A 26-year-old woman presents to the psychiatric clinic accompanied by her husband. She gav… — USMLE Step 2 CK

A 26-year-old woman presents to the psychiatric clinic accompanied by her husband. She gave birth to her first child 3 months ago. Over the past month, she has been experiencing recurrent, terrifying mental images of deliberately dropping her infant down the staircase. She finds these images deeply disturbing and recognizes them as products of her own mind. She has no desire to harm her child. To cope, she absolutely refuses to carry the infant near any stairs and repeatedly asks her husband to confirm she is a capable mother, occupying several hours of their day. Her psychiatric history is significant for bipolar II disorder, currently well-controlled on lithium. At age 21, following a severe stressor, she experienced auditory hallucinations that lasted for 2 weeks and resolved completely without long-term medication. Currently, in addition to lithium, she takes over-the-counter St. John's wort for mild fatigue. Which of the following is the most appropriate next step in management?

Engage the patient in specialized psychotherapy focusing on symptom habituationAnswer
B
Commence high-dose sertraline monotherapy
C
Disclose the patient's statements to local child welfare authorities
D
Prescribe phenelzine to target the severe intrusive symptomatology
E
Initiate maintenance therapy with a second-generation antipsychotic

Answer

Engage the patient in specialized psychotherapy focusing on symptom habituation

The patient's presentation of distressing, ego-dystonic intrusive images and subsequent avoidance and reassurance-seeking is diagnostic of Obsessive-Compulsive Disorder (OCD). First-line treatments for OCD include serotonergic antidepressants and specialized psychotherapy, specifically Exposure and Response Prevention (ERP). Because this patient has a confirmed history of bipolar II disorder, introducing an antidepressant monotherapy carries a significant risk of precipitating a hypomanic or manic episode. Therefore, initiating symptom-focused psychotherapy (which focuses on habituation to the feared stimulus without performing the compulsion) is the safest and most appropriate first-line intervention.

Step-by-Step Solution

Diagnose the current acute presentation based on clinical symptoms.

The patient has ego-dystonic intrusive thoughts (obsessions) and performs avoidance/reassurance-seeking behaviors (compulsions). This confirms Obsessive-Compulsive Disorder (OCD), specifically with postpartum onset.

Accurate diagnosis is required before selecting treatment. Her insight is intact, ruling out psychosis.

Evaluate the patient's psychiatric history and current medication profile.

History of Bipolar II disorder (on lithium), a remote 2-week Brief Psychotic Disorder, and current use of St. John's wort.

Comorbidities and supplements severely restrict pharmacological options in psychiatric management.

Select the safest first-line treatment for OCD balancing efficacy and contraindications.

While SSRIs are typically first-line, antidepressant monotherapy is contraindicated due to her bipolar history. St. John's wort precludes MAOIs. Therefore, specialized psychotherapy (Exposure and Response Prevention) is the safest and most effective initial step.

Psychotherapy provides robust treatment for OCD without the risk of precipitating a manic switch or causing fatal drug interactions.

Key Concept

Management of Obsessive-Compulsive Disorder in the context of Bipolar Disorder comorbidities

Estimated Time:1m 30s

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