports anxiety-induced spells of hyperventilation and lightheadedness.

Psychosocial History:

Patient reports that his last romantic relationship ended nearly fifteen years ago. He describes this relationship as abusive and states that he was physically aggressive toward his ex-wife Heather. At the end of this relationship Heather was pregnant; patient knows nothing about the whereabouts of the child. Patient’s only close relationship is that which he holds with his “business partner” Frank with whom he conducts illegal and fraudulent business endeavors. Although he works with Frank on a daily basis and considers him a close partner, Roy claims that he does not fully trust Frank because of their line of work.

Drug and Alcohol History:

Patient reports that he has a history of alcoholism beginning over fifteen years ago. Patient is known to have utilized some sort of illegally conjured prescription drug to self medicate for his symptoms. Patient smokes as many as eight packs of cigarettes each day.

Behavioral Observations:

Patient is alert and coherent however, he displays nervous behavior, fidgeting and ticks in his face and neck. Patient seems eager to leave the office and his eyes repeatedly dart around the room. He repeatedly and urgently requests a prescription for his symptoms and is hesitant to answer questions.

Mental Status Exam:

Speech pattern is urgent. Patient refuses to answer questions but seems capable of doing so when pressed. Patient seems to have high intellectual capacity and is completely conscious of his surroundings. Patient seems to have no control over obsessive thoughts.

Functional Assessment:

Patient does not recognize the severity of his illness. He believes that he must live with his illness but that only medication has the capability to help him. The patient is involved with illegal activity and has very little social interaction beyond that with his partner Frank. He does not function well in new environments and cannot go outside without becoming extremely uncomfortable. Without treatment the patient may be a suicide risk.

Strengths:

Patient is extremely intelligent and creative. He is organized, meticulous, and values cleanliness. Although his work is criminal, he excels in his ability to talk to people and persuade them into doing what he wants them to do.

Diagnosis:

Obsessive Compulsive Disorder

Treatment Plan:

It is recommended that patient begin a carefully monitored drug therapy and Cognitive therapy program. Patient will be strongly encouraged in therapy to withdraw from his criminal lifestyle in order to apply