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Author Gonzalo Romero (Reviewed by Yazan Daaboul)
Exam Type USMLE Step 1
Main Category Behavioral Science/Psychiatry
Sub Category General Principles
Prompt A 17-year-old male adolescent presents to the outpatient clinic accompanied by his mother for a routine check-up. The patient's mother explains that he developed a very strange behavior over the past year that is gradually worsening. Recently, his mother noticed that he spends a lot of time during the day washing his hands; although they are clean. She states that he washes his hands extensively at least 30 times a day. He doesn't touch any shared utensil in the house to "prevent germs from contaminating his hands". He spends a lot of time washing his hands to the extent he often arrives late to his classes and other scheduled meetings. When asked about his behavior, the patient replies: "I can't help it, it's so frustraing. I can't stop it although I tried. I feel that if I do not wash my hands every now and then I will get sick and die". Otherwise, the patient and his mother have no other complaints. On physical exam, his vitals are stable. The patient appears anxious; his hands are dry and cracking. What is the most likely diagnosis?
Answer A Generalized anxiety disorder
Answer A Explanation [[AnswerAExp::Generalized anxiety disorder is a disorder characterized by the excessive anxiety and worry about various daily activities. According to DSM-5 criteria, the diagnosis is made when at least 3 out of the following 6 symptoms are present for at least 6 months:
  • Restlessness or feeling on edge
  • Easily fatigued
  • Difficult to concentrate
  • Irritability
  • Muscle tension
  • Sleep disturbance

Most importantly, patients with generalized anxiety disorders require having symptoms that cause clinically significant impairment. Patients cannot confine their anxiety, which is not confined towards specific settings, but are rather anxious about several activities.]]

Answer B Obsessive compulsive personality disorder (OCPD)
Answer B Explanation [[AnswerBExp::Obsessive compulsive personality disorder is a pervasive cluster C personality disorder. Unlike those with OCD, individuals with OCPD do not have insight and do not regard their behavior as abnormal. OCPD patients are generally not flexible, are always overwhelmed with perfection, and are difficult to change. Persons with this disorder are extremely organized, love lists, order, perfection, and like routine activities.]]
Answer C Obsessive compulsive disorder (OCD)
Answer C Explanation OCD is characterized by the presence of obsessions that are only relieved by executing compulsions. In contrast to OCPD, patients with OCD have insight and recognize that their symptoms are excessive and out of the ordinary.
Answer D Paranoid personality disorder
Answer D Explanation [[AnswerDExp::Paranoid personality disorder is a cluster A or eccentric personality disorder, which is characterized by chronic mistrust of others. Patients often try to look for hidden meanings into comments and hold grudges.]]
Answer E Panic disorder
Answer E Explanation [[AnswerEExp::Panic disoder is an anxiety disorder, commonly observed in women, that is characterized by sudden episodes or attacks of fear even when not in a dangerous encounter. According to DSM-5 criteria, they may be classified into two groups: Expected and unexpected. These attacks often interfere with the patient's daily living. During the attack, the patient loses control and has a sense of impending doom.]]
Right Answer C
Explanation [[Explanation::The patient is most likely diagnosed with obsessive-compulsive disorder (OCD). OCD is characterized by obsessions about a specific thought that preoccupy a patient's behavior and his overall performance. The patient's obsessions cannot be relieved except by compulsions, which are repetitive actions to relief the unreasonable thoughts. This patient is overwhelmed with the obsessive thought that he has germs on his hands that might kill him; he has to constantly wash his hands to relieve those obsessions. The act of washing is hands is his compulsion, which relieves his obsessive thought. Because the patient has insight and is frustrated by his behavior and is aware that his behavior is not normal, the diagnosis of OCD is more likely.

Had the patient not recognized his symptoms as abnormal, the more likely diagnosis in that case would have been obsessive compulsive personality disorder (OCPD), which is a cluster C pervasive personality disorder.

The mainstay of therapy among patients with OCD is SSRI, an antidepressant medication. Clomipramine, a tricyclic antidepressant, may be used but is considered a second line therapy in treatment of OCD. In contrast, had the patient been diagnosed with OCPD, pharmacologic therapy would not have been helpful, and cognitive behavioral therapy would have been more helpful.
Educational Objective: Obsessive compulsive disorder (OCD) is characterized by the presence of obsessions, which are unreasonable thoughts, that lead to compulsions, which are repetitive behaviors to relief those obsessions. Unlike obsessive compulsive personality disorder (OCPD), patients with OCD have insight, are frustrated by their behavior, and recognize that their symptoms are not usual.
References: First aid page 501]]

Approved Yes
Keyword obsessive, compulsive, disorder, OCD, insight, personality, cluster C
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