Clinical Geriatrics

Case Presentation

Mr. X is a 62-year-old divorced male who presented for psychiatric evaluation with concerns regarding flying in an airplane and “claustrophobia.” His worries began approximately 4 months prior to evaluation when he had a scheduled plane trip with a friend. He noted significant anxiety leading up to the flight, which he identified as a fear of losing control. He knew these thoughts were irrational but was afraid he would become anxious while in the enclosed area of the plane cabin and have no escape. As a result of his fear, Mr. X canceled the flight and his vacation.

Upon further questioning, Mr. X identified that he had intrusive thoughts about causing harm to others and that these thoughts were causing marked anxiety. He acknowledged that fear of having these intrusive thoughts while on an airplane, where escape would be impossible, was a major factor for canceling his flight. The patient characterized these thoughts as “terrifying” and repeatedly stated he would never hurt another person. He was fearful they would never go away and was not sure why they had occurred.

Mr. X reported worsening depressed mood over the previous year, with an increase in the intensity and frequency of the obsessive thoughts as a result of worsening mood. He had previously been quite social, with multiple friends and various hobbies, including exercise, but the thoughts were affecting his ability to comfortably interact with others. As a result, he was feeling increasingly isolated and lonely. The patient continued to exercise despite the thoughts, feeling that physical activity was his only sanctuary from them.

He additionally reported early morning awakening but otherwise denied neurovegetative symptoms. Psychiatric review of systems was otherwise within normal limits. Mr. X has no history of prior psychiatric treatment. He acknowledged experiencing intrusive thoughts at various times throughout his life since college, but he stated that in the past, the thoughts were more of a nuisance; they never affected his engagement in pleasurable activities or his interactions with others. He denied any legal history, and had never been violent toward others.

Mr. X has benign prostatic hypertrophy and had an appendectomy and hernia repair in the remote past. His medications were finasteride 5 mg daily and terazosin 8 mg daily for his prostate condition. He has no known drug allergies.

On mental status exam, Mr. X was a well-groomed, fit-appearing male with good eye contact and appropriate social interaction. He described his mood as “sad and worried.” He denied memory concerns, and his Mini-Mental State Examination (MMSE) score was 30/30.1 Laboratory evaluation, including complete blood count, chemistry panel, liver function tests, and thyroid-stimulating hormone, were all within normal limits.

Mr. X was diagnosed with obsessive-compulsive disorder (OCD). He was administered the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), a validated rating scale for OCD.2 His score was 14/30, indicating mild OCD; however, his degree of distress and social impairment appeared to be in the moderate range.

Mr. X was offered a selective serotonin reuptake inhibitor (SSRI) for treatment of his OCD symptoms, as well as his depressed mood. He initially declined pharmacological treatment and opted to engage in a course of cognitive behavioral therapy (CBT) for management of his OCD. He was offered twice-monthly therapy with a Psychology intern.

After 3 weeks, Mr. X was seen again by Psychiatry. He reported that his symptoms had worsened. He was starting to have intrusive thoughts while exercising and was having thoughts of harming loved ones. He was increasingly despondent and wanted relief from his symptoms.