Transition from Obsession to Delusion in Schizo-obsessive Disorder: A Case Report and Literature Overview

| July 1, 2018 | 0 Comments

By Estevão Scotti-Muzzi, MD, MS, and Osvaldo Luis Saide, MD, PhD

Drs. Scotti-Muzzi and Saide are with the Psychiatry Unit, Pedro Ernesto University Hospital, State University of Rio de Janeiro, Brazil.

Funding: No funding was provided.

Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Abstract: Schizo-obsessive disorder has been proposed to classify those who show schizophrenia and obsessive compulsive disorder (OCD) diagnoses. This subgroup has recently shown to be much more prevalent than previously thought, as well as presenting distinct clinical, phenomenological and neurobiological features from the parental diseases. We present a case report of a 32-year-old man who first manifested obsessive-compulsive symptoms (OCS) in his early twenties, followed by emergence of consistent negative schizophrenia symptoms, as well as intermittent aggressive behavior. After some years, there was a de novo manifestation of OCS followed by a transition of an obsession into delusion. Hence, we provide a brief and updated literature overview on the delusional transition of obsessions. For that, we searched the literature across the main academic databases for relevant articles on such a phenomenon until early 2017. This case report demonstrates a transition of a consistent obsession into an over-evaluated idea in a schizo-obsessive patient, associated with a decrease of the insight. There is evidence in the literature demonstrating that the transition of an obsessive symptom into a psychotic symptom, albeit rare, seems to be modulated by the presence and extent of insight and a sign of poor prognosis in the schizo-obsessive spectrum.

Keywords: Comorbidity, insight, obsessive-compulsive disorder, schizophrenia

Innov Clin Neurosci. 2018;15(7–8):23–26

The co-occurrence of psychotic and obsessive-compulsive symptoms (OCS) has been noted since the 19th century, with low prevalence rates ranging from 1 to 3.5 percent.[1] Nevertheless, more recent studies have consistently found a much higher prevalence of both OCS (25%) and OCD (12%) in patients with schizophrenia.[2] The schizo-obsessive spectrum, comprising OCD, OCD with poor insight, OCD with schizotypal personality disorder, schizophrenia with obsessive-compulsive symptoms, schizophrenia with OCD, and pure schizophrenia, has been proposed[3] in which these conditions show clinical, phenomenological, genetic, neurobiological, and neurocognitive similarities.[4]

Within this spectrum, schizo-obsessive disorder has been proposed as a diagnosis for those who exhibit symptoms of schizophrenia and OCD.[5] In addition to occurring at a considerably higher than expected rate,[6] schizo-obsessive disorder has distinct clinical, neurobiological and neurocognitive features from both schizophrenia and OCD.[4] Furthermore, schizo-obsessive disorder shows a familial aggregation pattern, in that the probands of this group of patients show a greater likelihood of being diagnosed with obsessive-compulsive personality disorder or OCD itself compared with the probands of patients with schizophrenia alone.[7]

Here, we present the case of a patient who experienced intermittent symptoms of OCD and symptoms of schizophrenia over the course of several years, with obsessive egodystonic ideation eventually transitioning into delusional egosyntonic and over-valued ideation. We describe the patient’s disease progression and treatment, propose diagnoses, and discuss the longitudinal dynamics between OCS and schizophrenia.

Case Report

LD was an unemployed, high school-educated, 32-year-old man from Rio de Janeiro, Brazil. He had a brother and a sister and lived with his mother; his father passed away when he was 20 years old. After his father’s death, the patient began exhibiting OCS, such as repetitive hand washing, organizing objects in symmetrical order, and checking. The patient and his mother also reported that he became aggressive, particularly toward his mother, which prompted his first hospital admission. After this first hospital admission and based on subsequent medical consultations, paroxetine, fluoxetine, chlorpromazine, haloperidol, pimozide, and clonazepam were prescribed to the patient, which he took irregularly.

Over the next few years, the patient exhibited less obsessive-compulsive behaviors, but became particularly disorganized. By age 23, the patient had become unconcerned with tidiness and cleanliness and lost interest in activities that he had once enjoyed, isolating himself in his room and neglecting self-care. He also began exhibiting hetero-aggressive behavior, which resulted in another hospitalization. He was discharged, after nearly a month of inpatient treatment, on risperidone 4mg/day, fluoxetine 40mg/day, and clonazepam 4mg/day. Following this discharge, LD regularly attended an outpatient private psychiatric clinic and remained stable on his medications for the next several years.

At the age of 28, the patient presented to our hospital facilities for outpatient treatment due to intrusive thoughts regarding enrollment in a technical course on electronics. He had enrolled in the course but stopped attending classes a few months later due to poor academic performance. Ruminant and intrusive thoughts regarding the course remained, however, causing depressed mood and anxiety.

An assessment of his family history revealed a cousin with diagnosed schizophrenia and an aunt thought to have been diagnosed with OCD. Additionally, according to LD and his mother, his father had often exhibited eccentric behavior, with a strong interest in mystic and esoteric issues, as well as OCD behavior, such as being very concerned with symmetries and organization. These reported observations suggest to us that the father had schizotypal personality disorder; however, he never received a formal psychiatric diagnosis.

Treatment course. During the next six months of LD’s outpatient treatment with our clinic, the patient was maintained on risperidone 4mg/day and fluoxetine 40mg/day, as well as clonazepam 4mg/day due to marked symptoms of anxiety. However, the patient reported that he continued to have obsessive thoughts regarding studying electronics, which were persistent, intrusive, unwanted, and egodystonic, causing him distress and agitation. The patient reported that he could not ignore or prevent such thoughts from occurring, but he denied using compulsive or ritualistic behaviors to suppress them. It is important to note that the patient showed insight regarding these obsessive thoughts. Fluoxetine was titrated up to 80mg/day, but due to lack of response, we switched our patient to clomipramine (titrated up 200mg/day), which he tolerated well.

We observed a gradual improvement over the next three months in the patient’s OCS in that he no longer restricted his conversations to discussion of the electronics course. It took an additional nine months for the patient to achieve clinical stability, after which he remained stable for another year on clomipramine 200mg/day and risperidone 4mg/day. The patient, however, reported no improvement in anhedonia, apathy, or avolition.

While LD’s symptoms of obsessive, intrusive thinking improved, he became particularly worried about being unemployed and began exhibiting delusional ideation. Specifically, he refused to act on our recommendation to apply for medical disability, claiming his “girlfriend” would not approve of it. His mother, however, denied he had a girlfriend, reporting that LD had become convinced that a kindly neighbor was his girlfriend, which was not the case. The patient continued refusing to apply for medical disability over concern that the hypothetical girlfriend would not approve of him doing so, and no argument to the contrary was accepted by the patient. Unlike with his OCS, the patient appeared to have no insight into his delusional thinking. At this point, we increased the risperidone to 8mg/day, and, due to lack of response, we then switched him to olanzapine, titrated up to 15mg/ day. There was some reduction in the frequency and intensity of his over-valued ideation, and his OCS remained manageable and stable through his last follow-up visit.

Case Discussion

Our patient’s first psychopathological features manifested in his early 20s after his father’s death. At that time, the patient experienced OCS related to cleanliness, symmetries, organization, and checking, which consumed most his time. Thus, we can retrospectively presume a diagnosis of OCD would have been appropriate. Indeed, some years later, the patient again began manifesting strong obsessive ideation related to taking electronics courses, which became intrusive, perseverative, unwanted, unsuccessfully resisted, time-consuming, and distressful, significantly worsening the patient’s social functioning. The patient maintained insight into these symptoms.

Concomitant with improvement in OCS, negative schizophrenia symptoms began to manifest in our patient, such as hypobulia, anhedonia, social withdrawal, apathy, and avolition. The patient also experienced worsening of behavioral issues—in particular, hostility, psychomotor agitation, and hetero-aggression, which are typical symptoms of schizophrenia.

Based on the patient’s significant negative, affective, and cognitive symptoms of schizophrenia in addition to OCS, we settled on a diagnosis of schizo-obsessive disorder.[4,8] Schizo-obsessive disorder is a putative new clinical entity that manifests in individuals with dual diagnoses of schizophrenia and OCD.[8] According to Schirmbeck and Zink,[5] OCS can appear at any stage of psychosis, but more commonly is a prodromal manifestation in schizophrenia that can fluctuate or remain consistent throughout the course of illness. Similar to a report by Faragian et al,[9] OCS initially manifested in our patient at the prodromal stage of his schizophrenic illness, and, later, manifested more strongly and consistently with the emergence of negative symptoms of schizophrenia. Our patient consistently exhibited negative symptoms of schizophrenia, particularly anhedonia, apathy, and avolition; which is in line with the findings of several authors who report that patients who are schizo-obsessive exhibit worse negative symptoms than those solely diagnosed with schizophrenia.[10,11]

After his first psychopathological symptoms appeared, our patient experienced several episodes of aggression. The literature supports the findings that patients with schizo-obsessive traits tend to be more hostile and more anxious, present a higher incidence of hospitalization, exhibit greater dysfunction and social impairment, maintain smaller social networks, and exhibit poorer quality of life, in comparison with patients who have a diagnosis of schizophrenia alone.[12-14] We observed these aggressive characteristics in our patient, which corroborates with the finding that OCS has a deleterious effect on schizophrenia outcome.[15]

Although our patient initially did not manifest any positive symptoms typical of schizophrenia, such as hallucinations and delusions, he appeared to transition from obsessive to over-valued ideations. His obsession related to taking electronics courses was egodystonic, in that the patient was aware of its inaccuracy and symptomatic nature, which caused him resistance and emotional distress; however, the false belief about having a girlfriend and the fragile association of this belief with the refusal to seek government disability aid was an over-valued idea that was egosyntonic.

Several years after his first episode of OCS, he experienced a resurgence of OCS with a concomitant emergence of psychotic, egosyntonic over-valued ideation. Such progression has also been noted by Fontenelle et al.[16] Jacob et al[17] considered poor insight an epiphenomenon of OCD severity, which can modulate the conversions within the schizo-obsessive spectrum disorders.[4] This observed phenomenon corroborates the putative protective role of OCS against psychosis, as classically proposed.[1,18] OCS might have retarded the emergence of our patient’s psychotic symptoms initially; however, the negative and cognitive symptoms of schizophrenia remained fairly constant once they manifested, and while the patient’s over-valued ideation improved somewhat on olanzapine, his negative symptoms remained unresponsive to both olanzapine and risperidone. Negative symptoms that are refractory to antipsychotic treatment is a well-documented phenomenon among those individuals within the schizo-obsessive disorder spectrum,[10,11] as is poorer cognitive functioning, when compared with individuals solely diagnosed with schizophrenia.[5]

Our patient’s OCD was nonresponsive to fluoxetine, an SSRI, but showed good response to clomipramine, a tricyclic, at higher doses. Indeed, these medications, in association with cognitive behavioral therapy (CBT) with exposure and subsequent response prevention, are the most effective treatment for OCD.[19] Our patient did not engage in any of the recommended psychotherapy treatments due to the marked avolition.

Our patient achieved a good response to the combination of clomipramine and olanzapine regarding the obsessive and delusional symptoms, and this combination has been recommended as an augmentation strategy for refractory OCD.[19] Although the emergence of OCS in response to second-generation antipsychotics, particularly clozapine, is well documented,[20] it was not observed in this case.

Obsession Transitioning to Delusion

Methods. We searched the primary medical academic databases, such as PubMed and Google Scholar, up to early 2017, for relevant articles on the phenomenon of symptoms of OCD transitioning into symptoms of psychosis. First, we searched using the keywords schizo-obsessive disorder or schizo-obsessive spectrum disorders; and schizophrenia or psychosis or psychotic disorder linked with OCD, obsessive, or compulsive. Based on these results, we then searched for articles that specifically addressed the transition from obsession to delusion.

Literature overview. The clinical relevance of the OCS in psychosis has been well-established,[4] and the prodromal, intermittent, continual, and late-stage manifestations of these symptoms have all been observed in schizo-obsessive disorder.[2] However, the transition of an obsessive symptom into a psychotic one is still poorly understood.

Gordon[21] was the first to describe the possibility of obsessive thinking directly transitioning into a delusional idea. Thirty-six years later, Insel and Akiskal[22] suggested that some patients with OCD might have psychotic features, as confirmed by Eisen and Rasmussen.[23] More recently, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) validated a varying spectrum of insight in OCD,[23] which is thought to modulate the transition from obsession to delusion.[24-26] Thus, as the insight, resistance, and control of OCD decrease, the psychotic symptoms are likely to increase,[26] which can also be associated with affective disturbances.[22]

The transition of OCS into psychosis can occur at different stages and extents of schizo-obsessive disease progression. Typical egodystonic obsessions or compulsions that are at first unrelated to delusions or hallucinations can later become associated with the content of delusions and hallucinations, resulting in complex psychopathological syndromes known as “obsessive delusions” and “obsessive hallucinations.”[27] In this way, the DSM-IV and, subsequently, the DSM-5 recognized OCD “with good, fair, poor absent/delusional insight,”[28] corroborating the evidence of a complete shift of a egodystonic OCS into a egosyntonic delusion[26] or hallucination.[29] Conversely, delusions and hallucinations can be associated with a different degree of conviction and certainty in schizophrenia,[26] reinforcing the idea of a continuum from obsessions to overvalued ideas and then to delusions,[24] or the more complex schizo-obsessive spectrum.[4]

The at-risk mental states (ARMS) of patients that comprise those with attenuated psychotic symptoms and/or brief and limited intermittent psychotic symptoms[30] are particularly susceptible to the transition of OCS into a psychotic symptom. While Niendam et al[31] reported that OCS protects the ARMS or at ultra-high risk (UHR) populations from developing psychosis, Fontanelle et al[16] found that, although the remission of OCD did not increase the risk of psychosis, the de novo OCD manifestation was associated with the development of mood disorders with psychotic features. On the other hand, Dael et al[32] reported an increased transition to psychosis when its early manifestation was associated with co-occurring OCS. Accordingly, while some authors did not record any significant differences between ARMS individuals with or without OCD in terms of psychopathology,[16,31] most authors found that those with OCS were more likely to suffer from higher impairment in psychosocial functioning and more general psychopathology.[30,33]

Conclusion

We believe our diagnosis of schizo-obsessive disorder in the described patient is appropriate due to his symptoms of schizophrenia and OCD. The OCS at first seemed to have retarded the psychotic manifestation; however, the negative and cognitive symptoms of schizophrenia associated with OCS were prominent, and we believe this greatly contributed to the poor prognosis of our patient. The improvement of his OCS occurred with the emergence of an over-valued idea, corroborating the existence of a schizo-obsessive spectrum modulated by the presence and extent of phenomenological features related to insight. Therefore, although the transition of an obsessive into a psychotic symptom seems to be a rare event, it is possibly a sign of poor prognosis in the schizo-obsessive spectrum.

Acknowledgments

We are deeply indebted to the staff and colleagues from the Psychiatric Unit of the State University of Rio de Janeiro, in particular to Professor Max de Carvalho, for his helpful comments on the dissertation written by ESM and supervised by OLS.

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Category: Case Report, Current Issue, Neurodegenerative Disease, Schizophrenia

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