Rapid Remission of Refractory Hypochondriacal OCD in an Elderly Patient Under Glutamatergic Augmentation: A High-Resolution Case Observation

Older adults who live with severe obsessive–compulsive disorder (OCD) complicated by somatic anxiety rarely achieve meaningful relief on conventional serotonergic or antipsychotic regimens, and only a minority have access to intravenous ketamine, the best-validated rapid-acting glutamatergic option. We report the outpatient management of a 68-year-old man who had spent five years trapped in disabling health-related obsessions and reassurance-seeking rituals. Despite trials of mirtazapine, bupropion and several antipsychotics, his baseline burden remained high (PHQ-9 = 13).During routine follow-up, bedtime dextromethorphan 30 mg and piracetam 600 mg were added, with bupropion XL 150 mg retained to prolong dextromethorphan exposure through CYP2D6 inhibition. The patient supplied daily updates through encrypted messaging. By the fourth night he reported uninterrupted sleep, disappearance of morning restlessness and near-total quieting of intrusive health fears; residual daytime fatigue resolved after small downward adjustments of mirtazapine, risperidone and lemborexant. This experience shows that an easily deployed oral "ketamine-like" strategy—combining NMDA antagonism with AMPA potentiation—can bring about remission within days, even in a complex geriatric presentation that had resisted years of standard pharmacotherapy.