I am treating a patient who has both Schizophrenia and OCD, and the symptoms are intertwined. Who has information available on the (CBT) treatment of this combination?
I could find some literature on the prevalence of Schizophrenia with OCD, but nothing about treating these patients.
Thank you for your help!
Hi Roos I have tried unsuccessfully with psychosis-ocd-social anxiety and attach the case report with some suggestions - good luck!
Article Schizophrenia, obsessive covert mental rituals and social an...
Please, first check the diagnosis accurately. Often appear in OCD ideas that seem delusional and psychotic.
I have seen many patients with this combination. I have treated them with a combination of SSRIs and Antipsychotics. OCD part is harder to treat.
THe OCD can be the deffense mechanism from pszchotic decompensation! The diagnostic and therapy must be very carefully! Maybe use Abilify (aripirazole) as mono therapy or as add'on therapy to SSRI...
Do make sure that this patient has been diagnosed correctly. He may have OCD with a psychotic/delusional overlay, more commonly referred to as OCD Psychosis, in which case a larger dose of an SSRI like Sertraline with a low to moderate dose of an antipsychotic like Risperdal or Seroquel would be essential, your CBT only needs address the symptoms/problems of OCD as you would usually do. This is from my long experience with such patients - they are often misdiagnosed as Schizophrenia.
Using Olanzapin and Clozapine as an antipsychotic in schizophrenic patients may enhance obsessive symptoms. If you are using these APs you may substitute with aripiprazol. If the symptoms resist you may add SSRI or TCA (Clomipramin) very carefully. These drugs may increase psychotic symptoms.
Thank you all for your input!
Unfortunately, this patient refuses any medication.
I understand the concerns about the diagnosis. Fortunately, the diagnosis was established after careful assessment by the national 'Top-GGZ' clinic. The Schizophrenia was diagnosed about five years ago, while the OCD is a more recent development.
The voices of the patient become active when he experiences stress. If he tries to resist giving in to his compulsions after having had intrusive thoughts, his stress level rises and the voices start yelling. Related to the OCD they yell at him that if anything happens it will be his fault. They also offer strange advice that is very inappropriate for the situation. The voices do not scare patient, he knows he hears them because of the Schizophrenia.
But when they yell it does add stress, make it more difficult to concentrate and makes it more tempting to give in to the compulsions. Giving in to the compulsive behaviour is extra rewarding: it lessens his anxiety about his intrusive thoughts, but because the stress level goes down so do the voices.
You can only offer him symptomatic help if he does not agree to take medication.
I have one case with this combination of symptoms, the best clincal response was with sertaline and paliperidone. Olanzapine and clozapine got worse the ODC symptoms.
Is the civil commitment process available to you (so that the patient may be court ordered to take medication?) Family support?
What would make medication more desirable? It is clear what the patient has currently worked out: " Giving in to the compulsive behaviour is extra rewarding: it lessens his anxiety about his intrusive thoughts, but because the stress level goes down so do the voices". You also mention an awareness of the diagnoses, which could be a beginning of insight as to the need and desirability for medication.
The antipsychotic + SSRI seems the best choice if you can find a way to get the patient to agree to it.
What do you think of trying cognitive remediation?
Hello Roos,
In my experience, I would say that the concurrent presentation of psychosis and OCD is perhaps one of the most challenging presentations to treat.
Having said that, the combination of antipsychotics and SSRI seems to be the best one. I have tried before to engage patients in CBT, but I have found is very challenging as often times the compulsions not only are egosyntonic but there is also lack of insight .
Citalopram and fluvoxamine would be my preference, albeit fluvoxamine has potent pharmacological interactions through its effect on different CYP450 enzymes, so if used it should be done cautiously.
Last, I'm not sure if your patient is on clozapine. If that were the case, clozapine has been associated with emergence of OCD-like symptoms (also panic attacks and other anxiety), most likely mediated through its 5-HT blockade mechanism. So, that situation would be extra challenging to deal with.
Best regards,
Fidel
Thank you for the useful publication!
I'm happy to report that, even though my patient did not want any medication, the CBT treatment for OCD was still very effective. It did take a bit more time.
Just saw this review paper, thought it might interest readers of this question:
https://www.ncbi.nlm.nih.gov/pubmed/28078209
Cognitive-behavioural therapy for obsessive-compulsive disorder co-occurring with psychosis: Systematic review of evidence.
clarification of the diagnosis is important, because a delusional disorder could occur with OCD i agree with those above an SSRI along with an antipsychotic would be the way to go. CBT would be helpful, rather than a total reliance on medication which is necessary.
CBT can work for patients with OCD and comorbid schizophrenia.
The link below is to a study on the topic (“Cognitive behavioural therapy for obsessive-compulsive disorder with comorbid schizophrenia: a case report with repetitive measurements").
https://www.ncbi.nlm.nih.gov/pubmed/23899371
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