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History

A 37-year-old pharmacy assistant attends the GP surgery with a skin rash on his forearms and his palms. He seems rather reluctant to talk much and is visibly tense. When asked about allergies he says that he may have soap allergy. On direct questioning about symptoms of anxiety he acknowledges feeling anxious. He says that he worries a lot at work, specifically whether he has accidentally packed the wrong medicines. He works in a supermarket pharmacy and has to regularly check if he has dispensed the correct medicine in the correct dose. There are times when he has checked as often as 10 times before handing the medicines over to the customer. When really anxious he experiences palpitations, sweating and butterflies in his stomach. He feels better in himself after ‘checking it all out’, but the worry and fear that he has made a mistake returns a few hours later in relation to another customer. This makes him very slow at work and he has received two warnings from his boss. He frequently worries about handing the wrong medicines to his customers and in the past week has called his boss at home to check this. He admits that he washes his hands at least three times an hour when at work but often more so at home where he uses undiluted washing up liquid to ‘make sure they are really clean’. He started doing this two years ago when he was worried that he may have picked up an infection visiting a friend in hospital. He continues to worry about the risk of passing infection to his clients and ‘does not want to take any chances’. He admits it is bizarre that he has such irrational thoughts, but says he cannot help worrying about it. He has tried various strategies such as watching TV or listening to music to try and stop these thoughts, but has had no success. Increasingly he has become concerned about spreading infections and has spent thousands of pounds on pest control at home. Things have worsened over the past few weeks at work and he is very ‘depressed’ at the prospect of losing his job.

He does not have any previous medical or psychiatric history of note. He is not taking any medication. He lives with his wife. They do not have any children. His parents and his sister live locally. There is no family history of mental illness. He does not drink or smoke and has never tried any drugs.

Examination

Physical examination reveals excoriations with a red scaly rash on palms and forearms. There is no other finding of note on physical examination apart from mild tachycardia. He is anxious but does not have any thought disorder. He is preoccupied with repetitive

ANSWER 8

This man is presenting with a skin rash suggestive of contact dermatitis. However, it is important to ask screening questions to rule out an anxiety disorder. He exhibits a range of anxiety symptoms – both psychological (worry, fretting) and physical (palpitations, sweating) indicating an anxiety disorder. The focus of anxiety is the repetitive, intrusive thoughts of the fear of spreading infection. These are his own thoughts and he feels compelled to push them out of his mind and resist them. These are the features of

obsessions. The most common obsessions are about contamination or involve

pathological doubt. Occasionally, the ruminations may be in the form of impulses or vivid images rather than thoughts, usually with some disturbing content such as violence or unacceptable sexual practice.

His anxiety is relieved by hand washing which is an obsessional ritual or compulsion aimed at relieving tension or anxiety in this case by neutralizing the ruminations (an obsession of contamination in this case). Rituals of checking and cleaning are most common but compulsions for symmetry, hoarding and counting are also seen where they relieve tension by preventing obsessions (worry about things not being ‘right’ or something bad happening).

In the differential diagnosis other anxiety disorders should be considered. These include generalized anxiety disorder where the anxiety is constant and there is no focus to the anxiety symptoms, while in phobias, anxiety is triggered by the phobic situation (for example, skyscrapers in fear of heights). In post-traumatic stress disorder (PTSD) the focus of anxiety is the past trauma while in obsessive-compulsive disorder (OCD) the obsessions generate anxiety relieved temporarily by compulsions. Depression is commonly seen alongside OCD and other anxiety disorders. It is important to ask screening questions about depression including low mood, reduced energy and lack of interest in every case of anxiety disorder. Psychotic disorder can lead to ruminations and rituals. This man says his thoughts are ‘bizarre’ and that he is getting ‘paranoid’ which may arouse the suspicion of a psychotic disorder. In OCD, the thoughts are always recognized as ‘own’ thoughts (i.e. not hallucinatory) and are recognized as being irrational (i.e. not delusional).

Management of choice in OCD is cognitive behaviour therapy. This involves behaviour strategies such as exposure to the trigger (for example, filling the medication box) and response prevention (preventing or limiting checking). This is supported by challenge to attributions using Socratic questioning* and exploration of beliefs aided by relaxation techniques. The ‘flooding’ technique involves subjecting the patient to intense exposure of the anxiety-provoking stimuli until the severity of the fearful emotion subsides. This is not so commonly used in modern practice. Serotonin reuptake inhibitors such as clomipramine and fluoxetine have also been found useful for OCD in conjunction with CBT or behaviour therapy. Reassurance and support to patient and carers is important.

*Padesky CA (1993) Socratic questioning: changing minds or guiding discovery? Keynote address

delivered to the European Congress of Behavioural and Cognitive Therapies. London, 24 Sept 1993.

• Obsessions are one’s own thoughts, repetitive, intrusive and unpleasant.

• Compulsions are used to neutralize or prevent obsessions.

• Exposure and response prevention are key treatment strategies.

KEY POINTS