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?
Obsessive-compulsive disorder | |
Clinical features |
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Treatment |
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Obsessive-compulsive disorder (OCD) is diagnosed by the presence of obsessions, compulsions, or both—with most patients having a combination.
Obsessions are characterized by involuntary, intrusive distressing thoughts, images, or urges and are managed through suppression or neutralization with a compulsion. Compulsions are repetitive, unyielding external (eg, hand washing) or mental (eg, repeated counting) acts designed to protect against the obsession or reduce distress or anxiety. In some cases, obsessions in OCD include unwelcome violent urges or images, as seen in this patient who has images of stabbing her mother in the back with a knife, followed by her compulsion of repeatedly counting from 5 to 1 to neutralize the thought.
First-line treatment for 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 adverse-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 are sometimes 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 lorazepam do not treat 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 misuse and withdrawal.
Educational objective:
Treatment of obsessive-compulsive disorder consists of serotonergic antidepressants and cognitive-behavioral therapy based on exposure and response prevention. Selective serotonin reuptake inhibitors are first-line medications.