Clinical Challenge

CASE HISTORY Mr. R was a 19-year-old, single, unemployed, homeless Hispanic male with a history of Tourette’s syndrome (TS), obsessivecompulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), and posttraumatic stress disorder. In addition, he suffered from suicidal ideation, self-injurious behavior (superficial cutting and head banging), anxiety, depression, and anger outbursts. Hewas referred to our cognitivebehavioral therapy (CBT) partial hospitalization program (PHP) and associated homeless shelter for the targeted treatment of his OCD, TS, and anger outbursts after being discharged from a psychiatric hospital. At the time of presentation,Mr. R had recently aged out of a long-term adolescent state hospitalization program. Since that time, he has had a short stay in a crisis stabilization unit and a lengthier admission to a psychiatric hospital for poor impulse control and anger outbursts. At the crisis stabilization unit, he became “stuck” after the lights unexpectedly turned off in the bathroom, which led to uncontrollable tics, exacerbation of OCD symptoms, screaming that lasted three hours, and, finally, an angry outburst and acute hospitalization. After discharge, his outbursts were so severe that his mother did not feel safe with him at home. He was admitted