Clinical Case Presentation: Obsessive-Compulsive Disorder with Secondary Depression and Recurrent Suicidal Behaviour

1. Identification Data

• Age/Sex: 40 years, Female
• Occupation: Housewife (10th std. education; worked as a tailor for 1 year before marriage)
• Marital status: Married 23 years, mother of 2 children
• Religion/Language: Hindu, Tamil-speaking
• Socioeconomic status: Lower socioeconomic status (LSES)
• Referral: Brought by her daughter from Andipatti/grandmother's home, first consultation at this centre after frequent prior psychiatric consultations at Theni and Chennai

2. Chief Complaints (per attendant/daughter), duration ~18 years

• Fearfulness
• Recurrent thoughts of self-harm
• Recurrent suicidal attempts
• Low mood, crying spells
• Feelings of detachment from self (derealization/depersonalization-type experience)
• Checking compulsions

3. History of Present Illness

• Apparently well until 18 years ago (early marriage). Husband was excessively particular about cleanliness from the start of marriage, noticing even minor untidiness and repeatedly scolding/beating her over it.
• One year after her first child's birth, the husband's abusive behaviour escalated. She became increasingly fearful, developed sleep disturbance (delayed sleep onset, early morning awakening).
• After one episode of severe physical assault, she attempted self-immolation (poured kerosene on herself); husband stopped her. She subsequently felt guilty and cried frequently about the act.
• Developed recurrent intrusive thoughts of self-harm and death wishes - urges to jump into wells, thoughts of wanting to die when looking at natural surroundings. She experienced these as persistent and difficult to control (ego-dystonic obsessions).
• Age 30: Second self-immolation attempt (kerosene) after repeated assault, discontinued the act. This worsened marital conflict; husband became verbally abusive, called her "mad." Fearfulness worsened further, developing fear of loud sounds (e.g., firecrackers).
• Developed classic OCD checking compulsions: repeatedly checking whether the gas stove was off and doors were locked despite having already verified. Also developed feelings of unreality while doing housework ("I feel as though I am not myself") with associated recurrent death wishes.
• Age 32: Attempted suicide by unknown poison ingestion, admitted and evaluated at KMC Chennai, diagnosed with OCD with suicide attempt, started on medication.
• Followed up regularly for ~2 years post-discharge, then defaulted; thereafter took medication only intermittently. Despite this, continued to have persistent intrusive thoughts and suicidal ideation, though she remained functional (managed household, cared for children, slept with medication help).
• 5 months ago: Suicide attempt by crushing her own medications, mixing them into food given to her daughter, then consuming the remaining tablets herself. Both became unresponsive overnight; husband noticed but did not seek medical care; both regained consciousness the next day.
• 20 days ago: Attempted suicide by hanging with a saree while her daughter slept. Daughter woke accidentally, interrupted the act. Patient remained calm, did not shout, and the next morning claimed to be unaware of the act. This frightened the daughter, who brought her for consultation.

4. Negative History

5. Past History

• Known case of Type 2 Diabetes Mellitus (~2 years) on Tab. Metformin, Tab. Glimepiride
• No past history of psychiatric hospitalization, seizure disorder, hypertension, CAD, bronchial asthma, or thyroid disease (as documented)

6. Family History

• Father: cannabis use, died by suicide (poisoning) at age 58
• Brother: alcohol dependence, possible psychiatric illness, unmarried
• Daughter: possible psychiatric illness, query conversion disorder (past 3 months)

7. Personal History

• Born of non-consanguineous marriage, cried immediately after birth, no developmental delay, immunized appropriately
• Started school at age 5, studied up to 10th standard
• Menarche attained, regular uncomplicated cycles
• Married at 17 years (per family arrangement/consent), 2 children (sterilization done), husband has extramarital affairs and has been physically and verbally abusive throughout the marriage

8. Pre-morbid Personality

9. Mental State Examination (Day 1)

• Vitals: BP 110/80 mmHg
• General appearance/behaviour: Poorly kept in some respects but calm, in touch with reality, gaze/rapport maintained, cried during interview
• Psychomotor activity: Normal, mild tremor noted
• Talk: Relevant, coherent
• Thought: Form and stream normal; relevant to content
• Thought content: Obsessive intrusive thoughts present, suicidal ideation present, ideas of helplessness, hopelessness, worthlessness, decreased self-esteem
• Perception: No hallucinations elicited
• Affect: Sad
• Higher mental functions: Oriented to time/place/person; attention/concentration aroused and sustained; immediate, recent, and remote memory intact; general fund of knowledge and comprehension adequate; arithmetic ability intact (simple addition/subtraction/division/multiplication); abstraction intact (similarities/differences testable)
• Judgement: Personal, test, and social judgement all impaired
• Insight: Grade III (aware of being ill and that symptoms are due to a mental disturbance, but attributes it to unclear/external causes - partial insight)

10. Provisional Diagnosis

11. Investigations Ordered

12. Management Plan

13. Day-2 Progress Note (07/08/2026)

• Continuing diagnosis: OCD with secondary depression and suicidal ideation
• Sleep inadequate (8 pm-12 am, disturbed thereafter by fever); food intake adequate
• Low-grade intermittent fever since midnight, low backache
• On exam: conscious, oriented, afebrile at review; CVS/RS normal; right upper limb hand-grip power mildly reduced (4/5)
• MSE: ambulant, comprehending, rapport maintained, mild tremor/fidgetiness, talk relevant/coherent, thought form/stream normal, but fear of harming self and obsessive intrusive self-harm thoughts persisted, along with helplessness, hopelessness, and decreased self-esteem; depressive-anxious affect
• Medications continued unchanged, with addition of Tab. Paracetamol 500 mg (1-1-1) for fever and TPR chart monitoring ordered

Nursing/Clinical Teaching Points for This Case

• Diagnosis pattern: This illustrates OCD (obsessive ruminations + checking compulsions) evolving in the context of chronic intimate partner violence, with secondary major depressive features and chronic, escalating suicidality over 18 years - a classic case of comorbid OCD-depression with high suicide risk.
• Suicide risk factors present: multiple prior attempts (self-immolation x2, poisoning, overdose, hanging), family history of suicide, feelings of hopelessness/worthlessness, impaired judgement, ongoing intimate partner violence, and a highly concerning extended suicide attempt involving her daughter (mixing medication into food given to the child) - this is a critical safeguarding issue requiring child protection assessment alongside psychiatric care.
• Insight Grade III and impaired judgement mean she requires continuous supervision (correctly reflected in the "24-hour attendant + strict watch" order).
• Pharmacological rationale: SSRI (fluoxetine) at higher-than-standard-depression dose is consistent with OCD-dosing requirements; risperidone as an augmenting agent is evidence-based for treatment-resistant/high-risk OCD with depressive features; lithium may be used for mood stabilization/anti-suicidal augmentation; clonazepam and PRN lorazepam address anxiety/agitation and enable safe sedation during the acute suicide-risk period.
• Nursing priorities: 1:1 observation, environmental safety (removal of ligature/sharp/poisoning materials), regular mental state monitoring for shift in suicidal ideation, monitoring for lithium toxicity (given renal panel and electrolytes ordered), psychoeducation and family involvement (addressing the husband's abusive behaviour is essential to relapse prevention), and daughter's welfare assessment given her own possible psychiatric symptoms and exposure to the mother's attempts.