Case Summary

A 26-year-old woman presents with self-admitted exhaustive cleaning rituals that she now
only uses a portion of her home. She states that she worries that a non-clean house will lead to
her 3-year-old child becoming ill and possibly die. This has been going on for more than a year.
She reports rituals for disinfecting surfaces, utensils and crockery as well as washing her hands.
She verbalizes that she knows this is “over the top” and the rituals help temporarily to calm her
but the thoughts of items with germs on them returns nevertheless.
Diagnostic and Statistical Manual of Mental Disorders
Characteristics of generalized anxiety disorder (GAD) include persistent and/or excessive
worry about various domains the individual finds difficult to control such as work, environment
and health that have persisted for more than 6 months and are linked with real-life concerns such
as her child becoming ill and dying. Patients with specific phobias are anxious or fearful about
certain situations and may adopt avoidance behaviors. A differential diagnosis for this patient
includes obsessive-compulsive disorder (OCD) wherein the obsession is a recurrent thought
about the germs in her house affecting her child and the compulsion is her cleaning rituals that
she has adopted. In this case the patient is fearful about her natural environment, has avoided
rooms in her house and has extensive cleaning methods. She admits to her inability to control the
worry about germs and that this has been going on for more than 1 year. Her worry is associated
with her difficulty concentrating, feeling restless by the thought of germs and needing to clean
and then she is fatigued by her extensive rituals. She presents for evaluation as she admits to
difficulty controlling her thoughts. Her verbalization that her behavior is disproportionate to the
actual threat indicates that she has good to fair insight in regards to her OCD (American
Psychiatric Association [APA], 2022).
Pharmacological Treatment
The medical decision making included treating the patient for OCD as her primary diagnosis
and consider GAD as her secondary pending the outcome of initial medication treatment. OCD
first-line pharmacological treatment options include selective serotonin reuptake inhibitors
(SSRI). Within this grouping of medications fluoxetine, a SSRI, may be a good fit for this patient
with OCD, as it has good tolerability. Important for this patient is a discussion of typical side
effects of nausea, diarrhea and headache as it may be misconstrued for illness and perpetuate the
patient’s anxieties. For this reason, after a discussion of the side effects, it may be beneficial to
initiate therapy with fluoxetine 10mg for the 2 weeks to minimize potential side effects and
titrate to 20mg in the coming weeks. Fluoxetine has a half-life of 4 to 6 days and is metabolized
through the CYP2C19 and 2D6 pathway in the liver extensively and excreted in urine (Carlat
and Punzantian, 2022). The recommended dosing for OCD in adults is 20 to 60mg by mouth
daily. Consider monitoring with electrocardiogram if patient is at increased risk for QT
prolongation. Fluoxetine is considered low risk for fetal harm however neonatal withdrawal
syndrome is possible. There is also a low risk for infant harm while breastfeeding (Epocrates,
2024). While the patient in her current state may not deem this an important concept, as the
prescriber being aware of the potential for pregnancy should be included in the medical decision-
making process so that when remission is achieved and a return to function occurs, there are no
surprises.
 Non-Pharmacological
Assessment and education in regards to treatment options for OCD will help direct care and
assist in shared decision making with the patient on how to proceed. Information about resources
such as support groups either in the community or on the internet, literature describing evidenced
based self-help techniques are all possible adjunct treatment options the patient can pursue. This
patient may benefit from a "Worry Journal" to assist in helping her identify aggravating and
alleviating factors as well as document the frequency of episodes. This tool can serve as a visual
reminder to the patient of documented success of therapy or to alert if therapy is failing (Heggie
et al., 2018).
Treatment Appropriateness
As the management of treatment is considered long-term for patients with OCD and GAD due
to the high relapse rate when medication is discontinued, medication cost is a factor to consider
(Magellan). GoodRx details that in her geographical area of treatment, Walmart offers a standard
flat rate of $4 for 30-day supply of fluoxetine regardless of strength with no coupon needed. The
cost for 90-day supply is $10 (GoodRx, 2024). Fortunately, the internet and communities offer a
variety of no cost options for managing mental health. Patient encouragement to participate in a
variety of resources, when she is able, to find the ones that resonate with her for adjunct
management of her OCD and possible GAD is important as a multi-pronged approach has
proven more successful than monotherapy (Heggie et al., 2018).
Conclusion
The patient is encouraged to follow up with her primary care for an evaluation to rule out
alternative differential diagnoses that can contribute to anxiety such as thyroid or adrenal
disorders. A deeper dive into the patient’s past medical, social and family history can also guide
treatment and possibly foreshadow success of various different treatments. Offering good
psychospiritual support for the patient as well as for her child should be part of the plan of care
as well.

References
American Psychiatric Association. (2022). Anxiety Disorders and Obsessive-Compulsive and
Related Disorders. In Diagnostic and statistical manual of mental disorders (5th ed., text rev.).
https://doi.org/10.1176/appi.books.9780890425787Links to an external site.

Carlat, D., & Puzantian, T. (2022). Medication fact book for psychiatric practice (6th ed.).
Carlat Publishing.

Epocrates. (2024). Fluoxetine in Epocrates medical references (Version 24.1.0) [Mobile app].
Apple store. https://www.epocrates.comLinks to an external site.
Good Rx. (2024). Fluoxetine. Retrieved January 30, 2024, from https://www.goodrx.comLinks
to an external site.

Heggie, D., Henschen, G. M., Parrott, L. A., & Shorter, M. (2018). Magellan’s clinical practice
guideline for the assessment and treatment of generalized anxiety disorder in adults. Magellan
Providers. https://www.magellanprovider.com/media/11748/gad.pdf