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." After 12 weeks of twice-weekly therapy, the patient has made some improvement but still has significant anxiety and difficulty changing his rituals. Although he is better able to resist counting, he continues to shower excessively and still changes his clothes several times a day. The patient was offered a new job but turned it down when he learned that it would require him to share a computer keyboard with coworkers. He and his wife are frustrated that he has not made more progress. The patient is now more receptive to the idea of taking medication. His other medical problems include obesity and premature ejaculation. He takes no medication other than acetaminophen as needed. Physical examination is normal. Which of the following medications is the most appropriate next step in management of 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." After 12 weeks of twice-weekly therapy, the patient has made some improvement but still has significant anxiety and difficulty changing his rituals.  Although he is better able to resist counting, he continues to shower excessively and still changes his clothes several times a day.  The patient was offered a new job but turned it down when he learned that it would require him to share a computer keyboard with coworkers.  He and his wife are frustrated that he has not made more progress.  The patient is now more receptive to the idea of taking medication.  His other medical problems include obesity and premature ejaculation.  He takes no medication other than acetaminophen as needed.  Physical examination is normal.  Which of the following medications is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Serotonergic antidepressants have demonstrated efficacy in the treatment of obsessive-compulsive disorder (OCD). All selective serotonin reuptake inhibitor (SSRI) antidepressants (eg, fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram) and the tricyclic antidepressant clomipramine are effective. Although no medication has demonstrated superior efficacy over another, SSRIs are recommended as first-line treatment due to their superior side-effect profile compared with that of clomipramine. High doses and prolonged therapeutic trials are typically required, and gradual up-titration is necessary to enhance tolerability. Although SSRIs can cause sexual dysfunction in general, they would be beneficial in this patient. SSRIs are also used as first-line agents in the treatment of premature ejaculation due to their potential to cause delayed ejaculation. (Choice A) Bupropion is a nonserotonergic antidepressant that inhibits the reuptake of norepinephrine and dopamine. It is not effective in the treatment of OCD. (Choice B) Buspirone is used in the treatment of generalized anxiety disorder; it is not used to treat OCD. (Choice C) Clomipramine is considered a second-line agent due to its adverse effects, which include orthostatic hypotension, anticholinergic effects, and cardiac conduction delay. (Choice D) Olanzapine is a second-generation antipsychotic used to treat schizophrenia and bipolar disorder. It is not used as monotherapy in OCD. Antipsychotics may be added to an SSRI or clomipramine in treatment-refractory cases. Educational objective: Selective serotonin reuptake inhibitors (SSRIs) are first-line medications for obsessive-compulsive disorder. High doses and prolonged trials are typically required, and gradual up-titration is necessary to enhance tolerability. The tricyclic antidepressant clomipramine or antipsychotic augmentation can be used in patients who do not respond to SSRIs. References: Obsessive-compulsive disorder (OCD): practical strategies for pharmacological and somatic treatment in adults. (http://www.ncbi.nlm.nih.gov/pubmed/25681005) Pharmacotherapy of obsessive-compulsive disorder: evidence-based treatment and beyond. (http://www.ncbi.nlm.nih.gov/pubmed/23125399)

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