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Difficulty: HardAnxiety, OCD, and Trauma-Related Disorders

A 29-year-old man comes to the psychiatry clinic seeking help for distressing mental images. For the past 3 months, he has experienced recurrent, intrusive thoughts of violently harming strangers. He finds these images horrifying and states, "I would never do such a thing, but I just can't stop the thoughts." To temporarily relieve his anxiety, he taps his forehead exactly 15 times whenever an image appears. His psychiatric history is notable for treatment-resistant depression, for which he was prescribed phenelzine 2 years ago with a good response. A review of his electronic medical record reveals a 5-day episode last year characterized by grandiosity, a decreased need for sleep, rapid speech, and hypersexuality. The patient is employed as an accountant. His manager recently left a voicemail at the clinic requesting a medical update because the patient has been taking frequent breaks. Which of the following is the most appropriate next step in management?

  1. Refer the patient for exposure and response prevention therapyAnswer
  2. B
    Discontinue phenelzine, wait 14 days, and initiate fluoxetine monotherapy
  3. C
    Add clomipramine to the patient's current daily medication regimen
  4. D
    Diagnose schizophreniform disorder due to the 3-month duration of symptoms
  5. E
    Return the manager's phone call to state that the patient poses no physical threat

Answer

Refer the patient for exposure and response prevention therapy
The correct answer is to refer the patient for exposure and response prevention therapy. The patient's presentation of recurrent, intrusive, ego-dystonic thoughts relieved by repetitive physical acts is diagnostic of obsessive-compulsive disorder (OCD). First-line treatments for OCD include cognitive-behavioral therapy specifically focused on exposure and response prevention (ERP) and/or serotonergic antidepressants (SSRIs or clomipramine). In this patient, pharmacotherapy is complicated by two major factors. First, he is taking phenelzine, a monoamine oxidase inhibitor (MAOI); concomitant use of an MAOI and a serotonergic medication is contraindicated due to the risk of life-threatening serotonin syndrome. Second, he has a history of a hypomanic episode (5 days of grandiosity, decreased sleep, rapid speech), indicating an underlying Bipolar II disorder. Initiating antidepressant monotherapy in a patient with bipolar disorder carries a high risk of inducing a manic switch. Therefore, a non-pharmacologic approach using ERP therapy is the safest and most effective next step.

Step-by-Step Solution

1
Identify the primary psychiatric diagnosis based on the clinical presentation.
The patient has recurrent, intrusive, ego-dystonic thoughts (obsessions) and engages in repetitive tapping (compulsions) to relieve anxiety, establishing a diagnosis of Obsessive-Compulsive Disorder (OCD).
An accurate primary diagnosis is required to select the appropriate evidence-based therapy.
2
Analyze the patient's psychiatric and medication history for potential contraindications to standard OCD pharmacotherapy.
The patient has a history of a 5-day hypomanic episode (indicating Bipolar II disorder) and is currently taking phenelzine (an MAOI).
Comorbidities and current medications dictate the safety profile of potential treatments, particularly ruling out serotonergic antidepressants without a washout and identifying the risk of a manic switch.
3
Select the safest first-line treatment for OCD in this specific clinical context.
Exposure and response prevention (ERP) therapy is selected.
ERP is a definitive first-line OCD treatment that entirely avoids the risk of serotonin syndrome and mood destabilization.

Key Concept

First-line treatment for Obsessive-Compulsive Disorder (OCD) includes Exposure and Response Prevention (ERP) therapy, which is especially indicated when pharmacotherapy (SSRIs or clomipramine) is contraindicated due to drug interactions (e.g., MAOIs) or comorbid bipolar disorder.
Estimated Time:1m 30s
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Topics

Anxiety, OCD, and Trauma-Related Disorders

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