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Difficulty: MediumAnxiety, OCD, and Trauma-Related Disorders

A 26-year-old woman comes to the outpatient psychiatric clinic seeking help for distressing daily routines that are interfering with her job as an accountant. Over the past six months, she has felt compelled to repeatedly check that her computer is locked, her office door is bolted, and her files are perfectly aligned before she can leave work. This routine takes her nearly three hours every evening. She recognizes that these behaviors are excessive and illogical, but she experiences overwhelming dread if she attempts to leave without completing the sequence. Her psychiatric history is significant for a severe manic episode at age 21 that required hospitalization, leading to a diagnosis of bipolar I disorder. She is currently euthymic, and her mood is well-controlled on maintenance lithium therapy. During the assessment, she expresses intense fear that she will be fired if her boss finds out about her condition, explicitly stating she wants this kept completely private. Which of the following is the most appropriate next step in management?

  1. Commence exposure and response prevention therapyAnswer
  2. B
    Start sertraline as a single-agent therapy
  3. C
    Establish a diagnosis of schizophreniform disorder and start an antipsychotic
  4. D
    Disclose the psychiatric condition to her employer to secure workplace accommodations
  5. E
    Prescribe phenelzine as an adjunctive treatment to her current medication regimen

Answer

Commence exposure and response prevention therapy
The correct answer provides a definitive, first-line treatment for obsessive-compulsive disorder (OCD) that avoids the risks of pharmacotherapy in this specific clinical context. Exposure and response prevention (ERP) therapy involves exposing the patient to anxiety-provoking triggers (e.g., leaving the office without checking) while strictly preventing the corresponding compulsion (e.g., the checking ritual). Because this patient has a confirmed history of bipolar I disorder, prescribing the typical first-line medications for OCD, such as selective serotonin reuptake inhibitors (SSRIs), poses a significant risk of precipitating a manic switch. Therefore, a non-pharmacological, highly evidence-based psychotherapy like ERP is the safest and most appropriate initial management step.

Step-by-Step Solution

1
Identify the primary psychiatric diagnosis based on the clinical presentation.
The patient exhibits time-consuming obsessions (fears of leaving things unlocked or unaligned) and compulsions (checking rituals) with intact insight, confirming obsessive-compulsive disorder (OCD).
Accurate diagnosis is required to select the appropriate treatment algorithm.
2
Review the patient's past medical history for contraindications to standard therapies.
The patient has a history of bipolar I disorder, which makes standard OCD pharmacotherapy (antidepressant monotherapy) risky.
Antidepressants can precipitate manic episodes in patients with bipolar disorder.
3
Determine the safest and most effective first-line intervention.
Exposure and response prevention therapy is a highly effective, non-pharmacological first-line treatment for OCD that carries no risk of inducing mania.
Guidelines recommend psychotherapy, specifically ERP, as a primary treatment for OCD, particularly when medications pose significant risks.

Key Concept

Exposure and response prevention (ERP) therapy is a first-line treatment for obsessive-compulsive disorder (OCD) and is particularly indicated when first-line pharmacotherapy (SSRIs) is contraindicated, such as in patients with bipolar I disorder.
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Topics

Anxiety, OCD, and Trauma-Related Disorders

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