Late-onset obsessive-compulsive disorder: Risk factors and correlates
Introduction
Obsessive-compulsive disorder (OCD) is characterized by intrusive and distressing images, thoughts or urges (obsessions) and/or repetitive mental or motor acts aimed at reducing the anxiety or performed according to certain rules (compulsions). Epidemiological studies employing the Composite International Diagnostic Interview (CIDI) suggest that OCD is a frequent condition, with 1-month prevalence ranging from 0.3 to up to 3.1% (Fontenelle and Hasler, 2008). Most patients with OCD exhibit an onset of symptoms during adolescence or childhood (Fontenelle and Hasler, 2008). A recent meta-analysis (Taylor, 2011) confirmed the long held view that early-onset OCD is associated with male sex, greater OCD global severity, higher prevalence of most types of OC symptoms and of OCD in first-degree relatives, and comorbidity with tics and other obsessive-compulsive spectrum disorders.
While a great amount of attention has been paid to early-onset OCD, there is a dearth of studies on patients showing OCD for the first time at later stages of life. In fact, much of what is known about late-onset OCD is still based on single case reports and small case series (Frydman et al., 2010). Although late-onset OCD has been commonly associated with coarse brain injury (Frydman et al., 2010), prompting some to suggest that one should always investigate underlying organicity when OCD presents after age 40 (Koran, 1999), cases of OCD firstly appearing on later stages of the life cycle without any evidence of underlying brain lesions are probably more common.
To the best of our knowledge, only one systematic, controlled study tried to delineate the phenotype of patients presenting late-onset OCD without evidence of brain injury (Grant et al., 2007). In this study, Grant et al. reported that individuals who had OCD onset at or after age 30 years (11.3% of their sample) displayed, overall, a less severe condition, including significantly shorter duration of illness before treatment, milder obsessions, and less frequent contamination, religious, or somatic obsessions. Of note, comorbidity, insight, depressive symptoms, quality of life, and social functioning did not differ between early and late-onset groups.
It is possible that OCD appearing at latter stages of life (e.g. not before age 40 years) would be associated with even more clear-cut features. Indeed, as of yet, there is no consensus on what should be termed “late-onset OCD,” with various researchers suggesting quite distinctive ages at onset for this condition (e.g., 30, 40, or even 50 years as cut-off points) (Frydman et al., 2010). One needs to consider that OCD developing after age 30 (Grant et al., 2007) may still include some forms of the disorder that are essentially identical to early-onset OCD, and that low cut-off ages related to OCD onset may potentially minimize differences between late-onset and early-onset illness. Likewise, it is not clear whether age of onset should be determined according to the beginning of the obsessive-compulsive symptoms (OCS) or when the level of clinical impairment warrants a diagnosis of OCD (Rosario-Campos et al., 2001). In the present study, we defined “age of onset” of OCD as the age when distress and interference were firstly associated with OCS.
In this study, we aimed at determining possible risk-factors/correlates for OCD occurring at or after age 40, here termed late-onset OCD. Based on the available literature, we tested the performance of a series of statistical models (see Fig. 1) where female individuals (Fontenelle et al., 2002, Mathis et al., 2011, Torresan et al., 2009) with a family history of OCD (Albert et al., 2002, Roussos et al., 2003, Viswanath et al., 2011) and a personal history of subclinical obsessive-compulsive (OC) symptoms (Coles et al., 2011, Fullana et al., 2009, Roussos et al., 2003) would be at increased risk of developing late-onset OCD in the event of different environmental stressors (Murphy et al., 2010), such as birth and pregnancy (Forray et al., 2010), personal/family problems (Basile et al., 1996) and changes in interpersonal relationships (Tolin et al., 2010), infections (e.g. w/group A β-haemolytic streptococcus) (Alvarenga et al., 2009), or exposure to drugs (e.g. atypical antipsychotics) (Ryu et al., 2011). We also investigated whether a major depressive episode (Gittleson, 1996a, Gittleson, 1996b, Quarantini et al., 2011) and severe psychological trauma, as portrayed by comorbid post-traumatic stress disorder (Fontenelle et al., 2011, Fontenelle et al., 2012, Moraes et al., 2008) (both occurring after age 40), could have any role in the development of late-onset OCD.
Section snippets
Patients
Our sample was composed of 1001 OCD patients from the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (CTOC). Patients were recruited from seven universities in six different Brazilian cities. All patients met DSM-IV criteria for OCD and were interviewed from August 2003 to August 2009 with the Structural Clinical Interview for DSM-IV Axis I disorders (SCID-I). Patients with cognitive disability, schizophrenia and OCD due to a general medical condition were excluded.
Descriptive analysis
From the 1001 patients database only 983 were included in our analysis because 18 patients did not remember the age at which distress and interference related to OC symptoms started. From this sample, 8.6% (n = 85) reported displaying significant impairment at or after 40 years old (i.e. late-onset OCD), 22.5% before or at 16 years old (i.e. early-onset OCD) and 68.7% between 17 and 39 years old (i.e.regular OCD). Comparisons between the three groups in terms of sociodemographic and clinical
Discussion
Our results suggest that late-onset OCD is more likely to occur in females, in individuals with longer periods of subclinical OC symptoms, and in association with a major traumatic event occurring at or after age 40 and a history of recent pregnancy in self or in significant others. The general performance of this model was 29.4%, which is considered quite satisfactory, as compared to studies employing similar strategies in the public health or general medical fields. Also, these results are in
Role of the funding source
This research was supported by the Conselho Nacional de Desenvolvimento Científico e Tecnológico Grant (CNPq 420.122/2005-2).
Contributors
Ilana Frydman, Pedro do Brasil and Leonardo Fontenelle designed the study and wrote the protocol.
Ilana Frydman, Leonardo Fontenelle, Albina Torres, Roseli Shavitt, Ygor Ferrão, Maria do Rosário and Euripedes Miguel managed the literature searches and analyses.
Pedro do Brasil undertook the statistical analysis, and Ilana Frydman wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
All authors have nothing to disclose.
Acknowledgements
The author thank all the people involved in the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders (CTOC) for making this study possible.
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