Brooke Harbor Health System
PMHNP Clinical Learning Environment
Condition Guide
Intrusive thoughts, repetitive behaviors, and motor or vocal tics require careful phenomenology. Clarify what the patient experiences before assigning meaning, then assess distress, impairment, comorbidity, safety, development, and the effect of attempts to suppress or neutralize symptoms.
Clinical application
Apply these prompts within the simulated clinical context. They support—but do not replace—clinical judgment, supervision, consultation, current guidance, local policy, law, or emergency procedures.
Diagnostic Features
DSM-5-TR diagnosis depends on phenomenology, time course, impairment and exclusions—not the presence of repetition alone.
Obsessions, compulsions or both are present; they are time-consuming (for example, more than one hour daily) or cause clinically significant distress or impairment, and are not attributable to substances, medical illness or another mental disorder.
Preoccupation with perceived appearance defects not observable or slight to others is accompanied by repetitive behaviors or mental acts and causes significant distress or impairment; concerns are not better explained by body fat or weight in an eating disorder.
Persistent difficulty discarding possessions because of a perceived need to save them results in accumulation that congests living areas and causes distress or impairment, independent of another medical or mental disorder.
Recurrent hair pulling or skin picking causes loss or lesions, includes repeated attempts to decrease or stop, and causes distress or impairment after dermatologic, substance and other psychiatric explanations are considered.
Multiple motor tics and at least one vocal tic occur during the illness, may wax and wane, persist more than one year after first onset, begin before age 18, and are not attributable to substances or another medical condition.
Persistent motor or vocal tic disorder involves motor or vocal—but not both—tics for more than one year. Provisional tic disorder lasts less than one year; onset is before 18 and exclusions apply.
Rating Scales & Screening
Measures support case finding, severity and follow-up; they do not independently establish diagnosis.
Clinician-rated OCD severity scale for adults; reliable administration requires symptom review and anchor familiarity.
Open NIMH OCD resources ↗Brief adult self-report measure spanning major obsessive-compulsive symptom dimensions.
Open IOCDF screening tools ↗Clinician-rated severity tool adapted for children and adolescents; use with developmentally informed interviewing.
Open IOCDF clinician resources ↗Clinician-rated tic severity and self-reported premonitory urges can define targets and follow change.
Open Tourette Association resources ↗Alongside a standardized measure, document a small number of observable, meaningful targets such as time lost to rituals, school avoidance, pain from tics, or ability to participate in valued activities.
Assessment & Differential
Ask what occurs, what precedes it, what the person fears or expects, whether there is an urge or relief, and how symptoms change across settings and time.
Obsessions are intrusive, unwanted thoughts, urges, or images; compulsions are repetitive behaviors or mental acts performed in response. Assess time burden, avoidance, insight, distress, and functional interference.
Characterize motor and vocal tics, age at onset, waxing and waning, premonitory urges, suppressibility, rebound, pain, injury, social impact, and the difference between simple and complex tics.
Differentiate compulsions from tics, stereotypies, body-focused repetitive behaviors, psychosis, illness anxiety, autism-related routines, generalized worry, medication effects, and functional symptoms.
Screen for ADHD, anxiety, depression, trauma, autism, substance use, sleep disruption, self-harm, family accommodation, bullying, and school or occupational impairment.
Treatment
Treatment is collaborative and may include behavioral therapy, medication, school or workplace support, and treatment of co-occurring conditions.
Exposure and response prevention is a first-line psychotherapy. Build a collaborative hierarchy, reduce rituals and accommodation, and avoid turning reassurance into another compulsion.
Comprehensive Behavioral Intervention for Tics combines awareness, competing responses, functional intervention, and skills practice. It can be effective for children and adults.
SSRIs are commonly used; clomipramine and augmentation strategies may be considered when appropriate. Evaluate an adequate trial, adherence, tolerability, interactions, and bipolar-spectrum risk.
Alpha-2 agonists and selected antipsychotics may be considered according to impairment, comorbidity, and risk. Monitor cardiovascular, metabolic, neurologic, and sedation effects as applicable.
Monitoring & Coordination
Symptoms may change with stress, fatigue, development, medication exposure, and environmental responses.
Assess how reassurance, participation in rituals, avoidance, conflict, or punishment may maintain symptoms. Support caregivers without blaming them.
Consider privacy, breaks, testing conditions, sensory load, fatigue, attendance, bullying, and reasonable supports while preserving autonomy.
Track target symptoms, function, activation, suicidality, sedation, blood pressure, metabolic effects, EPS, and tardive dyskinesia according to the regimen.
Seek specialty input for diagnostic uncertainty, severe impairment, complex comorbidity, treatment resistance, dangerous self-injury, or consideration of advanced interventions.
Clinical Sources
These sources support clinical reasoning but do not replace a complete assessment, current prescribing information, local policy, consultation, or individualized shared decision-making.
American Psychiatric Association treatment guidance for obsessive-compulsive disorder.
Open source ↗American Academy of Neurology recommendations, including CBIT and medication monitoring.
Open source ↗Current FDA labeling for medication-specific dosing, contraindications, warnings, and monitoring.
Open source ↗