A 28-year-old woman presents to a psychiatrist for evaluation of “bad thoughts”. She relates that for the past three years, she has been plagued by thoughts of harming her husband. Every day, many times throughout the day, she experiences detailed visual images of stabbing him repeatedly with a kitchen knife, or of him lying bloody and mangled as she runs him over with her car. She repeatedly checks her purse to make sure she carries no knife with herself .She is very upset about and ashamed of these images, as she states that she loves her husband, does not want to hurt him, and would never act on these images. She attempts to ignore or suppress them, but they are completely beyond her control. She identifies them as her own thoughts, however. She denies auditory hallucinations, thought insertion, broadcasting, or withdrawal, delusions of control, or other paranoid phenomena. On examination, she appears extremely distressed and anxious but her thought process is organized and logical.
What is the most likely diagnosis?
Correct Answer E:
This patient's most likely diagnosis is obsessive-compulsive disorder (choice E) and it is diagnosed primarily by presentation and history. It is an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry; by repetitive behaviors aimed at reducing the associated anxiety; or by a combination of such obsessions and compulsions. This patient for example has intrusive thoughts of stabbing her husband with a kitchen knife and she repeatedly checks her purse to make sure she is not carrying a knife.
→ Schizophrenia, undifferentiated type (choice A) is incorrect.The images are experienced as being her own thoughts, and so do not qualify as hallucinations.
→ In sexual sadism (choice B), fantasies of injuring or humiliating other evoke sexual excitement, which is not present in this case.
→ Partner relational problem (choice C) is incorrect. This DSM-IV diagnosis is used when the clinical focus is a maladaptive pattern of interaction between spouses. This does not appear to be the case here.
→ In dissociative disorders (choice D), there is a loss of a unitary sense of self or identity. There is no evidence for dissociation here.
A 23-year-old patient presents to your office with complaints of depression. He has trouble sleeping, poor appetite, feelings of hopelessness, and passive suicidal ideation with no plan. He recently lost his job because he has been chronically late or missing many days of work. The patient reports that he would be late because he would need to check the parking brake on his car several times to make sure it was locked. He was embarrassed to admit that he missed work on days that he knew his coworkers had cold symptoms. He was fearful that he would catch their germs and become violently ill as a result. You also notice that patient’s hands are dry and irritated. The patient explains that he washes his hands frequently throughout the course of the day to avoid contamination.
Which of the following would be the best form of medication treatment for the patient?
Correct Answer D:
The patient exhibits symptoms of obsessive-compulsive disorder and would benefit from treatment with an antidepressant with serotonergic properties. Fluvoxamine is a selective serotonin reuptake inhibitor that has been FDA approved for treatment of OCD.
A. Bupropion is an antidepressant with dopaminergic and noradrenergic properties and has not been shown to be effective in treatment of OCD.
B. Desipramine is a tricyclic antidepressant with highly noradrenergic properties. Clomipramine is an alternative tricyclic antidepressant with serotonergic properties shown to be effective for OCD.
C. Nefazodone antagonizes the 5-HT2 receptor but shows modest blockade of 5-HT reuptake. Studies are lacking that show its effectiveness for treatment of OCD.
E. Nortriptyline is another noradrenergic tricyclic antidepressant.
A 26-year-old law student is referred to a psychiatrist by her family physician for treatment of symptoms of severe anxiety, frequent handwashing, and hoarding. She relates to the consulting psychiatrist that she has experienced a variety of obsessions and compulsions since age 10.
Which of the following statements about obsessive-compulsive disorder (OCD) is incorrect?
Correct Answer A:
Various twin studies have calculated concordance rates greater than 80% in monozygotic twins. This indicates non shared or environmental factors play a role as the concordance rate is not 100%. Nonetheless genetics have become increasingly implicated in the etiology of the disease.
If presented, it is used to distinguish OCD from other anxiety disorders.
Correct Answer B:
Compulsions are the best differentiating symptoms within the anxiety disorders category to make the diagnosis of OCD. Phobias and of course obsessions are common aspects of OCD. The phobias in OCD tend to become generalized over time. Obsessional ruminations are seen to some extent within all the anxiety disorders.
After validating the referring physician’s diagnosis of OCD for this patient, the consulting psychiatrist recommends a specific pharmacological treatment.
Which is the best class of psychotropic medications to choose from?
Correct Answer C:
The selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacologic agents used to treat OCD. This class includes the tricyclic clomipramine as well as the more specific SSRIs such as fluoxetine, paroxetine, citalopram, sertraline, and fluvoxamine. The consulting psychiatrist suggests this patient receive fluoxetine at a starting dose of 20 mg each day.
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