Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0104Obsessive–compulsive DisorderJames LindesayUniversity of Leicester, Leicester, UKAlthough obsessive–compulsive disorder (OCD) is known tooccur in old age, studies are few and information is limited. Thismay be because it is often not perceived as a disorder of late life.The mean age of onset is 20–25 years 1–3 and it is unusual for OCDto have its first onset after the age of 50 years. However, OCD is achronic disorder if untreated, and a significant proportion of casespersist into old age, when they may present to services for the firsttime. It is important, therefore, that old age psychiatrists areaware of this disorder and of its management.CLINICAL FEATURESDiagnostic CriteriaOCD is characterized by intrusive, persistent obsessive thoughts,images or impulses and/or compulsive behaviours that are asignificant source of distress, or interfere with the patient’spersonal or social functioning. The current diagnostic criteria, asset out in DSM-IV 4 and ICD-10 5 , apply to all patients,irrespective of age. The limited evidence available indicates thatthe clinical features of OCD in elderly patients are very similar tothose of younger adults. In their comparative study, Kohn et al. 6found that concerns about symmetry, need-to-know and countingrituals were less common in elderly patients, and hand-washingand fear of having sinned were more common, but otherwise therewere few differences in clinical features compared with youngerOCD patients. Extreme ego-syntonic religiosity has been proposedas a variant of OCD that may be more common in olderpatients 7 .Differential DiagnosisUnpleasant, intrusive thoughts and abnormal stereotyped behavioursoccur in other mental disorders, and OCD is not diagnosedif their content is exclusively related to another disorder, e.g.guilty preoccupations in depression, worries in generalizedanxiety, concern with illness in hypochondriasis, weight controlin anorexia or avoidance in phobic disorders 4 . It should be bornein mind that conditions such as depression, generalized anxietyand substance abuse may be co-morbid with OCD. In elderlypatients, increased anxious orderliness may be a prodrome ofdementia; however, this behaviour is not resisted or associatedwith the tension that occurs in OCD. The compulsive behavioursof OCD resemble the stereotyped behaviours that occur in certainother disorders, such as Tourette’s syndrome, Sydenham’s chorea,encephalitis and partial complex seizures. Tourette’s syndromeand OCD commonly co-occur 8 , and patients with OCD may havea history of Sydenham’s chorea in childhood 9 .Despite its similar name, obsessional personality disorder isquite distinct from OCD. It is characterized not by obsessions andcompulsions, but by a preoccupation with orderliness, perfectionand control dating back to early adulthood 4 . In some individuals,there is an inability to discard personal possessions, which maypresent as the so-called ‘‘senile squalor’’ syndrome after a lifetimeof accumulated rubbish.Not all patients with OCD have insight into the irrationalityand inappropriateness of their obsessions and compulsions. If theobsessional thoughts are held with delusional intensity, anadditional diagnosis of delusional disorder may be warranted.The ruminative delusions and stereotypies of schizophrenia areusually not ego-dystonic, and therefore would not be regarded asOCD 4 .Clinical AssessmentAn effective treatment plan for OCD requires a detailed clinicalassessment. What exactly are the main problems? What, ifanything, exacerbates or improves the symptoms? How long hasthe condition been present, and how has it evolved since its onset?What treatments, if any, have been tried in the past? What othersymptoms or disorders are present? Any concomitant depression,mania, psychosis or alcohol dependency will require specificmanagement before behavioural treatments for OCD can beeffective. If the patient is cognitively impaired, this will haveimplications for the choice of treatment; for example, somebehavioural strategies will not work if information cannot beretained or recalled. In elderly patients with OCD of recent onset,it is important to investigate carefully for any underlying cerebraldisease. Late-onset cases are associated with frontal dysfunction 10 ,which may be caused by a variety of focal and generalizeddisorders, including cerebrovascular disease, tumours and primaryneurodegenerative dementias. Late-onset OCD may also bethe result of external factors, such as adverse life events andexposure to trauma, that weaken an elderly individual’s resistanceto long-standing subclinical obsessionality 11 .EPIDEMIOLOGYMost of our knowledge about the epidemiology of OCD in oldage derives from the US National Institute for Mental Health(NIMH) Epidemiologic Catchment Area (ECA) Program. Overall,the 1 year prevalence for those aged 65 years and older wasPrinciples and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd