Obsessive-Compulsive Disorder

Obsessive-compulsive disorder is characterized by anxiety-provoking ideas, images, or impulses (obsessions) and by urges (compulsions) to do something that will lessen that anxiety. The cause is unknown. Diagnosis is based on history. Treatment consists of psychotherapy, drug therapy, or, in severe cases, both.

Geriatric Essentials

• Obsessive-compulsive disorder (OCD) occurs less commonly among the elderly than among those in mid-life, and it occurs about equally in men and women.
• Symptoms of OCD tend to abate with aging.

Obsessive-compulsive disorder (OCD) is characterized by recurrent, unwanted, intrusive ideas, images, or impulses (obsessions) that seem silly, weird, nasty, or horrible and by urges (compulsions) to do something that will lessen the anxiety caused by obsessions. The obsessions and compulsions can cause significant social dysfunction.

Symptoms

Symptoms are often not prominent in the elderly. The dominant theme of the obsessive thoughts may be harm, risk, danger, contamination, doubt, loss, or aggression. Typically, affected people feel compelled to perform repetitive, purposeful rituals to balance their obsessions (eg, washing balances contamination). Most rituals, such as hand washing or lock checking, are observable, but some, such as repetitive counting or making statements under one's breath, are not.

Because affected people fear embarrassment or stigmatization, they often conceal their obsessions and rituals. Relationships may deteriorate. Depression frequently accompanies OCD symptoms.

Diagnosis

Diagnosis is based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (DSM-IV-TR). The criteria stipulate that at some point, people with OCD recognize that their obsessions do not reflect real risks and that the compulsions are excessive or unreasonable. The criteria also stipulate that the obsessions and compulsions must cause marked distress, be time consuming, or significantly interfere with function.

Preservation of insight, although sometimes slight, differentiates OCD from psychotic disorders, in which contact with reality is lost.

Treatment

Exposure therapy is effective; its essential element is exposure to situations or people who trigger the anxiety-provoking obsessions and rituals. After exposure, the patients must forgo rituals, allowing the anxiety triggered by exposure to diminish through habituation. Improvement often continues for years, especially in patients who master the approach and use it even after formal treatment has ended.

Citalopram (initial dose of 10 mg, can be gradually increased to 40 mg po once/day) and sertraline (initial dose of 25 mg in the morning, can be gradually increased to 100 to 200 mg po once/day) are effective for treating more severe cases of OCD in elderly patients. Doses for treating OCD are often higher than those that are effective for treating depression.

This topic was last updated September 2005.