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Posted: February 3rd, 2025
Summary of the Clinical Case
A 26-year-old woman presents with severe cleaning rituals driven by an intense fear that her 3-year-old son will become ill and die if her home is not sufficiently clean. She spends several hours disinfecting surfaces, washing her hands repetitively, and sterilizing crockery and cutlery. These behaviors provide temporary relief from her anxiety, but the intrusive thoughts about germs and contamination quickly return, significantly impairing her daily functioning.
Her symptoms have persisted for over a year, and she recognizes that her actions are excessive but feels unable to stop. This has led to her being unable to enter three of the five rooms in her home, severely limiting her quality of life.
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DSM-5-TR Diagnosis
Based on the information provided, the most likely diagnosis is Obsessive-Compulsive Disorder (OCD). The patient exhibits classic symptoms of OCD, including intrusive, distressing thoughts (obsessions) about contamination and germs, and repetitive behaviors (compulsions) such as cleaning and handwashing performed to alleviate anxiety. These symptoms are time-consuming, cause significant distress, and impair her ability to function normally.
OCD is characterized by the presence of obsessions, compulsions, or both, which are not attributable to substance use, medical conditions, or other mental disorders. The patient’s fear of her son becoming ill due to contamination aligns with common OCD themes.
Pharmacological Treatment
According to clinical guidelines, the first-line pharmacological treatment for OCD is Selective Serotonin Reuptake Inhibitors (SSRIs). Examples include fluoxetine, sertraline, and paroxetine. These medications are effective in reducing the severity of obsessions and compulsions by increasing serotonin levels in the brain, which helps regulate mood and anxiety.
For this patient, sertraline would be a suitable choice due to its efficacy, tolerability, and lower risk of side effects compared to other SSRIs. The recommended starting dose is 25 mg daily, gradually increasing to a therapeutic dose of 100-200 mg daily based on response and tolerability.
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Rationale: SSRIs are preferred because they have been extensively studied and proven effective for OCD. They help reduce the frequency and intensity of obsessive thoughts and compulsive behaviors, improving overall functioning. Sertraline, in particular, is well-tolerated and has a lower risk of drug interactions, making it a safe option for long-term use.
Non-Pharmacological Treatment
A non-pharmacological treatment option for OCD, excluding psychotherapy, is Deep Brain Stimulation (DBS). DBS involves implanting electrodes in specific brain regions, such as the anterior limb of the internal capsule, to modulate neural activity and reduce OCD symptoms.
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Rationale: DBS is considered for severe, treatment-resistant OCD cases where pharmacological and psychotherapeutic interventions have failed. While it is an invasive procedure, it has shown promise in reducing symptoms and improving quality of life in refractory cases. However, it is typically reserved for extreme cases due to its cost, invasiveness, and potential risks.
Assessment of Treatment Appropriateness, Cost, Effectiveness, Safety, and Adherence
Sertraline:
Appropriateness: Highly appropriate as a first-line treatment for OCD.
Cost: At a local pharmacy, a 30-day supply of generic sertraline (100 mg) costs approximately
10
−
10−15, making it a cost-effective option.
Effectiveness: Proven to reduce OCD symptoms in 40-60% of patients.
Safety: Generally safe with mild side effects (e.g., nausea, insomnia) that often subside with continued use.
Adherence: High likelihood of adherence due to once-daily dosing and low side effect profile.
Deep Brain Stimulation:
Appropriateness: Appropriate only for severe, treatment-resistant cases.
Cost: Extremely expensive, with costs ranging from
50
,
000
t
o
50,000to100,000, including surgery and follow-up care.
Effectiveness: Effective in reducing symptoms in 50-60% of refractory cases.
Safety: Invasive procedure with risks such as infection, bleeding, and device malfunction.
Adherence: Requires ongoing follow-up and device maintenance, which may affect adherence.
"A Case of Severe Obsessive-Compulsive Disorder: Diagnosis, Treatment, and Management"
Obsessive-Compulsive Disorder, OCD, pharmacological treatment, non-pharmacological treatment, sertraline, Deep Brain Stimulation
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Anxiety & Sleep Wake Disorders
Answer the questions below based on the following case study.
A 26-year-old woman presented to the clinic after her cleaning rituals had so exhausted her that she had given up and could now enter only two of the five rooms in her home. For more than a year she has worried that if her house is not sufficiently clean, her 3-year-old son will become ill and could die. Having touched a surface she has to disinfect it repeatedly – a procedure performed in a particular way and taking several hours. In addition, she repetitively washes her hands and sterilizes all the crockery and cutlery before eating. She realizes that she is ‘going over the top’, but she cannot stop thinking that items may have germs on them. This leads to disabling anxiety and fear for her son’s health, which she can only resolve by cleaning. This helps temporarily, but soon the thoughts return again.
Summarize the clinical case.
What is the DSM 5-TR diagnosis based on the information provided in the case?
Which pharmacological treatment would you prescribe according to the clinical guidelines? Include the rationale for this treatment.
Which non-pharmacological treatment would you prescribe according to the clinical guidelines? Include the rationale for this treatment excluding a psychotherapeutic modality.
Include an assessment of the treatment’s appropriateness, cost, effectiveness, safety, and potential for patient adherence to the chosen medication. Use a local pharmacy to research the cost of the medication and provide the most cost-effective choice for the patient. Use great detail when answering questions 3-5.
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All replies must be constructive and use literature where possible.
Late work policies, expectations regarding proper citations, acceptable means of responding to peer feedback, and other expectations are at the discretion of the instructor.
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