# Clinical Cases: OCD and Related Disorders ## 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 --- ## Case 2: Body Dysmorphic Disorder ### Patient Demographics - **Age:** 22 years old - **Sex:** Male - **Occupation:** College senior (struggling to complete degree) ### Chief Complaint "My nose is deformed. I can't go out in public because everyone stares at it." ### History of Present Illness The patient presents with a 4-year preoccupation with perceived flaws in his appearance, specifically his nose, which he believes is "grotesquely large and asymmetrical." He spends 4-5 hours daily examining his nose in mirrors, taking photographs from different angles, and comparing his nose to others. He has consulted with 3 different plastic surgeons, all of whom told him his nose appears normal and declined to perform surgery. He has avoided attending classes in person for the past year, completing coursework online when possible, and failing courses that required in-person attendance. He avoids social situations, canceled plans to attend his best friend's wedding, and has not dated in 3 years because he believes no one could be attracted to him. When he must go out, he wears a hat pulled low and keeps his head down. He frequently asks his roommate for reassurance that his nose "doesn't look too bad today." He has researched surgical options overseas and is considering traveling abroad for rhinoplasty against medical advice. ### Mental Status Examination **Appearance:** Young man with objectively normal facial features including nose, appears uncomfortable being observed, turns face away from examiner **Behavior:** Repeatedly touches nose, avoids direct eye contact, positions head to minimize examiner's view of his face **Speech:** Normal rate and volume **Mood:** "Hopeless about my appearance" **Affect:** Anxious, dysphoric, ashamed **Thought Process:** Linear but repetitive (returns to nose) **Thought Content:** - Preoccupation with perceived nose defect (not noticeable to examiner) - Overvalued ideas about appearance (believes flaw is obvious to everyone) - Referential thinking (believes others notice and judge his nose) - Denies suicidal ideation currently but reports passive thoughts in past - No homicidal ideation **Perceptions:** No hallucinations **Cognition:** Alert, oriented, intact **Insight:** Poor - convinced appearance concerns are valid despite contrary evidence **Judgment:** Impaired - considering unnecessary surgery abroad ### Psychiatric Workup **Screening Tools:** - BDD-YBOCS (Yale-Brown OC Scale modified for BDD): 34 (severe) - BDD Questionnaire (BDDQ): Positive screen - PHQ-9: 18 (moderate-severe depression) - Suicidal ideation screen: History of passive SI, currently denies ### Diagnosis **Body Dysmorphic Disorder with Absent Insight/Delusional Beliefs (F45.22)** **DSM-5 Criteria:** - Preoccupation with perceived defects in appearance not observable or appearing slight to others - present (nose appears normal) - Repetitive behaviors in response to appearance concerns: - Mirror checking - present - Excessive grooming - present - Reassurance seeking - present - Comparing appearance to others - present - Causes clinically significant distress or impairment - present (avoidance, academic failure) - Not better explained by an eating disorder (no weight/shape concerns) **Insight specifier:** Absent insight/delusional beliefs - completely convinced appearance beliefs are true **High-Risk Features:** - BDD has high suicide rates (suicidal ideation in 80%, attempts in 25%) - Insight is poor (delusional variant) - Considering surgery against medical advice ### Treatment Plan **Pharmacotherapy:** - Start fluoxetine 20 mg daily - Titrate to 60-80 mg (high doses needed for BDD, similar to OCD) - May require doses up to 80 mg or switch to clomipramine - If delusional insight, may augment with antipsychotic **Psychotherapy:** - CBT adapted for BDD - Cognitive restructuring targeting appearance beliefs - Exposure and response prevention: - Exposure to avoided situations (going out without camouflage) - Response prevention (limit mirror checking, no reassurance seeking) - Perceptual retraining (reduce selective attention to perceived flaw) **ERP Targets:** - Reduce mirror checking to 2 brief checks daily (set timer) - Eliminate reassurance-seeking from roommate - Gradually increase time in public without camouflage (hat, positioning) - Attend one in-person activity weekly **Safety:** - Assess suicide risk at each visit - Safety plan in place - Family involvement for monitoring **Address Cosmetic Surgery:** - Psychoeducation: Cosmetic surgery does NOT help BDD and often worsens symptoms - Patients typically become preoccupied with surgical result or shift focus to new "flaw" - Strongly advise against surgery; document discussion **Follow-up:** - Weekly visits initially - BDD-YBOCS monitoring - Suicide risk assessment ongoing --- ## Case 3: Hoarding Disorder ### Patient Demographics - **Age:** 62 years old - **Sex:** Female - **Occupation:** Retired librarian ### Chief Complaint Brought by adult daughter: "The city is threatening to condemn her house. You can barely walk through it." ### History of Present Illness The patient's daughter brings her to the clinic after receiving a citation from the city regarding unsafe living conditions in the patient's home. The patient has accumulated large quantities of possessions over the past 20 years since her husband's death. Rooms are filled floor to ceiling with newspapers, magazines, books, clothing, kitchenware, and various items purchased at yard sales. Only narrow pathways remain to navigate the home. The kitchen is unusable due to clutter, and she eats only takeout food. One bathroom is completely inaccessible; she uses the other, though it is also severely cluttered. She sleeps in a recliner because her bedroom is filled with items. She experiences significant distress at the thought of discarding possessions, stating each item has "potential usefulness" or "sentimental value." She acquires new items regularly, attending yard sales and accepting free items. She has refused her daughter's offers to help clean, becoming angry and distressed when items are touched. She does not see the accumulation as a problem, stating "I know where everything is." The daughter reports her mother has become increasingly isolated, declining visits because she is embarrassed about the home's condition. ### Mental Status Examination **Appearance:** Elderly woman, somewhat disheveled, clothing clean but wrinkled **Behavior:** Cooperative but defensive when discussing possessions, becomes tearful when daughter mentions discarding items **Speech:** Normal rate and volume **Mood:** "Fine, everyone is overreacting" **Affect:** Defensive, anxious when discussing belongings, otherwise euthymic **Thought Process:** Linear, goal-directed, detailed when discussing possessions **Thought Content:** - Strong emotional attachment to possessions - Beliefs about usefulness/need for items - Denial of severity of hoarding - No suicidal or homicidal ideation - No overt delusions (beliefs are exaggerated but not bizarre) **Perceptions:** No hallucinations **Cognition:** Alert, oriented x4; MoCA 26/30 (minor executive function deficits) **Insight:** Poor - does not see hoarding as problematic **Judgment:** Impaired by hoarding behaviors ### Psychiatric Workup **Screening Tools:** - Saving Inventory-Revised (SI-R): 72 (severe; clinical cutoff is 41) - Clutter subscale: 28 - Difficulty discarding: 24 - Acquisition: 20 - Clutter Image Rating Scale: 8/9 (severe) - PHQ-9: 8 (mild depression) - MoCA: 26/30 **Assessment of Living Conditions:** - Fire hazard due to blocked exits - Fall risk due to narrow pathways - Unsanitary conditions (unable to clean properly) - No working kitchen - Social isolation ### Diagnosis **Hoarding Disorder with Good or Fair Insight (F42.3)** **DSM-5 Criteria:** - Persistent difficulty discarding possessions regardless of actual value - present - Perceived need to save items and distress discarding - present - Accumulation of possessions that congest living areas - present (severe) - Hoarding causes clinically significant distress or impairment - present (safety hazard, social isolation, legal issues) - Not attributable to medical condition (e.g., brain injury, cognitive decline) - Not better explained by another mental disorder **Insight specifier:** Fair insight - recognizes some difficulty but underestimates severity **Specifier: With excessive acquisition** - present (yard sales, accepting free items) ### Treatment Plan **Pharmacotherapy:** - Start sertraline 50 mg daily - Titrate to 150-200 mg (limited evidence for medications in hoarding, but SSRIs may help) - May reduce anxiety about discarding **Psychotherapy (First-line):** - CBT for Hoarding Disorder (specialized protocol) - Components: - Motivational interviewing (enhance motivation for change) - Skills training (organization, decision-making, categorization) - Exposure to discarding (gradual practice letting go of items) - Cognitive restructuring (challenge beliefs about possessions) - Acquiring prevention (reduce incoming items) **Practical Intervention:** - In-home therapy sessions (essential for hoarding) - Sorting practice with therapist support - Start with less emotionally significant items - Clear pathways for safety first - 15-30 minutes daily sorting practice **Address Immediate Safety:** - Work with city to develop remediation plan - Clear pathways to exits as immediate priority - Coordinate with Adult Protective Services if self-neglect - Consider professional organizer with hoarding experience **Family Involvement:** - Educate daughter about hoarding disorder - Family should not discard items without patient consent (causes trauma) - Support groups for family members **Prognosis:** - Hoarding disorder is chronic and difficult to treat - CBT produces modest but meaningful improvement - Relapse prevention is essential - Treatment may require years **Follow-up:** - Weekly therapy sessions - Home visits - Regular assessment of living conditions