I do not believe the authors of “Afraid to leave home,” (Cases That Test Your Skills, Current Psychiatry, June 2009) adequately defended their rationale for dismissing a diagnosis of obsessive-compulsive disorder (OCD) and did not consider posttraumatic stress disorder (PTSD) for Mr. B, the patient described in the article. DSM-IV clearly states that the person exhibits either obsessions or compulsions; both are not needed for a diagnosis. The patient was described as having “intense fear of bridges, upper-floor windows, express buses, subways, [and] riding in speeding vehicles,” which leads him to have intrusive, ego-dystonic thoughts that are ruminative; and he “avoids these triggers at all costs.” Clinically these sound like obsessions, which would qualify for OCD if he met other criteria, which—based on the case—he did. Furthermore, Mr. B was actively avoiding multiple situations when he felt he might harm himself. Avoidance is a common, often overlooked component of OCD that can reduce anxiety.
It would have been more helpful if Drs. Klein and Myers had described why they felt the patient did not have OCD or PTSD. It seems Mr. B would—if willing and not psychotic—have been a good candidate for exposure response prevention therapy. With such an anxious patient, this therapy could have been started as a home-based program. In addition I feel the authors did not consider the PTSD diagnosis stemming from the fear of relapse of his psychosis, which added to the clinical picture.
Megan Toufexis, DO
Child and adolescent psychiatry fellow
University of South Florida
Tampa, FL
Dr. Klein responds
OCD was the primary working diagnosis for quite some time because the thoughts did have the quality of being intrusive, ego-dystonic, and inappropriate. Furthermore, some reports associate clozapine treatment with the emergence or exacerbation of OCD symptoms.1-3 However, OCD was ruled out after we established a strong therapeutic alliance and discovered that the thoughts did not distress him. Instead, it was the inherent fear of losing control and having no escape. The fear appeared first, and the situations in which he experienced that fear were subconsciously created because they explained the emergence of the feeling.
On a different note, Mr. B’s obsessions did not appear if he successfully avoided the situation and—most importantly—he did not find them entirely unreasonable. Mr. B felt his fear was well justified because it protected him from public humiliation or self-harm.
Regarding the PTSD diagnosis, although I would agree that Mr. B had a traumatic recollection of his illness presentation and course, he did not re-experience the events, he did not avoid the situations associated with it, and his hyper vigilance could be better explained by residual paranoia of his main disease process, which is schizophrenia, chronic paranoid type.
Carolina A. Klein, MD
Clinical assistant instructor
SUNY Downstate Medical Center
Brooklyn, NY