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.These thoughts occur many times aday.She states that she grows increasingly anxious until she is able totake a shower and clean herself.The patient claims that the amount oftime she spends in the shower is increasing because she must wash her-self in a particular order to avoid getting the clean suds mixed up withthe dirty suds. If this happens, she must start the whole showeringprocess over again.The patient states that she knows that she must becrazy, but she seems unable to stop herself.The patient s mother veri-fies the patient s history.She claims that her daughter has always beenpopular in school and has many friends.She emphatically states that herdaughter has never used drugs or alcohol.The patient s only medicalproblem is a history of asthma, which is treated with an albuterolinhaler.The patient s mental status examination is otherwise unre-markable except as noted earlier.¤' What is the most likely diagnosis for this patient?¤' What would be the best type of psychotherapy for this condition?¤' What would be the best type of pharmacotherapy for this patient? 142 CASE FILES: PsychiatryANSWERS TO CASE 13:Obsessive-Compulsive Disorder (Child)Summary: A 13-year-old girl has a 6-month history of excessive showering, upto 5 hours at a time.This showering is preceded by recurrent thoughts of beingdirty or unclean.The patient becomes increasingly anxious because of thesethoughts unless she is able to shower.She has a particular order of showeringthat must be followed or she must start over again.The patient is aware of theabnormal nature of her thoughts and behavior and is distressed by them.¤' Most likely diagnosis: Obsessive-compulsive disorder (OCD)¤' Best psychotherapy: Behavioral therapy involving exposure and responseprevention¤' Best pharmacotherapy: A selective serotonin reuptake inhibitor (SSRI)ANALYSISObjectives1.Understand the diagnostic criteria of obsessive-compulsive disorder.2.Know the psychotherapeutic treatment of choice for this disorder.3.Know the pharmacologic treatment of choice for this disorder.ConsiderationsThis patient has a classic history of OCD.She has recurrent thoughts of beingdirty or unclean (obsessions) and must shower (the compulsion), or shebecomes increasingly anxious.The thoughts she has are not simply excessiveworries about real-life problems.She has tried to ignore these thoughts but isunable to do so and is distressed by them.(Note that the ability to see thatthe obsessions and/or compulsions are unreasonable is a prerequisite for thediagnosis in adults, although not in children.) There is no evidence that thispatient is abusing drugs or alcohol or has a medical disorder that might becausing her symptoms. CLINICAL CASES 143APPROACH TOObsessive-Compulsive Disorder (Child)DEFINITIONSCLOMIPRAMINE: A serotonin and dopaminergic neurotransmitter inhibitorin the class of tricyclic and tetracyclic agents that is effective in the treatmentof OCD.The main adverse effects are sedation, anticholinergic side effects,and at toxic levels, cardiac dysrhythmias.(Because of the side effects, manyclinicians use SSRIs for this disorder; higher doses than those used for depressionare required.)COMPULSIONS: Repetitive behaviors or mental acts that a person feelsdriven to perform in response to an obsession according to a rigid set of rules.These behaviors or mental acts are aimed at preventing or reducing distress orpreventing a feared event or situation.Typically, there is no realistic connectionbetween the feared event or situation and the behavior or mental act.EXPOSURE: Presenting the patient with the feared object or situation.Exposure to the feared object or situation, coupled with relaxation trainingand response prevention, constitutes a behavior modification program provensuccessful in patients with OCD.OBSESSIONS: Recurrent and persistent thoughts or images that are experi-enced as intrusive and inappropriate and cause marked anxiety or distress.They are not simply excessive worries about real-life problems.PANDAS Pediatric autoimmune neuropsychiatric disorders associated withstreptococcal infections a group of disorders, including obsessive-compulsivedisorder, that have been demonstrated to occur after a streptococcal infection.CLINICAL APPROACHAccording to the Diagnostic and Statistical Manual of Mental Disorders, 4th edi-tion, text revision (DSM-IV-TR) the hallmark of OCD is recurrent obsessionsand/or compulsions (Table 13 1).The obsessions are persistent in the con-scious awareness of the patient, who typically recognizes them as being absurdand irrational and often has a desire to resist them.However, half of allpatients offer little resistance to compulsions.Overall, OCD is a disabling,time-consuming, distressing disorder that interferes with one s normal rou-tine, occupational function, social activities, and/or relationships. 144 CASE FILES: PsychiatryTable 13 1 DIAGNOSTIC CRITERIA FOR OBSESSIVE-COMPULSIVE DISORDERThe presence of either obsessions or compulsions.The person realizes that the obsessions or compulsions are excessive and unreasonable;this requirement need not apply to children.The obsessions or compulsions cause marked distress, are time-consuming, or interferewith the person s normal routine.If another major mental illness is present, the contents of the obsessions or compulsionsare not restricted to it.The lifetime prevalence of OCD is approximately 2% to 3% across all ethnic-ities.Obsessive-compulsive disorder accounts for up to 10% of outpatient psychi-atric clinic visits, making it the fourth most common psychiatric diagnosis afterphobias, substance-related disorders, and major depressive disorder.Men andwomen are affected equally; however, adolescent males are more commonlyaffected than adolescent females.The mean age of presentation is 20 years ofage.Onset can occur in childhood, and case reports describe children asyoung as 2 years old with the disorder.Individuals affected with OCD oftenhave additional psychiatric disorders; these include major depressive disorder,social phobia, generalized anxiety disorder, alcohol use disorders, specific pho-bia, panic disorder, and eating disorders.Interestingly, 20% to 30% of OCDpatients have a history of tics, with Tourette disorder comorbid in 5% to 7%of patients.A functional study of patients with OCD and major depressivedisorder (MDD) also showed that altered anterior cingulate glutamatergic neu-rotransmission may be involved in the pathogenesis of OCD and MDD.DIFFERENTIAL DIAGNOSISThe differential diagnosis for OCD must include other anxiety disorders thatcould cause a person to behave outside his or her normal behavior patterns.Persons with obsessive-compulsive personality disorder do not meet the crite-ria for the disorder, and they have a lesser degree of impairment.Patients withphobias (specific phobia or social phobia) attempt to avoid the feared objectbut do not obsessively ruminate about it unless directly presented with it [ Pobierz caÅ‚ość w formacie PDF ]
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.These thoughts occur many times aday.She states that she grows increasingly anxious until she is able totake a shower and clean herself.The patient claims that the amount oftime she spends in the shower is increasing because she must wash her-self in a particular order to avoid getting the clean suds mixed up withthe dirty suds. If this happens, she must start the whole showeringprocess over again.The patient states that she knows that she must becrazy, but she seems unable to stop herself.The patient s mother veri-fies the patient s history.She claims that her daughter has always beenpopular in school and has many friends.She emphatically states that herdaughter has never used drugs or alcohol.The patient s only medicalproblem is a history of asthma, which is treated with an albuterolinhaler.The patient s mental status examination is otherwise unre-markable except as noted earlier.¤' What is the most likely diagnosis for this patient?¤' What would be the best type of psychotherapy for this condition?¤' What would be the best type of pharmacotherapy for this patient? 142 CASE FILES: PsychiatryANSWERS TO CASE 13:Obsessive-Compulsive Disorder (Child)Summary: A 13-year-old girl has a 6-month history of excessive showering, upto 5 hours at a time.This showering is preceded by recurrent thoughts of beingdirty or unclean.The patient becomes increasingly anxious because of thesethoughts unless she is able to shower.She has a particular order of showeringthat must be followed or she must start over again.The patient is aware of theabnormal nature of her thoughts and behavior and is distressed by them.¤' Most likely diagnosis: Obsessive-compulsive disorder (OCD)¤' Best psychotherapy: Behavioral therapy involving exposure and responseprevention¤' Best pharmacotherapy: A selective serotonin reuptake inhibitor (SSRI)ANALYSISObjectives1.Understand the diagnostic criteria of obsessive-compulsive disorder.2.Know the psychotherapeutic treatment of choice for this disorder.3.Know the pharmacologic treatment of choice for this disorder.ConsiderationsThis patient has a classic history of OCD.She has recurrent thoughts of beingdirty or unclean (obsessions) and must shower (the compulsion), or shebecomes increasingly anxious.The thoughts she has are not simply excessiveworries about real-life problems.She has tried to ignore these thoughts but isunable to do so and is distressed by them.(Note that the ability to see thatthe obsessions and/or compulsions are unreasonable is a prerequisite for thediagnosis in adults, although not in children.) There is no evidence that thispatient is abusing drugs or alcohol or has a medical disorder that might becausing her symptoms. CLINICAL CASES 143APPROACH TOObsessive-Compulsive Disorder (Child)DEFINITIONSCLOMIPRAMINE: A serotonin and dopaminergic neurotransmitter inhibitorin the class of tricyclic and tetracyclic agents that is effective in the treatmentof OCD.The main adverse effects are sedation, anticholinergic side effects,and at toxic levels, cardiac dysrhythmias.(Because of the side effects, manyclinicians use SSRIs for this disorder; higher doses than those used for depressionare required.)COMPULSIONS: Repetitive behaviors or mental acts that a person feelsdriven to perform in response to an obsession according to a rigid set of rules.These behaviors or mental acts are aimed at preventing or reducing distress orpreventing a feared event or situation.Typically, there is no realistic connectionbetween the feared event or situation and the behavior or mental act.EXPOSURE: Presenting the patient with the feared object or situation.Exposure to the feared object or situation, coupled with relaxation trainingand response prevention, constitutes a behavior modification program provensuccessful in patients with OCD.OBSESSIONS: Recurrent and persistent thoughts or images that are experi-enced as intrusive and inappropriate and cause marked anxiety or distress.They are not simply excessive worries about real-life problems.PANDAS Pediatric autoimmune neuropsychiatric disorders associated withstreptococcal infections a group of disorders, including obsessive-compulsivedisorder, that have been demonstrated to occur after a streptococcal infection.CLINICAL APPROACHAccording to the Diagnostic and Statistical Manual of Mental Disorders, 4th edi-tion, text revision (DSM-IV-TR) the hallmark of OCD is recurrent obsessionsand/or compulsions (Table 13 1).The obsessions are persistent in the con-scious awareness of the patient, who typically recognizes them as being absurdand irrational and often has a desire to resist them.However, half of allpatients offer little resistance to compulsions.Overall, OCD is a disabling,time-consuming, distressing disorder that interferes with one s normal rou-tine, occupational function, social activities, and/or relationships. 144 CASE FILES: PsychiatryTable 13 1 DIAGNOSTIC CRITERIA FOR OBSESSIVE-COMPULSIVE DISORDERThe presence of either obsessions or compulsions.The person realizes that the obsessions or compulsions are excessive and unreasonable;this requirement need not apply to children.The obsessions or compulsions cause marked distress, are time-consuming, or interferewith the person s normal routine.If another major mental illness is present, the contents of the obsessions or compulsionsare not restricted to it.The lifetime prevalence of OCD is approximately 2% to 3% across all ethnic-ities.Obsessive-compulsive disorder accounts for up to 10% of outpatient psychi-atric clinic visits, making it the fourth most common psychiatric diagnosis afterphobias, substance-related disorders, and major depressive disorder.Men andwomen are affected equally; however, adolescent males are more commonlyaffected than adolescent females.The mean age of presentation is 20 years ofage.Onset can occur in childhood, and case reports describe children asyoung as 2 years old with the disorder.Individuals affected with OCD oftenhave additional psychiatric disorders; these include major depressive disorder,social phobia, generalized anxiety disorder, alcohol use disorders, specific pho-bia, panic disorder, and eating disorders.Interestingly, 20% to 30% of OCDpatients have a history of tics, with Tourette disorder comorbid in 5% to 7%of patients.A functional study of patients with OCD and major depressivedisorder (MDD) also showed that altered anterior cingulate glutamatergic neu-rotransmission may be involved in the pathogenesis of OCD and MDD.DIFFERENTIAL DIAGNOSISThe differential diagnosis for OCD must include other anxiety disorders thatcould cause a person to behave outside his or her normal behavior patterns.Persons with obsessive-compulsive personality disorder do not meet the crite-ria for the disorder, and they have a lesser degree of impairment.Patients withphobias (specific phobia or social phobia) attempt to avoid the feared objectbut do not obsessively ruminate about it unless directly presented with it [ Pobierz caÅ‚ość w formacie PDF ]