A 31-year-old man comes to the office with his wife, who is threatening to leave him if he does not get help. The patient was recently fired from his job as a computer programmer due to frequent lateness and absences caused by his elaborate morning showering ritual. He feels compelled to clean each part of his body in a specific order while counting to 27. If he misses a body part or makes a mistake in counting, he must start over. His wife adds that he often takes 3 showers in a row because "he won't accept that the towels I give him were just cleaned. It has become extremely difficult to live with him." Once dressed, the patient must go out of his way to take a certain route to work to avoid "dirty" street corners that may soil or contaminate his clothes. He says, "I know it makes no sense, but I can't get rid of the thought that my clothes are splattered with urine. Once this idea takes hold, I have to go home and change." The patient became concerned with cleanliness as a young teen and wonders whether this was inherited from his mother, whom he describes as "a control freak." He says, "I know I need help but prefer not to take medication if possible."
Which of the following nonpharmacologic approaches would be most effective for this patient?

Question

A 31-year-old man comes to the office with his wife, who is threatening to leave him if he does not get help.  The patient was recently fired from his job as a computer programmer due to frequent lateness and absences caused by his elaborate morning showering ritual.  He feels compelled to clean each part of his body in a specific order while counting to 27.  If he misses a body part or makes a mistake in counting, he must start over.  His wife adds that he often takes 3 showers in a row because "he won't accept that the towels I give him were just cleaned.  It has become extremely difficult to live with him."  Once dressed, the patient must go out of his way to take a certain route to work to avoid "dirty" street corners that may soil or contaminate his clothes.  He says, "I know it makes no sense, but I can't get rid of the thought that my clothes are splattered with urine.  Once this idea takes hold, I have to go home and change."  The patient became concerned with cleanliness as a young teen and wonders whether this was inherited from his mother, whom he describes as "a control freak."  He says, "I know I need help but prefer not to take medication if possible." 
Which of the following nonpharmacologic approaches would be most effective for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c056_b0e6_8f63_35cf54091c91_MD0005_00 This patient is suffering from obsessive-compulsive disorder (OCD), and his obsessional fears of contamination and time-consuming cleaning rituals cause significant occupational and marital dysfunction. Exposure and response prevention therapy, a specific form of cognitive-behavioral therapy (CBT), is considered first-line psychotherapy for OCD. Exposure and response prevention therapy involves gradual and repetitive exposure to anxiety-provoking stimuli that produce obsessional thoughts (eg, contamination fears), followed by prevention of performing the associated compulsion or ritual (eg, compulsive cleaning, repetitive showers). Effective exposure and response prevention therapy requires that the patient remain in the exposure situation until the obsessional distress decreases spontaneously, without attempts to reduce the distress by performing the compulsion. Through the process of habituation, in which anxiety levels subside over time, OCD symptoms are reduced. (Choice A) Dialectical behavioral therapy is a form of CBT developed for the treatment of borderline personality disorder. (Choice C) Interpersonal psychotherapy focuses on improving dysfunctional relationships and interpersonal functioning. It is used primarily in the treatment of depressive disorders. (Choice D) Psychodynamic psychotherapy, which traces problems back to their origins in childhood, may provide the patient with insight but is not effective in changing the compulsive behaviors seen in OCD. (Choice E) Although supportive psychotherapy is helpful to reduce stress and improve coping skills, it does not specifically target obsessive and compulsive symptoms. Educational objective: Exposure and response prevention, a form of cognitive-behavioral therapy, is considered a first-line nonpharmacologic intervention for obsessive-compulsive disorder. References: Symptom dimensions in obsessive-compulsive disorder: phenomenology and treatment outcomes with exposure and ritual prevention. (http://www.ncbi.nlm.nih.gov/pubmed/23615340)

A 31-Year-Old Man Comes to the Office with His Wife