The Impact of Psychosocial Stressors on Treatment of a Teenage Girl with Obsessive Compulsive Disorder, Trichotillomania, and Anxiety.

Address correspondence to: Barbara J. Coffey, MD, MS, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1230, New York, New York 10029, E-mail: Barbara.coffey@mssm.eduChief Complaint and Presenting ProblemA. is a 16 year old adolescent girl referred for consultation regarding treatment of her obsessive-compulsive disorder (OCD), hair pulling, and anxiety.History of Present IllnessParents reported that A. was a competent and vivacious girl who had generally done well in school and with friends. In this context, parents reported that she had been having difficulty, characterized by increased anxiety, rituals, and hair pulling symptoms in recent months prior to referral.A number of events had happened in the preceding years that seemed to impact A. After her parents' divorce when she was 13, she and mother moved several times. Additionally, A. had developed conflicts with her father who began to show signs of alcohol abuse. On 200 mg sertraline for several months before the referral, A. had nevertheless developed an exacerbation of multiple rituals and compulsions, irritable mood, and panic attacks. Two months before the referral, A. was switched from sertraline to fluoxetine, a medication that had been effective for her father. As her anxiety symptoms had intensified during the transition, clonazepam was added. Sixty mg of fluoxetine reduced her anxiety symptoms, but did not impact her OCD symptoms. Fluoxetine was increased to 80 mg by a new psychiatrist with whom she had started one month before referral; it was subsequently reduced to 60 mg, as A. became more anxious, experienced a reduction in appetite, and lost 4.5 kg on the higher dose. A. reported that she had also attended a number of therapy sessions with her father with little benefit. The family decided to seek a second opinion because A.'s symptoms were not well controlled.In review of history, parents reported that A. first showed signs of OCD at age nine years. She had developed a fear of vomiting, which was thought to be due to undiagnosed acid reflux. Eventually, the thought of vomiting made her anxious, and she developed a fear of getting sick from contamination. She then began to have intrusive, violent thoughts. She began to obsess about "what if I tried to kill my mother or father?" A. did not actually try to harm anyone. However, her intrusive thoughts increased her anxiety, and she developed a need for excessive reassurance.A. subsequently developed a number of other OCD symptoms, such as counting to a certain number for certain activities, or having to do an action a certain number of times. She believed her rituals would help prevent the thoughts of killing someone she loved and reduce her anxiety. She also described sensory driven actions in which she would have to scan the environment and repeat actions a number of times until it felt "just right." Parents and A. reported that some of her behaviors were self-injurious, such as rituals around filing her nails that involved cutting her cuticles.Parents report that A.'s hair pulling first appeared at age 12 years when she abruptly cut off parts of her eyelashes. By age 13, she had picked off all of her eyelashes and eyebrows. As a result, she was teased in school and became socially withdrawn. A. pulled hairs from her scalp and arms; she reported that she pulled her hair when she was stressed, and that pulling was relaxing. A. reported that she also picked hairs off the family dog until it developed bald spots. In the past few months, she was struggling again with hair pulling, especially after a recent move.A. described her panic symptoms as an increase in her heart rate and experiencing a fear of dying which occurred in association with her intrusive thoughts. She endorsed worrying about her mother's health. A. also experienced anxiety with schoolwork, as she had trouble focusing and retaining the material; she also pointed out that she was often restless during class, at times needing to leave the room. …