Published on 03/03/2015 by admin
Filed under Neurology
Last modified 03/03/2015
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22 Obsessive-Compulsive Disorder
Kenneth Lakritz
A 36-year-old high school teacher consulted a psychiatrist because of difficulty driving to work. He had a long-standing fear that he would lose control of his car and accidentally run down a pedestrian. Recently, this fear had intensified to the extent that he had to stop driving and examine his car’s bumpers for signs of blood whenever he hit a bump in the road. It was taking him more than 2 hours each morning to make a 20-minute commute. On further questioning, the patient also admitted to fear that a knife or fork would accidentally slip from his hand while he ate dinner, and that he would inadvertently stab someone. He also had to check the appliances and faucets four times before leaving home to ensure they had been turned off, and he had a 1-hour ritual of washing and shaving that he needed to perform in strict order every morning.
Much to the patient’s dismay, the psychiatrist felt compelled to warn both his family and the police that the patient’s “suppressed anger” might get out of control. His family, however, was well aware of the patient’s habits and fears, and declared that they were not frightened. Likewise, the police dismissed the case after finding no criminal history and no imminent threat.
Despite his time-wasting habits and rituals, the patient had a successful career. He was well liked by friends and family, who worked around his “eccentricities.” His symptoms gradually diminished with combined treatment (provided by a second psychiatrist) with a serotonergic antidepressant and a behavioral program of exposure and response prevention.
Patients with obsessive-compulsive disorder (OCD) complain of unwelcome, intrusive, and repetitive thoughts or urge to act in ways they find meaningless or inappropriate. The thoughts or urges are “ego-dystonic”—they are perceived as unreasonable and seemingly imposed upon the patient. Someone who hoards newspapers and bits of string, or spends hours every day polishing a new car, but does so happily, does not have OCD, however odd the behavior. People with OCD are tormented by their thoughts and behaviors, usually struggling with them for years before seeking help.
OCD patients usually fit into one of a few categories. Some clean obsessively and worry about germs or contamination (Fig. 22-1
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