(BMJ)—A 38-yo woman presented w/ intense feelings of contamination on her body and fears that this is spreading and killing other people or animals. To neutralize it, she applied NaOH . PMHx: 39 ED visits in 8mo ; ICU admission for OD. She said she didn’t want to die but felt being dead was safer than spreading contamination. Skin: blistering red lesions. What is the dx?
Borderline personality disorder
Factitious disorder
Obsessive-compulsive disorder
You are correct. The pt had self-inflicted chemical burns of various ages, caused by obsessive-compulsive disorder (OCD), which is characterized by intensely frightening intrusive thoughts about danger or personal responsibility, plus compulsions that aim to prevent harm and distress. Her decontamination compulsions had escalated from soap to bleach to corrosives, causing permanent disability. Although clinicians may sometimes misidentify severe obsessions as ‘voices,’ compulsive decontamination is not characteristic of schizophrenia. Dx of personality d/o or factitious d/o must only follow specialist assessment; it is not appropriate to diagnose based on ED assessments alone, and there was no intentional feigning. OCD is very treatable. Following explanation and tx w/ high-dose sertraline + aripiprazole, the pt has stopped compulsive burning, not returned to ED in a year, and has been referred for CBT.

Emergency Medicine Journal 2020;37:331-344.