Review Question - QID 102760

This patient is presenting with obsessive-compulsive disorder given her compulsions (repeat wall touching) likely driven by some underlying anxiety that has not yet been explored (obsessions). The most appropriate initial treatment is cognitive behavioral therapy (CBT).

Obsessive-compulsive disorder (OCD) is described as consisting of repetitive and intrusive thoughts that cause distress and impairment that can only be relieved with ritualistic actions that ultimately neutralize the initial obsessions. Symptoms usually start in the teenage years. Appropriate first-line treatments include cognitive behavioral therapy with exposure and response prevention followed by a selective serotonin reuptake inhibitor. The chief complaint is not typically the obsession (what is causing the anxiety) but rather, the observed compulsion (the ritualistic or repetitive behavior). Examples of this behavior include repeat hand washing, rechecking/locking doors, entering/exiting buildings multiple times, or skin picking. The treatment is initially cognitive behavioral therapy (CBT) followed by SSRIs if symptoms are refractory to CBT alone.

Incorrect Answers:
Answer 1: Clomipramine is a TCA that could be used in the management of OCD; however, this is a third-line agent when compared to CBT and SSRIs.

Answer 3: Fluoxetine is an SSRI that could be used to treat OCD; however, it is generally started once CBT has failed. It is highly effective when combined with CBT.

Answer 4: Lorazepam is a benzodiazepine that could be used for situational panic disorder (such as panic when flying); however, it is not appropriate for treating general anxiety or the anxiety in OCD as its chronic use could lead to dependence.

Answer 5: Risperidone is an antipsychotic that could be added to treatment in severe and refractory cases of OCD as an adjunct but is not the primary treatment of OCD.

Bullet Summary:
The most appropriate initial step in the management of obsessive-compulsive disorder is CBT.