Patient Management Exercise for Obsessive-Compulsive Disorder
This exercise is designed to test your comprehension of material presented in this issue of FOCUS as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below, to the best of your ability, on the basis of the information provided, making your decisions as you would with a real-life patient.
Questions are presented at “decision points” that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections.
You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. On questions that focus on differential diagnoses, bonus points are awarded if you select the most likely diagnosis as your first choice. At the end of the exercise you will add up your points to obtain a total score.
VIGNETTE PART I
You are an adult psychiatrist in independent practice. You receive a phone message from a 24-year-old woman who is close to finishing her MBA at a competitive program in your city. She recently stopped seeing the psychiatrist she had been seeing for the past 2 years. She complains that she is not getting better and would like a second opinion. In her message, she sounds distressed and asks you to call her back to set up an appointment because, “I feel like I'm losing my mind. I need help.” You ask her if she is currently thinking about hurting or killing herself or anyone else and she responds, “I do not want to kill myself—I know it is stupid—but I cannot get the thought out of my head. I get other thoughts; like I'm never going to be a good mother and until I pat my head five times, I'll keep thinking it. I even think about killing my children, which I don't have. I don't even date!” She says she can stay safe and her mother is with her. You make it clear that if she feels like she is in danger of hurting herself she should call the local emergency room immediately. She says, “I think I'll be okay” with her mother, a registered nurse, but she insists upon seeing you. You arrange an urgent appointment for that evening. She tells you her mother will bring her.
The patient arrives. She is dressed smartly, is well-groomed, and is very polite but does not offer her hand to you when you reach out to shake hers as an introduction. She inspects the chair toward which you direct her to sit, looks around your office for something, and then seems to force herself to sit down. You note that within minutes she begins picking at individual hairs and there is a small round spot behind her right ear where hair is missing. The patient is visibly distraught and before she starts to talk you see her eyes well with tears. You wait for a few minutes. She does not say anything, so you ask a few general, nonthreatening questions in an attempt to help her relax and build a rapport. She stops you and says, “Sometimes I forget I pull my hair. I've been doing this for years. Sometimes I can stop, but right now I cannot. I get into these fits of anxiety and this is the only thing that makes me feel better.”
She tells you she has 2 months left to complete her MBA and she has had six job interviews scheduled over the last 4 months. She was not able to make it to any of them. “I bought two new interview suits, I practiced what I was going to say—all of this with my mother's help, mind you—but in the end I could not get myself to leave the house. Now I do not know what I'm going to do. I could not even pick between the two suits and my mother had to force me to buy them both because I kept her at the store for 3 hours. I don't think I can get these interviews back and I'm worried I may have ruined my career forever.” She begins to sob and takes a tissue from her purse, ignoring the box you provided on the table beside her in plain view. “I could not even leave my house at all until today and that is only because I made this appointment with you.”
Since starting undergraduate school she lived in the dorms with a roommate, then found an apartment with a different roommate during graduate school. She moved out of the apartment 6 months before finishing her MBA because of interpersonal trouble with her roommate and moved back home with her mother. She says her mother has been very helpful, but she can tell that her “problems” have begun to “drive my mother crazy, and it looks like I'm going to have to move out.” Her sobbing intensifies. “I do not know how I can do this. I have no place else to go.”
You ask her why things seem to be worse now. For a moment she stops sobbing and seems to be thinking. Then she says, “I've got OCD [obsessive-compulsive disorder]. I must have. And it is taking over my life.” You ask her what she means by that. “I do not know if it is specifically OCD—I'm not a psychiatrist—but I know that I've been having these thoughts, they just jump into my head, some of them horrible and violent, and little things I used to think were just my silly superstitions are now the focus of my day.” She tells you that as a child she had to be sure that her dolls were always in a particular order (shortest to tallest to shortest) on her bed, and that she would both remove them and replace them each day to use her bed in precisely the same manner. If she moved one doll by accident ahead of another, she would have to start all over or “it just did not feel right. I know it is stupid. Believe me, I know this is ridiculous.” She laughs nervously. “Since I was a kid I would have to keep all of the food on my plate completely separated, and if one thing touched another, like the potatoes touching the green beans, I would cry and my mother would fix me a new plate.” She looks at you. “My grandfather used to tell me, ‘it all goes to the same place!’ But I always felt that if the food touched on the plate then it would cause me to do something bad in school. Is this the dumbest thing you ever heard?”
Her posture in the chair does not change. She takes each used tissue, carefully folds it and places each tissue in her purse. “I think I'm starting to have panic attacks, too.” She describes her last episode as happening 4 weeks ago at the supermarket; she was with her mother. They were in the cereal aisle and someone had accidentally knocked a few boxes of cereal onto the floor. She remembers staring at the boxes and becoming sweaty, her heart started to pound, her palms were moist, she felt dizzy, nauseated, and like she was “losing her mind”; her chest hurt as if “someone was stabbing me.” At the time she wondered if she were having a heart attack and told her mother she needed to go to the emergency room. Within 10 minutes the attack subsided, but she still took the ambulance ride to the hospital and was told that her heart was fine, but that she probably had a panic attack. There was no precipitant to the attack that she can think of. It came on “out of the blue.”
“I haven't gone shopping since. I stay at home. I do not even want to go into the back yard to sit on the deck. I stay inside all day watching TV. Now I'm feeling depressed and hopeless. I feel like I can't go out or something bad is going to happen to me. I worry if I go out I'll have another attack and there will not be anyone to help me.”
DECISION POINT A
Given what you have learned so far from this patient's presentation, do you believe she should be seen in the local psychiatric emergency room? Points awarded for correct and incorrect answers are scaled from best (+5) to unhelpful but not harmful (0) to dangerous (−5).
| A1. ____ | Yes, the patient has described feeling suicidal. At this point you do not have corroborative evidence from her mother about the patient or their relationship. She should go to the emergency room to be evaluated for safety. |
| A2. ____ | Yes, the patient has described feeling suicidal and should be evaluated for safety. At this point you do not have corroborative evidence from her mother about the patient or their relationship. Additionally, you should give her alprazolam 1 mg from your stock of samples to treat her panic disorder. |
| A3. ____ | No, the patient can be treated as an outpatient. You should give her alprazolam 1 mg from your stock of samples to treat her panic disorder and arrange for her to see a cognitive behavioral therapist as soon as possible. |
| A4. ____ | Not at this time. She has a safety plan including her mother staying with her. You can manage this patient as an outpatient unless her symptoms further deteriorate, at which point you would admit her. |
| A5. ____ | Not at this time. She should be further assessed, including a mental status examination; history and evaluation of any additional comorbid mental illnesses and her particular obsessions and compulsions; family history; and evaluation of her potential for self-harm or suicide, impulsivity, violent or aggressive behaviors. |
VIGNETTE PART II
You obtain a more detailed psychiatric and medical history. The patient reports feeling depressed “off and on” since she was a junior in high school. She never received psychiatric treatment, but did go to her school's guidance counselor every 1–2 weeks to talk about issues when they came up. She has never taken psychiatric medications. Until recently, she never thought about dying or killing herself, and these thoughts are very distressing to her. “I'm not like this. I know I'm not. I always had friends. I was on the cheerleading squad at high school, I graduated from an Ivy League university with a 3.8, and I went to another prestigious university for my MBA.” She does not recall ever going with little sleep yet feeling refreshed the next day. “I need my sleep,” she smiles. She never used to get irritable, but over the past 6 months she noticed that she “snaps” very easily. She would like to work for a corporation because she prefers to be “one among many” rather than attempt to work in a smaller business or start her own. “At one time I wanted to work for one of the big investment houses in New York City, but now I can't imagine how I would be able to walk down the street with so many people.” She started feeling as though people were watching her or noticing that she performs little rituals such as touching the top right corner of a doorway three times with the pad of her index finger before entering a room. “If I did it before entering a room, people would like me. If I did not, I was sure someone would hate me.” She sighs, then tries to laugh. “I used to avoid cracks on the sidewalk like every other kid, but now I have trouble even walking down the street.”
She denies any current use of tobacco, alcohol, or other substances, although there was a period during college when she was drinking to excess. She stopped when someone close to her died during a car accident, driving while intoxicated. When asked about whether she was ever abused, she says her uncle fondled her from age 12 to 14 and was eventually jailed. “That is why my parents split up. My father did not believe his brother would do what he did.” She denies self-mutilating behaviors, aggressive or violent behaviors, and anorexia or bulimia nervosa but has experienced extreme mood swings, especially in the past 6 months.
She had her tonsils and adenoids removed when she was 3 years old, a mole removed at 12 years of age, mononucleosis for approximately 1 month during 9th grade, but no other medical problems. She never had head trauma, loss of consciousness, or seizures, and is taking no medications other than birth control pills.
Her father and mother separated when she was 13 and divorced when she was 15. She describes it as “ugly.” In the end, her mother had full legal custody and her father “gave up.” Because she was mad at her father for taking her uncle's side in the molestation case she did not speak with him until she was accepted to the university. Now they speak weekly; she sees him at least once per month but not in the past half-year because of her difficulties in leaving the house. Her mother will not allow him to come to her house.
Currently, she reports that she has difficulty initiating sleep and has frequent wakenings. She describes lying in bed ruminating about whether she completed all the tasks she writes out for herself every night, sometimes staying up late, simply making a long list. Normally, she is a “self-motivated” student who works “harder than most of my classmates.” Some of her MBA project colleagues have told her she is difficult to work with and at times, “inflexible, ” but she disagrees with that assessment. “I like things to be done a certain way, but I'm able to be flexible.” She is very well-organized in the way she does her work. “I love office supplies!” But she says most of her colleagues are like this because “you have to be in this program. A mess on your desk or in your room is an outward manifestation of an inner spiritual state.” She sits back and lets you ponder what she seems to feel is a deep thought.
She is typically forward-thinking but recently, since her symptoms have “taken over,” she has lost interest in trying to figure out what to do with her life. She feels as though she is responsible for the rituals and obsessive thinking and as a result is very hard on herself. She has increasingly diminished energy as she feels more helpless and hopeless and is unable to focus even on a TV show without being easily distracted. Her appetite is less than usual, but she has not had major changes of weight. During the interview, she has diminished kinetics, sitting still in her chair.
You tell her you have to end the session, but you would like her to come back in 2 days when you have your first open appointment. She agrees and says she feels a little better after having spoken with you.
DECISION POINT B
Given what you learned from the patient's presentation, what is your differential diagnosis? (+2) points are given for correct answers, including appropriate rule-out diagnoses, and (−2) points are given for incorrect answers.
DECISION POINT C
Which of the following statements are true and which are false? (+2) points for each correct answer.
| C1. ____ | Obsessions are intrusive, persistent, unwanted thoughts, impulses, or images that give rise to marked anxiety or distress. |
| C2. ____ | There are several established environmental risk factors for OCD including exposure to authority figures such as teachers who have OCD, exposure to close friends, or romantic relationships with individuals who have OCD. |
| C3. ____ | Higher rates of OCD symptom severity, such as higher rates of compulsions without obsessions and higher rates of clinically significant OCD symptoms, are associated with early-onset OCD. |
| C4. ____ | The symptoms of OCD between children and adults are very different. |
| C5. ____ | Streptococcal infection may be associated with a form of early-onset OCD, often abbreviated PANDAS (pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection), that involves an abrupt onset of OCD symptoms and co-occurring tics. |
| C6. ____ | the mean age of OCD onset ranges from 18 to 22 years of age, with at least one third of cases beginning by age 40. |
| C7. ____ | The heritability of panic disorder is roughly 22%. |
| C8. ____ | In two of the larger twin studies for OCD, concordance rates ranged from 80% to 87% for monozygotic twins and from 47% to 50% for dizygotic twins. |
| C9. ____ | OCD can be caused by neurological conditions such as brain trauma, stroke, encephalitis, temporal lobe epilepsy, Prader-Willi syndrome, Sydenham's chorea, carbon monoxide poisoning, manganese poisoning, and neurodegenerative diseases such as Parkinson's disease and Huntington's disease. |
| C10. ____ | A compulsion is a physical or mental act by the patient whose performance of this act is done to undo a thought, magically prevent a feared event, or reduce anxiety or distress. |
VIGNETTE PART III
The patient goes home with her mother and returns for her scheduled appointment in 2 days. She still seems distressed but tells you she feels better since talking to you. You ask to speak with her mother for collateral information, to which the patient consents. The patient's mother reports that she noticed the behaviors the patient described, but adds that in the past 4–6 months the patient has also started checking door locks several times, turning off the sink three times each time she uses it, and has had at least four panic attacks that she witnessed. She retells the story about the supermarket in an identical fashion to the patient's version.
She tells you the patient was born at 38 weeks with a normal vaginal delivery. The mother did not use medications during pregnancy, there were no complications, and the patient had APGAR scores of 9 and 9. The patient did not require a stay in the neonatal intensive care unit and was promptly discharged with her mother within 2 days. She described the patient's temperament as fussy, colicky, and anxious. She walked at 1 year, talked at 1 year, was potty trained at 2.5 years, and never had problems with separation anxiety. The patient did well in school until middle school when she was molested by her uncle. At that point her grades suffered for about 6 months; her mother found a child psychiatrist and the patient was seen for psychotherapy over the next 3 years, partly due to the molestation and the cantankerous divorce. “She has a way of blocking things out. I quit trying.” After that, her mother tells you, “she seemed to be back to normal, whatever that means. She received straight A's at a competitive school and I did not think there was a problem until recently.” Her mother does not recall any episodes of her daughter having insomnia, grandiosity, hyperverbal or pressured speech, or risky behaviors. “She has always been an angel, a very thoughtful person.” She goes on: “Her last psychiatrist wanted to give her medication after medication until she told me she ‘could not feel anything’ anymore, or she was having severe stomach aches and headaches. We asked the doctor to take her off the medications and then we never went back.”
Her daughter's mood has been increasingly low, and this is worrisome to the patient's mother. “She normally likes to garden with me, go to an occasional movie on the weekend, go out to dinner, or spend time with her friends. I do not think she has talked to her friends in months. When they call, she tells me to say she is not at home.” She tells you her daughter mentioned feeling like she wanted to die a few times over the past month; she feels so frustrated spending so much time doing little rituals or not being able to stop thinking about something.” They have had conversations about drugs and alcohol and the patient's mother does not keep any alcohol in the house. Two months ago she locked her own medications in a drawer because she did not want “to take a chance her daughter might do something stupid.”
You ask about the family's psychiatric history. On the mother's side there are two cousins in their 40s with major depressive disorder who are in treatment and doing well. On the father's side, there is alcoholism in her father (sober for 14 years) and uncle (alcoholic, now in prison), and possible schizophrenia in two great-uncles.
The patient returns and both the patient and her mother would like to discuss treatment options. “I'm desperate, Doctor,” says the patient. “I'll do anything you say. I cannot live like this.”
You ask her to complete a Y-BOCS (Yale-Brown Obsessive Compulsive Scale) and she scores 27 out of 40, indicating severe symptoms.
DECISION POINT D
Given what you know about this patient and her history, how would you treat this patient? Answers are true or false. (+2) points for correct answers and (−2) points for incorrect answers.
| D1. ____ | First, you must establish a therapeutic alliance. |
| D2. ____ | You already know enough about the patient's symptoms to make a correct diagnosis of OCD and Panic Disorder with Agoraphobia. Tell the patient you will start therapy with an selective serotonin reuptake inhibitors (SSRI) plus refer her to a cognitive behavioral therapist. You ask to see her again in 3 months to monitor her medications. |
| D3. ____ | Further explore all of the patient's symptoms. You do not know her well and you have already noted that her mother has additional collateral information the patient did not reveal. Differentiate her symptoms from other psychiatric disorders that have similar symptomatology, such as depressive ruminations, generalized anxiety disorder, intrusive thoughts and images of posttraumatic stress disorder, and schizophrenic and manic delusions. |
| D4. ____ | Evaluate the patient's safety to protect against self-harm or harming others. |
| D5. ____ | Complete the psychiatric assessment. |
| D6. ____ | Establish goals for treatment. |
| D7. ____ | Establish the appropriate setting for treatment. |
| D8. ____ | Enhance treatment adherence. |
DECISION POINT E
What would you choose as your initial treatment modality? Points range from (+5) points for the best answer to (−5) points for dangerous.
| E1. ____ | Cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) only |
| E2. ____ | CBT with ERP plus a serotonin response inhibitor (SRI) |
| E3. ____ | An SRI alone |
| E4. ____ | An SRI augmented with clomipramine |
| E5. ____ | Clomipramine augmented with an SRI |
ANSWERS: SCORING, RELATIVE WEIGHTS, AND COMMENTS
DECISION POINT A
| A1. ____ | +5 The patient describes feeling suicidal but has not divulged any intention or plan. She is ambivalent about her ability to remain safe at present. You should definitely explore her feelings about suicide and determine how safe she is to make a decision about a trip to the emergency room and potentially a hospitalization. This patient has a close social support with medical training, her mother, a registered nurse, who is staying with her during this crisis. If the mother does not feel she can manage the patient, and if there is no satisfactory safety plan in place, then she should be brought to the emergency room for further evaluation. If the mother is satisfied that she can manage the patient until her next outpatient appointment, a trip to the emergency room might be avoided. Comorbid psychiatric illness may increase the likelihood of the patient attempting suicide or other self-injurious behaviors, so further evaluation during this urgent evening appointment suggests that a trip to the emergency room is warranted. |
| A2. ____ | −2 The patient should be considered a safety risk as described in answer A1; however, she is not presently experiencing a panic attack, and a medium acting, fast-onset benzodiazepine such as alprazolam is not indicated. |
| A3. ____ | −2 The patient's safety issues should be further investigated. There is no indication for the use of alprazolam as described in answer A2. CBT is one of the gold standard treatments for her anxiety and impulse-control issues; however, your evaluation of the patient is not complete enough to recommend a treatment course of strictly CBT. Establishing rapport with this patient is crucial, so sending her off to another specialist before determining the extent of her illness could possibly give her the impression that you are not aligned substantially. You also must educate the patient and her mother regarding your findings and the various treatments you may suggest once the evaluation is complete. |
| A4. ____ | −2 It is true that the patient has a safety plan and there is no clear evidence that every patient who expresses passive suicidal ideation would benefit from hospitalization. Moreover, you have not completed your psychiatric evaluation, so you cannot know the extent of the illness, the presence of comorbid illnesses, or the psychosocial picture that would enable or hinder her ability to participate in treatment. These details could be drawn out in future sessions and the fact of establishing a therapeutic relationship with the patient may relieve some of her symptoms temporarily, enough to keep her out of the hospital and continue work with you. However, safety should be first on your mind. Additionally, you have no corroboration from her mother, with whom the patient says she would stay for safety. It is not yet clear whether this is a feasible plan. |
| A5. ____ | +1 The key to this answer is that you have ruled out further evaluation in an emergency room for an ambivalently suicidal patient. The remainder of the answer is correct, regarding the additional information necessary for your evaluation with the addition of corroborative history from her mother, the person she asserts will keep her safe. You could evaluate this patient in your office and possibly arrange a satisfactory safety plan with the patient, but given the limited and worrisome information you have about the patient, she would probably benefit more from the safety and resources available in an emergency room. |
Panic disorder with agoraphobia (+2). The patient accurately describes a panic attack, including palpitations, sweating, chest pain, dizziness, fear of dying, fear of losing control or going crazy, and nausea, having their apex within 10 minutes. For DSM-IV-TR diagnosis of a panic attack, a patient requires 4 of 13 symptoms. This patient endorses 6 and her account is corroborated by her mother. Other symptoms include trembling or shaking, sensations of shortness of breath or smothering, feeling of choking, derealization (feelings of unreality) or depersonalization (being detached from oneself), paresthesias (numbness or tingling sensations), and chills or hot flashes. She meets the criteria for agoraphobia because she is worried about having new attacks and subsequently stays home, which represents a significant change in behavior related to the attacks.
Major depressive disorder, recurrent, without psychotic features (+2). The patient describes feeling anhedonic and depressed, meeting both of criteria A for major depression when only one was required. She also has a diminished appetite, low energy, difficulty concentrating, and recurrent thoughts of death. These symptoms are not related to a medical illness and have contributed to an impairment in her social and academic/professional functioning. She does not currently abuse alcohol or substances, and these symptoms are not better accounted for by bereavement.
Obsessive-compulsive disorder (+2). This patient has a long history beginning in childhood of arranging her dolls in a certain order and repeating the process if she did not do it perfectly. She worried that if her food touched on her plate she would do something bad in school. She complained that she had intrusive thoughts that made her anxious such as being a bad mother, requiring an “undoing” ritual of patting her head five times. She had to touch the right corner of a door jamb three times before entering a room or she would be sure someone in the room she was entering would hate her and she would have to leave. If she worried about someone hating her, she felt that the touching of the door jamb would protect her.
According to DSM-IV-TR:
| A. | Obsessions are defined by:
| ||||||||||||||||||||||||||||||||||||||||
| B. | At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children. | ||||||||||||||||||||||||||||||||||||||||
| C. | The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships. | ||||||||||||||||||||||||||||||||||||||||
| D. | If another axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder). | ||||||||||||||||||||||||||||||||||||||||
| E. | The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. | ||||||||||||||||||||||||||||||||||||||||
Social phobia (−2). Although this patient has described a marked and persistent fear of social situations, exposure to unfamiliar people or scrutiny by others, worrying that her behavior will be embarrassing or humiliating, she has developed compulsions to counteract the provoked anxiety. Her perceived negative scrutiny is also consistent with the agoraphobic feature of her panic disorder. Additionally, she describes intrusive thoughts that carry greater weight than a general worry about social situations, which until recently she was able to manage quite well, achieving high marks at very competitive academic institutions. She does not describe her panic attacks as provoked by a situation, but rather “out of the blue.”
Trichotillomania (+2). You notice at her first visit that she is pulling her hair and there is hair loss behind her right ear. She admits she has been doing this for a while to relieve tension.
Rule out bipolar disorder (0). The patient does not describe any symptoms consistent with this diagnosis except for some family history. Even though she does not present with bipolar disorder, you must obtain as much collateral information as possible to be sure she is not at risk for this disorder as the pharmacological treatment for OCD and major depressive disorder most certainly include SRIs, which could cause a mixed state. It seems highly unlikely in this patient, but you should carefully explore this possibility in your evaluation.
Rule out posttraumatic stress disorder (0). The patient was molested by her uncle for 2 years from 12–14 years of age. She does not provide a detailed description of this part of her life; however, there may be shared symptomatology with OCD, especially with her need to control aspects of her life. This molestation should be explored as a possible etiology for her symptoms given her history to help the therapist better understand the nature of her illness. However, at this stage there is little to support this diagnosis, such as the lack of nightmares, no restricted affect, no avoidance behaviors relating to, for example, her uncle or places where she might have been molested by her uncle.
Rule out adjustment disorder, chronic (−2). The patient does not describe a significant event or stressor that occurred within 6 months of the onset of symptoms. The stressor, if it is finding a job or moving back home to live with her mother, may be chronic, but her symptoms preceded this time frame.
Rule out generalized anxiety disorder (−2). This patient does describe excessive anxiety and worry about her future after completing her MBA, which is legitimate since she did not show up for interviews. She also describes having panic attacks in public and is having difficulty controlling the worry as evidenced by her OCD symptoms. She does not describe being restless or keyed up, easily fatigued, irritable, or having muscle tension. She only meets 2 of 6 criteria regarding the anxiety and worry, e.g., difficulty concentrating and sleep disturbance. She is worried about specific stressors rather than having general anxiety over numerous issues.
Rule out anxiety disorder, not otherwise specified (−2). Because this patient's symptoms can be better categorized as OCD and panic disorder with agoraphobia, this is not an appropriate diagnosis.
Rule out obsessive-compulsive personality disorder (−2). There is evidence that the patient received comments about being inflexible and describes herself in terms that suggest some perfectionism and dedication to her work; however, she does not meet the criteria of a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts.
DECISION POINT C
| C1. ____ | +2 True |
| C2. ____ | +2 False |
| C3. ____ | +2 True |
| C4. ____ | +2 False |
| C5. ____ | +2 True |
| C6. ____ | +2 False. The mean age at OCD onset ranges in epidemiological studies between 22 and 35 years, with at least one third of cases beginning by age 15 years. |
| C7. ____ | +2 False. The heritability of panic disorder has been estimated to be approximately 43%. |
| C8. ____ | +2 True |
| C9. ____ | +2 True |
| C10. | +2 True |
DECISION POINT D
| D1. ____ | +2 True. The therapeutic alliance is key to joining the therapist and the patient in a joint enterprise that will enable the patient to feel comfortable, especially while enduring therapeutic techniques such as ERP in which the patient must endure anxiety-provoking experiences for that anxiety to be relieved by desensitization. The therapist must gauge the aggressiveness of the treatment and the nuances of the patient's response to treatment and essentially understand the patient as much as possible to best facilitate a restructuring of his or her link between unwanted cognitions and behaviors. |
| D2. ____ | −2 False. You can establish an educated diagnostic picture, but you would not avoid the process of building rapport as described in answer D1, nor would you send the patient off to another therapist or prescribe a medication to a medication-naive patient without first closely observing his or her response to treatment. This would be considered a dangerous action. |
| D3. ____ | +2 True |
| D4. ____ | +2 True |
| D5. ____ | +2 True |
| D6. ____ | +2 True |
| D7. ____ | +2 True |
| D8. ____ | +2 True |
DECISION POINT E
| E1. ____ | +3 Starting with CBT and ERP alone is certainly acceptable. Given this patient's severity of symptoms plus major depressive symptoms, once you determine that she is not at risk for bipolar disorder and developing a mixed state from use of an SRI, you would probably want to begin treatment with pharmacotherapy simultaneously. Studies have shown that combination therapies of CBT with ERP and SRIs are more effective than CBT or medications alone. However, beginning with psychotherapy alone is still considered an effective strategy before starting medications. This patient has been through many medication trials and has never tried CBT with ERP, so she might prefer this approach. Starting with psychotherapy with this particular patient may be useful to build rapport and trust with you. |
| E2. ____ | +5 Assuming you have ruled out bipolar disorder, this patient would benefit most from a more aggressive approach including both psychotherapy and psychopharmacotherapy. Studies have shown that combining therapies is more effective than monotherapy in some patients. Of course, you need to know what treatments she had with her prior psychiatrist so as not to repeat past failures |
| E3. ____ | +3 Starting with an SRI alone is acceptable, especially if the patient has had good results in the past and does not wish to do psychotherapy. SRIs are the first-line treatment of choice because they have a better side effect profile than the older gold standard, clomipramine. |
| E4. ____ | 0 Because of their relative safety compared with older medications such as clomipramine, the standard of care for treating OCD is to begin with SRIs. If the patient does not respond to the first trial of an SRI, studies suggest switching to a different SRI as it is difficult to determine an individual's response to each SRI. Clinical experience suggests that response rates to a second SRI trial are close to 50% but may diminish as the number of failed adequate trials increases. The initial treatment should be based upon the patient's medication history, and augmentation strategies are not appropriate as first-line treatment. Because we do not know the patient's history, and this question asks specifically for an initial treatment, considering augmentation to SRIs is not yet supported. |
| E5. ____ | 0 If clomipramine is added, an augmentation strategy supported by at least three open-label studies, however, plasma concentration of clomipramine and desmethylclomipramine should be assayed 2–3 weeks after a dose of 50 mg/day is reached, and the total plasma concentration should be kept below 500 ng/ml to avoid cardiac and central nervous system toxicity. This answer assumes that the patient is already taking an SRI. Some clinicians might start the augmentation strategy if the initial SRI was not sufficiently effective. Others might choose a second SRI trial before beginning an augmentation strategy. This is an inappropriate option for an initial treatment because it implies that she is already taking a drug. As we do not know the patient's history, and this question asks specifically for an initial treatment, considering augmentation to SRIs is not yet supported. |
SCORING
Abramowitz JS: Does cognitive-behavioral therapy cure obsessive-compulsive disorder? A meta-analytic evaluation of clinical significance. Behav Ther 1998; 29: 355Crossref, Google Scholar
American Psychiatric Association: Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry (in press)Google Scholar
Burke KC, Burke JD Jr., Regier DA, Rae DS: Age at onset of selected mental disorders in five community populations. Arch Gen Psychiatry 1990; 47: 511– 518Crossref, Google Scholar
Cannon TD, Kaprio J, Lonnqvist J, Huttunen M, Koskenvuy M: The genetic epidemiology of schizophrenia in a Finnish twin cohort: a population-based modeling study. Arch Gen Psychiatry 1998; 55: 67– 74Crossref, Google Scholar
Carey G, Gottesman II: Twin and family studies of anxiety, phobic and obsessive disorders, in Anxiety: New Research and Changing Concepts. Edited by Klein DF, Rabkin J. New York, Raven Press, 1981, pp 117– 136Google Scholar
Clifford CA, Murray RM, Fulker DW: Genetic and environmental influences on obsessional traits and symptoms. Psychol Med 1984; 14: 791– 800Crossref, Google Scholar
Cottraux J, Bouvard MA, Milliery M: Combining pharmacotherapy with cognitive-behavioral interventions for obsessive-compulsive disorder. Cogn Behav Ther 2005; 34: 185– 192Crossref, Google Scholar
Cottraux J, Note I, Yao SN, Lafont S, Note B, Mollard E, Bouvard M, Sauteraud A, Bourgeois M, Dartigues JF: A randomized controlled trial of cognitive therapy versus intensive behavior therapy in obsessive compulsive disorder. Psychother Psychosom 2001; 70: 288– 297Crossref, Google Scholar
Eddy KT, Dutra L, Bradley R, Westen D: A multidimensional meta-analysis of psychotherapy and pharmacotherapy for obsessive-compulsive disorder. Clin Psychol Rev 2004; 24: 1011– 1030Crossref, Google Scholar
Fisher PL, Wells A: How effective are cognitive and behavioral treatments for obsessive-compulsive disorder? A clinical significance analysis. Behav Res Ther 2005; 43: 1543– 1558Crossref, Google Scholar
Freeston MH, Rheaume J, Ladouceur R: Correcting faulty appraisals of obsessional thoughts. Behav Res Ther 1996; 34: 433– 446Crossref, Google Scholar
Goodman WK, Price LH, Rasmussen SA, Mzaure C, Fleischmann RL, Hill CL, Heninger GR, Charney DS: The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry 1989; 46: 1006– 1011Crossref, Google Scholar
Hettema JM, Neale MC, Kendler KS: A review and meta-analysis of the genetic epidemiology of anxiety disorders. Am J Psychiatry 2001; 158: 1568– 1578Crossref, Google Scholar
Inouye E: Similar and dissimilar manifestations of obsessive-compulsive neuroses in monozygotic twins. Am J Psychiatry 1965; 121: 1171– 1175Crossref, Google Scholar
Jonnal AH, Gardner CO, Prescott CA, Kendler KS: Obsessive and compulsive symptoms in a general population sample of female twins. Am J Med Genet 2000; 96: 791– 796Crossref, Google Scholar
Ravizza L, Barzega G, Bellino S, Bogetto F, Maina G: Drug treatment of obsessive-compulsive disorder (OCD): long-term trial with clomipramine and selective serotonin reuptake inhibitors (SSRIs). Psychopharmacol Bull 1996; 32: 167– 173Google Scholar
Szegedi A, Wetzel H, Leal M, Hartter S, Hiemke C: Combination treatment with clomipramine and fluvoxamine: drug monitoring, safety, and tolerability data. J Clin Psychiatry 1996; 57: 257– 264Google Scholar
Van Balkom AJ, de Haan E, van Oppen P, Spinhoven P, Hoogduin KA, van Dyck R: Cognitive and behavioral therapies alone versus in combination with fluvoxamine in the treatment of obsessive compulsive disorder. J Nerv Ment Dis 1998; 186: 492– 499Crossref, Google Scholar
Weissman MM, Bland RC, Canino GJ, Greenwald S, Hwu HG, Lee CK, Newman SC, Oakley-Browne MA, Rubio-Stipec M, Wickramaratne PJ, Wittchen H-U, Yeh E-K, the Cross National Collaborative Group: The cross national epidemiology of obsessive-compulsive disorder. J Clin Psychiatry 1994; 55(Mar suppl): 5– 10Google Scholar
Whittal ML, Thordarson DS, McLean PD: Treatment of obsessive-compulsive disorder: cognitive behavior therapy vs. exposure and response prevention. Behav Res Ther 2005; 43: 1559– 1576Crossref, Google Scholar
