Chief Concern
Bethany's chief concern is severe obsessive-compulsive disorder characterized by contamination obsessions and cleaning/sanitizing compulsions that consume significant time daily and prevent her from leading a normal life, accompanied by emerging depressive symptoms including hopelessness and loss of purpose.
Areas of Concern to Explore and Red Flags
Immediate Red Flags Requiring Urgent Assessment
Suicidal ideation and intent: Bethany reports feeling hopeless and that her life has no purpose, combined with a history of suicide attempt (Tylenol overdose at age 34). A comprehensive suicide risk assessment must be conducted immediately, including current suicidal thoughts, plans, means, and intent 1, 2.
Current major depressive episode: Given the high comorbidity between anxiety disorders and major depressive disorder (estimated at 56%), and the significant suicide risk associated with comorbid presentations, assess whether Bethany meets criteria for a current major depressive episode 1, 3.
Areas Requiring Detailed Exploration
OCD symptom severity and time consumption: Quantify exactly how many hours per day Bethany spends on obsessions and compulsions, as this determines treatment intensity. Assess whether symptoms are time-consuming (>1 hour/day) and cause significant distress or impairment 1.
Specific contamination fears and avoidance patterns: Detail which situations trigger her contamination fears, what she avoids (crowded places, medical settings), and how this impacts daily functioning including grocery shopping, social contact, and healthcare access 1.
Panic attack characteristics: Bethany describes anxiety accompanied by shortness of breath and chest tightness. Determine if these episodes meet criteria for panic attacks (discrete periods reaching peak within 10 minutes with ≥4 symptoms) versus generalized anxiety symptoms 2.
Social isolation and loneliness: Bethany has no friends and speaks with her brother only monthly. Assess the extent of social withdrawal, whether this predates OCD worsening or resulted from it, and her desire for social connection 1.
Sleep architecture: While she reports 4 hours uninterrupted sleep, explore total time in bed, sleep latency, early morning awakening, and whether obsessions/compulsions interfere with sleep initiation or maintenance.
Functional impairment: Quantify specific activities she can no longer perform (leaving home, attending appointments on time, maintaining relationships) and how this has changed over the past few years as symptoms worsened.
Previous treatment response: She discontinued citalopram (ineffective) and paroxetine (weight gain) but has been off all psychotropics for 10 years. Explore what doses were tried, duration of trials, and whether she received any psychotherapy, particularly CBT with exposure and response prevention 1.
Medical rule-outs: Assess for hyperthyroidism symptoms (heat intolerance, palpitations, weight loss, tremor) as this can mimic or exacerbate anxiety symptoms including OCD 1.
Diagnostic and Psychometric Tests
1. Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
Rationale: The Y-BOCS is the gold standard clinician-rated instrument for measuring OCD symptom severity, with scores ≥28 indicating severe OCD. This will quantify the severity of her contamination obsessions and cleaning compulsions and establish a baseline for treatment monitoring 1.
2. Thyroid Stimulating Hormone (TSH) and Free T4
Rationale: Hyperthyroidism can mimic or exacerbate anxiety symptoms including those of OCD. Medical rule-outs such as hyperthyroidism should be considered in the differential diagnosis, particularly given her anxiety, hand-wringing, and visible agitation 1.
3. Beck Depression Inventory-II (BDI-II) or Patient Health Questionnaire-9 (PHQ-9)
Rationale: Given her statements about hopelessness and life having no purpose, combined with poor sleep and low energy, a structured depression severity measure is essential to assess whether she meets criteria for major depressive disorder and to quantify suicide risk 1, 2.
4. Columbia-Suicide Severity Rating Scale (C-SSRS)
Rationale: With her history of suicide attempt and current statements of hopelessness, a standardized suicide risk assessment tool is mandatory to assess current suicidal ideation, intent, plan, and access to means 1, 2.
5. Generalized Anxiety Disorder-7 (GAD-7)
Rationale: The GAD-7 measures nervousness, inability to control worry, excessive worry, trouble relaxing, restlessness, and irritability to distinguish generalized anxiety from OCD-specific anxiety. This helps differentiate whether her anxiety is primarily OCD-related or represents comorbid GAD, which would influence treatment planning 1.
Differential Diagnoses with Rule-In/Rule-Out Table
| Hypothesis | Rule-In (Positive Findings) | Rule-Out (Negative Findings) |
|---|---|---|
| #1 Obsessive-Compulsive Disorder (OCD) with comorbid Major Depressive Disorder (MDD) | • Recurrent intrusive obsessions about contamination/germs that are time-consuming and distressing [1] • Repetitive compulsions (hand sanitizing, cleaning apartment, showering) recognized as excessive [1] • Symptoms significantly impair functioning (late to appointments, avoids crowded places, cannot lead "normal life") [1] • Symptoms worsening over past few years [1] • Hopelessness, loss of purpose, poor sleep (4 hours), low energy, poor concentration [1,3] • History of MDD diagnosis in 30s [3] |
• No evidence of psychotic features or bizarre delusions • Contamination fears are ego-dystonic (she recognizes them as excessive) rather than overvalued ideas • No evidence of hoarding, symmetry obsessions, or other OCD subtypes dominating presentation |
| #2 Generalized Anxiety Disorder (GAD) with OCD features | • Long history of being "anxious person" who "worries about everything" [4] • Previous GAD diagnosis in her 30s [4] • Visible anxiety (flushed face, hand-wringing, foot-tapping) [5] • Poor concentration and low energy [4] • Anxiety symptoms present for many years [4] |
• Current symptoms are specifically focused on contamination/germs rather than multiple worry domains [1] • She explicitly states anxiety has "changed" and now "mostly worries about health, germs/contamination" [1] • Presence of clear compulsions (cleaning rituals) beyond worry [1] • Time-consuming rituals (>1 hour/day) more consistent with OCD than GAD [1] |
| #3 Illness Anxiety Disorder (IAD) with OCD features | • Preoccupation with having or acquiring serious illness [6] • Excessive health-related behaviors (hand sanitizing, avoiding medical clinic) [6] • High health anxiety about contracting illness [6] • Anxiety about being in medical settings where "people are sick" [6] |
• Primary focus is on contamination/germs and cleaning rather than belief she currently has a serious illness [6] • Compulsions extend beyond health-checking to general cleaning of apartment and environment [1] • No evidence of excessive doctor visits or reassurance-seeking about having specific diseases [6] • Rituals are to prevent future illness rather than checking for current illness [6] |
Primary/Provisional Diagnosis: Obsessive-Compulsive Disorder with comorbid Major Depressive Disorder. The presence of time-consuming, distressing obsessions and compulsions that significantly impair functioning, combined with depressive symptoms including hopelessness and suicidal history, best explains her presentation 1, 3.
Initial Treatment Plan for First 2 Weeks
Immediate Safety Planning (Days 1-3)
Conduct comprehensive suicide risk assessment using C-SSRS and develop safety plan given her history of suicide attempt and current hopelessness. Identify warning signs, coping strategies, social supports (brother), and crisis resources 1, 2.
Establish crisis contact protocol: Provide 24-hour crisis line numbers and schedule follow-up within 3-5 days for high-risk monitoring, as patients with comorbid anxiety and depression have elevated suicide risk 2, 3.
Pharmacotherapy Initiation (Day 1)
Start sertraline 50 mg once daily (morning or evening). SSRIs are first-line pharmacotherapy for OCD, and sertraline is FDA-approved for OCD treatment. The combination of CBT plus SSRI is recommended for moderate-to-severe symptoms 1, 2.
Rationale for sertraline over other SSRIs: Given her past trials of citalopram (ineffective) and paroxetine (weight gain), sertraline offers a different SSRI option with FDA approval for both OCD and depression. Starting dose is 50 mg daily for OCD per FDA labeling 2.
Educate patient that therapeutic response for OCD typically requires 8-12 weeks at adequate doses, and doses may need to increase up to 200 mg/day. Warn about potential initial anxiety increase and common side effects (nausea, insomnia, sexual dysfunction) 2.
Monitor for clinical worsening and suicidality especially during initial weeks of SSRI treatment, as antidepressants carry black box warning for increased suicidal thinking in adults with depression 2.
Psychotherapy Referral (Week 1)
Refer immediately for Cognitive Behavioral Therapy with Exposure and Response Prevention (CBT with ERP), which is the most effective psychological treatment for OCD with evidence supporting its use alone or combined with SSRIs 1.
Incorporate behavioral activation into CBT sessions to address social isolation and low energy. Develop a graduated plan for increasing social contact (starting with phone calls to brother, then brief outings) 1.
Target contamination fears systematically: Work with therapist to create exposure hierarchy starting with lower-anxiety triggers (touching doorknobs) and progressing to higher-anxiety situations (visiting crowded places, attending medical appointments without excessive cleaning) 1.
Medical Workup (Week 1)
Order TSH and Free T4 to rule out hyperthyroidism as a contributor to anxiety symptoms 1.
Repeat ECG given that last ECG was 5 years ago (QTc 435ms) and she is starting sertraline. Baseline ECG is prudent given her age (70) and to monitor for QTc prolongation, though sertraline has lower risk than citalopram 2.
Monitoring and Follow-up (Weeks 1-2)
Schedule follow-up appointment in 1 week to assess medication tolerability, side effects, suicidal ideation, and ensure connection with CBT therapist 2.
Administer Y-BOCS at baseline and Week 2 to quantify OCD severity and establish treatment response metrics 1.
Monitor for serotonin syndrome symptoms (agitation, confusion, tremor, tachycardia, hyperthermia) particularly if patient takes any other serotonergic medications 2.
Assess adherence barriers: Given her contamination fears, ensure she can tolerate taking oral medication and storing medication bottle in her home without excessive cleaning rituals interfering with adherence 1.
Psychoeducation (Ongoing)
Explain OCD neurobiology: Help Bethany understand that OCD involves brain circuits and is not a character flaw, which may reduce shame and increase treatment engagement 1.
Normalize comorbidity: Explain that 72% of lifetime anxiety cases have history of depression, and that treating both conditions simultaneously is standard practice 3.
Set realistic expectations: Emphasize that OCD is a chronic condition requiring long-term management, but that significant improvement is achievable with combined CBT and medication 1, 2.
Brief Case Summary
Bethany is a 70-year-old widowed female with worsening obsessive-compulsive disorder characterized by contamination obsessions and cleaning/sanitizing compulsions that consume significant daily time and severely impair her functioning, preventing her from leading a normal life. She presents with comorbid depressive symptoms including hopelessness, loss of purpose, social isolation, poor sleep, and low energy, along with a remote history of suicide attempt, placing her at elevated risk. Her anxiety has evolved from generalized worry in younger years to predominantly contamination-focused OCD over the past several years, with progressive functional decline. She requires immediate suicide risk assessment, initiation of sertraline 50 mg daily combined with CBT with exposure and response prevention, medical workup to rule out hyperthyroidism, and close monitoring given her high-risk profile with comorbid OCD and depression.