MKSAP quiz: Severe anxiety and repetitive behavior
A 25-year-old man evaluated during a new patient visit is concerned about his ability to arrive on time at a new job because every morning before leaving his apartment, he feels compelled to perform multiple checks to ensure that all electronic devices are turned off and all windows and doors are locked. What is the most appropriate management?
A 25-year-old man is evaluated during a new patient visit. He is experiencing severe anxiety about the start of a new job next month. Specifically, he is concerned about his ability to arrive on time because every morning before leaving his apartment, he feels compelled to perform multiple checks to ensure that all electronic devices are turned off and all windows and doors are locked. These activities consume approximately 1 hour of time. He performs these same activities each night before going to bed and often repeats them several times because of overwhelming feelings that he has forgotten something and his apartment will catch fire or be robbed. As a result of his anxieties, the patient rarely socializes outside of his home. When he is away from home, he uses a surveillance application to monitor his apartment 11 minutes after every hour.
Which of the following is the most appropriate management?
A. Buspirone
B. Clonazepam
C. Cognitive behavioral therapy
D. Risperidone
MKSAP Answer and Critique
The correct answer is C. Cognitive behavioral therapy. This content is available to MKSAP 18 subscribers as Question 119 in the General Internal Medicine section. More information about MKSAP is available online.
The preferred initial treatment for this patient with obsessive-compulsive disorder (OCD) is cognitive behavioral therapy (CBT). OCD is an anxiety disorder in which patients experience obsessions (recurrent, intrusive thoughts, images, or impulses causing distress) and compulsions (repetitive behaviors done to alleviate obsession-related anxiety). Loss of time and disrupted social interactions from these thoughts and behaviors cause significant functional impairment. CBT is first-line treatment because it is more effective than pharmacotherapy alone. However, a combination of CBT and selective serotonin reuptake inhibitor (SSRI) therapy is useful for patients with severe symptoms or inadequate response to CBT. Although evidence is strongest for adjunctive therapy with SSRIs, more recent data support the adjunctive use of neuroleptics, deep-brain stimulation, and neurosurgical ablation for treatment-resistant OCD.
Buspirone is beneficial in the treatment of generalized anxiety disorder without comorbid anxiety or mood disorders but has no demonstrated benefit in patients with OCD.
Benzodiazepines, such as clonazepam, are used for short-term treatment of debilitating symptoms from severe generalized anxiety disorder and panic disorder, but they are not effective in the treatment of OCD.
Risperidone is an antipsychotic medication that can be used in the treatment of schizophrenia or other psychiatric conditions with psychotic features. Patients with OCD have obsessions and compulsions but do not have hallucinations, delusions, or disorganized thoughts that would warrant antipsychotic therapy.
Key Point
- Obsessive-compulsive disorder should be treated with cognitive behavioral therapy (CBT); a combination of CBT and selective serotonin reuptake inhibitor therapy is useful for patients with severe symptoms or inadequate response to CBT.