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
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
“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
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