A 32-year-old woman comes to the clinic due to persistent thoughts about killing her 3 children. She says, "This is so upsetting because I love my children and would never harm them. I have had these thoughts for the past 3 months and cannot get them out of my head. It happens when I'm in the kitchen preparing dinner. As I reach for a knife in the drawer, I get this sudden thought about stabbing all three of them. The thoughts are senseless and ridiculous, but I worry that I'm going crazy. I wish I never had these thoughts but can't make them stop." The patient is happily married and says that all 3 children are well behaved. Her medical problems include hypothyroidism and microcytic anemia. She has no previous psychiatric history, but recalls being very anxious as a child. The patient says, "I was always worried that something bad was going to happen to my parents if I didn't do the right thing and would get really upset if anyone touched my possessions." Current medications include levothyroxine and iron. Temperature is 37 C (98.6 F), blood pressure is 131/78 mm Hg, and pulse is 87/min. On examination, the pupils are equal and reactive to light and mucous membranes are moist. There is no thyromegaly. Auscultation of the lungs reveals normal breath sounds. Heart sounds are normal. Neurologic examination reveals no focal deficits. The patient appears tense and her mood is anxious. Which of the following is the most likely diagnosis?

Question

A 32-year-old woman comes to the clinic due to persistent thoughts about killing her 3 children.  She says, "This is so upsetting because I love my children and would never harm them.  I have had these thoughts for the past 3 months and cannot get them out of my head.  It happens when I'm in the kitchen preparing dinner.  As I reach for a knife in the drawer, I get this sudden thought about stabbing all three of them.  The thoughts are senseless and ridiculous, but I worry that I'm going crazy.  I wish I never had these thoughts but can't make them stop."  The patient is happily married and says that all 3 children are well behaved.  Her medical problems include hypothyroidism and microcytic anemia.  She has no previous psychiatric history, but recalls being very anxious as a child.  The patient says, "I was always worried that something bad was going to happen to my parents if I didn't do the right thing and would get really upset if anyone touched my possessions."  Current medications include levothyroxine and iron.  Temperature is 37 C (98.6 F), blood pressure is 131/78 mm Hg, and pulse is 87/min.  On examination, the pupils are equal and reactive to light and mucous membranes are moist.  There is no thyromegaly.  Auscultation of the lungs reveals normal breath sounds.  Heart sounds are normal.  Neurologic examination reveals no focal deficits.  The patient appears tense and her mood is anxious.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c1aa_331d_8f63_7b746faed083_MD0005_00 This patient is experiencing persistent, intrusive, unwanted thoughts of stabbing her children that cause her marked distress and anxiety. This description is most consistent with an obsession, a core symptom of obsessive-compulsive disorder (OCD). Obsessions can include thoughts about contamination, images of violent or horrific scenes, or unwanted urges (eg, to stab someone). Because this patient's symptoms are interfering with her daily routine and causing her severe distress, she meets the criteria for OCD. In OCD, obsessions do not necessarily have to be associated with compulsions, and the presence of either is sufficient for the diagnosis. In addition to this patient's current intrusive thoughts, her anxiety as a child is also suggestive of the disorder. Patients with OCD frequently have fears of causing dreaded events and may perform repetitive behaviors or mental acts to prevent them from happening. OCD typically starts in adolescence, although the diagnosis is frequently delayed. Management consists of serotonergic antidepressants and cognitive-behavioral therapy. (Choice A) In brief psychotic disorder, there is a sudden development of psychotic symptoms (delusions, hallucinations, and/or disorganized speech or behavior) that last <1 month. This patient has obsessions (not psychotic symptoms) that have lasted 3 months. (Choice B) Delusional disorder is characterized by persistent delusions (false beliefs) and not obsessions. Patients with delusional disorder typically do not experience their thoughts as intrusive and unwanted. (Choice C) Patients with generalized anxiety disorder have chronic anxiety about multiple real-life issues. This patient's anxiety is related to her obsessional thoughts. (Choice D) Although overtreatment with levothyroxine could present with anxiety, this patient's history and physical examination are not suggestive of medication toxicity. Educational objective: Patients with obsessive-compulsive disorder experience obsessions, compulsions, or both. Obsessions can include intrusive thoughts, violent images, and unwanted urges. References: Obsessive-compulsive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26039854)

A 32-Year-Old Woman Comes to the Clinic Due to Persistent