A 19-year-old woman who is struggling academically comes to the university health clinic. The patient is assessed by a counselor and referred to the clinic's physician for symptoms of anxiety, insomnia, and fatigue. For the past year, the patient has worried excessively about whether her door is locked and the stove is turned off, so she checks the door and stove multiple times during the day and night. Although she knows she has locked the door and turned off the stove and that her fears "don't make sense," she is unable to stop thinking about them until she checks. She also is concerned that spending so much time on these thoughts does not allow her time to complete assignments or get enough sleep. When the patient does complete assignments, she spends a great deal of time checking her work repeatedly. Her medications include daily oral contraceptives. She has no significant medical or psychiatric history. The patient does not use illicit drugs and has no feelings of depression or hopelessness. Physical examination is unremarkable. Which of the following would be the most appropriate treatment for this patient?

Question

A 19-year-old woman who is struggling academically comes to the university health clinic.  The patient is assessed by a counselor and referred to the clinic's physician for symptoms of anxiety, insomnia, and fatigue.  For the past year, the patient has worried excessively about whether her door is locked and the stove is turned off, so she checks the door and stove multiple times during the day and night.  Although she knows she has locked the door and turned off the stove and that her fears "don't make sense," she is unable to stop thinking about them until she checks.  She also is concerned that spending so much time on these thoughts does not allow her time to complete assignments or get enough sleep.  When the patient does complete assignments, she spends a great deal of time checking her work repeatedly.  Her medications include daily oral contraceptives.  She has no significant medical or psychiatric history.  The patient does not use illicit drugs and has no feelings of depression or hopelessness.  Physical examination is unremarkable.  Which of the following would be the most appropriate treatment for this patient?

Quizplus · Accepted Answer

11ec25c8_d7d8_0c8e_bc81_8f6deb6dbd12_MD0003_00 This patient has obsessive-compulsive disorder (OCD), a condition characterized by time-consuming, recurrent, unwanted thoughts (obsessions) and repetitive behaviors that the patient feels compelled to perform (compulsions). First-line treatment includes cognitive-behavioral therapy based on exposure and response prevention (ERP) and/or pharmacotherapy with a selective serotonin reuptake inhibitor (eg, fluoxetine, fluvoxamine, paroxetine, sertraline). ERP therapy involves repeated exposure to thoughts, images, and situations that provoke obsessional fears followed by prevention of the accompanying compulsion. For example, a therapist would guide this patient to practice leaving home after checking the stove and door once (exposure) and then prevent her from checking repeatedly (response prevention). Initially, anxiety increases, but with prolonged and repetitive exposure, habituation occurs and the anxiety subsides. (Choice A) Buspirone is used to treat generalized anxiety disorder; it does not have a role in OCD. (Choice B) Clomipramine is a tricyclic antidepressant that inhibits the reuptake of serotonin and norepinephrine. Although it has comparable efficacy to selective serotonin reuptake inhibitors in the treatment of OCD, it is not used first-line due to its unfavorable side-effect profile (eg, sedation, urinary hesitancy, orthostatic hypotension, cardiac conduction delay). (Choice D) Dialectical behavioral therapy is a type of psychotherapy developed for borderline personality disorder that integrates standard cognitive-behavioral therapy techniques with principles of mindfulness, distress tolerance, and emotion regulation. This patient's OCD symptoms are more likely to respond to ERP techniques. (Choices E and G) Psychodynamic psychotherapy, which traces problems back to their origins in childhood and unconscious conflict, may provide the patient with insight, but it is not effective in changing the compulsive behaviors seen in OCD. Supportive psychotherapy is a broadly applicable approach that helps to reduce stress, improve coping skills, and maintain hope. However, it does not specifically target obsessive and compulsive symptoms. (Choice F) The combination of a serotonergic agent (eg, sertraline) and an antipsychotic (eg, aripiprazole) is not a first-line treatment and would be reserved for patients who respond poorly to monotherapy. Educational objective: First-line treatments for obsessive-compulsive disorder are exposure and response prevention techniques based on cognitive-behavioral therapy and selective serotonin reuptake inhibitors. References: Psychotherapy for obsessive-compulsive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/19635238) Clinical practice: obsessive-compulsive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/25119610) Obsessive-compulsive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/24576790)

A 19-Year-Old Woman Who Is Struggling Academically Comes to the University