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Clomipramine
8%
23/278
Dialectical behavioral therapy
42%
117/278
Fluoxetine
27%
74/278
Interpersonal psychotherapy
14%
38/278
Supportive psychotherapy
6%
16/278
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This patient is presenting with excoriation disorder in the setting of obsessive thoughts suggesting a diagnosis of obsessive-compulsive disorder (OCD). The most appropriate initial therapy for OCD is cognitive behavioral therapy (CBT) and a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine. OCD presents with obsessive, recurring thoughts, and repetitive behaviors or compulsions that relieve the stress associated with these thoughts. OCD is an ego-dystonic disorder in which the patient is aware that their behavior is not healthy yet they have trouble changing it. A physical exam can reveal hand dermatitis related to excessive hand washing, patchy hair loss related to compulsive hair pulling, and excoriations or nodules related to compulsive skin picking. OCD is also an impulse control disorder that responds well to SSRI medications, as well as CBT. Pittenger and Bloch review the treatment of patients with obsessive-compulsive disorder. They discuss how selective serotonin reuptake inhibitors are the first line of treatment for this disease. They recommend clomipramine and the addition of low-dose neuroleptic medications in patients who are refractory to initial treatment. Incorrect Answers: Answer 1: Clomipramine is a serotonergic TCA and is a second-line therapy for OCD. If CBT and an SSRI were to fail in managing this patient's symptoms, then it could be appropriate to use clomipramine. Side effects include nausea, vomiting, and drowsiness. Answer 2: Dialectical behavioral therapy is indicated in patients with borderline personality disorder or in patients who exhibit self-harm behaviors such as cutting. This therapy promotes acceptance and change and also improves emotional regulation and awareness. It would not be effective in patients with obsessive-compulsive disorder. Answer 4: Interpersonal psychotherapy is a short-term intervention that focuses on relationship conflicts and grief with a focus on current issues and conflicts. This modality can be used to help individuals work through difficult situations. While stress exacerbates this patient's symptoms, his underlying diagnosis is most likely obsessive-compulsive disorder. Answer 5: Supportive psychotherapy is indicated in lower functioning or cognitively impaired patients in crisis. In supportive psychotherapy, the therapist acts as a guide who offers ongoing treatment that reinforces coping skills and builds up the patient's defense mechanisms. Bullet Summary: The most appropriate initial therapy for obsessive-compulsive disorder is cognitive behavioral therapy and a selective serotonin reuptake inhibitor.
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