Clinical profile of schizophrenia comorbid with obsessive-compulsive symptoms: A comparative study

OBJECTIVE

Describe and compare the clinical profile of schizophrenic patients with and without obsessive-compulsive symptoms and obsessive-compulsive disorder (OCD) patients.

METHODS

A descriptive and analytical cross-sectional study was carried out at the psychiatry department of Hassan II University Hospital in Fez over 12 months to compare three groups of patients: "schizo-obsessive" (n=32), "schizophrenia" (n=34), and "OCD" (n=46). All participants (n=112) were assessed using the mini-international neuropsychiatric interview (MINI), the Yale-Brown obsessive-compulsive scale (Y-BOCS), the Brown assessment of beliefs scale (BABS), the Hamilton anxiety rating scale (HAM-A), the Beck's depression inventory (BDI-II), the positive and negative syndrome scale (PANSS), and the clinical global impressions-severity scale (CGI-S).

RESULTS

The "schizo-obsessive" group differed from the "schizophrenia" group in: more severe psychotic symptoms (mean=64.16±17.049, P<0.001), higher anxiety (mean=8.87±5,655, P<0.001) and depression (mean=7.50±5.989, P<0.001) scores, more prevalent suicide attempts (46.9%), higher illness severity score (mean=5.13±1.157, P=0.02), and more professional disinsertion (78.1%). The "schizo-obsessive" group (mean= 14.47±3.388) had significantly poor insight (P<0.001) compared to the "OCD" group (mean= 8.35±4.542). There were similarities in the obsessive and compulsive themes between the "schizo-obsessive" and the "OCD" groups, with no significant difference of severity (P=0.26).

CONCLUSION

A careful assessment of obsessive symptomatology is essential in schizophrenia for better patient management and prognosis.

Obsessive-compulsive symptoms in schizophrenia patients and their first-degree relatives and the association with subclinical psychotic symptoms

OBJECTIVE

This study aimed to investigate the presence of obsessive-compulsive symptoms (OCS) in patients being followed for schizophrenia and their first-degree relatives (mother, father, siblings, and children) and the relationship between OCS and clinical/subclinical psychotic symptoms.

MATERIALS AND METHODS

The study included 110 schizophrenia patients followed up in a community mental health center and their first-degree relatives. Patients and relatives were evaluated using the SCID-I (Structured Clinical Interview Form for DSM-IV Axis-I Disorders) to ascertain their diagnosis and exclude other axis-I diagnoses. The Yale-Brown Obsessive Compulsive Scale was used to measure OCS severity. Psychotic symptom severity was evaluated in patients using the Positive and Negative Syndrome Scale (PANSS) and subthreshold psychotic symptoms and psychosis proneness were assessed in relatives using the Schizotypal Personality Questionnaire.

RESULTS

The prevalence of clinically significant OCS was 41.8% in schizophrenia patients and 28.2% in their relatives. PANSS positive and general psychopathology subscale scores were higher in patients with OCS. Suspiciousness and interpersonal schizotypy scores were significantly higher in relatives with OCS compared to those without. The first-degree relatives of patients with OCS did not exhibit a higher prevalence of OCS or psychotic symptoms compared to the relatives of patients without OCS.

CONCLUSION

Our study demonstrates that obsessive-compulsive phenomena are common in schizophrenia patients and their relatives. Although there seems to be a positive association between OCS and psychotic symptoms in patients and their first-degree relatives, the intergenerational transmission of these two symptom groups may occur independently.

Structural brain imaging studies offer clues about the effects of the shared genetic etiology among neuropsychiatric disorders

Genomewide association studies have found significant genetic correlations among many neuropsychiatric disorders. In contrast, we know much less about the degree to which structural brain alterations are similar among disorders and, if so, the degree to which such similarities have a genetic etiology. From the Enhancing Neuroimaging Genetics through Meta-Analysis (ENIGMA) consortium, we acquired standardized mean differences (SMDs) in regional brain volume and cortical thickness between cases and controls. We had data on 41 brain regions for: attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), bipolar disorder (BD), epilepsy, major depressive disorder (MDD), obsessive compulsive disorder (OCD), and schizophrenia (SCZ). These data had been derived from 24,360 patients and 37,425 controls. The SMDs were significantly correlated between SCZ and BD, OCD, MDD, and ASD. MDD was positively correlated with BD and OCD. BD was positively correlated with OCD and negatively correlated with ADHD. These pairwise correlations among disorders were correlated with the corresponding pairwise correlations among disorders derived from genomewide association studies (r = 0.494). Our results show substantial similarities in sMRI phenotypes among neuropsychiatric disorders and suggest that these similarities are accounted for, in part, by corresponding similarities in common genetic variant architectures.

Comorbidity in Schizophrenia: Conceptual Issues and Clinical Management

Schizophrenia is a complex psychiatric disorder that affects cognitive, perceptual, and emotional functioning. The currently available evidence suggests heterogenous intertwining of biological and psychosocial etio-pathogeneses. Clinical and research interests in the comorbidity issues of schizophrenia were borne out of the real-world clinical challenges that patients often present with multiple coexisting psychopathologies as well as comorbid medical conditions. The recent DSM-5 shift toward a symptom dimensional-based perspective, the NIMH Research Domain Criteria (RDoC) initiative to examine biopsychosocial pathogeneses in mental illness, and the FDA's emphasis on real world-based clinical trial criterion all have promoted a shift in clinical research that has facilitated understanding and treatment of comorbidity in schizophrenia. This emerging conceptual shift as well as pharmacological developments that address the multidimensional pathogeneses in schizophrenia may pave the way for a better understanding and treatment.

The Bed Nucleus of the Stria Terminalis, Homeostatic Satiety, and Compulsions: What Can We Learn From Polydipsia?

A compulsive phenotype characterizes several neuropsychiatric illnesses - including but not limited to - schizophrenia and obsessive compulsive disorder. Because of its perceived etiological heterogeneity, it is challenging to disentangle the specific neurophysiology that precipitates compulsive behaving. Using polydipsia (or non-regulatory water drinking), we describe candidate neural substrates of compulsivity. We further postulate that aberrant neuroplasticity within cortically projecting structures [i.e., the bed nucleus of the stria terminalis (BNST)] and circuits that encode homeostatic emotions (thirst, hunger, satiety, etc.) underlie compulsive drinking. By transducing an inaccurate signal that fails to represent true homeostatic state, cortical structures cannot select appropriate and adaptive actions. Additionally, augmented dopamine (DA) reactivity in striatal projections to and from the frontal cortex contribute to aberrant homeostatic signal propagation that ultimately biases cortex-dependent behavioral selection. Responding becomes rigid and corresponds with both erroneous, inflexible encoding in both bottom-up structures and in top-down pathways. How aberrant neuroplasticity in circuits that encode homeostatic emotion result in the genesis and maintenance of compulsive behaviors needs further investigation.

Schizo-obsessive spectrum disorders: an update

The presence of obsessive-compulsive symptoms (OCS) and obsessive-compulsive disorders (OCD) in schizophrenia is frequent, and a new clinical entity has been proposed for those who show the dual diagnosis: the schizo-obsessive disorder. This review scrutinizes the literature across the main academic databases, and provides an update on different aspects of schizo-obsessive spectrum disorders, which include schizophrenia, schizotypal personality disorder (SPD) with OCD, OCD with poor insight, schizophrenia with OCS, and schizophrenia with OCD (schizo-obsessive disorder). An epidemiological discussion on the discrepancies observed in the prevalence of OCS and OCD in schizophrenia across time is provided, followed by an overview of the main clinical and phenomenological features of the disorder in comparison to the primary conditions under a spectral perspective. An updated and comparative analysis of the main genetic, neurobiological, neurocognitive, and pharmacological treatment aspects for the schizo-obsessive spectrum is provided, and a discussion on endophenotypic markers is introduced in order to better understand its substrate. There is sufficient evidence in the literature to demonstrate the clinical relevance of the schizo-obsessive spectrum, although little is known about the neurobiology, genetics, and neurocognitive aspects of these groups. The pharmacological treatment of these patients is still challenging, and efforts to search for possible specific endophenotypic markers would open new avenues in the knowledge of schizo-obsessive spectrum.

Associations of obsessive-compulsive symptoms with clinical and neurocognitive features in schizophrenia according to stage of illness

This study aimed to investigate the association of obsessive-compulsive symptoms with clinical and neurocognitive features in patients with schizophrenia. This study enrolled 163 people with schizophrenia who were receiving risperidone monotherapy. Comorbid obsessive-compulsive symptoms were assessed using the Yale-Brown Obsessive-Compulsive Scale, and subjects with a score ≥ 10 constituted the obsessive-compulsive symptom group (n=30, 18.4%). The learning index was significantly higher in patients with obsessive-compulsive symptoms than in those without such symptoms after adjusting for age, stage (early and chronic), duration of illness, and CDSS score. However, there was no significant interaction between obsessive-compulsive symptoms and stage of illness. Scores on Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, and Beck Depression Inventory were significantly higher in the obsessive-compulsive symptom group. In addition, the Subjective Well-being under Neuroleptic Treatment score was significantly lower in the obsessive-compulsive symptom group. In conclusion, comorbid obsessive-compulsive symptoms in patients with schizophrenia were associated with a higher learning ability without a significant interaction with stage of illness. However, schizophrenia patients with obsessive-compulsive symptoms had more severe psychotic and depressive symptoms and poorer quality of life.

Do the obsessive-compulsive symptoms have an effect in schizophrenia?

OBJECTIVE

Schizophrenia presents with different symptom domains and functionality during its course. Obsessive-compulsive (OC) symptoms in schizophrenia have many themes to be clarified. Our aim was to compare schizophrenia patients with and without OC symptoms in terms of symptom domains, cognitive functions, and quality of life.

METHOD

Sixty-two patients who met schizophrenia diagnosis were assessed with Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition consecutively over a period of 12 months in the setting of an outpatient clinic at medical university hospital. Yale-Brown Obsessive-Compulsive Scale, Scale for the Assessment of Negative Symptoms, Scale for the Assessment of Positive Symptoms, and neuropsychologic tests were used. Quality of life was assessed with Quality of Life Scale for Patients with Schizophrenia.

RESULTS

Obsessive-compulsive symptoms along with schizophrenia were present in a considerable number in our sample (35.5%). Level of psychotic symptoms was more severe and quality of life was lower in schizophrenia patients with OC symptoms. A positive correlation was found between obsessions and delusions. Moreover, there was a positive correlation between compulsions and total Scale for the Assessment of Positive Symptoms score and bizarre behaviors subscore. There was no difference between the 2 groups regarding neurocognitive functions. The level of quality of life of schizophrenic patients with OC symptoms was lower. Besides, no correlation was found between OC symptoms and neurocognition and quality of life.

CONCLUSIONS

The findings of this study indicate that schizophrenia patients with OC symptoms had severe psychotic symptoms with a distinctive clinical picture including good neurocognition but poor functioning.

The neuropsychology of the schizo-obsessive subtype of schizophrenia: a new analysis

BACKGROUND

Interest in the neuro-cognitive profile of patients with schizophrenia and co-morbid obsessive compulsive disorder (schizo-OCD) is rising in response to reports of high co-morbidity rates. Whereas schizophrenia has been associated with global impairment in a wide range of neuro-cognitive domains, OCD is associated with specific deficits featuring impaired performance on tasks of motor and cognitive inhibition involving frontostriatal neuro-circuitry.

METHOD

We compared cognitive function using the CANTAB battery in patients with schizo-OCD (n=12) and a schizophrenia group without OCD symptoms (n=16). The groups were matched for IQ, gender, age, medication, and duration of illness.

RESULTS

The schizo-OCD patients made significantly more errors on a task of attentional set-shifting (ID-ED set-shift task). By contrast, no significant differences emerged on the Stockings of Cambridge task, the Cambridge Gamble Task or the Affective Go/NoGo tasks. No correlation emerged between ID-ED performance and severity of schizophrenia, OCD or depressive symptoms, consistent with neurocognitive impairment holding trait rather than state-marker status. Schizo-obsessives also exhibited a trend toward more motor tics emphasizing a neurological contribution to the disorder.ConclusionOur findings reveal a more severe attentional set-shifting deficit and neurological abnormality that may be fundamental to the neuro-cognitive profile of schizo-OCD. The clinical implications of these impairments merit further exploration in larger studies.

Management of schizophrenia with obsessive-compulsive features

Although obsessive-compulsive symptoms (OCS) in schizophrenia have been conceptually controversial and clinically challenging, recent evidence suggests that schizophrenia with OCS may constitute a distinct schizophrenic subgroup. Recent epidemiological and clinical findings have shown that the subgroup obsessive-compulsive (OC) schizophrenia is associated with poor outcome and is more frequent than previously realized. Emerging biological evidence suggests that OCS in schizophrenia has more than one pathogenesis, with distinct mechanisms that may require different treatment interventions. Therefore, the management of OCS in patients with schizophrenia requires an individualized treatment approach based on the pathogenesis and clinical status of the patient. For example, the atypical antipsychotics that are potent serotonin antagonists sometimes induce de novo or exacerbate preexisting OCS, which resolves if the patient is switched to an antipsychotic with a different profile or if adjunctive treatment with serotonin reuptake inhibitors (SSRIs) is undergone. Regarding OC schizophrenia, SSRIs are often a necessary part of treatment, with knowledge of potential pharmacokinetic interactions with antipsychotic drugs essential. In this article, recent progress and current knowledge of OC schizophrenia is reviewed and treatment guidelines are offered for this complex and challenging subgroup of schizophrenic patients.

Schizophrenia and eating disorders

Schizophrenia requires diverse and individualized treatment approaches. Accurate identification and management of comorbid psychiatric syndromes determine outcome. Disturbances in eating and the distorted perception of body image are difficult to separate from other psychotic phenomena. Eating is a complicated integration of psychoneuroendocrinology. Despite the difficulties in defining the distinction between behaviors and cognitive perceptions that are and are not of diagnosable severity, there are patients with clearer coexistence of eating disorders and schizophrenia that carry on independent courses. This article presents clinical cases that portray a spectrum of eating pathology in patients with schizophrenia.

Comparative Analysis of Cognitive Function in Schizophrenia with and without Obsessive Compulsive Disorder

OBJECTIVE

We investigated the neurocognitive deficits in schizophrenic patients with and without obsessive-compulsive disorder (OCD).

METHODS

We grouped 27 patients as either obsessive-compulsive or non-obsessive-compulsive based on the presence of OCD. The two groups completed the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Positive and Negative Symptom Scale (PANSS), and Hamilton Depression Scale. The intelligence quotient (IQ) was tested using the Korean Wechsler Adult Intelligence Scale. The memory quotient (MQ) was tested using the Korean-Auditory Verbal Learning and Korean-Complex Figure Test. The executive intelligence quotient (EIQ) was determined using the Kims executive intelligence test (EXIT).

RESULTS

Ten of the 27 patients had OCD. The compulsion score of Y-BOCS was positively correlated with positive symptoms, negative symptoms, and the total scores of PANSS. The OCD-schizophrenia patients had higher IQs. No difference was found in MQ. Although the EIQ did not differ between the two groups, the OCD-schizophrenia patients performed better at the Stroop-interference and verbal fluency tests, which was highly dependent on executive function.

CONCLUSION

Our findings suggest that OCD may have a protective effect on some cognitive function, at least in relatively early stage of illness. Moreover, based on clinical, neurocognitive features, schizophrenia with OCD could be considered as a distinct subtype of schizophrenia.

Schizo-obsessive and obsessive-compulsive disorder: comparison of clinical characteristics and neurological soft signs

The purpose of the study was to examine whether schizophrenia with obsessive-compulsive disorder (OCD) represents a severe form of OCD-spectrum disorders on the basis of neurological soft signs (NSS) and obsessive-compulsive (OC) symptoms. Sixteen patients with OCD-schizophrenia, 25 OCD patients and 23 healthy controls (HC) were studied. Scales for the Assessment of Positive (SAPS) and Negative Symptoms (SANS), Clinical Global Impressions Scale and Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) were used to assess the schizophrenic and OC symptomatology. NSS were evaluated with the Neurological Evaluation Scale (NES). OCD-schizophrenics had significantly higher scores on total NES than HC. The patients with OCD were more likely to have total Y-BOCS and subscale scores of compulsions than patients with OCD-schizophrenia. The rate of symmetry obsessions and cleaning/washing compulsions were significantly higher in patients with OCD compared to OCD-schizophrenics. We have found no correlation of OC symptoms with schizophrenic symptomatology. Our findings may suggest that OCD-schizophrenia is a distinct subtype of schizophrenia, not a more severe form of OCD-spectrum disorder.

Obsessive and compulsive symptoms in schizophrenia: a randomized controlled trial with fluvoxamine and neuroleptics

Obsessive-compulsive-related disorders are frequently comorbid with schizophrenia. The existence of obsessive and compulsive symptoms in patients with schizophrenia represents one of the most severe types of psychotic disorders and may predict a poor prognosis in most cases. Previous pilot studies and case reports have shown that the condition of some patients with schizophrenia did not exacerbate and even improved when serotonin reuptake inhibitors (SSRIs) were added to their standard neuroleptic regimen. The aim of this study was to evaluate the efficacy of a combination treatment of an SSRI (fluvoxamine) and standard neuroleptics for the treatment of obsessive-compulsive (OC) symptomatology in patients with schizophrenia compared with administration of neuroleptics only. Thirty inpatients who met DSM-IV criteria for schizophrenia and also had prominent OC symptoms were randomly divided into two groups. Fourteen patients were treated with conventional neuroleptics and fluvoxamine in doses of 100 to 200 mg/day for 8 weeks. Sixteen patients comprised a control group and received only their previous therapeutic neuroleptic therapy. The patients were assessed using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the Positive and Negative Syndrome Scale (PANSS), and the Clinical Global Impression Scale (CGI) at baseline and endpoint. Side effects were assessed weekly. The data were analyzed using an analysis of variance. A considerable reduction in PANSS (34.3%) and Y-BOCS (29.4%) scores was noted, and CGI scores decreased moderately in both groups. None of the patients showed an acute exacerbation at the end of the study. Side effects were mild and easily tolerated in most patients. This open, randomized, controlled study reveals that coadministration of fluvoxamine, an SSRI, and neuroleptics in patients with schizophrenia and OC symptoms was associated with specific improvements of these symptoms. Thus, the use of an SSRI in treating a patient with schizophrenia and OC symptomatology may be warranted and safe. Other implications of the findings, including general safety of the combined pharmacotherapy and the use of new antipsychotic medications, are also discussed.

Obsessive-compulsive disorder among schizophrenic patients: an exploratory study using functional magnetic resonance imaging data

Despite the growing research on the etiology of obsessive-compulsive disorder (OCD), and schizophrenia, the clinical distinction between the two disorders is not clearly understood. In the present investigation, we sought to better understand the relationship between OCD and psychotic disorders by examining functional magnetic resonance imaging (fMRI) data from a group of schizophrenic patients with varying degrees of OCD symptomatology, based on results of the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the National Institute of Mental Health (NIMH) rating scales of OCD. While subjects performed a cognitive challenge paradigm that included a verbal fluency task, activation data from the left dorsolateral prefrontal cortex were collected and analyzed. We hypothesized that the fMRI signal patterns in schizophrenic patients with high levels of OCD symptomatology would differ from that of schizophrenic patients with a low level of OCD. For the group as a whole, no significant relationship was found for scores of either rating scale and fMRI signal change; however, a significant association was found for a subgroup of patients. For these schizophrenics, there was a negative relationship between OCD symptomatology and activation of the left dorsolateral prefrontal cortex. These results support the suggestion of several researchers that a relationship between OCD severity and neurophysiological activity exists in schizophrenia.