OBSESSIVE – COMPULSIVE AND SCHIZOPHRENIA SPECTRUM MIXTURE OF SYMPTOMS – A TRANSNOSOLOGICAL CLINICAL CASE
Prezentăm cazul unei paciente care timp de 22 ani a fost tratată pentru schizofrenie și care la prezentarea actuală a fost diagnosticată pentru prima oara cu TOC comorbid, care aparent a debutat in urmă cu 12 ani. Pacienta a fost internată pentru un sindrom depresiv, anxietate severă, obsesii agresive (inclusiv ideație suicidară), idei mistice și erotomane, obsesia sărăciei care a determinat-o să colecționeze obiecte nefolositoare. Anterior internării a fost tratată cu diferite antipsihotice in doze crescute. A suferit o recădere după aproximativ un an fără tratament. In clinică a primit tratament cu un antipsihotic atipic și un antidepresiv in doze terapeutice, iar dupa 6 săptămâni s-a obținut remisia simptomatologiei. In acest caz , diagnosticul de TOC a fost un episod tranzițional in contextul comorbidității dintre tulburările din spectrul schizofreniei și depresia post tratament antipsihotic.
In the psychiatrist’s daily practice it is very difficult to establish the limit between patients with both psychotic and obsessive-compulsive symptoms. These patients may fit into different nosological entities like: comorbid schizophrenia with obsessive-compulsive disorder (OCD), schizophrenia with obsessive- compulsive symptoms (OCS) , OCD with poor insight and psychotic simptoms or schizophrenia with antipsychotic- induced obsessive-compulsive symptoms (1).
The lifetime prevalence for schizophrenia is 1% and for OCD it is 2% to 3%. Up to 70% of OCD outpatients remain unrecognised and untreated (2).
There is a high rate of comorbidity between OCD and schizophrenia. . In the schizophrenic population, the reported prevalence of clinically significant OCS and of OCD ranges from 10% to 52% and from 7.8% to 26%, respectively (1). A 2010 japaneese study shows that 51,1% patients diagnosed with schizophrenia have obsessive compulsive symptoms while 14,1% meet all the criteria for OCD (2).
A growing number of studies sustain the hypothesis of a common neurobiological basis for OCD ans schizophrenia (4, 5) and even the existence of a „schizo-obsessive” subtype of schizophrenia (6, 7).
T h e p r e s e n c e o f o b s e s s i v e – c o m p u l s i v e symptoms or comorbid OCD in a per son with schizophrenia has been associated with poorer prognosis and a significantly higher risk of suicide attempt (8).
We are presentig the case of a 42 years female patient, that for a very long time (22 years) was treated for schizophrenia and at the present evaluation was for the first time diagnosed with comorbid OCD.
OCD apparently had the onset 12 years ago. At current admission the patient presents a depressive syndrome, severe anxiety, aggressive obsessions ( including suicidal ideas ), mystic and sexual ideas and the obsessional thought of poverty that makes the patient to collect useless objects.
Her psychiatric history begins at the age of 20 when the patient’s father and sister left the family and the patient ended up living only with her mother that blamed her for her father’s leaving. In this context she started to isolate herself from her friends, she interrupted her studies, became interpretive, suspicious and started having delusions of beeing followed („I thought a man was following me everywhere“) and after that she stopped leaving the house and her room. After a violent fight with her mother she is admitted in a psychiatric hospital and she is diagnosed with schizophrenia.
During the next 9 years she has numerous psychotic episodes followed by admissions and she is treated with different antipsychotics.
In 1999 a simptomatology change appears. The patient starts to have obsessive ideas described as “black thoughts” and compulsions (“I had this idea that I would hurt my mother, that I would kill her and then kill myself, I felt the impulse of doing that and everytime I saw a knife I asked my mother to take it away from me, to hide the knife and tie me to the bed. The only thing that helped me and made these thoughts go away were prayers. Sometimes the thoughts lasted all day and it was hard to accept that I could have such thoughts so I liked to think that the devil sent them to me.”)
Over the years more obsessive ideas appear and after her mother’s death the patient also starts to have auditory hallucinations (“I heard a voice telling me that my mother is dead so I don’t deserve to live anymore and I should stop my medication and kill myself”), reference ideas (“At the TV, when they were talking about the murder case of Elodia I thoght that they were actually talking about me”, “all men were looking at me with a double meaning”, “lots of people were talking about me”) and depressed mood with anhedonia.
During these years the patient followed different treatment plans that included high doses of tipical and atipical antipsychotics, SSRI’s, benzodiazepines and mood stabilizers and managed to obtain partial and even complete remission of symptoms (with a combination of olanzapine and paroxetine) for a short period of time. Side effects like weight gain, severe constipation and restlessness led to noncompliance an so, when the patient arrived to our clinic, she had interrupted her treatment for about 1 year.
She has been living alone since her mother’s death and she is receiving disability pension and financial support from her sister. It is also her sister that keeps her taxes and invoices up to date and does her everyday shopping.
There is no record of family psychiatric history and the past medical history of the patient mentiones irritable bowel, gallstones, kidney stones and mild hepatic steatosis. Blood tests and physical examination were normal.
Mental status examination:
The patient showed proper hygiene, tense posture with moist hands and perspiring forehead and wide eyes. She was oriented in time, place and person and had spontaneous hypoprosexia with consecutive anterograde hypomnesia. Denied qualitative perceptual disturbances at present admission but recalled auditory hallucinations in the past (mentioned previously in the above text). She had mystic and sexual ideas; obsessions with aggressive content, including suicidal ideas, and the obsessive idea of poverty that lead to compulsive collection of useless objects and praying. She also had severe anxiety, depressed mood and anhedonia. Her social and occupational functioning were diminished and also presented insomnia and decreased appetite. She showed good insight of symptoms.
Psychological tests performed:
SCID I found no psychotic symptoms at current
Rorschach test: revealed reduced flexibility of
thought content and poorly structured perception as a endofenotipic marker for schizophrenia spectrum disorders.
HAM – D score : 16 – Moderate depression
Yale Brown Obsessive – Compulsive Scale total score :
Treatment with atypical antipsychotic and an antidepressant in therapeutical doses (10 mg Olanzapine and 10 mg of Escitalopram) was started at admission and after 6 weeks lead to clinical symptoms’ remission.
In most cases of schizophrenia with co-morbid OCD, obsessive compulsive symptoms emerge before psychotic symptoms (8). In our patient case the OCS ocurred with a delay of 10 years from the debut of schizophrenia.
There is substantial evidence that OCS in schizophrenia represents more than just an expression of enduring psychosis. This evidence includes observations that conventional antipsychotic medications appear to be of limited use in the treatment of OCS in schizophrenia, the persistence of OCS even after successful treatment of the psychotic symptoms, and the effectiveness of serotonin reuptake inhibitors in the treatment of OCS in patients with schizophrenia (2).
In recent years there were multiple case reports that drew attention to the appearance of induced OCS and OCD in schizophrenic patients, treated with different atypical antipsychotics that antagonize both dopamine and serotonin receptors (9, 10, 11, 12).
And it is also known that SSRIs may exacerbate psychotic symptoms. There are authors sustaining that OCD that occurs in this context should be treated pharmacologically as though it existed alone, although the positive symptoms should be monitored. Hence, accurate diagnosis of patients with both psychotic and obsessive- compulsive symptoms is important both for treatment and prognosis (1). The OCD diagnosis was in this case a new transitional episod in the context of a comorbidity between schizophfrenia spectrum disorders and postantipsychotic treatment depression.
1. Rodriguez C, Corcoran C, Simson H. Diagnosis and Treatment of a Patient With Both Psychotic and Obsessive-Compulsive Symptoms. Am J Psychiatry 2010;167: 754–761.
2. Wahl K, Kordon A, Kuelz KA, Voderholzer U, Hohagen F, Zurowski B. Obsessive-Compulsive Disorder (OCD) is still an unrecognised disorder: a study on the recognition of OCD in psychiatric outpatients. Eur Psychiatry 2010;25(7): 374-7.
3. Owashi T, Ota A, Otsubo T, Susa Y, Kamijima K. Obsessive- compulsive disorder and obsessive-compulsive symptoms in Japanese inpatients with chronic schizophrenia – a possible schizophrenic
subtype. Psychiatry Research 2010;179(3): 241-6.
4. Zinkstok J, van Nimwegen L, van Amelsvoort T et al. Catechol-O- methyltransferase gene and obsessive-compulsive symptoms in patients with recent-onset schizophrenia: preliminary results. Psychiatry Research 2008;157: 1-8.
5. Poyurovsky M, Kriss V, Weisman G et al. Familial aggregation of schizophrenia-spectrum disorders and obsessive-compulsive associated disorders in schizophrenia probands with and without OCD. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics 2005;133B: 31-36.
6. Bottas A, Cooke RG, Richter MA. Comorbidity and pathophysiology of obsessive-compulsive disorder in schizophrenia: is there evidence for a schizo-obsessive subtype of schizophrenia? Journal of Psychiatry and Neuroscience 2005;30: 187-193.
7. Rajkumar RP, Reddy YC, Kandavel T. Clinical profile of „schizo- obsessive” disorder: comparative study. Comprehensive Psychiatry
2008; 49(3): 262-8.
8. Devulapalli KK, Welge JA, Nasrallah HA. Temporal sequence of clinical manifestation in schizophrenia with co-morbid OCD: review and meta-analysis. Psychiatry Research 2008; 161(1): 105-8.
9. Tranulis C, Potvin S, Gourgue M, Leblanc G, Mancini-Marie A, Stip E. The paradox of quetiapine in obsessive-compulsive disorder. CNS Spectrums 2005;10(5): 356-61.
10. Mukhopadhaya K; Krishnaiah R; Taye T et al. Obsessive-compulsive disorder in UK clozapine-treated schizophrenia and schizoaffective disorder: a cause for clinical concern. Journal of Psychopharmacology 2009;23(1): 6-13.
11. Morrison D, Clark D, Goldfarb E, McCoy L. Worsening of obsessive- compulsive symptoms following treatment with olanzapine (letter). American Journal of Psychiatry 1998;155: 855.
12. Mottard JP, de la Sablonniere JF. Olanzapine-Induced Obsessive- Compulsive Disorder. American Juornal of Psychiatry 1999;156(5):