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: