5- Obsessive-Compulsive Disorder (Medication)

Case 5 - Clinical History: (pp. 61-65)

Key Answer: C) Obsessive-compulsive disorder, with good or fair insight

Explanation: Pat meets DSM-5 criteria for OCD, with obsessions (contamination fears) and compulsions (washing/cleaning), time-consuming rituals (>4 hrs/day), and significant impairment. The specifier is good/fair insight because she recognizes her fears are excessive, even if she cannot control them.

Which of the following best represents Pat’s principal DSM-5 diagnosis?

A) Specific phobia, situational type
B) Persistent depressive disorder, late onset
C) Obsessive-compulsive disorder, with good or fair insight
D) Generalized anxiety disorder

Key Answer: C) Antidepressants (Tricyclic and SSRI)

Explanation: Clomipramine is a tricyclic antidepressant (TCA), and fluoxetine is a selective serotonin reuptake inhibitor (SSRI). Both are evidence-based first-line pharmacological treatments for OCD.
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• Anafranil (Clomipramine) is a tricyclic antidepressant.

• Anafranil is the brand name (or trade name) owned by the company that is used commonly by the people.

• Clomipramine is the official, standard, generic, medical, and scientific name that is used by health care professionals

• It is mainly used to treat Obsessive-Compulsive Disorder (OCD). It is also sometimes used for major depressive disorder, panic disorder, and other conditions.

Pat was prescribed clomipramine (Anafranil) and fluoxetine (Prozac) prior to psychosocial referral. What class of medication do these represent?

A) Benzodiazepines
B) Antipsychotics
C) Antidepressants (Tricyclic and SSRI)
D) Beta-blockers
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• Prozac (fluoxetine) is a Selective Serotonin Reuptake Inhibitor (SSRI) antidepressant.

• Prozac is the brand name (or trade name) owned by the company that is used commonly by the people.

• fluoxetine is the official, standard, generic, medical, and scientific name that is used by health care professionals

Key Answer: B) Recurrent handwashing, cleaning, and ritualized showering

Explanation: Compulsions are repetitive behaviors performed to reduce anxiety or prevent perceived harm. Pat’s compulsions included excessive handwashing (40+ times daily), long showers, dishwashing, and cleaning objects.

Which of the following best describes Pat’s compulsions?

A) Repeated intrusive images about contamination
B) Recurrent handwashing, cleaning, and ritualized showering
C) Excessive fears about causing harm to others
D) Thoughts of snakes that cause marked anxiety

Key Answer: B) Family history of anxiety disorders (father and sister with panic disorder)

Explanation: Predisposing factors increase vulnerability to developing the disorder (e.g., family history of anxiety). A is precipitating, C is perpetuating, and D relates to comorbid depression.

In the 4Ps formulation of Pat’s OCD, which of the following is an example of a predisposing factor?

A) Exposure to funerals triggered increased contamination fears
B) Family history of anxiety disorders (father and sister with panic disorder)
C) Husband removing "contaminated" items at her request
D) Her hopelessness after failed medication attempts

Key Answer: A) Supportive husband who cooperates with rituals

Explanation: Perpetuating factors are those that maintain the disorder. Her husband’s accommodation of rituals (removing contaminated items, allowing separate foods) reinforces compulsions instead of challenging them, maintaining the cycle.

In the 4Ps formulation, which factor is most clearly perpetuating Pat’s OCD?

A) Supportive husband who cooperates with rituals
B) Stopping work due to fear of contamination
C) Fear of snakes
D) Onset of compulsive symptoms in high school

Key Answer: B) Low appetite, insomnia, fatigue, guilt, hopelessness

Explanation: Pat showed symptoms of moderate depression, including poor appetite, sleep disturbance, decreased interest in activities, fatigue, guilt, concentration difficulties, and hopelessness — consistent with persistent depressive disorder with current moderate episode.

Which of the following depressive features did Pat report during her clinical history?

A) Euphoria, racing thoughts, grandiosity
B) Low appetite, insomnia, fatigue, guilt, hopelessness
C) Visual hallucinations, thought insertion
D) Excessive energy and impulsivity

Key Answer: B) Husband cooperative and supportive of her overall struggles

Explanation: A protective factor is something that reduces risk or aids recovery. Pat’s family, especially her husband’s general support, provided emotional stability and reduced total distress, even if his accommodation perpetuated rituals.

What protective factor was evident in Pat’s case?

A) Husband occasionally frustrated with her compulsions
B) Husband cooperative and supportive of her overall struggles
C) High level of occupational impairment
D) Long-standing fear of snakes

Key Answer: C) She recognized her fears as excessive but still could not control them

Explanation: DSM-5 includes an insight specifier for OCD. Pat had good/fair insight because she recognized her obsessions were unreasonable, even though fear overpowered rational understanding.

Why was Pat’s OCD specified as “with good or fair insight” in DSM-5?

A) She believed her contamination fears were completely realistic
B) She lacked awareness of her behaviors being excessive
C) She recognized her fears as excessive but still could not control them
D) She had delusional beliefs about contamination unrelated to compulsions

Key Answer: B) Increase in contamination fears around 6 years ago with no clear trigger

Explanation: Precipitating factors are events or conditions that trigger the onset or escalation of symptoms. Pat reported her OCD became severe about 6 years ago, even though she could not link it to a specific stressor.

Which of the following best represents a precipitating factor in Pat’s OCD case?

A) Family history of panic disorder
B) Increase in contamination fears around 6 years ago with no clear trigger
C) Husband accommodating rituals
D) Supportive family relationship

Key Answer: C) Symptoms cause clinically significant impairment in functioning

Explanation: DSM-5 requires OCD symptoms to be time-consuming or cause significant distress/impairment in social, occupational, or academic functioning. Pat quitting her job and avoiding people due to fears of funerals clearly meets this criterion.

Which DSM-5 criterion of OCD does Pat’s unemployment and avoidance of funerals illustrate?

A) Obsessions are intrusive and unwanted
B) Compulsions are performed to reduce distress
C) Symptoms cause clinically significant impairment in functioning
D) The disturbance is not attributable to substance use

Key Answer: B) Resisting triggered panic attacks, which subsided only after rituals

Explanation: Pat reported that resisting compulsions triggered panic attacks, leading her to engage in rituals (washing/cleaning) to relieve the anxiety. This illustrates the OCD cycle of obsession → anxiety → compulsion → temporary relief.

Why did Pat often give in to her urges to wash after trying to resist?

A) She recognized her compulsions were harmless
B) Resisting triggered panic attacks, which subsided only after rituals
C) She enjoyed the sensation of cleanliness
D) Her husband encouraged her to wash

Key Answer: C) OCD shares features with related disorders like body dysmorphic disorder and hoarding disorder

Explanation: In DSM-5, OCD was reclassified because it shares core features (obsessions, compulsions, repetitive behaviors, poor insight) with related disorders (e.g., body dysmorphic disorder, hoarding disorder), distinguishing it from traditional anxiety disorders.

According to DSM-5, why was OCD reclassified from an anxiety disorder to the category of “Obsessive-Compulsive and Related Disorders”?

A) OCD does not involve anxiety
B) OCD has closer ties to psychotic disorders than to anxiety
C) OCD shares features with related disorders like body dysmorphic disorder and hoarding disorder
D) To simplify the diagnostic manual

Key Answer: B) OCD-related beliefs are directly linked to obsessions and compulsions

Explanation: Even when insight is absent (delusional beliefs), OCD is diagnosed if the beliefs are directly tied to obsessions and compulsions, and the person lacks other features of psychotic disorders (e.g., hallucinations, thought insertion).

Which feature helps distinguish OCD with poor/absent insight from a psychotic disorder?

A) Delusions are often bizarre in psychosis
B) OCD-related beliefs are directly linked to obsessions and compulsions
C) Psychotic disorders never include contamination fears
D) Patients with OCD always have full insight