Obsessive compulsive symptoms associated with quetiapine treatment in a schizophrenic patient: a case report

Induced Obsessive Compulsive Symptoms (OCS) in schizophrenia patients under Atypical 2 Antipsychotics (AAPs): review and hypotheses

The prevalence of OCS and OCD is higher in schizophrenic patients than in the general population. These disorders are sometimes induced by AAPs. There is higher frequency of OCS and greater severity in patients treated with antipsychotics with predominant anti-serotoninergic profiles opposed to those with predominant dopaminergic blockade. Induced OCS may be due to complex neuromodulation involving many serotonin, dopamine and glutamate receptors and several subtypes. Concerning connectivity, AAPs differentially influence the BOLD signal, depending on the intensity of D2 receptor blockade. The OFC could play a significant role, on account of its involvement in inhibitory control. There is a paradox: AAPs are efficient as augmentation to SSRI in treatment resistant OCD, some of them such as risperidone or aripiprazole have favourable effects in schizoptypic OCD, but AAPs cause induced OCS in schizophrenic patients. When prescribing AAPs, we should inform patients about this potential side effect and assess systematically OCS with Y-BOCS assessment after 1 month of treatment. Afterwards there are different strategies: Aripiprazole in combination can reduce OCS induced by clozapine, SSRI are slightly effective and CBT shows a few encouraging results. OCS are sometimes dose-dependent, so we also recommend prescribing the minimum effective dose and gradual introduction.

Second generation antipsychotic-induced obsessive-compulsive symptoms in schizophrenia: a review of the experimental literature

Second generation antipsychotics (SGAs) have been implicated in the de novo emergence and exacerbation of obsessive-compulsive symptoms (OCS) in patients with schizophrenia. Among SGAs, clozapine, olanzapine, and risperidone are the most prominent agents associated with these sequelae, according to case reports. Comorbid OCS can impede recovery by compromising treatment benefits, medication compliance, and clinical prognoses. Previous reviews of SGA-induced OCS have predominantly focused on descriptive case reports, with limited attention paid toward experimental findings. To address this paucity of data, we sought to review the effects of SGAs on OCS in schizophrenia in the experimental literature, while addressing the role of different treatment (duration, dose, serum levels) and pharmacogenetic factors. Our findings suggest that clozapine confers the greatest risk of OCS in schizophrenia, with 20 to 28% of clozapine-treated patients experiencing de novo OCS, in addition to 10 to 18% incurring an exacerbation of pre-existing OCS. Clozapine can also yield full threshold obsessive-compulsive disorder (OCD), in some cases. Olanzapine is another high risk drug for secondary OCS which occurs in 11 to 20% of schizophrenic patients receiving olanzapine therapy. At this time, there is insufficient experimental evidence to characterize the effects of other SGAs on OCS. Despite some experimental support for the involvement of longer treatment duration and genetic factors in mediating drug-induced OCS, more research is needed to clearly elucidate these associations. Based on these results, schizophrenic patients should be routinely monitored for OCS throughout the course of SGA treatment, particularly when clozapine or olanzapine is administered.

Hypochondriasis and obsessive-compulsive disorder in schizophrenic patients treated with clozapine vs other atypical antipsychotics

OBJECTIVE

The aim of the study was to investigate the prevalence rates of obsessive-compulsive disorder (OCD) and hypochondriasis in schizophrenic patients treated with atypical antipsychotics (AAPs) and to investigate the different comorbidity rates of OCD and hypochondriasis between clozapine-treated patients and patients treated with other AAPs.

METHODS

We therefore recruited 60 schizophrenic patients treated with clozapine or other AAPs. We assessed the prevalence rates of OCD or OC symptoms and hypochondriasis or hypochondriac symptoms in the whole group of patients and in clozapine-treated patients versus patients treated with other AAPs.

RESULTS

Schizophrenic patients had a higher comorbidity rate of OCD (26.6% vs 1-3%) and hypochondriasis (20% vs 1%) than the general population. These comorbidities were more frequent in schizophrenic patients treated with clozapine versus patients treated with other AAPs (36.7% vs 16.7% and 33.3% vs 6.7%). Clozapine-treated patients showed a higher mean Y-BOCS and HY-BOCS score when compared to patients treated with other AAPs (10.90 vs 5.90, p = .099; 15.40 vs 8.93, p = .166). A statistical significant correlation was found between the Y-BOCS and HY-BOCS scores of the whole group (r = .378, p = 0.03). Furthermore, we found an inverse correlation between the global level of functioning and the diagnosis of hypochondriasis (p = .048) and the severity of hypochondriac symptoms (p = .047).

CONCLUSIONS

Hypochondriasis could represent an important clinical feature of schizophrenic patients treated with atypical antipsychotics, and further research is needed in this field.

Symptom structure of antipsychotic-induced obsessive compulsive symptoms in schizophrenia patients

OBJECTIVE

The use of clozapine or other second generation antipsychotics (SGAs) has been reported to produce obsessive compulsive (OC) symptoms as adverse mental affects. However, it is not yet clear if SGA-induced OC symptoms have the same phenomenological characteristics as those displayed in obsessive compulsive disorder (OCD). This study investigated the nature of symptoms and dimensions of SGA-induced OC symptoms in schizophrenia patients, which were then compared with those reported in pure OCD.

METHODS

The study subjects were fifty-one schizophrenia patients with SGA-induced OC symptoms. Symptom evaluation was performed using the Korean version of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Exploratory factor analysis of symptom categories of Y-BOCS symptom checklist (Y-BOCS-SC) was conducted.

RESULTS

Frequencies of individual symptom categories were comparable to those reported in Korean OCD patients. Five factors (forbidden thoughts, hoarding, cleaning, symmetry, and counting) were generated from 13 main symptom categories, which accounted for 70.7% of the total variance. This factor structure is also remarkably similar to those reported in pure OCD patients. The factor score of 'cleaning' was significantly correlated with the overall severity of OC symptoms (P<0.01).

CONCLUSION

A high level of similarity between the nature of symptoms and dimensions identified in patients with SGA-induced OC symptoms and those revealed in OCD patients suggests a common biological mechanism underlying these two clinical conditions.

Obsessive-compulsive symptoms in schizophrenia: prevalence, clinical features and treatment. A literature review

OBJECTIVES

To investigate the prevalence of obsessive-compulsive symptoms in schizophrenia, the clinical features of the sub-group of patients with schizophrenia and obsessive-compulsive symptoms and treatment options for these patients.

METHOD

A literature review of studies investigating the prevalence, clinical features and treatment of patients with schizophrenia and obsessive-compulsive symptoms.

RESULTS

The prevalence of obsessive-compulsive symptoms in schizophrenic patients, while generally found to be higher than in the general population, varies widely between different studies. Differences in symptom severity between schizophrenic patients with obsessive-compulsive symptoms and those without have been found, however findings so far have been inconsistent. A number of case reports have implicated atypical antipsychotic medication in the emergence of obsessive-compulsive symptoms. There is evidence to support a combined treatment with an antipsychotic agent and an anti-obsessional agent.

CONCLUSION

Studies investigating the prevalence of obsessive-compulsive symptoms in schizophrenia and their effect on the clinical symptoms have yielded inconsistent results and further studies using larger samples of patients and looking at different subgroups of schizophrenic patients are required. Treatment options need further research to investigate whether the results of relatively small studies can be replicated.

Obsessive-compulsive disorder comorbidity: clinical assessment and therapeutic implications

Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder affecting approximately 1-3% of the population. OCD is probably an etiologically heterogeneous condition. Individuals with OCD frequently have additional psychiatric disorders concomitantly or at some time during their lifetime. Recently, some authors proposed an OCD sub-classification based on comorbidity. An important issue in assessing comorbidity is the fact that the non-response to treatment often involves the presence of comorbid conditions. Non-responsive patients are more likely to meet criteria for comorbid axis I or axis II disorders and the presence of a specific comorbid condition could be a distinguishing feature in OCD, with influence on the treatment adequacy and outcome.

Obsessive-compulsive disorder in UK clozapine-treated schizophrenia and schizoaffective disorder: a cause for clinical concern

The association between schizophrenia and obsessive-compulsive disorder (OCD) is complex. This study systematically examined a UK cohort of clozapine-treated individuals with schizophrenia/schizoaffective disorder. Fourteen of 59 cases (24%) scored positively on item H of the Mini-International Neuropsychiatric Interview (MINI) for OCD. The mean Yale- Brown Obsessive-Compulsive Scale (Y-BOCS) score in MINI-positive cases was 17.6 (SD+/-6.3). Sixty-four percent scored 16 or more on the Y-BOCS, representing clinically meaningful illness severity. Seven (50%) patients with OCD had previously received the diagnosis by their treating clinicians and were already receiving with selective serotonin re-uptake inhibitors (SSRIs) treatment. OCD cases scored significantly worse than their non-OCD counterparts on the Abnormal Involuntary Movement Scale (P=0.01) and the Simpson Angus Scale (SAS; P=0.01). There was also a non-significant trend toward higher ratings for OCD cases on the Clinical Global Impression-Schizophrenia scale (P=0.06). Comparing the OCD cases taking SSRI (n=7) with those not on SSRI (n=7), significant differences emerged on the SAS (P=0.03). Our results suggest that OCD is common among patients receiving clozapine for schizophrenic disorders and that the comorbidity is associated with greater motoric impairment. The role of medication in this condition remains unclear.

Neurobiology confirms psychopathology. On the antagonism of psychosis and obsessive-compulsive syndromes

BACKGROUND

Psychopathological concepts of the 19th and early 20th century postulated an antagonism between psychotic and obsessive-compulsive disorders, assuming obsessions and compulsions to have protective effects on psychotic disintegration. Although both disorders have been subject to intense multimodal research, their pathogeneses are yet to be fully understood.

METHODS

Here, we discuss recent neurobiological findings pointing towards opposite directions which are strongly reminiscent of the historical psychopathological antagonism.

RESULTS

Obsessive-compulsive syndromes (OCS) are efficiently treated with serotonergic substances, while on the other hand modern antipsychotic drugs exert antiserotonergic effects. Especially these atypical antipsychotic substances, however, were found to involve the risk of inducing second-onset OCS. Dopamine antagonists are potent antipsychotic substances, whereas the partial dopamine agonist aripiprazole has been associated with an antiobsessive potency. Within the glutamatergic system, reduced NMDA-dependent glutamatergic neurotransmission is discussed to be one major pathomechanism of psychotic disorders, whilst NMDA antagonists have proven to be effective in improving treatment-resistant OCS. While neurogenetic findings seem to separate the populations in heterogeneous samples, detailed neuroimaging studies suggest that both disorders affect similar neurocircuits in different manners.

CONCLUSIONS

With regard to these findings, future research on schizo-obsessive syndromes will have to be multimodal, integrating psychopathology, neuropsychology, functional imaging, neurogenetics and psychopharmacology. Prospective trials involving these methods might be able to elucidate the dysbalances of neurotransmission and to locate the neuroanatomical and neuropsychological correlates. In particular, this might contribute to defining schizophrenic patients at risk for developing second-onset OCS and to evaluating new treatment strategies in patients suffering from both psychosis and OCS.