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Clinical Crossroads |

A 45-Year-Old Woman With Obsessive-Compulsive Disorder

Michael A. Jenike, MD, Discussant
JAMA. 2001;285(16):2121-2128. doi:10.1001/jama.285.16.2121.
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DR PARKER: Mrs T is a 45-year-old woman who has obsessive-compulsive disorder (OCD). Though currently disabled secondary to her OCD, she decided to discontinue all psychiatric medications because of adverse effects. She is married with a healthy teenaged daughter. Her commercial insurance has completely covered her extensive outpatient and inpatient therapies.

Although Mrs T did not know it then, in retrospect, she sees clues of OCD in her childhood behaviors. She recalls spending hours at the age of 5 years counting the sides of squares on her bedroom wallpaper. When she was 9 years old, her house was robbed, triggering rituals such as checking under the beds and inspecting closets around the house. Mrs T recalled that these actions seemed to reassure her that no one in her family would get hurt. A few years later, graphic antismoking commercials increased her anxiety that her father, a smoker, would die of lung cancer. While watching television with others present, she would do counting rituals in her head, so others would not know she was doing it. She felt a need to "control things."

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Figure. Brain Images in Obsessive-Compulsive Disorder
Graphic Jump Location
Statistical parametric maps reflecting composite results from a provoked obsessional stimulus (eg, contaminated towel on left hand) minus control stimulus (eg, clean towel on left hand) across the group of patients studied. The positron-emission tomography changes with provocation are superimposed on structural magnetic resonance images for anatomic reference. These are 4 horizontal slices from different brain levels. These activated areas may represent a circuit that is activated when patients with obsessive-compulsive disorder obsess. All images are transverse sections parallel to the anterior commissure-posterior commissure plane, shown in conventional neuroimaging orientation (top = anterior, right = left). Each transverse section is labeled with its z coordinate, denoting its position (mm = millimeters) with respect to the anterior commissure-posterior commissure line. From Rauch et al.13



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