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Presentation Hi, my name is DG, and today, I will be presenting a complex case study on a patient that I saw at my clinical site. Here is my ID. The objective of this presentation is: M.P., a 35-year-old Caucasian male, reports severe anxiety and depression characterized by sadness, lack of interest, concentration issues, and restlessness since 2009. He has superstitions about turning dials, avoiding the number 6 and dark floor tiles. Although he has occasional, fluctuating homicidal thoughts triggered by a past movie, he currently has no intent or plan to act on them. His symptoms significantly affect his work and social relationships. He denies suicidal thoughts and sleeps around 5 hours per night, with no recent changes in appetite or weight, and no racing thoughts or psychotic symptoms. Previously diagnosed with obsessive-compulsive disorder (OCD) by his psychiatrist. M.P. has tried various medications, including gabapentin (discontinued due to increased heart rate), buspirone, and Lexapro, found them ineffective, and stopped Seroquel after an unintentional overdose and was hospitalized for a week. He stopped therapy due to a lack of connection with the therapist. M.P. has a history of childhood sexual trauma at age 4 but lacks clear memories or disclosures about the event. He is an ex-smoker and quit drinking and using cannabis four years ago, denying any current substance use. His mother dealt with depression and anxiety, leading to suicidal attempts and hospitalizations, and his sister also struggles with similar issues. Recent tests, including an echocardiogram and EKG, were normal, but M.P. was started on Metoprolol for an increased heart rate. He has no known allergies (NKA). His current medications are: – Venlafaxine 150 mg twice daily – Mirtazapine 30 mg at bedtime – Metoprolol 50 mg daily at lunchtime – Clonazepam 1 mg as needed. He is single, lives with a roommate, and works as an electrician. He has few friends but does not socialize with them. He denies any current sexual activity or legal issues. He reports fatigue, mood swings, heart racing during anxiety, and difficulty concentrating when anxious. Diagnostic tools indicate moderate OCD symptoms (Y-BOCS score of 23), severe anxiety (DASS-21 score of 26), and moderately severe depression (PHQ-9 score of 15), with normal thyroid function. The patient is alert, well-groomed, and maintains fair eye contact. Their speech is normal in pace but includes increased pauses. The mood is anxious, with a restless and irritable affect. Thought processes are goal-directed and organized. While the patient denies suicidal ideation, they acknowledge homicidal thoughts without intent or plan. There are no psychotic features, and memory, concentration, and attention are intact. Judgment and insight are fair. Primary Diagnosis: Obsessive-Compulsive Disorder, Unspecified (ICD-10: F42.9) The DSM-5 criteria for Obsessive-Compulsive Disorder (OCD) include the presence of obsessions, compulsions, or both, which cause significant distress or impair functioning. The patient’s superstitions—such as turning dials and avoiding certain numbers and dark tiles—reflect compulsive behaviors. A Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) score of 23 further indicates OCD. For Major Depressive Disorder (MDD), recurrent and moderate (ICD-10: F33.1), the DSM-5 states that the condition is marked by a persistently depressed mood or loss of interest, along with symptoms like sleep disturbances and fatigue. The patient exhibits these symptoms, with a PHQ-9 score of 15 indicating moderately severe depression, further confirmed by the reports of fatigue and distress affecting daily activities. Generalized Anxiety Disorder (GAD) is marked by excessive anxiety and worry occurring more days than not for at least six months and is should be absence of other disorders like panic or ocd. The patient has a long-standing history of anxiety, supported by high DASS-21 scores, with symptoms affecting work and social life. While some symptoms overlap with obsessive-compulsive disorder (OCD), the patient’s anxiety extends beyond obsessions and compulsions, indicating primarily GAD traits, which complicates the diagnosis. For Post-Traumatic Stress Disorder (PTSD), as defined by the DSM-5, the condition involves re-experiencing traumatic events, avoidance, negative mood changes, and hyperarousal following trauma. Although the patient has a history of childhood trauma and reports intrusive thoughts, he does not meet the full PTSD criteria due to a lack of active re-experiencing or clear trauma recollections. If I could conduct the session again, I would administer additional psychometric tests, such as the Beck Anxiety Inventory (BAI) and the PTSD Checklist (PCL-5), to better understand the patient’s anxiety and potential PTSD symptoms. Exploring family dynamics and support is important due to their history of mental health issues. Monitoring the patient’s response to medication and therapy will be crucial in future follow-ups. If a follow-up isn’t possible, I would collaborate with community resources and support networks to ensure ongoing care and address any financial barriers, while remaining vigilant for escalating risk factors. To manage M.P.’s mental health concerns, the focus should be on integrating Cognitive Behavioral Therapy (CBT) with exposure and response prevention to address OCD and anxiety. Educating the patient about lifestyle modifications—such as exercise, meditation, and reducing caffeine—may help alleviate symptoms. Incorporating mindfulness-based stress reduction techniques can also enhance emotional regulation and reduce anxiety. From a medication standpoint, gradually taper off venlafaxine and consider switching to sertraline at 25mg, increasing as needed for OCD. Since mirtazapine is not effective for sleep, trazodone 25mg may be used off-label for insomnia, at bedtime. Augmenting treatment with atypical antipsychotics like aripiprazole can address intrusive thoughts. For mood stabilization, add lamotrigine only if symptoms are not managed better. Clonazepam may be used short-term for acute anxiety symptoms. The patient reports fleeting homicidal thoughts while immediate hospitalization may not be necessary, close outpatient monitoring and collaboration with a therapist and primary care provider are essential, with reassessment for inpatient care if dangerous ideations occur. Non-pharmacological management includes regular exercise and good sleep hygiene, while alternative therapies, such as yoga or acupuncture, may help promote relaxation. Follow-up appointments should be weekly to monitor symptoms and medication side effects. A social determinant of health that impacts mental health status is limited social support, along with restricted social relationships with friends and the current living situation with a roommate. A history of trauma impacts M.P.’s mental health, so a referral to a trauma-focused therapist and consideration of social support groups such as groups for mental well-being or shared experiences would be beneficial. Resources like the International OCD Foundation (IOCDF) and the National Alliance on Mental Illness (NAMI) can also offer valuable support. Question to peers: How can healthcare providers overcome barriers related to treatment adherence and accessibility? Discuss the role of alternative therapies, support groups, or community resources in enhancing support and efficacy. Considering the patient’s endorsement of homicidal thoughts, what safety concerns should be addressed during treatment planning, and what steps can be taken to ensure both patient and public safety? Response to my presentation by Sylvia Thank you for your great presentation and for sharing important discussion questions from your presentation. I looked into the questions you raised, and based on the relevant literature, here is what I found regarding safety concerns, alternative therapies, and overcoming treatment barriers in patients with homicidal thoughts. Considering the patient’s endorsement of homicidal thoughts, what safety concerns should be addressed during treatment planning, and what steps can be taken to ensure both patient and public safety? When a patient endorses homicidal thoughts, it is crucial to assess intent, plan, and risk factors using tools like the Columbia-Suicide Severity Rating Scale (C-SSRS). While M.P. denies intent, structured safety planning is essential, including frequent monitoring, crisis intervention, and access to emergency resources. Pharmacologic management, such as SSRIs, atypical antipsychotics, or mood stabilizers, may help reduce intrusive thoughts and impulsivity (Rowa et al., 2025). Therapy approaches like Cognitive Behavioral Therapy (CBT) and Exposure and Response Prevention (ERP) can further aid in managing distressing obsessions. If risk escalates, involuntary hospitalization may be necessary. Engaging M.P. in psychoeducation, family support, and collaborative care can help mitigate risks while improving treatment adherence. Discuss the role of alternative therapies, support groups, or community resources in enhancing support and efficacy. Complementary therapies, support groups, and community resources play a critical role in enhancing treatment outcomes for M.P. Mindfulness-Based Cognitive Therapy (MBCT) and Dialectical Behavior Therapy (DBT) help reduce emotional dysregulation and obsessive thoughts (Schaefer et al., 2023). Support groups like the International OCD Foundation (IOCDF) and National Alliance on Mental Illness (NAMI) provide peer support, coping strategies, and a sense of belonging. Community mental health centers offer affordable therapy, crisis intervention, and case management services, which are vital for patients with financial barriers. Holistic interventions, including yoga, exercise, and guided meditation, have been shown to promote emotional resilience and symptom reduction. Integrating these approaches alongside traditional treatment can optimize recovery and quality of life. How can healthcare providers overcome barriers related to treatment adherence and accessibility? Treatment adherence and accessibility barriers can be addressed through shared decision-making, digital health solutions, and financial assistance programs. Telepsychiatry and mobile mental health apps provide remote access to therapy and medication management, reducing barriers related to location and stigma (Rosenbaum et al., 2021). Motivational interviewing and psychoeducation can improve M.P.’s engagement by emphasizing the importance of consistent treatment. Simplifying medication regimens, providing financial aid for medications, and offering flexible therapy schedules further enhance accessibility. Encouraging culturally sensitive care ensures treatment aligns with M.P.’s values, improving trust and long-term adherence. Collaboration with community resources and peer support networks can reinforce treatment commitment and reduce dropout rates. Provide response to Sylvia either agree or disagree

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