Deborah
J. Hales, M.D., Mark Hyman Rapaport, M.D., FOCUS Editors
focus.psychiatryonline.org
Thomas Kramer, M.D., Carlyle Chan, M.D., Associate Editors for Clinical eFOCUS
Welcome to the first Clinical eFOCUS, a continuation of the FOCUS program of
lifelong learning. Learn more about OCD patient management through this
activity; the patient vignette exercise provides an opportunity for you to
share your opinion on OCD management and see how others approach the same case.
Given your knowledge of OCD and the points made in the vignette, which
treatment approach would you choose? Next month, expert commentary by John
Greist, M.D. will review the result and discuss the merit of the options
presented. Indicate your choice using the voting buttons. There are no wrong
choices. To read more about OCD: Greist JG, Jefferson J:
Obsessive–compulsive disorder. FOCUS 2007 3:283-298
Obsessive-Compulsive Disorder
by Thomas Kramer, M.D.
A primary care physician asks you to consult on a 38 year-old divorced white
male. Three months ago, during a routine office visit for a yearly physical
examination, the patient reported a 2 month history of subjective depressed
mood, difficulty concentrating causing some decreased job performance, sleep
changes including both difficulty initiating sleep and early morning awakening,
and mild anhedonia. The patient also reported an increased subjective sense of
anxiety, but was not certain whether this was a result of his difficulties at
work and concern about possible demotion. The patient denied history of
psychiatric illness or treatment, as well as significant drug or alcohol use.
The primary care physician made a diagnosis of major depression, single
episode, started fluoxetine 20 mg per day, and scheduled a return visit in
approximately 1 month.
At one-month follow-up, the patient reported partial resolution of his mood
symptoms and with great hesitation revealed to his physician that he has had
numerous counting and checking rituals since he was a child. These include
compulsively counting tiles on floors, needing to do activities such as eating
snack foods or personal care activities in threes, repetitively checking that
doors are locked, and inordinate concern about cleanliness and contamination.
These symptoms had gotten considerably worse during his mood episode and
currently are causing him serious difficulty in functioning. The primary care
physician added the diagnosis of obsessive-compulsive disorder and increased
the fluoxetine to 40 mg per day, with a follow-up visit in one month. At the
next visit, he reports only marginal improvement on the increased dose of
fluoxetine. At this point, the primary care physician recommends psychiatric
consultation, and the patient agrees.
At consultation, psychiatric examination was remarkable for mild to moderate
anxiety, some constriction of affect and occasional tearfulness on interview.
He also complained of increased insomnia, night sweats, dyspepsia, and mild
sexual dysfunction in the form of ejaculatory delay since the dose increase of
the fluoxetine. He states that these side effects would be tolerable if the
medication was more effective in treating his psychiatric symptoms. Yale Brown
Obsessive-Compulsive Scale was 23.
Would you next:
A. increase the dose of fluoxetine to 60 mg
B. switch to a different SSRI
C. start or refer for cognitive behavior therapy (CBT)
D. increase the dose of fluoxetine to 60 mg and initiate CBT
E. switch to a different SSRI and initiate CBT
If the intervention/interventions you made in question # 1 were ineffective,
would you next:
A. switch his medication to clomipramine
B. switch to another SSRI
C. augment his medication with a second generation antipsychotic
D. augment his medication with another medication other than an antipsychotic
E. increase the dose of fluoxetine to 80 mg