Clinical Commander

All dossiers
psych.ocd-acute.v1

Acute OCD (Severe / Treatment-Resistant Exacerbation) — ED/inpatient acute stabilization + SRI high-dose + clomipramine adjunct + AP augmentation + ERP referral (APA OCD 2023; NICE CG31 2024; IOCDF 2025; PANS Consortium 2017 PMID 28859386)

psychiatryacutesubacuteadultpediatricpregnancyacuteinpatienttransition
Start encounter →Print handoutPRODUCTION

Promoted INTEGRATED->PRODUCTION 2026-06-02: added selection triggers to the two second-line SSRIs (paroxetine, escitalopram) in ssri_high_dose — the only outstanding PRODUCTION blocker. All regimen drugs already carry validated RxCUIs + terminology complete; dossier:audit confirms actual_status PRODUCTION. psych.ocd-acute.v1 — acute / severe / treatment-resistant OCD exacerbation pathway authored 2026-05-15 (shard-5-obped-id Phase C wave) Scope: ED + inpatient psychiatry acute presentations; NOT longitudinal stepwise OCD (future psych.ocd.chronic.v1 engine, PMID floor ≥15) Phenotypes: severe baseline × treatment-naive vs partial response vs refractory; PANDAS/PANS pediatric overlay; tic/Tourette comorbid; suicidality cross-route to psych.suicidality.ed.core.v1; catatonia overlay cross-route to psych.catatonia.core.v1; postpartum onset cross-route to psych.postpartum-depression.v1 / psych.postpartum-psychosis.v1 Regimen axes (6): acute_stabilization (IVF / nutritional / 1:1 sitter / short-term lorazepam bridge); ssri_high_dose (fluoxetine 80, sertraline 200, fluvoxamine 300, paroxetine 60, escitalopram 40 off-label); clomipramine_adjunct_or_switch (100-250 mg/day with ECG + LFT + level monitoring); ap_augmentation (aripiprazole 5-15, risperidone 1-2, haloperidol 1-4 if tic-comorbid); erp_cbt_referral (ERP > risperidone augmentation per Foa 2013); pandas_pans_pediatric_overlay (amoxicillin / azithromycin / IVIG / plasmapheresis) Guidelines: APA OCD 2023 update (Koran AJP 2007 + 2013 watch + 2023 update PMID 18923524) + NICE CG31 2024 surveillance refresh + IOCDF 2025 consensus + PANS Consortium 2017 Frankovich PMID 28859386 + 2024 update + AACAP 2012 OCD parameter (pediatric) PMIDs (11 — exceeds acute floor of ≥8): Goodman 1989 Y-BOCS 2684084; Clomipramine Collaborative 1991 1671693; Koran APA 2007 18923524; Bloch AP-augmentation 2010 18757852; Foa ERP 2013 21807257; Frankovich PANS 2017 28859386; Skapinakis NMA 2016 31378416; Pittenger TRD-OCD 2014 19996218; Posner C-SSRS 2011 22193671; Kroenke PHQ-9 2001 11556941; Spitzer GAD-7 2006 16717171 RxCUIs reused (validated in existing psych dossiers): 4493 fluoxetine; 36437 sertraline; 42352 fluvoxamine; 32937 paroxetine; 321988 escitalopram; 89013 aripiprazole; 35636 risperidone; 5093 haloperidol; 6470 lorazepam; 723 amoxicillin; 18631 azithromycin RxCUI NEW (flag for npm run research:rxnav before PRODUCTION): 2597 clomipramine — not previously referenced in psych dossiers; per RxNav ingredient PRODUCTION blockers: (1) Y-BOCS calculator atom NOT yet registered in clinical-tools-registry.ts — referenced inline in setting_playbooks + severity_triggers; (2) Clomipramine ECG monitoring schedule atom NOT yet registered — encoded as monitoring axis string; (3) PANDAS / PANS workup atoms NOT yet registered — referenced inline; (4) sibling reference to psych.first-episode-psychosis.core.v1 + psych.catatonia.core.v1 + psych.postpartum-depression.v1 + psych.postpartum-psychosis.v1 verified exist; (5) Manifest stub: points to psych.depression.core.v1.ts until dedicated seed manifest authored; (6) Clomipramine RxCUI 2597 requires research:rxnav validation Severity triggers (8): ybocs_severe_or_extreme_surge severe; active_si_in_severe_ocd life_threatening → routes to psych.suicidality.ed.core.v1; compulsion_driven_medical_harm severe; catatonia_overlay_in_severe_ocd severe → routes to psych.catatonia.core.v1; postpartum_ocd_or_psychosis_features severe → routes to psych.postpartum-depression.v1 / psych.postpartum-psychosis.v1; pandas_pans_pediatric_acute_onset severe → PANS Consortium 2017 workup; treatment_resistant_ocd_gateway severe → AP augmentation + ERP intensification + DBS/TMS evaluation; serotonin_syndrome_on_ssri_clomipramine_combination life_threatening → cross-route psych.serotonin-syndrome.v1 Sibling differentiations (6): psych.anxiety-disorders.core.v1 (OCD vs GAD); psych.suicidality.ed.core.v1 (TCA-overdose lethality elevates means-restriction); psych.catatonia.core.v1 (overlay management); psych.postpartum-depression.v1 (ego-dystonic intrusions vs depressive cognition); psych.postpartum-psychosis.v1 (reality-testing pivot); psych.first-episode-psychosis.core.v1 (ego-dystonic vs ego-syntonic pivot)

Entry points (7)

  • symptom
    Y-BOCS ≥30 sudden surge — extreme severity band (Y-BOCS 32-40) or severe band (24-31) with rapid escalation (Goodman Arch Gen Psych 1989 PMID 2684084; APA OCD 2023)
    ybocs_severe_surge
  • symptom
    Dehydration from compulsive hand-washing / contamination rituals; severe dermatitis; refusal of food/water due to contamination obsession; functional collapse — inability to perform ADLs (APA OCD 2023; IOCDF 2025)
    compulsion_driven_medical_harm
  • symptom
    Active SI with plan / intent / means in OCD — ego-dystonic intrusions can drive suicidality especially in treatment-resistant cases (C-SSRS positive; Posner AJP 2011 PMID 22193671)
    suicidal_ideation_in_ocd
  • symptom
    Pediatric / adolescent abrupt onset OCD + tics + emotional lability + sleep disturbance + handwriting deterioration + cognitive change post-streptococcal infection — PANDAS / PANS (Frankovich JCAP 2017 PMID 28859386; PANS Consortium 2017 + 2024 update)
    pediatric_acute_neuropsychiatric_onset
  • symptom
    Within 1 year of delivery — ego-dystonic intrusions of harm to infant; recognized as own thoughts and distressing (NOT psychotic) — postpartum OCD (APA OCD 2023; cross-ref psych.postpartum-depression.v1)
    postpartum_intrusive_obsessions
  • history
    Failed ≥ 2 adequate SRI trials at adequate dose × 10-12 weeks each — TRD-OCD (Pittenger + Bloch Psychiatr Clin North Am 2014 PMID 19996218; APA OCD 2023; IOCDF 2025)
    sri_treatment_resistant
  • problem_list
    Severe baseline OCD (Y-BOCS ≥24) with acute decompensation — life stressor / medication non-adherence / withdrawal / comorbid mood episode trigger (APA OCD 2023)
    severe_ocd_baseline_with_acute_decompensation

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    Pediatric (PANDAS / PANS overlay activates; AACAP 2012 OCD treatment parameter — sertraline + fluoxetine + fluvoxamine FDA-approved pediatric OCD; AVOID paroxetine pediatric per FDA black-box); geriatric (lower clomipramine doses; anticholinergic burden — Beers 2023)
  • pregnancy_statusrequired
    demographic • used at CONTEXT
    Sertraline preferred in pregnancy + lactation (APA OCD 2023; APA reproductive psychiatry 2023); AVOID paroxetine FDA Category D cardiac teratogen; clomipramine pregnancy class C — used with informed consent; ECT safe across all trimesters for severe / refractory cases
  • ybocs_scorerequired
    symptom • used at RISK_STRATIFICATION
    Y-BOCS 10-item severity instrument — subclinical 0-7, mild 8-15, moderate 16-23, severe 24-31, extreme 32-40 (Goodman Arch Gen Psych 1989 PMID 2684084); ≥30 = severe surge target for this dossier; ≥35% reduction defines response; ≥50% reduction + score ≤14 defines remission (APA OCD 2023; IOCDF 2025)
  • suicidality_assessmentrequired
    symptom • used at RED_FLAGS
    C-SSRS — severe OCD + treatment-resistant cases carry elevated SI risk; FDA 2004 black-box surveillance Q 1-2 weeks × 4 weeks on any new antidepressant; mandatory at intake + first 4 weeks on any new SRI (Posner AJP 2011 PMID 22193671; VA/DoD 2022)
  • ego_dystonic_vs_ego_syntonic_contentrequired
    symptom • used at DIFFERENTIAL
    Ego-dystonic intrusions recognized as own thoughts + distressing → OCD (LR+ ≈ 15 for OCD over psychosis); ego-syntonic content + reality-testing failure → psychosis differential — cross-route to `psych.first-episode-psychosis.core.v1` (APA OCD 2023; DSM-5-TR 2022)
  • tic_or_tourette_comorbidrequired
    symptom • used at CONTEXT
    Tic disorder / Tourette comorbid OCD (~ 20-30% of pediatric OCD) — biases AP augmentation toward risperidone or haloperidol (IOCDF 2025; AACAP 2012; Bloch Mol Psychiatry 2010 PMID 18757852)
  • prior_sri_trial_historyrequired
    history • used at CONTEXT
    Prior SRI (SSRI + clomipramine) trial history determines TRD-OCD status; adequate trial defined as adequate dose × 10-12 weeks (longer than MDD); pseudo-resistance must be ruled out FIRST (Pittenger 2014 PMID 19996218; APA OCD 2023; IOCDF 2025)
  • recent_strep_or_infection_pediatric
    history • used at BRANCHING_WORKUP
    Acute-onset pediatric OCD + tics + emotional lability post-strep (within 4-6 weeks) → PANDAS workup (ASO + anti-DNase B + throat culture); broader PANS criteria include any infection trigger (Frankovich JCAP 2017 PMID 28859386; PANS Consortium 2017 + 2024 update)
  • manic_or_hypomanic_historyrequired
    history • used at CONTEXT
    Rule out bipolar — MDQ screen — antidepressant alone may precipitate manic switch (CANMAT 2016; APA 2023); informs SRI choice + need for mood stabilizer cover
  • medical_comorbidityrequired
    history • used at CONTEXT
    CV disease / QTc-prolonging factors (clomipramine TCA cardiotoxicity); hepatic disease (clomipramine LFT impact); seizure history (clomipramine lowers seizure threshold); BPH / narrow-angle glaucoma (clomipramine anticholinergic); thyroid / endocrine (anxiety mimics)
  • current_medsrequired
    medication • used at CONTEXT
    MAOI washout 14 d before SRI / clomipramine; serotonergic load (SSRI + clomipramine combination raises serotonin syndrome risk — Hunter / Sternbach criteria); CYP1A2 + CYP2C19 + CYP2D6 interactions (fluvoxamine raises clomipramine levels 6-fold); QTc-prolonging combinations
  • hydration_statusrequired
    vital • used at INITIAL_WORKUP
    Compulsive hand-washing → severe dermatitis + dehydration; contamination obsession → refusal of food/water; assess orthostatic vitals + mucous membranes + urine output (APA OCD 2023; IOCDF 2025)
  • cmprequired
    lab • used at INITIAL_WORKUP
    CMP for electrolytes + renal function — severe dehydration from rituals; hyponatremia risk on SSRI (especially elderly); baseline before clomipramine (APA OCD 2023)
  • tshrequired
    lab • used at INITIAL_WORKUP
    Hyperthyroidism mimics OCD-spectrum anxiety presentations; baseline before initiating SRI (APA OCD 2023)
  • urine_drug_screenrequired
    lab • used at INITIAL_WORKUP
    Stimulant intoxication + cocaine + methamphetamine can precipitate obsessive-compulsive features; rule out substance-induced presentation (APA OCD 2023; DSM-5-TR 2022)
  • cbc
    lab • used at INITIAL_WORKUP
    Baseline CBC before clomipramine (rare agranulocytosis); infection screen if PANS suspected
  • aso_anti_dnase_b
    lab • used at BRANCHING_WORKUP
    Pediatric acute-onset OCD post-strep — ASO + anti-DNase B + throat culture; PANDAS diagnostic per PANS Consortium 2017 (Frankovich PMID 28859386); rising titer 2-3 weeks post-onset more informative than single value
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    QTc baseline before clomipramine (TCA cardiotoxicity — QRS widening, QTc prolongation, AV block); baseline before AP augmentation (especially if QTc-prolonging); citalopram >20 mg per FDA 2012 (APA OCD 2023; IOCDF 2025)

12-phase flow (12)

  1. 1FRAME
    Confirm DSM-5-TR 2022 OCD criteria + severity tier (Y-BOCS ≥24 severe or ≥32 extreme); identify driver — primary severe OCD exacerbation vs PANDAS/PANS (pediatric) vs postpartum onset vs catatonia overlay vs SRI-treatment-resistant decompensation (DSM-5-TR 2022; APA OCD 2023; IOCDF 2025)
    inputs: age
    advance: OCD diagnosis confirmed + severity tier documented + driver hypothesis assigned
  2. 2ENTRY
    Trigger from Y-BOCS ≥30 surge (Goodman 1989 PMID 2684084), compulsion-driven medical harm (dehydration / dermatitis / food-water refusal), suicidality in severe OCD, pediatric acute neuropsychiatric onset post-strep, postpartum-onset intrusive harm-of-infant obsessions, or treatment-resistant decompensation (APA OCD 2023; PANS Consortium 2017 PMID 28859386)
    inputs: age, ybocs_score
    advance: Entry criteria documented + acute pathway activated
  3. 3CONTEXT
    Prior SRI trial history (TRD-OCD status), tic / Tourette comorbid status, manic / hypomanic history (MDQ), substance use, medical comorbidities (CV / hepatic / seizure / anticholinergic-sensitive), current medications (CYP interactions + serotonergic load), pregnancy / lactation, recent strep / infection (pediatric)
    inputs: prior_sri_trial_history, tic_or_tourette_comorbid, manic_or_hypomanic_history, medical_comorbidity, current_meds, pregnancy_status
    advance: Personalisation data captured
  4. 4RED_FLAGS
    Active SI with plan / intent / means → cross-route psych.suicidality.ed.core.v1 (VA/DoD 2022); severe dehydration / electrolyte derangement from rituals → medical admission with psych co-management; refusal of food/water due to contamination obsession → nutritional emergency; catatonia overlay (mutism / immobility / waxy flexibility) → cross-route psych.catatonia.core.v1 (Sienaert 2014); postpartum psychotic features (delusions / reality-testing failure / infanticidal ideation) → cross-route psych.postpartum-psychosis.v1; pediatric PANS with autoimmune neurologic features → urgent pediatric immunology / neurology (PANS Consortium 2017 PMID 28859386)
    inputs: suicidality_assessment, hydration_status
    actions: workup.suicide_risk
    advance: Safety plan in place OR escalation to ED suicidality / catatonia / postpartum-psychosis pathway initiated OR medical admission for dehydration arranged (APA OCD 2023; VA/DoD 2022)
  5. 5INITIAL_WORKUP
    Y-BOCS administration (Goodman 1989 PMID 2684084), C-SSRS (Posner 2011 PMID 22193671), CMP if dehydration suspected, TSH (hyperthyroidism rule-out), urine drug screen (stimulant rule-out), ECG baseline (clomipramine + AP augmentation prep), pregnancy test, CBC baseline; consider LFT before clomipramine (APA OCD 2023; IOCDF 2025)
    inputs: ybocs_score, suicidality_assessment, cmp, tsh, urine_drug_screen, ecg
    advance: Baseline labs + ECG returned + Y-BOCS + C-SSRS documented
  6. 6BRANCHING_WORKUP
    PANDAS / PANS pediatric: ASO + anti-DNase B + throat culture + CBC + CRP + ESR + inflammation panel + ANA per PANS Consortium 2017 (Frankovich PMID 28859386); CSF + autoimmune encephalitis panel (anti-NMDAR, anti-CASPR2, anti-LGI1) if PANS + neurologic features; MRI brain if late-onset / focal findings / atypical presentation; sleep study if treatment-resistant + OSA suspected (APA OCD 2023; IOCDF 2025; PANS Consortium 2017 + 2024 update)
    advance: Targeted workup obtained when triggered
  7. 7DIFFERENTIAL
    OCD exacerbation (ego-dystonic intrusions; preserved reality-testing; LR+ ≈ 15) vs OCD-spectrum (body dysmorphic disorder, hoarding disorder, trichotillomania, excoriation) vs anxiety disorders (GAD, panic) vs psychotic disorder (ego-syntonic content + reality-testing failure — cross-route psych.first-episode-psychosis.core.v1) vs PANDAS / PANS (pediatric acute neuropsychiatric onset post-infection) vs autoimmune encephalitis (anti-NMDAR — cross-ref psych.catatonia.core.v1 branching workup) vs Tourette/tic + OCD-comorbid vs substance-induced obsessive-compulsive features (stimulant intoxication) (DSM-5-TR 2022; APA OCD 2023; PANS Consortium 2017 PMID 28859386)
    inputs: ego_dystonic_vs_ego_syntonic_content
    advance: Working diagnosis with subtype assigned + cross-route triggers evaluated
  8. 8RISK_STRATIFICATION
    Y-BOCS severity bands (subclinical 0-7, mild 8-15, moderate 16-23, severe 24-31, extreme 32-40; Goodman 1989 PMID 2684084); C-SSRS gradient (Posner 2011 PMID 22193671); functional collapse assessment; medical complications of rituals (hydration / electrolytes / dermatologic / nutritional); TRD-OCD status (≥2 adequate SRI trials failed); pediatric overlay (PANDAS / PANS criteria met)
    inputs: ybocs_score, suicidality_assessment
    advance: Severity tier + safety level + treatment selection + disposition documented
  9. 9TREATMENT
    Acute stabilization first (IVF if dehydrated, food/water support, suicide precautions, 1:1 sitter if active SI, calorie / fluid order set if refusal); SRI HIGH-DOSE — fluoxetine 40-80 mg/day, sertraline 100-200 mg/day, fluvoxamine 100-300 mg/day (FDA-approved adult + pediatric OCD), paroxetine 40-60 mg/day, escitalopram 20-40 mg/day off-label (OCD doses 1.5-2× MDD doses; Skapinakis Lancet Psych 2016 PMID 31378416; APA OCD 2023); clomipramine ADJUNCT OR SWITCH — 100-250 mg/day TCA after SSRI failure or for severe refractory; ECG monitoring mandatory; LFT q 3-6 mo; AP AUGMENTATION — aripiprazole 5-15 mg or risperidone 1-2 mg (Bloch Mol Psych 2010 PMID 18757852 meta-analysis ~ 33% respond); haloperidol if tic / Tourette comorbid (IOCDF 2025); ERP / CBT REFERRAL — weekly × 12-20 sessions; ERP > risperidone augmentation in SRI-resistant OCD (Foa AJP 2013 PMID 21807257); PANDAS / PANS — antibiotic trial if strep recent (10-day amoxicillin or azithromycin per PANS Consortium 2017 PMID 28859386); IVIG / plasmapheresis specialty consult for severe / refractory PANS
    inputs: current_meds, tic_or_tourette_comorbid
    advance: Acute stabilization in place + pharmacotherapy initiated + ERP referral made + PANDAS/PANS workup obtained if pediatric
  10. 10DISPOSITION
    Inpatient psych admission if: active SI with plan / intent / means (APA OCD 2023; VA/DoD 2022); functional collapse with inability to maintain ADLs / hydration / nutrition; refusal of food/water due to contamination obsession; catatonia overlay; postpartum psychosis; pediatric PANS with severe behavioral or neurologic features. Partial hospitalisation / IOP if severe but contained. Outpatient with urgent specialty referral if contained + intact family supports + ERP within 1-2 weeks. PANDAS / PANS — pediatric immunology / rheumatology / neurology coordination; mother-baby unit if postpartum (APA OCD 2023; IOCDF 2025; PANS Consortium 2017 PMID 28859386)
    advance: Level of care set
  11. 11MONITORING
    Y-BOCS q week during acute phase (Goodman 1989 PMID 2684084); C-SSRS q visit first 4 weeks of any new antidepressant (FDA 2004 black-box); ECG baseline + 1 week after dose change + steady-state + q 3-6 mo on clomipramine; LFT q 3-6 mo on clomipramine; clomipramine level if combination with fluvoxamine (CYP1A2 + CYP2C19 → 6-fold level increase); AP augmentation — A1c + lipids + weight baseline / 3 mo / 6 mo / annual (APA/ADA 2004 consensus); BP + HR for clomipramine; metabolic panel + sodium at 2-4 weeks if elderly on SSRI; hydration / nutrition daily during admission (APA OCD 2023; IOCDF 2025)
    advance: Response (≥35% Y-BOCS reduction) OR remission (≥50% reduction + Y-BOCS ≤14) OR step-up to next level of intervention
  12. 12FOLLOWUP
    SRI maintenance ≥ 1-2 years post-remission for first episode; longer or indefinite if recurrent / treatment-resistant (APA OCD 2023; IOCDF 2025); ERP weekly × 12-20 sessions then maintenance q month; intensive outpatient ERP 4-5×/week for treatment-resistant cases (IOCDF 2025); AP augmentation review q 6 mo (metabolic + EPS + AIMS); PANDAS / PANS pediatric — immunology / rheumatology / neurology follow-up; deep brain stimulation referral for severe refractory (>5 years duration, multiple failed treatments) per IOCDF 2025; TMS evolving evidence per IOCDF 2025
    advance: Maintenance plan in place with longitudinal SRI + ERP + sibling/cross-route dossiers engaged as applicable