Question 1

A 34-year-old man describes spending 3 hours daily checking that doors are locked and appliances are off. He says the checking is "ridiculous" and he "hates" doing it, but if he doesn't check he experiences overwhelming anxiety that his house will burn down. Which feature most strongly supports a diagnosis of OCD over OCPD?

Accepted Answer

The ego-dystonic quality is the key differentiator. This patient recognizes his checking as excessive and unwanted — he "hates" doing it. In OCPD, the patient views their rigidity and perfectionism as reasonable or even virtuous (ego-syntonic). Time consumption, the type of behavior (checking), and anxiety alone do not distinguish OCD from OCPD. The patient's distress about and resistance to their own symptoms is the defining feature of OCD.

Question 2

A 28-year-old woman with OCD believes that if she does not touch a doorknob exactly three times, her mother will die in a car accident. She is completely convinced this is true and becomes agitated when challenged. She has no hallucinations, no thought disorganization, and functions well in other domains. What is the most appropriate treatment approach?

Accepted Answer

This is OCD with absent insight — the belief is circumscribed (linked to a specific compulsive ritual), there are no hallucinations or formal thought disorder, and functioning is preserved outside of the OCD symptoms. The treatment is ERP + SSRI, not antipsychotic monotherapy. Antipsychotic augmentation (not monotherapy) may be considered if SSRI + ERP is insufficient. Benzodiazepines do not target the obsession-compulsion cycle and can interfere with ERP learning.

Question 3

A patient with OCD has been on sertraline 100mg for 6 weeks with a partial response — her Y-BOCS score dropped from 28 to 22. She asks about next steps. What is the most appropriate recommendation?

Accepted Answer

OCD typically requires higher SSRI doses (sertraline 150-200mg) and longer trials (8-12 weeks at adequate dose) than depression. A partial response at 100mg after 6 weeks is not a treatment failure — it is an indication to optimize dose and duration. Switching prematurely is a common prescribing error in OCD. Antipsychotic augmentation is reserved for cases that do not respond to an adequate SSRI trial. Combining medication with ERP is typically more effective than either alone.

Question 4

A previously healthy 7-year-old boy develops severe contamination obsessions and hand-washing compulsions seemingly overnight. He also shows emotional lability, urinary urgency, and deterioration in handwriting. His mother reports he had strep throat 3 weeks ago. What diagnosis should be considered?

Accepted Answer

The abrupt, dramatic onset of OCD symptoms in a previously well prepubertal child following streptococcal infection is the classic PANDAS presentation. The accompanying features — emotional lability, urinary urgency, and motor changes (handwriting deterioration suggesting choreiform movements) — further support this diagnosis. Typical childhood OCD has a more gradual onset. The mechanism is autoimmune/inflammatory, and treatment may include antibiotics and anti-inflammatory agents in addition to standard OCD approaches.

Question 5

A patient describes intrusive, unwanted thoughts about harming her infant. She is horrified by these thoughts, has never acted on them, and goes to great lengths to avoid being alone with the baby. She has no history of psychosis or violence. What is the most accurate clinical interpretation?

Accepted Answer

The content of obsessions does not predict behavior. This patient's harm obsessions are ego-dystonic — she is horrified by them and avoids situations where they might be triggered. In the absence of comorbid psychosis or impulse-control disorders, harm obsessions are not associated with increased violence risk. The distress is evidence of ego-dystonicity. Separating her from the infant based solely on thought content would be clinically inappropriate. While mild intrusive thoughts are common in new parents, the severity and avoidance pattern here warrant clinical attention and treatment (ERP + SSRI).

Obsessive-Compulsive Disorder

Red Flags & Key Clinical Considerations

Suicidality

Acute Pediatric Onset

Taboo Obsessions and Shame

Reassurance-Seeking as a Compulsion

Medication Considerations

Related Medications

References & Further Reading