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psych.ocd-acute.v1PRODUCTION
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)

psychiatryacutesubacuteadultpediatricpregnancy
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

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)

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OCD diagnosis confirmed + severity tier documented + driver hypothesis assigned

Patient inputs (18)

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)

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

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 (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)

Rule out bipolar — MDQ screen — antidepressant alone may precipitate manic switch (CANMAT 2016; APA 2023); informs SRI choice + need for mood stabilizer cover

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)

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

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)

Compulsive hand-washing → severe dermatitis + dehydration; contamination obsession → refusal of food/water; assess orthostatic vitals + mucous membranes + urine output (APA OCD 2023; IOCDF 2025)

CMP for electrolytes + renal function — severe dehydration from rituals; hyponatremia risk on SSRI (especially elderly); baseline before clomipramine (APA OCD 2023)

Hyperthyroidism mimics OCD-spectrum anxiety presentations; baseline before initiating SRI (APA OCD 2023)

Stimulant intoxication + cocaine + methamphetamine can precipitate obsessive-compulsive features; rule out substance-induced presentation (APA OCD 2023; DSM-5-TR 2022)

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)

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)

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)

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)

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

Baseline CBC before clomipramine (rare agranulocytosis); infection screen if PANS suspected

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningactive_si_in_severe_ocd (C-SSRS; Posner 2011 PMID 22193671)
    C-SSRS positive for active SI with intent / plan / preparatory behaviour in severe OCD — TCA / clomipramine overdose lethality elevates means-restriction priority
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningserotonin_syndrome_on_ssri_clomipramine_combination (Boyer NEJM 2005; APA OCD 2023)
    Tremor, hyperreflexia, clonus, hyperthermia, autonomic instability, AMS in patient on SSRI + clomipramine combination — Hunter / Sternbach criteria; risk especially elevated with fluvoxamine + clomipramine (CYP1A2 + CYP2C19 → 6-fold clomipramine level rise)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereybocs_severe_or_extreme_surge (Goodman 1989 PMID 2684084; APA OCD 2023)
    Y-BOCS ≥30 sudden surge — extreme band (32-40) or severe band (24-31) with rapid escalation; functional collapse with inability to perform ADLs
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecompulsion_driven_medical_harm (APA OCD 2023; IOCDF 2025)
    Severe dehydration / electrolyte derangement from compulsive hand-washing; severe dermatitis; refusal of food/water due to contamination obsession leading to nutritional decompensation
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecatatonia_overlay_in_severe_ocd (Sienaert 2014 PMID 24523668; Bush 1996 PMID 8729911)
    Catatonic features (mutism / immobility / waxy flexibility / negativism / posturing) overlaying severe / refractory OCD — BFCSI ≥ 2 features
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepostpartum_ocd_or_psychosis_features (DSM-5-TR 2022 peripartum specifier; APA OCD 2023)
    OCD or psychotic features (delusions / hallucinations / reality-testing failure / infanticidal ideation) with onset within 1 year of delivery; postpartum OCD typically ego-dystonic intrusions of harm to infant — distinct from postpartum psychosis with reality-testing failure
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepandas_pans_pediatric_acute_onset (PANS Consortium Frankovich JCAP 2017 PMID 28859386)
    Pediatric / adolescent abrupt onset OCD + tics + emotional lability + sleep disturbance + handwriting deterioration + cognitive change post-streptococcal infection (PANDAS) OR post-any-infection (broader PANS criteria)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretreatment_resistant_ocd_gateway (Pittenger Psychiatr Clin North Am 2014 PMID 19996218; APA OCD 2023; IOCDF 2025)
    Treatment-resistant OCD = failure of ≥ 2 adequate SRI trials at adequate dose × 10-12 weeks each (longer than MDD adequate trial); pseudo-resistance (subtherapeutic dose / inadequate duration / non-adherence / unrecognized comorbidity / medical mimic) must be ruled out FIRST
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Acute OCD stabilization — IVF if dehydrated, food/water support, suicide precautions, 1:1 sitter (APA OCD 2023; IOCDF 2025)
axis: acute_stabilization
Selected axis "Acute OCD stabilization — IVF if dehydrated, food/water support, suicide precautions, 1:1 sitter (APA OCD 2023; IOCDF 2025)" by default fallback (first axis)
  • IV fluid resuscitation
    rescue
    crystalloid
    NS or LR 1-2 L bolus → maintenance 75-125 mL/hr titrated to UOP • IV • continuous until rehydrated
    triggers: dehydration_from_compulsive_hand_washing, refusal_of_water_due_to_contamination_obsession, orthostatic_hypotension, electrolyte_derangement
    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
    rescue
    nutrition
    Calorie + protein targets per dietitian; NG tube if persistent refusal; psychiatric oversight of forced feeding ethics • PO/NG • q meal with monitoring
    triggers: food_refusal_contamination_obsession, weight_loss_>10pct, refeeding_risk_assessment
    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
    rescue
    safety_observation
    Continuous 1:1 observation while active SI present; means restriction (lock-box for meds, firearm restriction per Stanley-Brown 2012) • NA • continuous
    triggers: active_si_with_plan_or_intent_or_means, severe_functional_collapse_with_safety_concern
    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
    rescue
    benzodiazepine
    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 (max: 4-6 mg/day short-term during admission only)
    triggers: severe_acute_anxiety_or_agitation_during_stabilization, short_term_bridge_during_sri_titration
    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)
    rxcui 6470

ed playbook — drug actions (5)

  1. 1. address acute medical contributors first
    IVF if dehydrated (NS or LR 1-2 L bolus → maintenance); electrolyte correction; nutritional support; antibiotics if pediatric PANS with documented strep • IV/PO • as indicated
    trigger: Medical complications of rituals OR pediatric PANS criteria met (APA OCD 2023; PANS Consortium 2017 PMID 28859386)
    Reversible medical contributors worsen if missed; pediatric PANS antibiotic trial should not delay if criteria met (PANS Consortium 2017)
  2. 2. short-term anxiolytic if severe agitation
    Lorazepam 0.5-1 mg PO/SL/IM PRN — short-term only • PO/SL/IM • PRN q 4-6 h
    trigger: Severe acute anxiety / agitation while stabilization in progress (APA OCD 2023)
    Short-term bridge only — does NOT treat obsessions/compulsions; long-term benzo monotherapy in OCD inappropriate (APA OCD 2023; NICE CG31 2024)
  3. 3. AVOID initiating new SRI in ED unless coordinated with admitting team
    NA • NA • NA
    trigger: Indication present (APA OCD 2023)
    SRI takes 10-12 weeks at therapeutic dose; safety plan + admission decision are higher priority in ED (APA OCD 2023; IOCDF 2025)
  4. 4. continue home SRI / clomipramine unless contraindication
    Same dose • PO • as before
    trigger: No contraindication (APA OCD 2023)
    Discontinuation worsens OCD + risks discontinuation syndrome (APA OCD 2023; Horowitz Lancet Psych 2019)
  5. 5. consult psychiatry urgently for disposition planning
    NA • NA • NA
    trigger: Severe OCD presentation requiring inpatient / partial / urgent specialty referral (APA OCD 2023)
    Disposition complexity in severe / refractory OCD warrants psychiatric specialty input (APA OCD 2023; IOCDF 2025)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: 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); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**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)** (psych.ocd-acute.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Acute OCD stabilization — IVF if dehydrated, food/water support, suicide precautions, 1:1 sitter (APA OCD 2023; IOCDF 2025)**.
1. IV fluid resuscitation NS or LR 1-2 L bolus → maintenance 75-125 mL/hr titrated to UOP IV continuous until rehydrated (crystalloid, rescue) — 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)
2. 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 (nutrition, rescue) — 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)
3. 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 (safety_observation, rescue) — 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)
4. 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 (benzodiazepine, rescue) — 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)

Setting playbook (ed) — Identify and contain acute severe / refractory OCD presentations — Y-BOCS surge with functional collapse, compulsion-driven medical harm, suicidality, postpartum-onset intrusions, pediatric PANS — initiate acute stabilization + appropriate disposition (APA OCD 2023; IOCDF 2025; VA/DoD 2022)
5. address acute medical contributors first IVF if dehydrated (NS or LR 1-2 L bolus → maintenance); electrolyte correction; nutritional support; antibiotics if pediatric PANS with documented strep IV/PO as indicated — Medical complications of rituals OR pediatric PANS criteria met (APA OCD 2023; PANS Consortium 2017 PMID 28859386) (Reversible medical contributors worsen if missed; pediatric PANS antibiotic trial should not delay if criteria met (PANS Consortium 2017))
6. short-term anxiolytic if severe agitation Lorazepam 0.5-1 mg PO/SL/IM PRN — short-term only PO/SL/IM PRN q 4-6 h — Severe acute anxiety / agitation while stabilization in progress (APA OCD 2023) (Short-term bridge only — does NOT treat obsessions/compulsions; long-term benzo monotherapy in OCD inappropriate (APA OCD 2023; NICE CG31 2024))
7. AVOID initiating new SRI in ED unless coordinated with admitting team NA NA NA — Indication present (APA OCD 2023) (SRI takes 10-12 weeks at therapeutic dose; safety plan + admission decision are higher priority in ED (APA OCD 2023; IOCDF 2025))
8. continue home SRI / clomipramine unless contraindication Same dose PO as before — No contraindication (APA OCD 2023) (Discontinuation worsens OCD + risks discontinuation syndrome (APA OCD 2023; Horowitz Lancet Psych 2019))
9. consult psychiatry urgently for disposition planning NA NA NA — Severe OCD presentation requiring inpatient / partial / urgent specialty referral (APA OCD 2023) (Disposition complexity in severe / refractory OCD warrants psychiatric specialty input (APA OCD 2023; IOCDF 2025))

Non-pharmacologic actions:
- 1:1 sitter for active SI (VA/DoD 2022)
- Means restriction counselling — especially for TCA / clomipramine high-lethality overdose risk (Mann JAMA 2005; VA/DoD 2022)
- Stanley-Brown 2012 safety planning with patient + identified support
- Voluntary admission if accepted; involuntary hold if criteria met — imminent danger to self / others, grave disability (APA OCD 2023)
- Engage family / supports with consent — family accommodation reduction core in pediatric OCD (IOCDF 2025)
- Provide 988 lifeline + local crisis line (VA/DoD 2022)
- IVF for dehydration; nutritional support order set for food/water refusal
- Pediatric PANS — pediatric immunology / rheumatology / neurology consultation if criteria met (PANS Consortium 2017 PMID 28859386)

AVOID / contraindication checks:
- Assess_dehydration_severity_before_AP_augmentation (orthostatic hypotension risk; APA OCD 2023)
- 1_1_sitter_for_active_SI_with_plan_or_intent_or_means (Stanley Brown 2012; VA/DoD 2022)
- Means_restriction_counseling_for_any_SI_history (Mann JAMA 2005; VA/DoD 2022)
- NG_feeding_ethics_review_if_persistent_food_refusal (APA OCD 2023; AAP 2017 for pediatric)

Monitoring

Regimen monitoring:
- Hydration status q 4 6h during acute phase (APA OCD 2023)
- Vitals orthostatics q shift until stable (APA OCD 2023)
- BMP q 24h until normalized (APA OCD 2023)
- Daily weight and nutritional intake (APA OCD 2023)
- C-SSRS q visit while in acute phase (Posner 2011; VA/DoD 2022)

Setting (ed) monitoring:
- Continuous observation if active SI (VA/DoD 2022)
- Reassess C-SSRS q 1-2 h while in ED (VA/DoD 2022)
- Y-BOCS at presentation and re-administration q 4-8 h while in ED (Goodman 1989)
- Vitals + neuro for sedation if used (APA OCD 2023)
- Hydration status + UOP q 4-6 h until stable (APA OCD 2023)

Follow-up plan: 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
- Close-out criterion: Maintenance plan in place with longitudinal SRI + ERP + sibling/cross-route dossiers engaged as applicable

Monitoring phase: 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)

Disposition

Current setting: ed — Identify and contain acute severe / refractory OCD presentations — Y-BOCS surge with functional collapse, compulsion-driven medical harm, suicidality, postpartum-onset intrusions, pediatric PANS — initiate acute stabilization + appropriate disposition (APA OCD 2023; IOCDF 2025; VA/DoD 2022)

Disposition criteria:
- Voluntary or involuntary inpatient psychiatry admission for: active SI with plan/intent/means; functional collapse; refusal of food/water; catatonia; postpartum psychosis; severe pediatric PANS (APA OCD 2023; VA/DoD 2022)
- Partial hospitalisation / IOP for severe but contained OCD with intact family supports
- Discharge with safety plan (Stanley-Brown 2012), means restriction (especially TCA-overdose risk), family involvement, urgent specialty psychiatric + ERP referral within 1-2 weeks, crisis line numbers, written return precautions — IF SI is passive without intent/plan/means AND patient + family agree (VA/DoD 2022)
- Pediatric PANDAS / PANS — coordinate with pediatric immunology / rheumatology / neurology + outpatient OCD specialty referral (PANS Consortium 2017)

Escalation triggers (move to higher acuity):
- Active SI with intent / plan / means → cross-route psych.suicidality.ed.core.v1 → involuntary admission if patient declines voluntary (APA OCD 2023; VA/DoD 2022)
- Catatonia overlay (mutism / immobility / waxy flexibility) → cross-route psych.catatonia.core.v1 — lorazepam challenge + ECT pathway (Sienaert 2014 PMID 24523668)
- Postpartum psychotic features (reality-testing failure / infanticidal ideation) → cross-route psych.postpartum-psychosis.v1 → mother-baby unit (APA 2023)
- Severe dehydration / electrolyte derangement → medical admission with psych co-management (APA OCD 2023)
- Pediatric PANS with severe autoimmune neurologic features → urgent pediatric immunology / rheumatology / neurology (PANS Consortium 2017 PMID 28859386)

Patient Action Plan

**Acute OCD action plan + Stanley-Brown safety plan + family accommodation reduction (APA OCD 2023; IOCDF 2025; Stanley-Brown 2012)**
Personalised values: baseline_y_bocs_score, current_medication_list, erp_therapist_contact, identified_supports, crisis_line_numbers, reasons_for_living, means_restriction_steps, family_accommodation_targets.

**Doing well — Y-BOCS <14, sustained response, functioning at baseline, no acute medical complications of rituals (APA OCD 2023)** (green):
Triggers:
- Y-BOCS sustained <14 (remission per APA OCD 2023)
- No suicidal thoughts (C-SSRS; Posner 2011)
- Engaging with usual activities and relationships (APA OCD 2023)
- ERP homework + maintenance sessions occurring (IOCDF 2025)
Actions:
- Take SRI / clomipramine as prescribed every day — do not stop suddenly (APA OCD 2023)
- Continue ERP maintenance sessions q month + practice exposures daily (IOCDF 2025)
- Continue family accommodation reduction practices (IOCDF 2025)
- Keep follow-up appointments (APA OCD 2023)
- Keep crisis line numbers available (VA/DoD 2022)

**Caution — Y-BOCS rising, return of rituals, family accommodation creeping back, passive SI (APA OCD 2023; IOCDF 2025)** (yellow):
Triggers:
- Rituals returning or increasing duration (APA OCD 2023)
- Avoidance behaviour increasing (APA OCD 2023)
- Family accommodation increasing (IOCDF 2025)
- Passing thoughts that life is not worth living without intent or plan (C-SSRS; Posner 2011)
- Increased alcohol or substance use (VA/DoD 2022)
- Withdrawal from supports (APA OCD 2023)
Actions:
- Use coping strategies from your safety plan — call ERP therapist, contact support person, return to recent exposure exercises (Stanley-Brown 2012; IOCDF 2025)
- Contact your provider for an early appointment — within 1 week (APA OCD 2023)
- Review SRI adherence + dose adequacy with provider (APA OCD 2023)
- Family accommodation review session with therapist (IOCDF 2025)
- Avoid means of self-harm — lock or remove firearms; secure or limit medications to short supply (especially TCAs; VA/DoD 2022)
Contact provider when:
- Symptoms not improving after 1-2 weeks of self-care (APA OCD 2023)
- Y-BOCS rises by ≥5 points (Goodman 1989)
- Any thoughts of suicide become more frequent (VA/DoD 2022)
- Functioning at work / home declines (APA OCD 2023)

**Medical alert — active SI with intent / plan / means, dehydration / refusal of food-water from rituals, catatonia, postpartum psychosis, pediatric PANS acute worsening (APA OCD 2023; VA/DoD 2022; PANS Consortium 2017)** (red):
Triggers:
- Specific thoughts of how to end your life (C-SSRS; Posner 2011)
- Access to means — firearms, large-quantity meds (especially TCAs; VA/DoD 2022)
- Recent self-harm or attempt (APA OCD 2023)
- Dehydration / refusal of food / water from rituals (APA OCD 2023)
- Mutism / immobility / waxy flexibility — catatonia overlay (Sienaert 2014)
- Postpartum with intrusive harm-of-infant obsessions OR reality-testing failure (APA OCD 2023; cross-ref psych.postpartum-psychosis.v1)
- Pediatric — acute neuropsychiatric worsening + tics + autonomic features post-infection (PANS Consortium 2017 PMID 28859386)
Actions:
- Call 988 (US) / your local crisis line / emergency services NOW (VA/DoD 2022)
- Go to the nearest emergency department; do not be alone (APA OCD 2023)
- Hand any means (firearms, TCAs / pills) to a trusted person before going (VA/DoD 2022)
- Tell someone you trust what is happening (Stanley-Brown 2012)
- Do not use alcohol or non-prescribed substances (APA OCD 2023)
- Pediatric — caregivers contact pediatrician + go to ED if acute autoimmune neurologic features (PANS Consortium 2017)
Contact provider when:
- Any red zone trigger — emergency department immediately, do not wait (APA OCD 2023; VA/DoD 2022)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] C-SSRS positive for active SI with intent / plan / preparatory behaviour in severe OCD — TCA / clomipramine overdose lethality elevates means-restriction priority
- [LIFE_THREATENING] Tremor, hyperreflexia, clonus, hyperthermia, autonomic instability, AMS in patient on SSRI + clomipramine combination — Hunter / Sternbach criteria; risk especially elevated with fluvoxamine + clomipramine (CYP1A2 + CYP2C19 → 6-fold clomipramine level rise)
- [SEVERE] Y-BOCS ≥30 sudden surge — extreme band (32-40) or severe band (24-31) with rapid escalation; functional collapse with inability to perform ADLs

Citations

- 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) [PMID:2684084](https://pubmed.ncbi.nlm.nih.gov/2684084/)
- Cited evidence (PMID 1671693) [PMID:1671693](https://pubmed.ncbi.nlm.nih.gov/1671693/)
- Cited evidence (PMID 18923524) [PMID:18923524](https://pubmed.ncbi.nlm.nih.gov/18923524/)
- Cited evidence (PMID 18757852) [PMID:18757852](https://pubmed.ncbi.nlm.nih.gov/18757852/)
- Cited evidence (PMID 21807257) [PMID:21807257](https://pubmed.ncbi.nlm.nih.gov/21807257/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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) — PMID:2684084
  • Cited evidence (PMID 1671693) — PMID:1671693
  • Cited evidence (PMID 18923524) — PMID:18923524
  • Cited evidence (PMID 18757852) — PMID:18757852
  • Cited evidence (PMID 21807257) — PMID:21807257