A 13-year-old boy is brought to the office by his mother due to behavioral problems at school. The patient started at a new school 2 months ago after his family moved to the area for his father's job. His teachers report that he is fidgety in the classroom and has difficulty completing assignments on time. His mother states that he has always been a good student, but his grades have been declining over the past year, despite spending 3-4 hours on homework every night. The patient states that assignments have been taking longer to complete because he must rewrite them until his handwriting is "just right." He worries that if he does not achieve this, his father will lose his job and the family will have to move again. The patient has had no change in sleep or appetite. He does not feel sad or depressed but describes feeling anxious. Physical examination shows no abnormalities, and results of routine laboratory evaluation are within normal range. Which of the following is the most appropriate management for this patient's condition?

Question

A 13-year-old boy is brought to the office by his mother due to behavioral problems at school.  The patient started at a new school 2 months ago after his family moved to the area for his father's job.  His teachers report that he is fidgety in the classroom and has difficulty completing assignments on time.  His mother states that he has always been a good student, but his grades have been declining over the past year, despite spending 3-4 hours on homework every night.  The patient states that assignments have been taking longer to complete because he must rewrite them until his handwriting is "just right."  He worries that if he does not achieve this, his father will lose his job and the family will have to move again.  The patient has had no change in sleep or appetite.  He does not feel sad or depressed but describes feeling anxious.  Physical examination shows no abnormalities, and results of routine laboratory evaluation are within normal range.  Which of the following is the most appropriate management for this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d787_5434_bc81_c793dc1b8eb6_MD0003_00 This patient's time-consuming obsession with getting his handwriting "just right" and compulsive rewriting that is performed to prevent a feared event are consistent with obsessive compulsive disorder (OCD). OCD is a chronic condition that often begins in childhood or adolescence. Patients frequently have high levels of chronic anxiety because they struggle to suppress distressing, intrusive obsessions. Compulsions are intended to prevent a feared event from occurring and are usually not connected to the event in a realistic way (eg, the ability for handwriting appearance to prevent the father from losing his job). First-line treatment for OCD includes selective serotonin reuptake inhibitors (SSRIs) and/or cognitive-behavioral therapy (CBT) based on exposure and response prevention. The SSRIs fluoxetine, fluvoxamine, and sertraline have been shown to be safe and effective in the treatment of pediatric OCD. CBT is the most effective form of psychotherapy and involves exposing patients to thoughts, images, and situations that make them anxious and preventing the accompanying compulsion. (Choice A) Buspirone is an antianxiety medication that is used in the treatment of generalized anxiety disorder (GAD), which would not explain this patient's obsessions and compulsions. OCD can be associated with chronic anxiety but is not necessarily accompanied by GAD. (Choice B) Dialectical behavior therapy focuses on treating emotional dysregulation and self-harm behaviors in borderline personality disorder (eg, unstable relationships, impulsivity). It has no demonstrated efficacy for OCD. (Choice D) Methylphenidate is a stimulant medication used primarily in attention deficit hyperactivity disorder. This patient's fidgeting and difficulty completing assignments are likely due to his anxiety related to the intrusive obsessions and compulsions. A stimulant would risk worsening his anxiety. (Choice E) CBT is the psychotherapy of choice for OCD. Psychodynamic psychotherapy, which focuses on unconscious conflicts and developing insight, does not include the targeted behavioral exposure techniques aimed at decreasing compulsive behaviors. (Choice F) Reassurance and follow-up would not adequately address this patient's symptoms that are causing increasing distress and academic dysfunction. OCD requires pharmacological treatment and/or structured psychotherapy with a CBT-trained therapist. Educational objective: First-line treatment of pediatric obsessive-compulsive disorder includes selective serotonin reuptake inhibitors and/or cognitive-behavioral psychotherapy. References: Obsessive-compulsive disorder in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/25398447)

A 13-Year-Old Boy Is Brought to the Office by His