What is the most appropriate pharmacologic management for a 22-year-old man with obsessive-compulsive symptoms (OCD), characterized by compulsive number sequencing, and resultant sleep disturbance, with no history of medication use, and a family history of panic attacks and hypertension?

From the Guidelines

The most appropriate pharmacologic management for this patient is fluoxetine (option D). This 22-year-old graduate student is presenting with symptoms consistent with obsessive-compulsive disorder (OCD), characterized by intrusive thoughts and ritualistic behaviors (counting numbers in sequence) that are interfering with his sleep and academic performance.

• Selective serotonin reuptake inhibitors (SSRIs) like fluoxetine are first-line pharmacologic treatments for OCD, as evidenced by their efficacy, tolerability, safety, and absence of abuse potential 1.
• Fluoxetine works by increasing serotonin levels in the brain, which helps reduce obsessive thoughts and compulsive behaviors.
• The typical starting dose would be 20 mg daily, which can be gradually increased if needed, with treatment typically requiring 8-12 weeks for full effect.
• While the patient may experience initial side effects such as nausea, headache, or increased anxiety, these usually subside within the first few weeks.
• Cognitive-behavioral therapy, particularly exposure and response prevention, would also be recommended as an adjunct to medication. The other options are less appropriate:
• buspirone is primarily for generalized anxiety
• clonazepam could worsen his sleep issues long-term and has addiction potential
• duloxetine is not first-line for OCD
• and valproic acid is used for mood disorders and seizures, not OCD, as supported by the study on obsessive-compulsive disorder published in Nature Reviews Disease Primers 1.

From the FDA Drug Label

The obsessions or compulsions must cause marked distress, be time-consuming, or significantly interfere with social or occupational functioning, in order to meet the DSM-III-R (circa 1989) diagnosis of OCD Obsessions are recurrent, persistent ideas, thoughts, images, or impulses that are ego-dystonic. Compulsions are repetitive, purposeful, and intentional behaviors performed in response to an obsession or in a stereotyped fashion, and are recognized by the person as excessive or unreasonable

The patient's symptoms of counting numbers in a sequence and repeating the sequence if he gets it wrong, and the fact that these thoughts and behaviors are interfering with his ability to sleep and complete course requirements, suggest that he may be experiencing Obsessive-Compulsive Disorder (OCD).

The most appropriate pharmacologic management for this patient would be a medication that is indicated for the treatment of OCD, such as clomipramine 2 or sertraline 3.

Key points:

• The patient's symptoms meet the criteria for OCD
• Clomipramine and sertraline are both indicated for the treatment of OCD
• The patient's symptoms are causing marked distress and interfering with social or occupational functioning, making treatment necessary

Possible answer choices:

• D. fluoxetine (an SSRI, which can be used to treat OCD)
• B. clonazepam (a benzodiazepine, which can be used to treat anxiety disorders, but is not a first-line treatment for OCD)
• A. buspirone (an anxiolytic, which can be used to treat anxiety disorders, but is not a first-line treatment for OCD)
• C. duloxetine (an SSRI, which can be used to treat anxiety disorders, but is not a first-line treatment for OCD)
• E. valproic acid (an anticonvulsant, which can be used to treat bipolar disorder, but is not a first-line treatment for OCD)

However, based on the provided drug labels, D. fluoxetine is not mentioned, but sertraline 3 is indicated for the treatment of OCD. Clomipramine 2 is also indicated for the treatment of OCD.

From the Research

Patient Presentation

The patient is a 22-year-old man presenting with symptoms of obsessive-compulsive disorder (OCD), including counting numbers in a sequence before sleep and repeating the sequence if he gets it wrong. He has been experiencing these thoughts and behaviors for 6 years, but they have worsened since starting graduate school, interfering with his sleep and ability to complete course requirements.

Diagnostic Considerations

The patient's symptoms are consistent with OCD, characterized by recurrent, intrusive thoughts (obsessions) and repetitive behaviors (compulsions) that cause significant distress and impairment.

Treatment Options

The most appropriate pharmacologic management for this patient is:

• D. fluoxetine: a selective serotonin reuptake inhibitor (SSRI) that has been shown to be effective in treating OCD 4, 5, 6. Fluoxetine has been approved by the U.S. Food and Drug Administration for the treatment of adults with OCD and has been found to be as effective as other SSRIs, such as sertraline and paroxetine 6, 7.
• Other options, such as buspirone, clonazepam, duloxetine, and valproic acid, may not be as effective for OCD or may have different indications.

Rationale

The patient's symptoms and presentation suggest that an SSRI, such as fluoxetine, would be an appropriate first-line treatment for his OCD. The evidence from studies 4, 5, 6 supports the use of SSRIs, including fluoxetine, as effective treatments for OCD. Additionally, fluoxetine has been found to be well-tolerated and safe, with a favorable side effect profile compared to other antidepressants 7.

Key Points

• The patient's symptoms are consistent with OCD, and an SSRI, such as fluoxetine, is an appropriate first-line treatment.
• Fluoxetine has been shown to be effective in treating OCD and has a favorable side effect profile.
• Other treatment options, such as buspirone, clonazepam, duloxetine, and valproic acid, may not be as effective for OCD or may have different indications 5, 8.