A 29-year-old man comes to the office because he is "worrying all the time." The patient has a long history of anxiety and says, "It was manageable when I was allowed to work from home, but since I was promoted and have to come into the office, I'm completely overwhelmed." He spends hours rehearsing before meetings to find "the right words" to say and repeatedly edits emails until they are "good enough." The patient also has difficulty leaving the house in the mornings because he spends 1-2 hours making sure all the appliances are unplugged. He shares, "I know it sounds crazy, but when I'm at work, I constantly worry that there will be an electrical fire at home, and I can't concentrate." Physical examination shows no abnormalities. On mental status examination, the patient describes his mood as "really anxious"; he is restless and makes poor eye contact. Which of the following is the most likely diagnosis?

Question

A 29-year-old man comes to the office because he is "worrying all the time."  The patient has a long history of anxiety and says, "It was manageable when I was allowed to work from home, but since I was promoted and have to come into the office, I'm completely overwhelmed."  He spends hours rehearsing before meetings to find "the right words" to say and repeatedly edits emails until they are "good enough."  The patient also has difficulty leaving the house in the mornings because he spends 1-2 hours making sure all the appliances are unplugged.  He shares, "I know it sounds crazy, but when I'm at work, I constantly worry that there will be an electrical fire at home, and I can't concentrate."  Physical examination shows no abnormalities.  On mental status examination, the patient describes his mood as "really anxious"; he is restless and makes poor eye contact.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7d8_a8cf_bc81_f306d1eafd2a_MD0003_00 This patient's long-standing anxiety related to intrusive thoughts and repetitive behaviors is characteristic of obsessive-compulsive disorder (OCD). Obsessions in OCD may include excessive worries about safety and an obsessive need to find just "the right words," as seen in this patient. Compulsions are time-consuming, repetitive behaviors performed in response to the obsession, such as this patient's unplugging appliances and excessive checking, editing, and rehearsing. Patients with OCD typically become more anxious when they are unable to perform or complete their compulsive rituals that are aimed at relieving their obsessions (eg, this patient's recent increase in anxiety associated with having to work out of the home). Most, but not all, patients with OCD have some insight that their concerns and behaviors are excessive (eg, patient says, "I know it sounds crazy"). (Choice A) In adjustment disorder, anxiety symptoms develop within three months of an identifiable stressor and do not meet criteria for another specific disorder. Although this patient's symptoms have increased with the stress of having to go into the office since he received a promotion, he has a long history consistent with OCD. (Choices B, C, and F) Agoraphobia is characterized by anxiety about and/or avoidance of certain situations (eg, closed spaces, crowds) and is frequently comorbid with panic attacks. Patients with generalized anxiety disorder worry about everyday concerns. In social anxiety disorder, anxiety is focused on fears of scrutiny and embarrassment in social situations. Although anxiety is a prominent feature of OCD, OCD can be differentiated from these primary anxiety disorders by unwanted obsessions and associated rituals that are not realistically connected to each other and are clearly excessive (eg, spending hours unplugging appliances). (Choice E) Schizoid personality disorder involves a lifelong pattern of behavior characterized by lack of desire for and detachment from social relationships and restricted emotions. Educational objective: Obsessive-compulsive disorder is characterized by intrusive, recurrent, and persistent unwanted thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) in response to the obsessions. Patients typically have prominent anxiety symptoms that must be differentiated from those of primary anxiety disorders. References: Obsessive-compulsive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/25150561) Obsessive-compulsive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/24576790)

A 29-Year-Old Man Comes to the Office Because He Is