Psychiatry · Year 2 · from Psychiatry
Case 2: Obsessive-Compulsive Disorder - Contamination Type
Patient Presentation
Demographics: 28-year-old female
Chief Complaint: "I can't stop washing my hands. They're raw and bleeding, but I can't stop."
History of Present Illness: A 28-year-old elementary school teacher presents with a 5-year history of progressively worsening contamination fears and washing compulsions. She experiences intrusive, distressing thoughts that she has been contaminated by germs after touching doorknobs, shaking hands, or touching surfaces outside her home. These thoughts create intense anxiety that she will become ill or spread illness to her students. To reduce this anxiety, she engages in compulsive handwashing, washing her hands 40-60 times daily for 3-5 minutes each time, using hot water and antibacterial soap. She follows a rigid washing ritual: soap applied three times, each area scrubbed in a specific order, rinse three times. If the ritual is interrupted, she must start over. Her hands are severely chapped, cracked, and bleeding. She also showers for 2 hours nightly, following a specific sequence. She has begun avoiding touching her students, eating at school, or using school restrooms. She spends 6+ hours daily on contamination-related thoughts and washing. She recognizes her fears are excessive ("I know germs aren't that dangerous") but cannot stop the rituals. She has considered quitting teaching.
Physical Examination:
- Hands: Severe xerosis, fissures, bleeding, contact dermatitis from excessive washing
Mental Status Examination:
- Appearance: Well-groomed, hands wrapped in bandages
- Behavior: Avoids touching surfaces in office
- Mood: "Frustrated with myself"
- Affect: Anxious, distressed when discussing contamination
- Thought process: Linear but preoccupied
- Thought content: Contamination obsessions, insight present - recognizes as excessive (ego-dystonic)
- No psychotic symptoms
Workup:
- Y-BOCS (Yale-Brown Obsessive Compulsive Scale): Score 32 (severe; >24 is severe)
- PHQ-9: Score 12 (moderate depression, likely secondary to OCD impairment)
Diagnosis: Obsessive-Compulsive Disorder, contamination subtype, with good insight
Treatment:
- Psychoeducation about OCD cycle: obsession creates anxiety, compulsion reduces anxiety temporarily but reinforces cycle
- Started fluvoxamine 50 mg at bedtime (SSRI with FDA approval for OCD), titrated to 200 mg over 6 weeks
- Higher dose required for OCD than depression - target 200-300 mg
- Referral for Exposure and Response Prevention (ERP):
- Developed exposure hierarchy from least to most anxiety-provoking contamination situations
- Practiced touching progressively "contaminated" surfaces without washing
- Response prevention: delayed and shortened handwashing rituals
- Dermatology referral for hand treatment
- At 8 weeks: Y-BOCS improved to 22 (still moderate)
- At 16 weeks with continued ERP: Y-BOCS improved to 16 (mild-moderate)
- Handwashing reduced to 10-12 times daily with normal duration
- Returned to full teaching duties including contact with students
Clinical Pearl: OCD treatment typically requires higher SSRI doses (often 2-3 times depression doses) and longer trials (10-12 weeks) than depression treatment. Exposure and Response Prevention (ERP) is the gold-standard psychotherapy - exposures must be done without the compulsive ritual for habituation and extinction to occur. The Y-BOCS is the standard measure for severity and treatment response. Contamination OCD is one of the most common subtypes along with checking, symmetry, and forbidden thoughts.