Treating just-right symptoms in geriatric obsessive-compulsive disorder.

Sir,

Obsessive-compulsive disorder (OCD) is characterized by considerable clinical heterogeneity; one common symptom includes “just right” phenomenon in which the affected individual compulsively repeats or delays a behavior until it feels “right” to discontinue the ritual and/or proceed with the next behavior. Although exposure and response prevention (ERP) and pharmacological therapy utilizing antidepressants have demonstrated efficacy,[1] most studies have been conducted in samples with mean age of approximately 35 years, in which treatment has been conducted in a nonintensive format among patients who are not treatment resistant.[2] There is little empirical support for treatment modifications specific to geriatric patients who exhibit OCD symptoms; as such, we report on a 68-year-old male “Douglas” (pseudonym) who was treated with ERP in a partial hospitalization program. This program included 21 h of ERP/week, 4 h of group therapy/week, and 2 h of ERP homework. Douglas' sertraline dose was increased from 50 mg to 200 mg, which he felt further contributed to his mood improvement and ability to engage in ERP.

Douglas, a retired, married man from the southeastern United States with no prior ERP treatment, began experiencing “just right” symptoms during adolescence, manifesting in behaviors including tapping, avoidance, and repeating. He counted (to no specific number) while tapping his zipper and other fasteners on his pants such as his belt. He completed this ritual every time he voluntarily and involuntarily touched the groin region of his pants, including going to the restroom, dressing, or undressing, and laying his hands in his lap when sitting. To reduce the frequency of urination, Douglas avoided consuming liquids. His “just right” obsession generalized to other motor movements. For example, he would repeat his steps, put lids on containers and bottles, and stand or sit only when it felt right. Due to Douglas' rituals, it took approximately 45 min to unfasten his pants and urinate. Douglas experienced pain from restricting or delaying urination and experienced urinary incontinence, necessitating the use of adult diapers. Douglas' symptoms worsened after retiring. Due to his fear of stigma, should his condition be known, he hid his OCD symptoms from his colleagues and family, including his wife; however, eventually, his symptoms began to impact his marriage and his functioning in many areas, including sleeping, dressing, and leaving his home.

Douglas' symptom severity was measured using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS);[3] an assessment of OCD symptom severity with scores ranging from 0 to 40. On presentation, Douglas received a Y-BOCS score of 33, indicating severe symptoms. His treatment duration lasted over 7 weeks.

There were several ways in which treatment was tailored given Douglas' presentation and advanced age. First, behavioral activation was integrated into the treatment given his comorbid depression. Behavior activation allowed patient to re-engage in activities that he and his wife enjoyed doing together resulting in an increase in marriage satisfaction. Second, given the level of family accommodation consisting of excessive amount of reassurance by his wife and children and Douglas' rituals interfering with their plans, treatment incorporated daily family sessions to help his family learn how to be supportive and reduce accommodation. Third, the treatment challenged his cognitions related to self-stigma, by having him complete exposures that involved disclosing his OCD symptoms to his closest family members. As his self-stigma reduced, so did his depression, a positive correlation supported by similar findings in prior research.[4]

On discharge, Douglas' Y-BOCS score was 16, corresponding with mild symptom severity. His functioning greatly improved, as evidenced by his ability to complete activities of daily living (i.e., showering, urinating, dressing, and leaving the house within a reasonable amount of time) within a reasonable duration, increased ability to resist compulsions, and self-reports of increased marriage satisfaction.

In sum, Douglas had suffered from severe OCD for over 50 years, with intermittent episodes of depression, with no benefit from prior interventions. This report suggests that for geriatric patients, intensive multimodal intervention may be a useful approach to addressing symptoms provided certain accommodations are made. Specifically, an integration of behavior activation, family involvement, and cognitive therapy may provide the additional support needed for geriatric patients to better benefit from ERP treatment of OCD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.