Psychiatry · Year 3 · from Psychiatry

Case 1: Obsessive-Compulsive Disorder - Contamination Subtype

Patient Demographics

  • Age: 29 years old
  • Sex: Female
  • Occupation: Accountant (currently on medical leave)

Chief Complaint

"I can't stop washing my hands. They're raw and bleeding, but I still feel dirty."

History of Present Illness

The patient presents with a 5-year history of obsessions about contamination and compulsive washing behaviors that have progressively worsened. She experiences intrusive, unwanted thoughts that she has been contaminated by germs, chemicals, or "invisible" toxins. These thoughts cause intense anxiety and disgust. To reduce the anxiety, she engages in extensive washing rituals - she washes her hands 50-100 times per day, following a specific pattern (soap, scrub for 5 minutes, rinse, repeat 3 times). She showers for 2-3 hours daily, again following rigid sequences. She has begun avoiding touching doorknobs, money, public surfaces, and shaking hands with others. She requires her husband to remove his clothes at the door and shower before sitting on furniture. Her symptoms have become so time-consuming (6-8 hours per day on rituals) that she had to take medical leave from work. She recognizes the fears are excessive but feels unable to resist the compulsions. She has tried to stop washing but experiences unbearable anxiety. She reports she tried sertraline 50 mg in the past but stopped after 3 weeks because it "wasn't working."

Mental Status Examination

Appearance: Woman appearing stated age, visibly anxious, hands are erythematous, cracked, and excoriated

Behavior: Avoids touching furniture, uses tissue to handle doorknob, keeps hands elevated

Speech: Normal rate, volume, and rhythm

Mood: "Miserable" and "trapped"

Affect: Anxious, distressed, some shame

Thought Process: Linear, goal-directed, though frequently returns to contamination themes

Thought Content:

  • Obsessions: Intrusive thoughts about contamination from germs/chemicals, fear of causing illness to self/others
  • Recognizes obsessions are product of own mind (ego-dystonic)
  • No suicidal ideation, no homicidal ideation
  • No psychotic symptoms

Perceptions: No hallucinations

Cognition: Alert, oriented x4, attention and concentration intact

Insight: Good - knows fears are irrational but cannot control them

Judgment: Impaired by OCD symptoms

Psychiatric Workup

Screening Tools:

  • Yale-Brown Obsessive Compulsive Scale (Y-BOCS): 32 (severe; >24 is severe)
  • Obsession subscale: 16
  • Compulsion subscale: 16
  • OCI-R (Obsessive-Compulsive Inventory-Revised): 42 (clinical range)
  • PHQ-9: 15 (moderate depression, secondary to OCD)

Laboratory Studies:

  • CBC, CMP: Normal
  • TSH: Normal

Diagnosis

Obsessive-Compulsive Disorder with Good Insight (F42.2)

DSM-5 Criteria:

  • Obsessions (intrusive, unwanted thoughts causing anxiety):
  • Contamination fears - present
  • Attempts to suppress/neutralize with compulsions - present
  • Compulsions (repetitive behaviors to reduce anxiety):
  • Hand washing - present
  • Showering rituals - present
  • Avoidance behaviors - present
  • Time-consuming (>1 hour/day) - present (6-8 hours)
  • Causes significant distress/functional impairment - present
  • Not attributable to substance or medical condition
  • Not better explained by another disorder

Insight specifier: Good insight - recognizes beliefs are probably not true

Treatment Plan

Pharmacotherapy:

  • Start fluvoxamine 50 mg QHS (or increase sertraline - higher doses needed for OCD)
  • Titrate to maximum tolerated dose (fluvoxamine target: 200-300 mg; sertraline target: 200 mg)
  • OCD typically requires higher SSRI doses than depression
  • Expect 8-12 weeks for full response
  • Consider augmentation with low-dose aripiprazole if insufficient response to SSRI alone

Psychotherapy (Essential - First-line):

  • Exposure and Response Prevention (ERP) - gold standard for OCD
  • Components:
  • Exposure: Gradually contact feared contaminants (doorknobs, money, public surfaces)
  • Response Prevention: Refrain from washing rituals after exposure
  • Habituation: Anxiety decreases naturally over time without rituals

ERP Hierarchy Example:

  1. Touch "clean" surface, delay washing 5 minutes
  2. Touch doorknob in home, delay washing 15 minutes
  3. Touch money, delay washing 30 minutes
  4. Touch public doorknob, delay washing 1 hour
  5. Touch bathroom surface, no washing for 2 hours
  6. Eventually: Normal hand washing (brief, after restroom, before meals only)

Psychoeducation:

  • OCD is a neurobiological condition, not a character flaw
  • Compulsions provide short-term relief but maintain OCD long-term
  • Anxiety will decrease naturally without rituals (habituation)
  • Treatment is challenging but highly effective

Supportive Care:

  • Treat hand dermatitis with emollients and topical steroids
  • Family education - avoid accommodating rituals

Follow-up:

  • Weekly ERP sessions
  • Medication check in 2 weeks
  • Y-BOCS monitoring

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