What do you guys think? Need some help!

Discussion in 'Psychiatry' started by jenjas, May 1, 2004.

  1. jenjas

    jenjas REDSOXNATION
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    This is a case I have to present, could anyone tell me if I'm on the right path.

    When Robert was referred for an evaluation, he was in his mid-thirties and had a bright career ahead. He was a practicing radiologist, a few years our of a very competative medical school form which he had graduated in the top third of his class. Robert was being referred by an experienced general psychiatrist principally because of his compuslive symptoms. These were increasingly interfering with his practice and social life.

    Robert's compulsions emerged almost 2 years before the initial consultation, just after the death of a close relative. This relative had informally consulted with him a few months prior to her death. SHe had complained of persistent GI distress and abdominal discomfort. To this description Robert added: "It was unusual for her to voice any complaints.....she was relatively young and had always been in good health...I took her symptoms very seriously." Robert had examined her and ordered some laboratory and X-ray's at his office. When all tests were negative, he had reassured his relative and prescribed symptomatic treatment. her symptoms continued, and within a few weeks she was losing weight, looking as if she had aged several years, and was unalbe to keep food down. A reevaluation revealed an inoperable malignancy. The course of her illness was rapid; within a month she was dead.

    After her death Robert reviewed her original x-rays. He carefully noted the position of her G.I organs and said to himself, "Perhaps if I had looked at this area more meticulously...indeed there is a suggesiton of an anatomical distortion...she could be alive today." As this doubt emerged, Robert began to doubt all of his judgements.

    During the interview Robert monotonously described how painful it was now to read a normal chest x-ray: "I have interpreted thousands of them before..now I can't finish one...I will read the x-ray the usual way and recognize that is is normal....then I ask myself how I know that it is normal....does the mediastinum seem normal....are the costophrenic angles as sharp as they should be....are there any hairline fractures....is that the right nipple of a soft tissue mass? I can't read one x-ray. My partners know there is something wrong.....I ask them to let me do all of the other procedures.

    Robert's symptoms had affected his family and marital life as well. During the past few months his depression had intenified. It was now a chore to escort his wife to a restaurant or to a gathering with his colleagues. They had enjoyed a strong and positive relationship, but now they were drifting apart. His wife knew about his worries, and like everyone in his family, she thought that his concerns were nonsense and that the death was inevitable. yet, he felt severe guilt.

    As the interview progressed, it was difficult to be certain about Robert's diagnosis. Over the last few months intensive psychotherapy and pharmacotherapy, which was focused principally on the depression, had been of little help.

    sorry that was long, but when I read this I thought that because of the stressor (the death of his relative, which now blames himself), has made him obsessive-compulsive.....he can't get anything done because he spends so much time reading them....like he is afraid he will miss something again. What do you guys think....is there an underlying depression.....do you treat with Chlomipramine or SSRI's, what is your oppinion, am I way off?
     
  2. mdblue

    mdblue Senior Member
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    CBT+SSRI trial.
    Depression is a common co-morbidity of OCD. However having obsessional thoughts only is not diagnostic of OCD (most docs are to certain extent anal :) . It might be an adjustment d/o-I presume he is not having significant vegetative s/sx, so I guess the prognosis is excellent. However his spouse and the family/colleagues need to be aware of the fact that this is not a " sign of weakness" and provide whatever suppport he needs.
    Hope this helps
     
  3. sdude

    sdude Member
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    I would also consider psychodynamic therapy, since I think your pt needs to work through some of these mourning/guilt issues. Ideally he should have a therapist who is good at both psychodymanic and CBT, and can utilize the methods of each depending on the pt.

    Since you are dealing with a very high level pt., I would suggest Parnate over an SSRI, and titrate the dose as quickly as you and he feel comfortable (remember dosages above 30mg are usually necessary, and going up to 100 mg/day is not that uncommon). Parnate has the advantage of being both stimulating and--for unknown reasons--much faster acting than other AD's. He may get relief within days. Obviously, this would be better for a professional than possibly waiting 5 weeks for an SSRI to kick in--assuming it even worked.
     

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