# Clinical Cases: Trauma-Related and Obsessive-Compulsive Disorders ## Case 1: Post-Traumatic Stress Disorder ### Patient Presentation **Demographics:** 34-year-old male **Chief Complaint:** "I keep having nightmares about the accident. I can't drive anymore." **History of Present Illness:** A 34-year-old construction worker presents 4 months after being involved in a serious motor vehicle accident. He was driving home from work when a truck ran a red light and struck his vehicle on the driver's side. He was trapped in the vehicle for 45 minutes before being extracted and was hospitalized for 2 weeks with multiple fractures and a pulmonary contusion. He states, "I was sure I was going to die." Since the accident, he has been plagued by intrusive memories of the crash that occur multiple times daily, often triggered by traffic sounds or seeing similar vehicles. He has nightmares about the accident 3-4 times per week, waking in a panic. He avoids driving entirely and becomes highly distressed when a passenger in a car. He also avoids the route where the accident occurred and has stopped watching news or shows featuring accidents. He reports feeling emotionally numb and disconnected from his wife and children. He is hypervigilant when near traffic, easily startled by loud noises, and has difficulty concentrating. He has become irritable and has had angry outbursts at home. He sleeps only 4-5 hours per night due to fear of nightmares. He admits to increased alcohol use (4-5 beers nightly) to "quiet my mind." **Physical Examination:** - Healed fracture sites with residual stiffness - Vital signs: BP 138/86, HR 92 (elevated) **Mental Status Examination:** - Appearance: Fatigued, tense, guarded - Behavior: Hypervigilant, startled by door closing - Mood: "On edge, can't relax" - Affect: Constricted, anxious - Thought content: Intrusive trauma memories, avoidance behaviors, no SI/HI - Cognition: Concentration impaired **Workup:** - **PCL-5 (PTSD Checklist):** Score 58 (clinical cutoff is 31-33) - **PHQ-9:** Score 14 (moderate depression) - **AUDIT:** Score 14 (harmful drinking) - **Life Events Checklist:** Confirmed Criterion A trauma **Diagnosis:** Post-Traumatic Stress Disorder; Alcohol Use Disorder, mild (likely trauma-related self-medication) **Treatment:** - Psychoeducation about PTSD symptoms as normal responses to abnormal events - Started sertraline 50 mg daily, titrated to 150 mg (FDA-approved for PTSD) - Prazosin 1 mg at bedtime for trauma-related nightmares, titrated to 4 mg with significant nightmare reduction - Referral for Prolonged Exposure (PE) therapy: - Imaginal exposure to trauma memory with processing - In vivo exposure hierarchy starting with sitting in parked car, progressing to driving - Brief intervention for alcohol use; agreed to limit to 1-2 drinks/night during treatment - At 12-week follow-up: Nightmares reduced to 1/week on prazosin - Completed PE therapy with significant reduction in avoidance - Successfully drove short distances with plan to gradually increase - PCL-5 decreased to 32 **Clinical Pearl:** PTSD requires exposure to actual or threatened death, serious injury, or sexual violence, followed by symptoms from four clusters: intrusion (nightmares, flashbacks), avoidance (of reminders), negative alterations in cognition/mood, and hyperarousal. Prazosin, an alpha-1 adrenergic blocker, has specific evidence for reducing trauma-related nightmares. Prolonged Exposure and Cognitive Processing Therapy are first-line psychotherapies with strong evidence. Importantly, benzodiazepines should be avoided in PTSD as they may interfere with extinction learning and worsen outcomes. --- ## 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. --- ## Case 3: Obsessive-Compulsive Disorder - Harm Obsessions ### Patient Presentation **Demographics:** 35-year-old male **Chief Complaint:** "I have terrible thoughts about hurting my daughter. Please help me." **History of Present Illness:** A 35-year-old father of a 2-year-old girl presents in significant distress. For the past 8 months, he has been experiencing intrusive thoughts about harming his daughter - images of stabbing her, throwing her down stairs, or suffocating her. He is horrified by these thoughts and emphasizes, "I would never hurt her. I love her more than anything." The thoughts occur dozens of times daily, especially when he is alone with his daughter. To prevent acting on these thoughts, he has hidden all knives in the house, refuses to be alone with his daughter, avoids going near stairs when holding her, and repeatedly seeks reassurance from his wife that he is not dangerous. He mentally reviews his actions constantly to confirm he has not harmed her. He has begun avoiding his daughter, which causes him profound grief. He has seen multiple providers who reassured him he is not dangerous, but the relief lasts only minutes. He has no history of violence, no desire to harm anyone, and no psychotic symptoms. He tearfully states, "I feel like a monster." **Mental Status Examination:** - Appearance: Visibly distressed, tearful - Behavior: Anxious, seeking reassurance - Mood: "Terrified" - Affect: Anxious, distressed, tearful - Thought content: Ego-dystonic intrusive thoughts of harm; no intent or desire to act; no psychosis; passive SI due to shame - Insight: Good - recognizes thoughts are irrational and ego-dystonic **Workup:** - **Y-BOCS:** Score 28 (severe) - **PHQ-9:** Score 16 (moderate depression) - **Detailed risk assessment:** No actual intent to harm, no psychotic symptoms, thoughts are ego-dystonic and distressing (consistent with OCD, not concerning for violence) **Diagnosis:** Obsessive-Compulsive Disorder, harm obsession subtype (forbidden thoughts), with good insight **Treatment:** - Extensive psychoeducation that harm obsessions in OCD are not predictive of violence - the distress and ego-dystonic nature distinguish OCD from actual harmful intent - Explained that reassurance-seeking and avoidance maintain the cycle - Started sertraline 50 mg daily, titrated to 200 mg - Referral for specialized OCD treatment with ERP: - Imaginal exposure to feared harm scenarios (writing scripts, visualizing) - In vivo exposure: gradually spending time alone with daughter, near knives - Response prevention: eliminated reassurance-seeking, stopped checking behaviors - Family therapy to address impact on marriage and help wife stop providing reassurance - At 12 weeks: Y-BOCS improved to 18, thoughts still present but less distressing - Able to be alone with daughter, knives returned to kitchen - At 6 months: Near-complete resolution, Y-BOCS 11 **Clinical Pearl:** Harm obsessions (violent, sexual, or blasphemous intrusive thoughts) are among the most distressing OCD presentations because patients fear they are dangerous. These thoughts are ego-dystonic (inconsistent with values), cause marked distress, and are NOT associated with violence risk - the very fact that the thoughts are distressing and unwanted distinguishes OCD from actual harmful intent. Education about this distinction is therapeutic. Avoidance and reassurance-seeking are maintaining behaviors that must be addressed in ERP. --- ## Clinical Image ![OCD brain circuits](case_01_image.jpg) **Image Description:** Neuroimaging showing hyperactivity in the orbitofrontal cortex-striatum-thalamus circuit in OCD. This cortico-striato-thalamo-cortical (CSTC) loop shows increased activation in patients with OCD compared to healthy controls, particularly in the orbitofrontal cortex and caudate nucleus. **Attribution:** Brain imaging demonstrating the neural basis of OCD. CSTC circuit hyperactivity is a consistent finding across neuroimaging studies. Educational use. **Image Source:** Wikimedia Commons - Search for "OCD brain imaging" or "cortico-striatal circuit"