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

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 intensity^1,9 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 studies^10,11 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 studies^12,13 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

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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.