Patient Intake and History The patient is

Patient Intake and History The patient is a 57-year-old man whose chief complaint is “a major case of OCD” The patient states that he had a pervasive fear of death and high general anxiety as a child and that he experienced a series of depressive episodes in high school He did not develop obsessive compulsive symptoms until he was in his 20s; these were preceded by panic and fear symptoms that he developed while taking diet pills He stopped taking the diet pills, but the fear, panic, and obsessive-compulsive symptoms did not resolve Soon after, he became Christian, which he feels helped resolve some of his anxiety, but only temporarilyIn his early 20s, he committed what he believes to be the unforgivable sin of blaspheming the Holy SpiritHe began to obsess about this thought and developed other repetitive ideas, including the thought that if he listened to or recalled a particular song, he would go mad These obsessive thoughts waxed and waned over the next several years without many corresponding compulsions, and the patient received no treatment The patient married at age 30 and had a son at age 31At age 33, he began to have obsessive thoughts that he would hurt his son; this was relieved by ritual prayers He also developed other compulsions, including checking locks His marriage ended at that time, in large part due to the patient’s symptoms At about that time, he was hospitalized with the diagnoses of obsessive-compulsive disorder (OCD) and depression He was given electroconvulsive therapy (ECT) and was subsequently prescribed clomipramine, with limited benefit He also received Christian counseling, which he considered helpful Since that time, the patient has had trials of various selective serotonin reuptake inhibitors (SSRIs), including fluoxetine, sertraline, paroxetine, citalopram, and escitalopram, as well as augmentation trials with quetiapine and lithium He has never received fluvoxamine, adjunct buspirone, or any other adjunct atypical antipsychotic The patient states that he had essentially no response to medications in the early years of treatment He is currently taking fluoxetine 80 mg/day and trazodone 50 mg/night; he reports only a vague, incomplete, and unsatisfying response to this combination but acknowledges that these are the best results that he has ever experienced with medication Fairly recently, he began cognitive behavioral therapy (CBT), and he has responded well to it; however, he continues to experience significant symptoms of OCD as well as depression He currently rates his OCD as a 7/10 in severity and his depression as a 7/10 in severity Additional history No significant medical or family history Prior alcohol abuse; none in the last 18 months Questions/activities: 1) Explain the distinguishing features of OCD? Be specific! 2) complete a decision-tree for the diagnosis of OCD 3) What initial treatment strategy would you pursue for this patient? For example, would you increase the dose of his current SSRI (Fluoxetine), switch to a different SSRI, switch to Clomipramine, or refer for deep brain stimulation (DBS). Be sure and provide a rationale for your response.

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