This handout is for 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). Your care team identified this based on: 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).
Other reasons your team may use this plan: 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); 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); 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).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| IV fluid resuscitation | NS or LR 1-2 L bolus → maintenance 75-125 mL/hr titrated to UOP | IV | continuous until rehydrated | Severe compulsions producing medical harm — refusal of water due to contamination obsession or excessive hand-washing rituals leading to dehydration require IVF + electrolyte correction before further OCD pharmacotherapy (APA OCD 2023; IOCDF 2025) |
| nutritional support order set | Calorie + protein targets per dietitian; NG tube if persistent refusal; psychiatric oversight of forced feeding ethics | PO/NG | q meal with monitoring | Severe contamination obsession with food refusal causing nutritional decompensation — dietitian + psych co-management; refeeding syndrome risk if prolonged starvation (cross-ref workup.refeeding; ESPEN 2020) |
| 1:1 sitter + suicide precautions | Continuous 1:1 observation while active SI present; means restriction (lock-box for meds, firearm restriction per Stanley-Brown 2012) | NA | continuous | Active SI in severe OCD requires continuous observation + means restriction; Stanley-Brown safety plan documented; cross-route psych.suicidality.ed.core.v1 (Mann JAMA 2005; Stanley-Brown 2012; VA/DoD 2022) |
| lorazepam | 0.5-1 mg PO / SL / IM PRN for severe agitation or anxiety during stabilization; short-term only | PO/SL/IM | PRN q 4-6 h short-term | Short-term anxiolytic bridge only (<4-6 weeks); NEVER long-term monotherapy in OCD — does not treat obsessions / compulsions; AVOID with opioids (FDA 2016 black-box); AVOID in elderly (Beers 2023); preferred in hepatic disease over diazepam (APA OCD 2023; IOCDF 2025) |
Plan: Acute OCD stabilization — IVF if dehydrated, food/water support, suicide precautions, 1:1 sitter (APA OCD 2023; IOCDF 2025)
Use these zones to know what to do based on how you feel.
Call 911 or go to the nearest emergency room right away if you have:
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
Guideline: APA Practice Guideline for OCD — Koran AJP 2007 + 2013 watch reaffirmation + 2023 update (PMID 18923524) + NICE CG31 2024 surveillance refresh + IOCDF 2025 consensus + PANS Consortium Frankovich JCAP 2017 PMID 28859386 + 2024 update + AACAP 2012 OCD parameter (pediatric)