Late-Onset Obsessive-Compulsive Disorder

Case 1. Ms. A., a 70-year-old married white woman, first developed obsessive-compulsive symptoms at the age of 53, which prompted her to seek psychiatric treatment. Her symptoms included obsessions that “something terrible” (e.g., a fire or flood in her home) would happen while she was sleeping. These fears led to checking rituals, usually, but not solely, before bedtime. She felt compelled to check the light switch, turning it on and off several times until she would “put it out right.” She repeatedly checked the stove, the sinks and drains, and her pillow, which she feared might be touching the bedside lamp. These fears and rituals disrupted her life and frequently prevented her from falling asleep for hours. Despite trials of fluoxetine, alprazolam, and triazolam, she had not gained relief. She presented for psychopharmacologic consultation.

Her Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)³² score was 24 (scale 0–40), and her score on the Maudsley Obsessive-Compulsive Inventory (MOCI)³³ was 9 (scale 0–30). Although she had a history of a prior depressive episode, she was not currently depressed. Her Beck Depression Inventory (BDI)³⁴ score was 16 (scale 0–63). Her medical history was notable only for cirrhosis of the liver secondary to chronic hepatitis C. She did not use alcohol or tobacco. Her family history was significant for major depression in one sister and schizophrenia in one of her three sons. Non–contrast-enhanced cranial CT demonstrated diffuse, mild cortical atrophy. A focal area of low attenuation was also noted in the head of the left caudate, consistent with a lacunar infarct of uncertain age.

The patient continued to have OCD symptoms and was able to tolerate only low-dose (0.25 mg) clonazepam. She died at the age of 75 secondary to complications of hepatic failure.

Case 2. Ms. B., a 56-year-old married white woman, first developed obsessive-compulsive symptoms (contamination fears) at the age of 50. At that time, a child with cytomegalovirus (CMV) enrolled in the daycare center where she worked, and Ms. B. became overwhelmed with the fear that she might somehow pass this infection on to her husband, who was chronically ill. Her worries became so severe that she quit her job and obtained work at a convenience store. While there, she shared a cigarette with a co-worker who had recently been tested for human immunodeficiency virus (HIV) status. Ms. B. became morbidly afraid that she might have contracted HIV, a fear she realized was unreasonable. She sought psychiatric help and was started on clomipramine, with resolution of her symptoms.

She did well for approximately 4 years, and the clomipramine was discontinued. At age 54, following an episode of marital infidelity, she again became obsessed with HIV contamination fears. She worried that people might have residual semen on their hands; touching objects that had been handled by others became anxiety-provoking for her. She found it especially difficult to handle money, and she began to wash her hands excessively. Despite restarting clomipramine and clonazepam, her symptoms persisted. Her Y-BOCS score was 22 and her MOCI score was 15.

Ms. B. had hypothyroidism, controlled with oral hormone replacement, and narrow-angle glaucoma. Recurrent syncopal spells with poor coordination and unclear visual changes had led to a neurological evaluation. No specific diagnosis was made. She had a 20-pack-a-year smoking history but did not use alcohol. Her father and one brother had a history of major depression.

A CT scan of the head, done as part of the syncopal workup, revealed abnormal T₂ hyperintensities in the bilateral frontal periventricular white matter adjacent to the frontal horns. A hyperintense lesion was also noted in the central pons.

Case 3. Mr. C., a 75-year-old widowed white man, first developed obsessive-compulsive symptoms related to feelings of guilt over marital infidelity at the age of 52. At 75, he was seen in psychiatric consultation for symptoms of anxiety while hospitalized for three-vessel coronary artery bypass graft surgery. Mr. C.'s symptoms included excessive worries regarding infection and contamination. He ruminated about his current girlfriend's risk of contracting HIV from touching the hand of a homosexual door attendant (of unknown HIV status) at his apartment complex. During the interview, Mr. C. inquired several times whether this was a likely possibility. He ruminated about a variety of medical illnesses (including infectious diseases) and often sought reassurance from doctors. Since his symptoms had begun, he had been washing his hands approximately 20 times per day to deal with fears of contamination and infection. Although he was unsure of his prior medication trials, an ongoing trial of fluvoxamine (150 mg daily) had led to minimal benefit.

His medical history was significant for hypertension as well as coronary and bilateral carotid artery disease. He had not smoked in over 45 years and denied alcohol use. His family history was negative for mental illness. Neurologic exam and bedside cognitive testing were unremarkable. A CT scan of the head done 2 years prior to admission revealed bilateral hypodense areas in the caudate nuclei, consistent with lacunar infarcts of unclear age.

Recommendations were made to increase the fluvoxamine dose and to add a small dose of lorazepam. The patient was discharged to outpatient psychiatric care.

Case 4 (previously published³). Mr. D., a 70-year-old married white man, first developed obsessive-compulsive symptoms at the age of 62. He specifically recalled the exact date and time of symptom onset: it had occurred when he recognized an actor in a television commercial but was unable to recall his name. He became quite anxious and “needed to know”; eventually he called several acquaintances and the television network. This “need to know” worsened, and it became common for him to wake his wife or phone friends in the middle of the night to obtain answers to questions that plagued him. He memorized bumper stickers, newspaper headlines, names of songs and their composers, and even comic strip character names. He started to collect old newspapers to create a database to answer questions that might come up. With time, however, Mr. D. was no longer able to read the newspaper because of a strong urge to memorize all of the headlines. He became unable to attend church because he felt compelled to look up all of the references during the sermon. Trials of nearly 35 medications from several different classes provided little to no relief.

Mr. D. had a history of hypertension, diabetes mellitus, and carotid artery disease (total occlusion of the right internal carotid artery with 30% to 40% stenosis on the left). This latter finding was discovered during a workup of recurrent brief paresthesias involving the left arm and face, eventually thought to be due to sensory seizures.

Neurologic exam revealed rare paraphasic errors in spontaneous speech, a mild constructional apraxia, and mild difficulty with Luria sequencing bilaterally. There was generalized hyporeflexia, with absent ankle jerks bilaterally. There was also evidence of bilateral sensory loss in a stocking distribution. A CT scan of the head revealed a 3-by-4-cm wedge-shaped infarct in the posterior right frontal lobe, with extension to the deep subcortical white matter. A [^99mTc] HMPAO SPECT scan revealed hypoperfusion in the area of the infarct, but no other notable abnormalities.

Mr. D. agreed only to an increased dose of clonazepam, with little effect on his obsessive symptoms. However, the paresthesias disappeared, raising the possibility that they were sensory seizures arising from the area of damaged frontal cortex.

Case 5. Mr. E., a 75-year-old married white man, first developed obsessive symptoms at the age of 71; he ruminated about his tongue. For 4 years he had been plagued with near-daily worries about his tongue; feeling that it was “not right,” or “too tight,” and complaining of intolerable tongue pain. Despite reassurances from several dentists and otolaryngologists that no abnormalities were present, his worries persisted. Although Mr. E. described himself as “perfectionistic” and “a worrier,” both he and his wife noted these obsessive symptoms to be excessive and unusual even for him. Trials of lorazepam and diazepam were minimally helpful. He had had two successful series of ECT over the preceding year for treatment of depression; neither had any significant effect on his obsessions. He presented for psychiatric consultation after his wife saw a television report on OCD.

Mr. E. was medically healthy and had no history of substance abuse. He had a history of recurrent depression, with onset at age 57, but he did not have depressive symptoms at the time of his consultation. His family history was notable for major depression in his father, alcoholism in one son, and panic disorder complicated by alcoholism in one daughter. A nephew had died by suicide.

He was a thin man who described himself as an avid gardener. His physical and neurological exams were normal, particularly with reference to the tongue. His Mini-Mental State Examination score was 29/30, with a single error in recall. A CT of the head done at age 73 was described as “within normal limits,” but the report itself is not available. An EEG done at the same time was also normal. His Y-BOCS score was 32. His score on the BDI was 14.

In addition to recurrent major depression, he was felt to have OCD or body dysmorphic disorder (i.e., monosymptomatic hypochondriasis). Although psychotic depression or a delusional disorder with somatic features was also possible, his insight into the excessiveness of these concerns and the lack of response to ECT argued against these diagnoses. He has been lost to follow-up.