Obsessive–compulsive symptoms in schizophrenia: associated clinical features, cognitive function and medication status
Introduction
Obsessive–compulsive (OC) symptoms are common in patients with schizophrenia. First recognized early in the 20th century (Jahreiss, 1926, Rosen, 1957), modern interest in this topic can be traced to Fenton and McGlashan (1986) who found clinically significant OC symptoms in 12.9% of 163 hospitalized schizophrenia patients, a prevalence rate well above what would have been expected by simple chance comorbidity. Subsequent studies have reported widely varying rates of comorbid OC symptoms in schizophrenia patients (Bermanzohn et al., 2000, Fabisch et al., 2001). In addition, several studies have found that schizophrenia patients with OC symptoms may exhibit more severe psychotic symptoms and poorer cognitive function compared to other patients with schizophrenia. Indeed, it has been suggested that these patients may have a subtype of schizophrenia with distinct pathophysiology, treatment response and clinical course (Berman et al., 1999).
We summarize relevant features of the 13 published studies which have examined demographic, clinical and cognitive characteristics in schizophrenia patients with OC symptoms (Table 1; Berman et al., 1995, Berman et al., 1998, Eisen et al., 1997, Hermesh et al., 2003, Hwang et al., 2000, Kruger et al., 2000, Lysaker et al., 2002, Lysaker et al., 2000, Nechmad et al., 2003, Ohta et al., 2003, Poyurovsky et al., 1999, Poyurovsky et al., 2001, Tibbo et al., 2000). The samples range in size from 20 to 108 subjects (mean 58) and include first-episode patients (Poyurovsky et al., 1999), chronic state hospital inpatients (Hwang et al., 2000) and outpatients recruited by advertisement (Tibbo et al., 2000). Several used a Structured Clinical Interview for DSM-IV (SCID) diagnosis of OCD to define clinically significant OC symptoms, while others relied on Yale–Brown Obsessive–Compulsive Scale (Y-BOCS) scores of greater than 7, 8 or 17. There have been no large studies examining both clinical and cognitive status in stable outpatients.
Most studies found differences in clinical characteristics of those patients with schizophrenia and comorbid OC symptoms compared to patients with schizophrenia alone. However, the pattern of findings was highly variable; some reported less severe positive and negative symptoms, others reported no differences, and still others reported more severe positive and negative symptoms in this population. With regard to cognitive functioning, most studies found an association between comorbid OC symptoms and impaired performance on tests of frontal lobe function. Impaired performance on the Wisconsin Card Sort Test (WCST) was the most commonly reported finding; a higher rate of perseverative errors only was found in some studies and nonperseverative errors only in others. These inconsistencies prompted Lysaker et al. (2002) to conclude: “Thus, the data so far suggest that OC symptoms in schizophrenia spectrum disorders are linked with a distinctive clinical picture, but the exact nature of that clinical picture remains unclear”.
The relationship between OC symptoms and atypical antipsychotic medications is similarly unclear. Atypical antipsychotics may be useful adjunctive therapy in treatment-refractory OCD but clozapine, risperidone, olanzapine and quetiapine may also induce or exacerbate OC symptoms in patients with schizophrenia (Lykouras et al., 2003). Predictably, the number of reports involving each medication appears to be proportionate to the length of time the medication has been available (Lykouras et al., 2003). Ziprasidone and aripiprazole have not yet been reported to exacerbate or ameliorate OC symptoms in patients with schizophrenia. Emergence of OC symptoms during treatment with atypical agents may be due to antiserotonergic properties of these medications. Following a review of the literature, we hypothesized a priori that clozapine and olanzapine would be more likely to be associated with OC symptoms than other antipsychotic medications (see Discussion).
We set out to study the clinical and cognitive characteristics of stable schizophrenia outpatients with OC symptoms. Our sample was well characterized in terms of clinical measures, cognitive functioning and current medications. Thus, we were interested in examining the cross-sectional relationships between OC symptoms and psychosis, cognition and medication status.
Section snippets
Subjects
Study subjects were outpatients at the Freedom Trail Clinic, a community mental health center in Boston, which provides specialized services for patients with psychotic illnesses. The sample consisted of consecutive subjects with a clinical diagnosis of schizophrenia or schizoaffective disorder. This study, part of a larger genetics project, was approved by the Institutional Review Board. All subjects provided written informed consent.
A DSM-IV diagnosis of schizophrenia or schizoaffective
Demographic characteristics
A total of 118 subjects completed the clinical and cognitive assessments. The three groups did not differ significantly in terms of age, gender and other demographic characteristics, or in IQ scores (Table 2). When standard score-based study entry criteria for OCD (Y-BOCS score of 16 or greater or a score of 10 or greater on Y-BO or Y-BC alone if only one type of symptom is present) were applied, only 10 subjects or 8.8% of study patients qualified as having clinically significant OCD.
Clinical and neuropsychological findings
The
Discussion
To our knowledge, this is the largest sample of stable schizophrenia outpatients to have been studied for the purpose of examining clinical and cognitive features associated with OC symptoms.
We found that patients with higher Y-BOCS scores also exhibit more positive symptoms in general and delusions in particular. Depressive symptoms were strongly associated with Y-BOCS scores. Thus, higher levels of OC symptoms were associated with a more symptomatic subgroup of patients. We did not find any
Acknowledgement
The authors acknowledge the helpful discussions with Jennifer Derenne, MD. Supported by PHS grant MH02025 (Dr. Goff).
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