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Feeling anxious, constant fear. Diagonised with obsessive-compulsive disorder and Hypoglycemia. Treatment?

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Practicing since : 2003
Answered : 2189 Questions
Here is a another situation....
XXXXXXX is a 32-year-old, married, Caucasian male who comes from a family with political connections and moderate wealth. The family money has been spent on various things, some frivolous and some not. He and his wife have two sons in elementary school. XXXXXXX has been in and out of psychotherapy since he was about 18 years old. He graduated from a prestigious university with a degree in math and physics, but he has not been able to use his education for more than a short time in a variety of jobs. His wife teaches school. XXXXXXX has come to see a psychologist for his problems.

During the interview, XXXXXXX seems to exhibit some shame about himself. He says he is a house husband because his psychopathology precludes success in gainful employment. He reports a number of symptoms, including feeling very anxious if he steps on gum that someone has thrown on the ground, if he has something sticky on his hands, and if he must handle cigarettes or something with a cigarette logo on it. His children are unable to invite other kids to the house because XXXXXXX becomes too uncomfortable. XXXXXXX cannot stand touching or being around school books or library books. He has been unable to use self-service gas pumps because of the anxiety he feels. If he leaves the house, before he can reenter, he must undress and then wash the clothes he wore while outside of the house. Much of the time he keeps the blinds closed and the house dark.
XXXXXXX recounts a very distressing moment when he looked out his kitchen window and saw a neighbor child's toy next to his driveway. He stated that he was naked in his kitchen when he observed this, and that he felt "dirty" and very upset and needed to wash all his clothes.
XXXXXXX reports that he has a constant fear that his wife is going to leave him, although there is no indication that she will do so. He feels guilty about not being able to allow his children to have friends over. He realizes that his fears make no sense, but he cannot seem to stop reacting to them. XXXXXXX says that he has started to use certain specific mantra-like prayers to help him, but finds that the more he prays the more he needs to pray. The psychologist asks if XXXXXXX has ever used drugs or alcohol to help control his fears, but XXXXXXX says no. There is a long family history of such anxious behavior, XXXXXXX says. His mother used to wash her hands 30 or 40 times a day during his childhood, though that behavior has slowed in recent years.

Is the Axis Correct?

Axis I:     300.3 (obsessive-compulsive disorder)
Axis II:     301.4 (Obsessive-Compulsive Personality Disorder)
AXIS III:      None
AXIS IV:      genetic
Axis V:      55

How do you think that Hypoglycemia would likely to impact or interact with Marvin’s described anxiety symptoms?

How would you sort out or understand the differential impacts of the two conditions obsessive-compulsive disorder and Hypoglycemia? Wouldn’t it be genetics?

Would you still make a diagnosis of obsessive-compulsive disorder on Axis I if you found that XXXXXXX also suffered from Hypoglycemia? I would still make the same diagnosis…what are your thoughts?

Posted Fri, 9 Nov 2012 in Mental Health
Answered by Dr. Jonas Sundarakumar 13 hours later

Your Axis I diagnosis is spot-on.

Obsessions: contamination, pathological doubts
Compulsions: washing / cleaning, ritualistic prayers

- with good insight
- causing significant distress
- resulting in significant socio-occupational dysfunction

- So, XXXXXXX clearly qualifies for the diagnosis of an due to his symptoms)

Now, as far as Axis II is concerned, there's really not much information to substantiate that XXXXXXX had long standing obsessive compulsive traits, to qualify for a OCPD. The history provided dates back to only 'since he was 18 years old'. (...whereas we know that personality traits are usually already evident by the time a person reaches that age). It is true that a small percentage of people diagnosed with OCD have displayed obsessive compulsive personality traits earlier on. But this is a only a small percentage and in fact, a majority do not have not had any OC personality traits before. So, though a comorbid OCPD can be present along with a diagnosis of OCD, in Marvin's case, I feel that there is not sufficient evidence to make this Axis II diagnosis. If there was a history such as "Marvin had always been a perfectionist right from childhood and his friends at school would often find him rigid and inflexible in his ways.. XXXXXXX then that gives us more evidence for an OCPD.

Axis IV includes Psycho-social and Environmental problems. So, "genetic" would not be appropriate there. So, maybe, 'unemployment' or 'marital discord' (needs further exploration) could be the possible Axis IV diagnosis.

Axis V - GAF of around 55 is a good estimate (moderate dysfunction)

Hypoglycemia has indeed been associated with anxiety symptoms. Remember, in my previous answer, it was one of the medical causes of anxiety. So, in Marvin's case, hypoglycemia is likely to worsen his anxiety symptoms and sometimes it could cause him difficulty in differentiating between the anxiety due to hypoglycemia and that due to the OCD.

However, there is no direct co-relation between OCD and hypoglycemia. If found together, they are just simply co-morbid conditions. There is also no genetic link between the two.

So, yes, I would definitely make a diagnosis of OCD in Axis I, even if the patient suffers from hypoglycemia. The justification is that OCD is not the direct consequence of hypoglycemia and so has to be diagnosed separately. In the multi-axial system, hypoglycemia would come under Axis III.

Best regards,
- Dr. Jonas Sundarakumar
Consultant Psychiatrist
Above answer was peer-reviewed by
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