A 17-year-old girl comes to the office due to "disturbing images" she has seen over the past year. She says, "I'd be standing in the kitchen helping my mother chop vegetables, and terrible images of stabbing her in the back with a knife would pop into my head." The patient is overwhelmed with anxiety each time this occurs, resulting in putting the knife down and running out of the kitchen. She describes counting down from 5 to 1 several times to try to "get rid" of the thoughts, but this has not been helpful. The patient has no medical history, and physical examination is unremarkable. Mental status examination shows a tense and anxious affect; she becomes tearful when discussing how she would never want to hurt her mother. She reports no depressed mood or suicidal ideation. Which of the following is the most appropriate management for this patient?

Question

A 17-year-old girl comes to the office due to "disturbing images" she has seen over the past year.  She says, "I'd be standing in the kitchen helping my mother chop vegetables, and terrible images of stabbing her in the back with a knife would pop into my head."  The patient is overwhelmed with anxiety each time this occurs, resulting in putting the knife down and running out of the kitchen.  She describes counting down from 5 to 1 several times to try to "get rid" of the thoughts, but this has not been helpful.  The patient has no medical history, and physical examination is unremarkable.  Mental status examination shows a tense and anxious affect; she becomes tearful when discussing how she would never want to hurt her mother.  She reports no depressed mood or suicidal ideation.  Which of the following is the most appropriate management for this patient?

Quizplus · Accepted Answer

11ec25c8_d7d9_1e00_bc81_dd6065da796b_MD0003_00 This patient's intrusive and distressing mental images of stabbing her mother and subsequent countdowns to eliminate the images are characteristic of obsessive-compulsive disorder (OCD). In addition to obsessional thoughts (eg, contamination), other types of obsessions in OCD may include violent images or urges, as seen in this patient. Compulsions are repetitive acts performed in response to obsessions and may include washing, checking and/or counting; repeating words (eg, countdown from 5 to 1) to get rid of the thoughts or images may also be seen, as in this case. First-line treatment of OCD includes exposure and response prevention (a type of cognitive-behavioral therapy) and pharmacotherapy with a serotonergic antidepressant. All selective serotonin reuptake inhibitor (SSRI) antidepressants (eg, fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram, escitalopram) and the tricyclic antidepressant clomipramine are effective. SSRIs are preferred as initial treatment due to their superior side-effect profile. (Choices A and C) Aripiprazole, a second-generation antipsychotic, and haloperidol, a first-generation antipsychotic, are not indicated as monotherapy in OCD. Antipsychotics may be used as augmentation in patients with inadequate response to SSRIs. (Choices B and D) Although anxiety is a prominent feature of OCD, anxiolytic medications, such as buspirone and the benzodiazepine lorazepam, have not demonstrated efficacy in treating obsessions and compulsions. Buspirone has a role in the pharmacotherapy of generalized anxiety disorder. Lorazepam is used in anxiety disorders and the short-term management of acute anxiety, but it carries risks of abuse and dependence. (Choices E and G) Cognitive-behavioral therapy consisting of exposure and response prevention is the psychotherapy of choice for OCD. Psychodynamic psychotherapy (which focuses on unconscious conflicts and developing insight) and general supportive psychotherapy have limited evidence for use in OCD. Educational objective: Treatment of obsessive-compulsive disorder consists of serotonergic antidepressants and exposure and response prevention based cognitive-behavioral therapy. Selective serotonin reuptake inhibitors are first-line medications. References: Pharmacological treatment of obsessive-compulsive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/25150568) Obsessive-compulsive disorder (OCD): practical strategies for pharmacological and somatic treatment in adults. (http://www.ncbi.nlm.nih.gov/pubmed/25681005)

A 17-Year-Old Girl Comes to the Office Due to "Disturbing