PAINE #PANCE Pearl – Psychiatry



Question

A 20yo man, with no significant past medical history, is brought in by his parents for evaluation of concerning behaviors. They state he often feels he “needs” to arrange the items in his room in a certain way and becomes very agitated if they are moved. He also must make sure that there is no dirt on his shoes before he walks in his room and is meticulous in his cleaning endeavors every day. His parents are worried about his level of functioning and ability to move out and maintain his own apartment. He denies any thoughts of self-harm, homicidal ideations, or audio-visual hallucinations. On physical examination, he seems composed, non-distracted, and answers all questions appropriately. When asked about these behaviors, he recognizes that they are a problem, but states he can’t relax and has severe anxiety unless these are taken care of.

  1. What is the most likely diagnosis based on this presentation?
  2. What criteria must be met per the DSM-V for diagnosis?


Answer

The most likely diagnosis is obsessive compulsive disorder and is defined by the DSM-V using the below criteria:

A. Presence of obsessions, compulsions, or both

  • Obsessions as defined by:
    • Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
    • The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (ie, by performing a compulsion).
  • Compulsions as defined by:
    • Repetitive behaviors (eg, hand washing, ordering, checking) or mental acts (eg, praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.
    • The behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

B. The obsessions or compulsions are time-consuming (eg, take more than one hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of another mental disorder.

DSM-V Specifiers

  • Patient’s degree of insight into the illness
    • With good or fair insight
      • The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
    • With poor insight
      • The individual thinks obsessive-compulsive disorder beliefs are probably true.
    • With absent insight/delusional beliefs
      • The individual is completely convinced that obsessive-compulsive disorder beliefs are true.
  • Tic-Related – The individual has a current or past history of a tic disorder.

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