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

Abstract

Byline: Natalie. Noel, Phillip. Seibell, Joshua. Nadeau, Eric. Storch 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,[sup][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.[sup][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);[sup][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. …