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.
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.
Full Answer Section
Diagnosis
Based on the DSM 5-TR criteria, the most likely diagnosis is Obsessive-Compulsive Disorder (OCD), specifically with contamination obsessions and cleaning compulsions.
- Obsessions: Intrusive thoughts about germs and contamination causing harm to her son.
- Compulsions: Repetitive cleaning rituals performed in a specific way to reduce anxiety.
Pharmacological Treatment
Selective Serotonin Reuptake Inhibitors (SSRIs): This class of medications is the first-line pharmacological treatment for OCD according to clinical guidelines. SSRIs work by increasing serotonin levels in the brain, which is thought to play a role in regulating OCD symptoms.
Rationale: Studies have shown SSRIs to be effective in reducing OCD symptoms, including obsessions and compulsions. In this case, SSRIs may help decrease the intrusive thoughts about germs and the anxiety associated with them, potentially leading to a reduction in cleaning compulsions.
Cost-Effectiveness:
- Brand Name: SSRIs come in various brand names, which can be expensive.
- Generic Options: Many generic versions of SSRIs are available, making them a more cost-effective choice. For example, the cost of a 30-day supply of generic fluoxetine (Prozac) can range from $10 to $40 depending on the pharmacy [sources vary on medication costs, so research is recommended].
Safety and Adherence: SSRIs are generally well-tolerated with common side effects including nausea, headache, and sexual dysfunction. It's important for the patient to discuss any side effects with their doctor as some may subside with time or require a medication adjustment. SSRIs typically take 4-8 weeks to show full benefit, so adherence is crucial for successful treatment.
Non-Pharmacological Treatment
Cognitive Behavioral Therapy (CBT): CBT is a first-line non-pharmacological treatment for OCD and is often used in conjunction with medication. In CBT, the patient learns to identify and challenge their negative thoughts and beliefs related to germs and contamination. They also develop coping skills to manage anxiety without resorting to compulsive cleaning rituals.
Rationale: CBT can help the patient understand that their thoughts about germs are distorted and that their cleaning rituals are not necessary to keep their son safe. By learning to challenge these thoughts and developing alternative coping mechanisms, the patient can potentially reduce the frequency and intensity of their compulsions and improve their overall functioning.
Treatment Appropriateness
Both medication and CBT are appropriate evidence-based treatments for OCD. The most effective approach often combines both.
Combining medication and CBT can offer a more comprehensive treatment plan. SSRIs can help manage the underlying anxiety that fuels obsessions, while CBT equips the patient with tools to manage their thoughts and resist compulsions.
It's important to note that the specific treatment plan should be tailored to the individual patient's needs and preferences in consultation with a qualified mental health professional.
Sample Answer
The patient is a 26-year-old woman with a young child who suffers from obsessive thoughts about germs and contamination. These thoughts lead to compulsive cleaning rituals that take several hours and significantly impair her daily life. She fears her son will become seriously ill or die if the house isn't clean enough. While aware her cleaning is excessive, she feels compelled to perform these rituals to temporarily reduce her anxiety.