Peer Reviewed
Obsessive-Compulsive Disorder in a 62-Year-Old Male
Case Presentation
Mr. X is a 62-year-old divorced male who presented for psychiatric evaluation with concerns regarding flying in an airplane and “claustrophobia.” His worries began approximately 4 months prior to evaluation when he had a scheduled plane trip with a friend. He noted significant anxiety leading up to the flight, which he identified as a fear of losing control. He knew these thoughts were irrational but was afraid he would become anxious while in the enclosed area of the plane cabin and have no escape. As a result of his fear, Mr. X canceled the flight and his vacation.
Upon further questioning, Mr. X identified that he had intrusive thoughts about causing harm to others and that these thoughts were causing marked anxiety. He acknowledged that fear of having these intrusive thoughts while on an airplane, where escape would be impossible, was a major factor for canceling his flight. The patient characterized these thoughts as “terrifying” and repeatedly stated he would never hurt another person. He was fearful they would never go away and was not sure why they had occurred.
Mr. X reported worsening depressed mood over the previous year, with an increase in the intensity and frequency of the obsessive thoughts as a result of worsening mood. He had previously been quite social, with multiple friends and various hobbies, including exercise, but the thoughts were affecting his ability to comfortably interact with others. As a result, he was feeling increasingly isolated and lonely. The patient continued to exercise despite the thoughts, feeling that physical activity was his only sanctuary from them.
He additionally reported early morning awakening but otherwise denied neurovegetative symptoms. Psychiatric review of systems was otherwise within normal limits. Mr. X has no history of prior psychiatric treatment. He acknowledged experiencing intrusive thoughts at various times throughout his life since college, but he stated that in the past, the thoughts were more of a nuisance; they never affected his engagement in pleasurable activities or his interactions with others. He denied any legal history, and had never been violent toward others.
Mr. X has benign prostatic hypertrophy and had an appendectomy and hernia repair in the remote past. His medications were finasteride 5 mg daily and terazosin 8 mg daily for his prostate condition. He has no known drug allergies.
On mental status exam, Mr. X was a well-groomed, fit-appearing male with good eye contact and appropriate social interaction. He described his mood as “sad and worried.” He denied memory concerns, and his Mini-Mental State Examination (MMSE) score was 30/30.1 Laboratory evaluation, including complete blood count, chemistry panel, liver function tests, and thyroid-stimulating hormone, were all within normal limits.
Mr. X was diagnosed with obsessive-compulsive disorder (OCD). He was administered the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), a validated rating scale for OCD.2 His score was 14/30, indicating mild OCD; however, his degree of distress and social impairment appeared to be in the moderate range.
Mr. X was offered a selective serotonin reuptake inhibitor (SSRI) for treatment of his OCD symptoms, as well as his depressed mood. He initially declined pharmacological treatment and opted to engage in a course of cognitive behavioral therapy (CBT) for management of his OCD. He was offered twice-monthly therapy with a Psychology intern.
After 3 weeks, Mr. X was seen again by Psychiatry. He reported that his symptoms had worsened. He was starting to have intrusive thoughts while exercising and was having thoughts of harming loved ones. He was increasingly despondent and wanted relief from his symptoms. Citalopram was initiated at that time.
Discussion
OCD is classified as an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.3 It is characterized by a pervasive pattern of anxiety, both actively experienced and anticipatory, coupled with an avoidance response. Classic cases of OCD involve patients who have fears, such as contamination, and subsequently wash their hands hundreds of times a day due to their excessive worry. However, there are many patients who have intrusive, obsessive, and persistent thoughts without obvious compulsive behaviors, such as checking, counting, or hand-washing. For many of these patients, their thoughts are often their “Achilles heel”; the topics they focus on are the most disturbing thoughts they could possibly imagine. Common obsessions fall into general categories: contamination, impulses, mistakes, order, and miscellaneous. Included in the impulsive obsession type are unwanted, repugnant thoughts that represent ego-dystonic morality and values.
Individuals who have unacceptable obsessions tend to exhibit greater symptom severity than those who have contamination or order obsessions.4 Examples of repugnant obsessions include thoughts of harming innocent or helpless others (eg, kicking an elderly person, throwing a baby off a balcony), violating religious beliefs (eg, swearing in church), and improper sexual acts (eg, touching another against his/her will). In many cases, patients experiencing repugnant obsessions engage in mental rituals and compulsions, as opposed to overt behaviors, to prevent or reduce stress. Examples include repeating a phrase in their head over and over or using self-reassuring statements. They may also engage in activities to help avoid obsessive thoughts, such as exercising, sleeping, or listening to music, and may seek reassurance from others (eg, do others think they are “bad” or “violent”?). Repugnant obsessions often give rise to checking that harm has not occurred and checking to ensure that harm will not occur. By seeking reassurance, the individual is looking to obtain certainty that the obsession is not accurate.
OCD is also characterized by an exaggerated sense of responsibility and erroneous beliefs that having a thought is the same as having intention to act on the thought or wanting the thought to be true. In order to meet diagnostic criteria for OCD, the obsessions and/or compulsions must be a significant source of distress and/or interfere with functioning. Psychiatric review of systems should include evaluation for mood and anxiety symptoms, somatoform disorders, and impulse control disorders (Table).3
OCD is distinct from obsessive-compulsive personality disorder (OCPD). OCPD is evident by a pervasive preoccupation with orderliness, perfectionism, and rigidity. This interpersonal control pattern is typically established in early adulthood. Relatively few individuals meet the diagnostic criteria for both OCPD and OCD.
OCD occurs about equally in men and women. Three-quarters of patients with OCD have an age of onset by the age of 30, with less than 5% becoming symptomatic after 40 years of age. Twelve-month prevalence of OCD has been estimated to be 1%.5 Lifetime prevalence has been estimated at 2.5%.6 OCD rarely remits without appropriate treatment. Due to delay in treatment brought about by the stigma of seeking treatment or lack of recognition, it is likely to be seen in the geriatric cohort.7
Standard treatment for OCD includes a combination of CBT and pharmacotherapy. In a recent Cochrane review, 17 studies, which included 3097 patients, demonstrated that SSRIs were more effective than placebo.8 The SSRIs reduced the symptoms of OCD after 6-13 weeks of treatment using the Y-BOCS as a measure of therapeutic response. Thirteen of these studies (2697 patients) showed that those receiving SSRIs were twice as likely as those receiving placebo to have clinical response (≥ 25% reduction in symptoms). Across the studies, the SSRIs (citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) had greater incidence of adverse effects as compared to placebo. The most common adverse effects reported were nausea, headache, and insomnia.8
The pharmacological agent clomipramine, a tricyclic antidepressant with serotonergic activity, has also been studied extensively for the treatment of OCD. Two randomized control trials revealed a 38% and 44% decrease in Y-BOCS scores, respectively, as compared to 3% and 5% reductions found with placebo.9 However, clomipramine, like all tricyclic antidepressants, should be used with caution in older adults due to its anticholinergic side effects, such as urinary retention, confusion, constipation, and dry mouth. Additionally, this class of medications requires an electrocardiogram (EKG) before initiation, as they are associated with several potential adverse effects, including atrioventricular block, ventricular arrhythmia, and QT prolongation.
CBT is an evidence-based treatment frequently used in the treatment of OCD.10 This treatment consists of a combination of exposure, where the patient is exposed to the intrusive thought, coupled with response prevention, in which the individual is prevented from engaging in compulsions or neutralizing behaviors. Although this initially results in an increase in anxiety, with repeated prolonged exposure the anxiety eventually decreases, and individuals are able to confront previously feared thoughts with little or no anxiety. This therapy directly interferes with the characteristic avoidance central to the illness. It helps patients learn that the obsessions, although distressing, can be safely ignored, thus causing the obsessions to lose importance. This results in the reduction and eventual elimination of the emotional response and the need to engage in avoidant, compulsive, and dysfunctional behaviors.10
Outcome of the Case Patient
Mr. X is currently engaged in a CBT program. Initially, he was seen for 60 minutes once every 2 weeks, but his sessions were increased to weekly as treatment progressed. Information was collected on Mr. X’s pattern of obsessions and neutralizing behaviors. As described above, his obsessions were centered on themes of causing harm to another person. His neutralized behaviors were largely covert (eg, self-reassurance, repeating a prayer in his head, examining the likelihood that an obsession could actually happen) coupled with distraction. A hierarchy of obsessions ranging from least to most distressing was created; this has formed the basis for exposure therapy in subsequent sessions. Mr. X was then instructed to write out in detail the least-distressing obsession from his list for the first exposure exercise. In session, he read the script aloud repeatedly until his anxiety peaked and then subsequently decreased. Throughout the exercise, Mr. X rated his subjective level of anxiety to track progress. After reading the first obsession script with no increase in anxiety (up to hundreds of times over several sessions), he progressed to the next obsession. The eventual goal is to read the most disturbing obsession with no increase in anxiety. Pacing of these exercises is individual and will be tailored to match Mr. X’s progress.
Outside of therapy, Mr. X has been incorporating exposure into daily activities (eg, not avoiding occupied aisles at the supermarket, continuing to spend time with grandchildren), and repeating the in-session exposure exercises as homework.
Mr. X did not tolerate citalopram. Although he was prescribed citalopram 10 mg daily with a plan to increase to 20 mg daily, he misunderstood the instructions and took 20 mg daily, and then increased the dose to 40 mg daily. This rapid titration caused significant anxiety and sleep disturbances. Citalopram was decreased to 10 mg, and he was given zolpidem 10 mg nightly as needed for his sleep disturbances. He reported continued anxiety and worsening intrusive thoughts. The citalopram and zolpidem were discontinued, and he was prescribed clonazepam 0.5 mg twice daily for management of his anxiety and sleep disturbances. One week later, he was started on sertraline 12.5 mg daily, which had the same adverse effects as citalopram. Sertraline was discontinued, and he was started on clomipramine 25 mg nightly. An EKG was performed before initiation, which was normal. He did not tolerate clomipramine due to its sedating properties and the fact that he felt “drugged” on this medication. He had opted to continue CBT at that point, and should he require further pharmacological treatment, another trial of an SSRI such as paroxetine will be considered.
Mr. X continues to experience obsessions; however, he reports an improvement in his ability to control his anxiety overall and believes treatment is having a positive effect. He continues on clonazepam 0.5 mg twice daily as needed (which he uses intermittently), with overall improved sleep and anxiety. He has been very successful at incorporating in vivo exposure into his everyday life, and has progressed through several different scripts addressing the content of his obsessions. Recently, he unexpectedly was invited on a family trip across the country and, despite still dealing with obsessions surrounding his behavior on a plane, Mr. X has chosen to take the trip. He expresses hope that this step, coupled with continued therapy, will lead to substantial relief from his symptoms in the months to come.
The authors report no relevant financial relationships.
Dr. Conroy is Assistant Clinical Professor of Psychiatry, Yale University School of Medicine, VA Medical Center, West Haven, CT; Dr. Barber is a Postdoctoral Fellow in Clinical Health Psychology, VA Connecticut Healthcare System, West Haven, CT; and Ms. Clark is a practicum student at VA Medical Center, West Haven, CT. Dr. Lantz is Chief of Geriatric Psychiatry, Beth Israel Medical Center, First Ave @ 16th Street #6K40, New York, NY 10003; (212) 420-2457; fax: (212) 844-7659; e-mail: mlantz@chpnet.org.