Psychiatry and Behavioral Health Rotation

Patient will present as → a 26-year-old PA student presents to the student health center with the complaint of difficulty sleeping. Although he is a very successful student, over the past few months, he has become increasingly preoccupied with failing. The patient reports waking 10-15 times per night to review his textbooks for factual recall. He has tried unsuccessfully to suppress these thoughts and actions, and he has become extremely anxious and sleep-deprived. He has no past medical history, and family history is significant for a parent with Tourette's syndrome. He is started on a first-line medication for his disorder, but after eight weeks of use, it is still ineffective.

Key Points:

Two components

• Obsessions: Recurring, intrusive thoughts that cause severe distress and impairment
• Compulsions: Performance of repetitive actions (rituals) in an attempt to neutralize the obsessions
  • e.g., hand washing, checking - the primary goal is not to lose control
  • The disorder is ego-dystonic: behavior inconsistent with one's own beliefs and attitudes - separates OCD from obsessive compulsive personality disorder
• Associated conditions - Tourette's disorder

DSM-5 Diagnostic Criteria

A. Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2):

1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

Compulsions are defined by (1) and (2):

1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hairpulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

First-line treatment includes cognitive-behavioral therapy (CBT), particularly exposure and response prevention (ERP)

• SSRIs (e.g., fluoxetine, fluvoxamine, sertraline) are first-line pharmacologic treatments; higher doses and longer duration may be needed compared to depression
• Clomipramine, a tricyclic antidepressant, may be effective in treatment-resistant cases
• Severe or refractory cases may benefit from augmentation with antipsychotics or referral for deep-brain stimulation (DBS)