Successful and Unsuccessful Treatment of Obsessive-Compulsive ...

P1: FMN Journal of Contemporary Psychotherapy [jcp]

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Style file version Nov. 19th, 1999

Journal of Contemporary Psychotherapy, Vol. 30, No. 2, 2000

Successful and Unsuccessful Treatment of Obsessive-Compulsive Disorder in Older Adults Cheryl N. Carmin, Ph.D. and Pamela S. Wiegartz, Ph.D.

Obsessive compulsive disorder (OCD) is a condition that was once thought to rarely occur in older adults. Subsequently, treatment of OCD in the elderly has received very limited attention. However, recent epidemiological studies have highlighted the prevalence of this disorder in late life and, thus, focus has turned to comprehensive treatment for this population. This article describes two older adults who received intensive, cognitive behavioral treatment in an inpatient setting. Treatment modifications incorporating age-specific concerns are discussed, as are potential factors influencing treatment success versus symptom relapse. KEY WORDS: Obsessive-compulsive disorder; treatment outcome; elderly; cognitive-behavioral therapy.

The past decade has been witness to a significant growth in both the clinical and research literature focusing on obsessive-compulsive disorder (OCD). In part, this burgeoning attention has been the result of epidemiological studies documenting that the prevalence of this disorder is much greater than suggested by initial estimates (Myers, Weisman, Tischler, et al., 1984; Rasmussen & Eisen, 1992; Robins, Helzer, & Weisman et al., 1984). Similarly, it was assumed that OCD rarely occurred in late life. However, relatively recent studies conducted across a broad range of community and institutional settings have found that OCD occurs in as many as 1.5% of adults over the age of 65 (Blazer, George, & Hughes, 1991; Flint, 1994; Kolada, Bland, & Newman, 1994; Myers et al., 1984). Typical OCD presentations, such as contamination fears with washing rituals, are commonly found in elderly patients (e.g., Calamari, Faber, Hitsman, & Poppe, 1994; Kohn, Westlake, Rasmussen, Marsland, & Norman, 1997), however, certain OCD symptoms have been suggested to be more likely in the elderly. These include obsessions and compulsions related to fear of forgetting names (Jenike, 1991) and Address correspondence to Cheryl Carmin, Ph.D., University of Illinois at Chicago, Department of Psychiatry (MC 913), 912 S. Wood Street, Chicago, IL 60611, USA; e-mail: [email protected]. 181 C 2000 Human Sciences Press, Inc. 0022-0116/00/0600-0181$18.00/0 °


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exaggerated ego-syntonic scrupulosity (Fallon, Liebowitz, Hollander, et al., 1990; Kohn et al., 1997). Much like research into the prevalence of OCD, there is an abundant literature concerning the treatment of OCD in children and young adults. Such studies have consistently demonstrated that while OCD is a potentially disabling condition, it can be effectively treated. Cognitive behavioral therapy (CBT), in the form of exposure and response prevention (ERP), continues to be the most effective and recommended treatment for this disorder (Baer & Minnichello, 1990; Dar & Greist, 1992; Franklin & Foa, 1998; March, Frances, Carpenter, & Kahn, 1997; Riggs & Foa, 1993; Stanley & Turner, 1995). ERP is based on the principle that obsessions generate anxiety or feelings of discomfort and that rituals are learned behaviors whose purpose is to neutralize that anxiety. Exposure, then, consists of deliberately confronting situations that trigger obsessions and the urge to ritualize and then staying in the situation without ritualizing (i.e., response prevention) until the urge to ritualize decreases. With repeated exposures to a feared situation or object, both the initial strength and the duration of anxiety decreases to more comfortable levels. One obvious concern with regard to the administration of any form of psychotherapy with older adults is whether there are normative cognitive changes that could impact the ability of elderly patients to benefit from verbally mediated treatments or to maintain treatment gains (Foa, Steketee, Grayson, & Doppelt, 1985). In addition, interventions such as ERP that may be physically taxing for the participant are often avoided with older adults due to complicating medical conditions or perceived fragility. However, some data exist (e.g., King and Barrowclough, 1991) that show older adults with various anxiety disorders are able to profit from cognitive behavioral interventions. These findings challenge the assumption that aging would negatively impact CBT treatment outcome. As alluded to, there is a sparse body of research specifically addressing the treatment of OCD in older adults (Calamari, et al., 1994; Pollard, Carmin, & Ownby, 1997). There are few studies addressing non-pharmacologic treatment and most of these are either case studies (Bajulaiye & Addonizio, 1992; Calamari et al., 1994; Junginger & Ditto, 1984; Rowan, Holburn, Walker, & Siddique, 1984) or single case designs (Turner, Hersen, Bellack, & Wells, 1979). Results from one study (Carmin, Pollard, & Ownby, 1998) compared ten OCD patients over the age of 60 with a group of ten younger patients matched for sex, level of depression, and clinical severity of their OCD. Results revealed that both groups improved and there were no significant differences in treatment outcome following intensive, inpatient ERP. These results are noteworthy in that the older group of patients reported being symptomatic for more than twice as long as the younger cohort. It would seem then, that the treatment strategy deemed efficacious for those under the age of 60 might be similarly suited for elderly OCD patients, regardless of symptom duration. However, additional, systematic research into the generalizability of existing treatment to older adults is needed in order for


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clinicians to have an empirically supported set of resources upon which to draw when providing treatment for this patient population. As has been outlined elsewhere (see Carmin et al., 1999), modifications of behavior therapy are likely to be needed to address the specific needs of older adult OCD patients. This article will present information regarding the cognitive behavioral treatment of two elderly patients with severe OCD, one who had a successful treatment outcome and one who experienced a relapse. In both instances, these patients were treated on a general in-patient psychiatric unit due to the severity of their OCD symptoms. Information that would allow the identification of these patients has been omitted from this report to protect patient confidentiality. Three advanced clinical psychology doctoral students trained in the cognitive-behavioral treatment (CBT) of anxiety disorders conducted the therapy for both patients. All students were trained in CBT, including exposure and response prevention (ERP), and supervised by the first author (CNC) a licensed clinical psychologist with expertise in anxiety disorders and CBT. Treatment sessions were divided equally and daily contact was maintained among treatment providers to facilitate consistency in the provision of ERP. A psychiatric resident provided pharmacotherapy and medical consultation in conjunction with the attending psychiatrist who specialized in neuropsychiatric treatment.

EXAMPLES OF TREATMENT The first patient, Mr. X, was a 78-year-old man experiencing recent onset of OCD. Data from the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown, DiNardo, & Barlow, 1994) and the Yale Brown Obsessive Compulsive Scale (YBOCS; Goodman, Price, Rasmussen, et al., 1989a, 1989b) along with a clinical interview revealed that his symptoms, which began 8 months prior to his hospital admission, involved “needing to know” and fears of being unable to correctly remember names and other information. His presenting symptoms were consistent with common obsessional themes noted in older OCD patients (Jenike, 1991). When the patient was unable to spontaneously produce an answer to these obsessions, he felt compelled to find information through external means. He typically neutralized his intrusive thoughts by repeatedly reviewing or checking his accumulated lists of names and references or by engaging in mental rituals. If the information was not in his archive or he could not produce the information by “quizzing” himself, he would call friends, acquaintances, his secretary, libraries, radio stations, etc. all over the world in an effort to find what he needed. He indicated that his telephone bills were in excess of $400 per month due to his dogged research. Family and colleagues noted that his persistence and reassurance seeking were repetitive and excessive to the point of interfering both with his ability to work as well as with the productivity of others. These rituals occupied up to 8 hours of his day.


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Mr. X had received prior intensive outpatient ERP treatment accompanied by pharmacological treatment for his OCD. However, he was unable to comply with therapeutic recommendations resulting in an unsuccessful outcome. Both he and his therapist noted that while he was able to engage in therapist-directed ERP, when he returned home or was unsupervised, he could not stop himself from ritualizing. As a result, whatever gains were made during the course of a therapy session could not be maintained. Intensive ERP was discontinued after two weeks and the patient was referred for inpatient treatment at our facility. He was admitted on Luvox 200 mg per day and Xanax .5 mg every 6 hours. He denied any history of psychiatric problems prior to his onset of symptoms. He did, however, report a long-standing history of anxiety symptoms beginning in his twenties. While vague with respect to details, he noted that he often felt like he was “going to have a heart attack” and he would avoid places unless he could sit close to an exit. He also reported a “phobia” of having his blood pressure taken due to a fear that the reading would be high. There was no evidence of depressive symptoms (Beck Depression Inventory score = 10) (BDI; Beck, Ward, Mendelson, et al., 1961). This patient’s medical history was significant for medically treated high blood pressure. On review of his MRI, recent, small basal ganglia infarcts were noted. These infarcts were estimated to have occurred prior to the onset of Mr. X’s OCD symptoms and may have etiologic significance as has been reported in other cases of post-stroke onset of OCD (e.g., Simpson & Baldwin, 1995). On a test of cognitive function, the Dementia Rating Scale (Mattis, 1976), Mr. X’s scores (DRS Total Score and scales of Attention, Construction, Initiation/Perseveration, and Memory) fell in the normal range for elderly subjects. He did show a deficit on the Conceptualization scale due to a tendency to respond to questions in a somewhat concrete fashion. Current stressors included the health of Mr. X’s wife of 30 years. She had been diagnosed with breast cancer several years prior and within the past year had been diagnosed with bone cancer for which she was undergoing chemotherapy. Their normally active social life had become progressively more limited over the past months as Mr. X’s symptoms worsened. Given his initially high blood pressure readings (e.g., 190/112), ERP was not started until the patient had been seen by the cardiology service and his hypertension was better controlled medically (e.g., 140/84). Instead, a program of progressive muscle relaxation training and diaphragmatic breathing was started both as a means of preparing him for ERP as well as to provide a behavioral intervention for his hypertension. This decision was based on studies that have found the benefits of non-pharmacological treatments for hypertension, such as relaxation, to be at least equivalent to the effects of medication in lowering systolic and diastolic blood pressure (e.g., Linden and Chambers, 1994). In addition, he was provided with a cognitive behavioral conceptualization of OCD and the rationale


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for ERP. Obsessive intrusions and rituals were explained to the patient as a “learned pattern of reacting to certain situations or objects” and were likened to “habits” that can be broken or weakened with effort. In order to “break these habits” and learn that anxiety will decrease, even in the absence of rituals, one must confront the situations or stimuli that provoke anxiety and refrain from ritualizing. Through repeated exposure, anxiety decreases to a manageable level and one learns that rituals are unnecessary in preventing or ending distress. During these first few days of treatment, Mr. X was observed asking staff their names and other questions and keeping copious notes and lists. Over the course of his stay, his prior medications were discontinued and he was placed on Zoloft 200 mg every morning, Ativan .5 mg twice a day, and Depakote 750 mg daily. ERP was introduced gradually due to both his high levels of anxiety and his difficulty understanding the rationale for treatment. He was seen for individual ERP sessions twice daily with each session lasting 60 to 90 minutes. A hierarchy of exposure experiences was developed and situations were presented to the patient in a gradual fashion beginning with the lower anxiety items. In creating the hierarchy the patient was queried about a number of situations (e.g., skimming the newspaper, watching TV while distracted) and how difficult those situations would be if prevented from ritualizing (e.g., asking questions, researching information). As a situation was introduced, he would rate his subjective anxiety on a 0 to 100-point scale. This method of rating proved difficult for the patient and was abandoned in favor of a low-medium-high rating system. He was asked to refrain from note writing for a 30-minute period each day. The patient was instructed to use his relaxation and/or diaphragmatic breathing skills to manage his anxiety. Once he could successfully accomplish this task, the period was lengthened. Within one week, he was able to discontinue all note taking and all of his accumulated lists, both at home and at the hospital, were discarded. He was then exposed to those situations that typically triggered his note taking, such as reading newspapers or magazines and watching television. While he could successfully abstain from taking notes, his anxiety caused him to ask questions of staff, family, and other patients. Response prevention took the form of reducing his telephone calls to elicit answers to no more than two per day and staff were instructed to redirect him to his therapist when he attempted to solicit information from them. Finally, the complete cessation of information-seeking phone calls and a continued ban of note taking were implemented. With the patient’s permission, his wife, coworkers, and staff on the unit were apprised of this goal and worked collaboratively to ensure his compliance with the ritual ban. Within the week, the patient was asking questions only infrequently and receiving virtually no information from the above sources. Discharge planning and relapse prevention strategies were initiated. The patient, as well as his family and coworkers, were instructed


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in the potential barriers to treatment maintenance and in appropriate responses to difficult or stressful situations. At the outset of treatment, Mr. X’s YBOCS score was in the severe range (YBOCS = 24). While not completely ritual-free, by the time of his discharge (day 21), his score had dropped to 19 and he had dramatically reduced the amount of time he spent ritualizing. He continued to increase his gains after leaving the hospital. At 12 weeks post treatment, his YBOCS had dropped to 2 and while he reported experiencing mild intrusive thoughts, he was able to resist any impulse to ritualize. He has maintained this level of functioning for at least one year. He reported that he is able to engage in all of his social and leisure activities without any interference or distress from his OCD symptoms. Our second patient, Mr. Y, was a 74-year-old man who reported symptoms of OCD beginning in high school. Information obtained from the ADIS-IV, YBOCS, and clinical interview revealed that he had been immobilized for the prior 7–8 months due to his symptoms. He was spending the majority of his day either in bed or sitting in a chair. During these times, he was preoccupied with obsessional doubts (e.g., whether doors or windows were locked, whether his underwear was correctly positioned on his body, or whether he had done things perfectly) as well as fears of contamination, nonsensical impulses, the consequences of blasphemous thoughts, and “bad” numbers and sexual images. His resultant compulsions involved counting, checking, washing, internal repetition, the need for symmetry or a “just right” feeling, and the oral repetition of nonsense syllables. These rituals were Mr. Y’s attempts to neutralize his fear that harm would befall him or others through some action (or inaction) on his part or as the result of some sinful thought or act. The severity of his OCD has been such that Mr. Y was unable to read without repetition and had been unable to complete college as a result. He had recently quit his part-time job due to interference from his rituals (e.g., insuring that there were no loose papers around, that materials were perfectly arranged on the shelves, etc.). Mr. Y’s psychiatric history involved multiple hospitalizations and attempted treatments of his OCD. He was first hospitalized in the late 1950’s for a period of 4 years. He was hospitalized on three other occasions as recently as 1998. During his first admission, he had several series of electroconvulsive therapy (ECT) treatments. Medications provided him with little symptomatic relief and on admission he was prescribed Celexa 20 mg every morning and Remeron 30 mg at bedtime. He had received no CBT treatment throughout the course of his illness. At the time of this admission he was significantly depressed as indicated by the presence of both vegetative and cognitive symptoms of depression as well as a Beck Depression Inventory score of 43. Mr. Y had been married for 45 years. He felt that his OCD had a considerable negative impact on his marital relationship. During the course of the initial interview, both his wife and daughter, who were seen separately from the patient,


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noted the need for Mrs. Y to have some relief from Mr. Y’s OCD. Mrs. Y also stated that she was dissatisfied with the state of their marriage and their intimate relationship. This patient’s medical history was significant for scalding injuries in childhood and recent colon surgery. On the Dementia Rating Scale, Mr. Y’s scores (DRS Total Score and scales of Attention, Conceptualization, Construction, and Memory) fell in the normal range for elderly subjects. He did show a significant deficit in initiation, perseverating on answers and having difficulty moving forward with the testing. These deficits may have been a result of his obsession with perfection and totally accurate responding. In addition, he showed evidence of semantic paraphasias during testing. A program of progressive muscle relaxation training and diaphragmatic breathing was started with this patient as a means of preparing him for ERP as well as to gauge compliance and comprehension. He was provided with the cognitive behavioral conceptualization of OCD and rationale for ERP. Due to Mr. Y’s preoccupation with perfection and “complete understanding,” therapists were forced to refrain from repetition of treatment information once Mr. Y’s knowledge was judged adequate. This estimation was complicated by Mr. Y’s insistence that his requests for repetition were due to hearing loss. An audiology consult was ordered and it was determined that Mr. Y’s hearing capabilities were within normal limits. This information was conveyed to all care providers who were asked to speak slowly, clearly, and loudly, but not to repeat questions or information for Mr. Y. During this time, Mr. Y’s medications were adjusted such that the Remeron was discontinued and Celexa was increased to 80 mg. Anafranil was added to his medication regimen at 25 mg at bedtime and, in part based on an abnormal EEG, Mr. Y was titrated up to 1750 mg of Depakote during his stay. Initial exposure work sought to address this obsession with perfection and the complete comprehension of both written and oral material. As with Mr. X, he was seen for individual ERP sessions twice daily for 60 to 90 minutes, a hierarchy of exposure experiences was developed, and rating of his subjective anxiety was employed. ERP began with Mr. Y reading short passages from a book or magazine without compulsively re-reading material. This resulted in only moderate anxiety for Mr. Y and, thus, he was encouraged to intentionally read “imperfectly.” This entailed skimming material, covering previously read material to prevent checking, introducing distractions, and time limits per page. Once he could successfully accomplish this task, he was asked to perform these exposures independent of the therapist and for longer periods of time. As Mr. Y became more adept at performing those exposures independently, focus turned to his time-consuming grooming rituals. Time limits were set for shaving, tooth brushing, and dressing and he was encouraged to perform these tasks “incorrectly.” Over the course of a week, Mr. Y was able to condense the duration of his morning grooming routine, although he continued to have difficulty performing these tasks without adherence to a rigid set of rules. Only with much


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Carmin and Wiegartz Table I. A Comparison of Demographic and Clinical Variables in Mr. X and Mr. Y (N = 2) Variable

Mr. X (successful case)

Mr. Y (unsuccessful case)

Demographic OCD Onset OCD Duration Pre-treatment OCD severity Rituals pre-treatment Symptom presentation Comorbid depression Social support Treatment duration Post-treatment OCD severity Rituals post-treatment

78 year-old, married male Late 8 months YBOCS = 24 8 hours/day Circumscribed BDI = 10 Good collateral support 21 days YBOCS = 19 1 hour/day

74 year-old, married male Early 60+ years YBOCS = 40 8 hours/day Diverse BDI = 43 Caregiver burnout, marital conflict 23 days YBOCS = 16 1 hour/day

prompting from a therapist was he able to deviate from his ordering and counting rituals. However, it was felt that the patient had progressed enough to be able to continue treatment on an intensive outpatient basis. Discharge planning and relapse prevention strategies were initiated. The patient and his wife were instructed in treatment maintenance and appropriate responses to difficult situations. At the time of admission, Mr. Y scored in the very severe symptom range on the YBOCS (40). At the time of discharge (day 23), his YBOCS self-rating was 16 and he was spending less than 1 hour per day engaged in rituals. No follow-up data was available for Mr. Y. He failed to pursue aftercare with the outpatient therapist in his area. Per collateral and self-report, he began ritualizing to premorbid levels soon after returning home. AGE-SPECIFIC CONCERNS In both of the examples noted above, certain considerations were taken into account in an attempt to meet the particular needs of our elderly patients. Treatment relevant issues for these and other elderly clients include comorbid medical illness and/or infirmity, cognitive decline, treatment resistance and familial support, as well as the interaction of fears or stress common in later life (see Carmin et al., 1999 for a more extensive review). Medical Comorbidity For both of these elderly patients, medical issues had an impact on case conceptualization and/or treatment. Mr. X’s case was an unusual presentation of OCD with rapid symptom onset late in life. The occurrence of basal ganglia infarcts proximal to the onset of OCD symptoms suggested that these neurological changes may have contributed to the etiology of Mr. X’s anxiety disorder, consistent with other studies noting OCD symptoms post-stroke (Simpson & Baldwin, 1995). While


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unclear whether Mr. X’s difficulties with abstraction were a consequence of this neurological insult or indicative of his premorbid functioning, his conceptual style necessitated the repetition and simplification of psychoeducational interventions to insure comprehension and retention. Mr. X’s positive response to treatment reinforces King and Barrowclough’s (1991) findings that cognitive changes do not necessarily affect treatment outcome, however, the need for therapeutic flexibility is clear. Additionally, Mr. X’s history of hypertension impacted the delivery of treatment. A variety of anxiety management strategies were employed (i.e., paced diaphragmatic breathing, relaxation) prior to beginning ERP in order to minimize blood pressure elevation. Frequent blood pressure monitoring also allowed daily decisions regarding the intensity of exposures in the event that his hypertension proved malignant. The daily monitoring had the added benefit of desensitizing Mr. X to his fears of blood pressure measurement. In Mr. X’s case, these adjustments were sufficient to prevent medical issues from having a negative influence on treatment outcome. Unfortunately, this was not the case for Mr. Y, primarily because the presentation of Mr. Y’s OCD symptoms overlapped considerably with a variety of medical conditions. This complicated treatment in that Mr. Y not only tended to become overly focused on objective medical concerns (e.g., psoriasis, incontinence) but also incorporated the treatment of these conditions into his compulsive regimen. Further, it was difficult to disentangle Mr. Y’s valid medical conditions from his subjective somatic complaints related to obsessive concerns. Complicating this issue was Mr. Y’s insistence and lack of insight into the mental origin of these symptoms. As mentioned previously, it was necessary to rule out a number of medical conditions that could mimic his OCD symptoms (e.g., cognitive decline, loss of hearing). Once objective data was available, it was employed to aid Mr. Y in understanding his symptoms as cognitively based. This diagnostic complexity is illustrated nicely by his ritual involving the repetition of nonsense syllables. In the absence of other data, one might suspect a neurological deficit or psychotic process. However, through collaboration with medical colleagues, this behavior was determined to be OCD-related and, thus, an important target of behavioral treatment. Similarly, once an auditory and/or cognitive deficit was ruled out, it was possible to categorize Mr. Y’s requests for the repetition of information as compulsive reassurance seeking and to mark these rituals for elimination. Family Involvement in Treatment As with younger adults, comprehension of the rationale for treatment and compliance with the protocol is essential to treatment success. However, in elderly clients the maintenance of these gains often relies on the support and involvement of collaterals during and following formal treatment. In Mr. X’s case, he initially sought help from the nursing staff under the guise of helping him to “remember”


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a therapist’s name or medical terminology/advice. Quickly it became clear that these questions were compulsive and that he was involving family and friends, as well as staff, in these rituals. Staff was then instructed to refrain from answering and to encourage Mr. X to tolerate his resultant discomfort or manage his anxiety through his relaxation skills. Friends and family were encouraged to discontinue telephone contact if the patient continued to seek answers or reassurance. With consistency and collaboration among staff and family he was eventually able to overcome this ritual. This illustrates the importance of education in appropriate responses to ritualizing for those interacting with the patient. While Mr. X was treated at a psychiatric facility, the same principle holds with family, home health aides, or nursing home staff. Mr. Y’s resistance to treatment became more evident as his eventual discharge drew nearer. Possibly due to the stress involved in returning to his home environment, his symptoms seemed to worsen prior to discharge. Rather than maintain a consistent focus on his OCD, he attempted to shift the focus of treatment to his marital relationship, became more distracted by his medical issues, and preoccupied with experiences in his distant past. He expressed concern that his wife would be displeased with his progress and that he would not be able to maintain his gains. While these are common and realistic concerns for many OCD patients, Mr. Y’s case provides an opportunity to highlight the potential impact of family involvement and support in effective treatment. In Mr. X’s case, despite her own medical problems, his wife as well as friends and coworkers were supportive and engaged in treatment. Given the recent onset of his symptoms, Mr. X had not exhausted or alienated his support system. In Mr. Y’s case, his wife and children were overwhelmed and overburdened after having dealt with his symptoms for decades. Mrs. Y clearly suffered caregiver burnout and viewed her husband’s hospitalization as a respite from dealing with his rituals. Discharge was viewed by patient and family as eminently distressing rather than as a sign of hope and progress. Thus, there was little motivation for or expectation of maintenance of gains.

Appropriate Aftercare In addition to familial support, adequate follow-up care is essential to prevent relapse. In Mr. X’s case, he had the advantage of being able to return to his previous therapist who was highly skilled in the treatment of OCD. As would be expected, Mr. X was able to maintain his gains in treatment and even continue to improve. For Mr. Y, the situation was less promising. Given his rural residence, few appropriate therapeutic options were available. While a referral was provided to a therapist familiar with OCD treatment, intensive step-down treatment was not provided and shortly after returning home, Mr. Y discontinued treatment entirely. Relapse occurred quickly without the benefit of transition to adequate outpatient treatment.


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CONCLUSIONS While there is a rather limited literature focusing on OCD treatment in the elderly, even less is known about what may influence successful or unsuccessful treatment of these individuals. Previous research suggests that older patients are comparable to younger adults in their ability to benefit from treatment (King & Barrowclough, 1991; Carmin et al., 1998), however, the two cases described above illustrate the interplay between myriad factors that influence treatment outcome. One obvious difference between these two men is the duration and severity of their OCD. While one patient was symptomatic for less than a year, the other was symptomatic for almost 60 years. In general, duration of illness has not been found to predict treatment outcome in OCD (Carmin et al., 1998), however, there is no way of determining what influence symptom longevity had on the recovery of these particular patients. Both patients responded to treatment with significant decrements in YBOCS scores (as based on the reliable change indices calculated for each at ±1.96; Jacobson and Truax, 1991) and both were discharged with approximately equivalent symptom levels (as measured by YBOCS scores). One can then hypothesize that post-treatment factors played a crucial role in their divergent outcomes. It is likely that his deficient social support system and lack of appropriate follow-up care were played a major part in Mr. Y’s inability to maintain treatment gains. While Mr. X had supportive and involved family and friends who encouraged his continued efforts, Mr. Y did not have benefit of such support to help motivate him to improve. This, coupled with inadequate therapeutic follow-up, could account for Mr. Y’s relapse. Without adequate support from family and therapist, it can be very difficult for patients to make the transition from a structured, in-patient setting and generalize their treatment gains to their home environment. We typically recommend “stepping-down” from in-patient to intensive outpatient treatment in order to ease this transition and to insure that treatment gains are generalized from the hospital to the home. Unfortunately, due to geographic constraints Mr. Y was unable to participate in intensive treatment and eventually chose to discontinue treatment altogether. Another potential explanation for treatment response in these two patients is the presence of comorbid conditions. Mr. Y reported significant depressive symptoms on initial measures of depression. While the treatment outcome literature is mixed with regard to the effects of depression on OCD treatment, there is some indication of a less positive treatment response in depressed patients (Steketee, Henninger, & Pollard, 1999). However, depressive symptoms are sometimes secondary to the constraints put on one’s life by OCD and often remit with the treatment of anxiety. It is unclear to what degree depressive symptoms contributed to Mr. Y’s relapse, but it is reasonable to assume that depression may have affected his motivation to continue ERP.


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An interesting distinction between these men was the strength of their beliefs regarding the plausibility of their symptoms. On one hand, Mr. X was able to accurately appraise his obsessive thoughts as unrealistic and meaningless while Mr. Y was not. Mr. X assigned very little meaning or importance to his obsessive thoughts and was able to recognize the futility of addressing them. For whatever reason, Mr. Y attributed much importance to his inability to control his thoughts and believed that the mere presence of these thoughts was threatening and indicative of future disaster. Not directly addressing these underlying beliefs may have left Mr. Y vulnerable to relapse when faced with novel situations. Both of these older men made considerable progress during the course of intensive, cognitive behavioral treatment indicating the utility of this treatment approach in elderly populations. Their differing long-term outcomes are instructive with respect to the content and process of psychotherapy. Further research will need to focus on whether or how duration of illness, comorbidity, and social support affects treatment outcome in this group. Likewise, the strength of obsessional beliefs, particularly as it relates to duration of illness, may be an important consideration in modifying the duration and content of treatment to maximize successful outcome. REFERENCES Baer, L., & Minnichello, W. E. (1990). Behavior therapy for obsessive compulsive disorder. In M. A. Jenike, L. Baer, & W. E. Minnichiello (Eds.), Obsessive-compulsive disorder: Theory and management (2nd ed., pp. 202–232). Chicago: Year Book Medical. Bajulaiye, R., & Addonizio, G. (1993). Obsessive compulsive disorder arising in a 75-year-old woman. International Journal of Geriatric Psychiatry, 7, 139–142. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J. E., & Erbaugh, J. K. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571. Blazer, D., George, L. K., & Hughes, D. (1991). The epidemiology of anxiety disorders: An age comparison. In C. Salzman & B. D. Liebowitz (Eds.), Anxiety in the elderly: Treatment and research (pp. 17–30). New York: Springer. Brown, T. A., DiNardo, P. A., & Barlow, D. H. (1994). Anxiety Disorders Interview Schedule for DSMIV. Phobia and Anxiety Disorders Clinic, Center for Stress and Anxiety, State University of New York at Albany. Calamari, J. E., Faber, S. D., Hitsman, B. L., & Poppe, C. J. (1994). Treatment of obsessive-compulsive disorder in the elderly: A review and case example. Journal of Behavior Therapy and Experimental Psychiatry, 25, 95–104. Carmin, C. N., Pollard, C. A., & Ownby, R. L. (1998). Obsessive-compulsive disorder: Cognitive behavioral treatment of older versus younger adults. Clinical Gerontologist, 19, 77–81. Carmin, C. N., Pollard, C. A., & Ownby, R. L. (1999). Cognitive behavioral treatment of older adults with obsessive-compulsive disorder. Cognitive and Behavioral Practice, 6, 110–119. Dar, R., & Greist, J. H. (1992). Behavior therapy for obsessive compulsive disorder. Psychiatric Clinics of North America, 15, 885–894. Fallon, B. A., Liebowitz, M. R., Hollander, E., Schneier, F. R., Campeas, R. B., Fairbanks, J., Papp, L. A., Hatterer, J. A., & Sandberg, D. (1990). The pharmacotherapy of moral or religious scrupulosity. Journal of Clinical Psychiatry, 51, 517–521. Flint, A. J. (1994). Epidemiology and comorbidity of anxiety disorders in the elderly. American Journal of Psychiatry, 151, 640–649. Foa, E. B., Steketee, G. S., Grayson, J. B., & Doppelt, H. G. (1985). Treatment of obsessive-compulsive: When do we fail? In E. B. Foa & G. M. G. Emmelkamp (Eds.), Failures in behavior therapy. New York: John Wiley & Sons.


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