A 24-year-old man comes to the office due to concern that he is unable to adequately complete his work at his construction job. He is constantly distracted by thoughts that he has hurt one of his coworkers and spends hours each day repeatedly checking to make sure he has completed his assignments and that no one is injured. The patient feels the need to hammer nails in a specific geometric pattern and to make sure he uses only an odd number of nails. He counts the number of nails at least 3 times, saying to himself, "If I don't do this, someone could fall or injure themselves." He is extremely distressed by these thoughts and behaviors. On his last performance review, his supervisor reported that the patient is very cautious and has good skills but takes longer to complete jobs than his coworkers. The patient is afraid he will be fired if he doesn't start working more efficiently. He is otherwise healthy but smokes cigarettes and occasionally uses marijuana.
Physical examination is unremarkable apart from hard callouses on his ring fingers and right thumb. Laboratory studies, including complete blood count, comprehensive metabolic panel, and TSH, are within normal limits.
Which of the following is the most appropriate next step in management of this patient?

Question

A 24-year-old man comes to the office due to concern that he is unable to adequately complete his work at his construction job.  He is constantly distracted by thoughts that he has hurt one of his coworkers and spends hours each day repeatedly checking to make sure he has completed his assignments and that no one is injured.  The patient feels the need to hammer nails in a specific geometric pattern and to make sure he uses only an odd number of nails.  He counts the number of nails at least 3 times, saying to himself, "If I don't do this, someone could fall or injure themselves."  He is extremely distressed by these thoughts and behaviors.  On his last performance review, his supervisor reported that the patient is very cautious and has good skills but takes longer to complete jobs than his coworkers.  The patient is afraid he will be fired if he doesn't start working more efficiently.  He is otherwise healthy but smokes cigarettes and occasionally uses marijuana.
Physical examination is unremarkable apart from hard callouses on his ring fingers and right thumb.  Laboratory studies, including complete blood count, comprehensive metabolic panel, and TSH, are within normal limits.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_98ab_6687_853d_232ec3c61f91_MD0002_00 This patient's repetitive, time-consuming thoughts about having harmed someone, along with an accompanying need to check and recheck his work, nail in a particular pattern, and count objects, are consistent with obsessive-compulsive disorder (OCD). Patients with OCD usually have distressing and intrusive obsessions that may include thoughts about contamination (eg, germs, dirt), unwanted urges (eg, to hurt someone or the self), violent images, or concerns with having harmed someone. Repetitive behaviors (eg, washing, checking, counting), often in the form of rituals, are undertaken to prevent the fears from materializing. Initial treatment of OCD consists of serotonergic antidepressants and/or cognitive-behavioral therapy (CBT). Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment due to their favorable side effect profile. A higher dose than what is generally used for depression may be required and should be continued for at least 6 weeks, as effects are often delayed. The tricyclic antidepressant clomipramine is typically used as second-line treatment in patients who do not respond to an adequate SSRI trial (Choice A). (Choices B and D) CBT that includes exposure and response prevention (eg, patient gradually exposed to obsessional fears and prevented from performing the compulsion) is the psychotherapy of choice for OCD. Dialectical behavioral therapy (ie, CBT focusing on dangerous/suicidal behavior) is the preferred treatment for patients with borderline personality disorder. Psychodynamic psychotherapy can be helpful in developing insight for many conditions but is less effective than CBT in targeting obsessions and compulsions. (Choice E) Antipsychotic monotherapy is not a first-line treatment for OCD. If a patient does not respond adequately to an SSRI alone, an antipsychotic can be used as augmentation. Educational objective: Treatment of obsessive-compulsive disorder consists of serotonergic medications and/or cognitive-behavioral therapy. Selective serotonin reuptake inhibitors are first-line treatment due to their favorable side effect profile. Higher doses and trials of at least 6 weeks are often necessary for response. __________ References: Treatment strategies of obsessive-compulsive disorder and panic disorder/agoraphobia. (http://www.ncbi.nlm.nih.gov/pubmed/22204483) The nature, assessment, and treatment of obsessive-compulsive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/22314125)

A 24-Year-Old Man Comes to the Office Due to Concern