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Difficulty: MediumAnxiety, OCD, and Trauma-Related Disorders

A 19-year-old college sophomore is evaluated at the university counseling center for a 6-month history of severe anxiety. She reports experiencing frequent, distressing images of herself being covered in deadly bacteria. To relieve this distress, she spends up to 4 hours a day washing her hands and disinfecting her belongings, causing her to fail two classes this semester. Three weeks ago, she visited a community clinic for low mood and was prescribed phenelzine, which she has been taking daily. She is now seeking treatment specifically for her intrusive thoughts and repetitive behaviors. Which of the following are appropriate management steps? (Select 2)

  1. Initiate exposure and response prevention therapyAnswer
  2. Discontinue phenelzine and observe a 14-day washout period before starting sertralineAnswer
  3. C
    Begin a gradual cross-taper from phenelzine to fluoxetine over the next two weeks
  4. D
    Add clomipramine to her current medication regimen to aggressively target the obsessions
  5. E
    Contact the patient's parents immediately to inform them of her academic decline and psychiatric status

Answer

The most appropriate next steps are to initiate exposure and response prevention (ERP) therapy and to discontinue phenelzine, observe a 14-day washout period, and then start an SSRI such as sertraline.
The patient's presentation of distressing, intrusive thoughts accompanied by time-consuming neutralizing behaviors confirms a diagnosis of Obsessive-Compulsive Disorder (OCD). First-line treatments for OCD include exposure and response prevention (ERP) therapy and Selective Serotonin Reuptake Inhibitors (SSRIs). ERP can be initiated immediately as it carries no pharmacologic interaction risk. However, because the patient is currently taking phenelzine (a monoamine oxidase inhibitor), an SSRI cannot be started immediately. A mandatory 14-day washout period is required after discontinuing the MAOI to allow for the regeneration of the MAO enzyme; failure to wait risks precipitating life-threatening serotonin syndrome.

Step-by-Step Solution

1
Identify the primary psychiatric diagnosis.
The patient is diagnosed with Obsessive-Compulsive Disorder (OCD).
She presents with persistent, distressing obsessions (images of bacteria) and time-consuming compulsions (handwashing for 4 hours a day).
2
Determine the standard first-line therapies for OCD.
First-line treatments include exposure and response prevention (ERP) therapy and Selective Serotonin Reuptake Inhibitors (SSRIs).
These modalities have the strongest evidence base for reducing OCD symptoms.
3
Evaluate the patient's current medication for potential drug interactions.
The patient is currently taking phenelzine, an MAOI. A 14-day washout period is required before starting an SSRI.
Combining an MAOI with an SSRI, or starting an SSRI too soon after stopping an MAOI, risks precipitating life-threatening serotonin syndrome.

Key Concept

Management of OCD involves ERP therapy and SSRIs, but initiating serotonergic agents in a patient on an MAOI requires a 14-day washout period to prevent serotonin syndrome.
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Topics

Anxiety, OCD, and Trauma-Related Disorders

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