Obsessive-Compulsive Symptoms in Schizophrenia: A Clinical and Therapeutic Review

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According to recent research findings, almost 30% of patients with schizophrenia have obsessive compulsive symptoms (OCS).1 These studies have also identified 3 main contexts of emergence: prodromal symptoms of schizophrenia, co-occurrence of OCS and schizophrenia, and antipsychotic-induced OCS.1

A 2011 meta-analysis of 50 studies found that 12.1% of patients with schizophrenia also had obsessive compulsive disorder (OCD).2,3 These data were confirmed in a 2013 meta-analysis, which found a 12.3% prevalence of OCD and a 30.3% prevalence of OCS in this patient population.3 Based on these data, as well as a century of reports on the co-occurrence of OCS in schizophrenia,1 investigators have conducted a review summarizing the recent epidemiological, clinical, and therapeutic developments on the relationship between OCD, OCS, and schizophrenia diagnosis, published in Current Psychiatry Reports.1

Prodromal Symptoms of Schizophrenia

Many studies describing individuals at an ultrahigh risk for psychosis are clinically heterogenous,1,4 “dragging scientists to focus on clinical characteristics or dimensions that could impact the risk of transition to psychotic disorder, or broad clinical outcome[s] of [ultrahigh risk].”1 Certain definitions, including the Comprehensive Assessment of At Risk Mental State, note that OCS is a criterion of ultrahigh risk.5 Multiple studies examining cohorts of patients at ultrahigh risk found the prevalence of OCD between 8.4% and 20%.1

Studies performed with small sample sizes provided
insignificant results, such as 1 retrospective cohort study of 64 patients who
were at ultrahigh risk. Of these patients 20% had diagnosed OCD, and
researchers found a “nonsignificantly lower risk for psychotic transition
rate among [patients] with OCD” compared with the nonOCD group.1,6

This, as well as additional research, suggests that due to
the nature of OCS as a prodromal symptom of psychotic disorders, the presence
of OCS — particularly among young patients — should be an indicator for
the necessity of specific early intervention.1

“However, the specific clinical value of OCS in
comparison to other prodromal symptoms [remains] unknown, and more longitudinal
studies are needed on this topic,” researchers noted.1

OCS and Schizophrenia Co-Occurrence

It is key to differentiate obsessive symptoms from delusional ideas. Investigators of 1 study sought to assess the relationship between OCS and schizophrenia, with a particular focus on patients’ awareness of both disorders.7 Using the Brown Assessment of Beliefs Scale and the Scale to Assess Unawareness of Mental Disorder, researchers found that in a patient population with comorbid OCS and schizophrenia, only 15.8% of patients lacked insight about their OCS, while “43.8% were considered unaware of their [schizophrenia] diagnosis.”1,7 In a group of patients with schizophrenia, but without OCS, 60% of patients were unaware of their schizophrenia diagnosis.1 There was a positive correlation between OCS and schizophrenia awareness, but not with awareness of delusions.1,7

A number of studies have assessed the effect of a diagnosis
of OCS in conjunction with schizophrenia. A 2009 meta-analysis1 found
that OCS in schizophrenia was associated with a greater severity of global,
positive, and negative psychotic symptoms (standardized mean difference 0.39,
0.28, and 0.36, respectively). In a specific analysis of OCD, investigators did
not note any significant differences between groups, “suggesting that the
categorical definition of OCD seem[s] irrelevant to characterize the patients
with schizophrenia.”1,8

Several studies have examined the effect of OCS on the
depressive dimension in patients with schizophrenia. One study of 65 patients
identified a “positive correlation” between suicidality and OCS
intensity1,9 as measured with the Yale-Brown Obsessive Compulsive
Scale. Total scores were significantly correlated with depressive symptoms
— in particular, a score higher than 8 was considered a “significant
independent predictive factor of suicide attempt.”1,9

Two additional studies10,11 found that following
first-episode psychosis with the presence of OCD, patients were more likely to
demonstrate suicidal behaviors, plans, and attempts 1 month prior to
hospitalization.10 A longitudinal follow-up study of patients with
first-episode psychosis found that, among patients with OCS or OCD, those with
OCD “displayed more severe depressive symptoms at admission and during
follow up.”1,11

“Overall, OCS appeared reliably associated to
depressive symptoms and suicidality among patients with [schizophrenia],”
researchers noted. “[F]urther studies seem necessary to acknowledge the
impact of OCS on depressive symptoms in [schizophrenia].”1

In terms of global outcomes, OCS in schizophrenia has been
significantly associated with lower global functioning and reduced quality of
life.1 One 5-year longitudinal study11 found that
following first-episode psychosis, the presence of comorbid OCS and OCD was
linked with worse baseline social functioning, and was predictive of lower
global functioning at follow up.11

Antipsychotic-Induced OCS

Two studies12,13 are responsible for the observation of antipsychotic-induced OCS following clozapine treatment. Since these studies, a “large body of evidence” has developed implicating numerous second-generation antipsychotics in antipsychotic-induced OCS.1

One recent review specifically examined the relationship
between OCS and clozapine, olanzapine, and risperidone treatments,14
while another comprehensive review found that several months of clozapine
treatment resulted in OCS incidences of 76% within some study populations.15
A dose-response pattern may be at play, as researchers have identified a
positive correlation between OCS severity and plasma levels of clozapine and a
subsequent decrease in OCS after a decrease in clozapine dosage.1

However, researchers caution that although the dose-response
pattern of OCS and clozapine has been identified, reducing clozapine dosage may
increase the risk for psychotic exacerbation, therefore suggesting that this is
not a “reasonable therapeutic alternative.”1

Currently, a high dose of selective serotonin reuptake
inhibitors (SSRIs) is the first line pharmacological treatment for OCD.1
However, high resistance rates of 40% to 60% to SSRI treatments has been noted
among patients with OCD. Numerous studies have found that adjunctive
aripiprazole has a positive effect clozapine-induced OCS.1

In addition to pharmacological interventions, only 1 case
report examines the use of electro-convulsivo-therapy (ECT) in a patient with a
psychotic disorder with comorbid clozapine-induced OCD.16 Following
ECT, the patient showed an “immediate remission of OCS, correlated with
possibility of clozapine decrease through ECT-efficacy on psychotic symptoms.”1

Conclusions

“Taken together, the current literature provides various evidences for patterns of associations between OCS and [schizophrenia],” the researchers noted.1 “The main striking information appears that OCS could be considered as a severity marker in [schizophrenia]. Considering the importance of such association, the influence of OCS in [schizophrenia] needs to be polished through the results of large-scale longitudinal studies of patients.”1

References

1. du Montcel CT, Pelissolo A, Schürhoff F, Pignon B. Obsessive-compulsive symptoms in schizophrenia: an up-to-date review of literature. Curr Psychiatry Rep. 2019;21(8):64.

2. Fontenelle LF, Medlowicz MV, Versiani M. The descriptive epidemiology of obsessive-compulsive disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2006;30(3):327-337.

3. Swets M, Dekker J, van Emmerik-van Oortmerssen K, et al. The obsessive compulsive spectrum in schizophrenia, a meta-analysis and meta-regression exploring prevalence rates. Schizophr Res. 2014;152(2-3):458-468.

4. Fusar-Poli P, Cappucciati M, Borgwardt S, et al. Heterogeneity of psychosis risk within individuals at clinical high risk: a meta-analytical stratification. JAMA Psychiatry. 2016;73(2):113-120.

5. Yung AR, Yuen HP, McGorry PD, et al. Mapping the onset of psychosis: the comprehensive assessment of at-risk mental states. Aust N Z J Psychiatry. 2005;39(11-12):964-971.

6. Niendam TA, Berzak J, Cannon TD, Bearden CE. Obsessive compulsive symptoms in the psychosis prodrome: correlates of clinical and functional outcome. Schizophr Res. 2009;108(1-3):170-175.

7. Jacob ML, Larson MJ, Storch EA. Insight in adults with obsessive-compulsive disorder. Compr Psychiatry. 2014;55(4):896-903.
 

8. Baytunca B, Kalyoncu T, Ozel I, Eremis S, Kayahan B, Ongur D. Early onset schizophrenia associated with obsessive-compulsive disorder: clinical features and correlates. Clin Neuropharmacol. 2017;40(6):243-245.

9. Addington D, Addington J, Maticka-Tyndale E, Joyce J. Reliability and validity of a depression rating scale for schizophrenics. Schizophr Res. 1992;6(3):201-208.

10. Poyurovsky M, Faragian S, Kleinman-Blaush V, Pashinian A, Kurs R, Fuchs C. Awareness of illness and insight into obsessive-compulsive symptoms in schizophrenia patients with obsessive-compulsive disorder. J Nerv Met Dis. 2007;195(9):765-768.

11. Hagen K, Hansen B, Joa I, Larsen TK. Prevalence and clinical characteristics of patients with obsessive compulsive disorder in first-episode psychosis. BMC Psychiatry. 2013;13:156.
 

12. de Haan L, Linszen DH, Gorsira R. Clozapine and obsessions in patients with recent-onset schizophrenia and other psychotic disorders. J Clin Psychiatry. 1999;60(6):364-365.

13. Baker RW, Chengappa KN, Baird JW, Steingard S, Christ MA, Schooler NR. Emergence of obsessive compulsive symptoms during treatment with clozapine. J Clin Psychiatry. 1992;53(12):439-442.

14. Zink M. Comorbid obsessive-compulsive symptoms in schizophrenia: insight into pathomechanisms facilitates treatment. Adv Med. 2014;2014:317980.

15. Fonseka TM, Richter MA, Müller DJ. Second generation antipsychotic-induced obsessive-compulsive symptoms in schizophrenia: A review of the experimental literature. Curr Psychiatry Rep. 2014;16(11):510.

16. Tundo A, Necci R. Cognitive-behavioural therapy for obsessive-compulsive disorder co-occurring with psychosis: Systematic review of evidence.World J Psychiatry. 2016;6(4):449-455.

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