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Obsessive-Compulsive Syndromes in Schizophrenia: A Case for Polypharmacy?

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Polypharmacy in Psychiatry Practice, Volume II

Abstract

Obsessive-compulsive symptoms (OCS) are often associated with schizophrenia. So far no single pathogenetic theory was able to convincingly explain this co-occurrence, due to heterogeneous subgroups within the comorbid sample. Based on long-term case observations, one hypothesis assumes that second-onset OCS in the course of schizophrenia might be a side effect of second generation antipsychotics (SGA), most importantly clozapine (CLZ). This review summarizes the supporting epidemiological and pharmacological evidence and defines several open questions regarding pathogenetic influence of genetic factors, differential neurocognitive profiles, affective comorbidity and interactions of serotonergic, dopaminergic and glutamatergic neurotransmission. Treatment of comorbid patients might involve cognitive behavioural therapy (CBT) with graduated exposure and response prevention (ERP). However, so far no controlled clinical trials confirmed efficacy and tolerability of psychotherapy for this specific indication. Strategies of polypharmacy are often preferred, although based on similarly scarce systematic evidence. The combination of amisulpride or aripipirazole with pro-obsessive, antiserotonergic antipsychotics in minimally sufficient dose levels yielded favourable effects. Adding serotonergic antidepressants or mood stabilizers resemble augmentation approaches. In perspective, individual psychotherapeutic and pharmacological strategies have to be further evaluated. Head to head trials of different approaches as well as combinations of the mentioned strategies promise therapeutic progress and will help to improve treatment options for schizophrenia patients suffering from comorbid OCS.

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Abbreviations

AD:

Antidepressant

AMS:

Amisulpride

APZ:

Aripiprazole

ARMS:

At risk mental state

CBT:

Cognitive behavioural therapy

CDSS:

Calgary depression scale for schizophrenia

CGI-S:

Clinical global impression, severity of illness

CLZ:

Clozapine

ERP:

Exposure and response prevention

FEP:

First episode schizophrenic patients

FGA:

First generation antipsychotics

HAL:

Haloperidole

OCD:

Obsessive compulsive disorder

OCS:

Obsessive compulsive symptoms

OLZ:

Olanzapine

PANSS:

Positive and negative syndrome scale

PP:

Per protocol

PSP:

Personal and social performance scale

RCT:

Randomised placebo-controlled trial

SA:

Schizoaffective disorder

SANS:

Scale for the assessment of negative symptoms

SCH:

Schizophrenia

SGA:

Second generation antipsychotics

SIPS:

Structured interview for prodromal symptoms

SZ:

Schizophrenia and schizophrenia spectrum disorders

UHR:

Ultra high risk

Y:

Years

YBOCS:

Yale-Brown-Obsessive-Compulsive Scale

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Acknowledgments

F.S. was supported by a research grant of the Evangelisches Studienwerk. M.Z. receives unrestricted scientific grants of ERAB (European Research Advisory Board), German Research Foundation (DFG), Servier, Pfizer Pharma GmbH, Bristol-Myers Squibb GmbH & CoKGaA, further speaker and travel support from Pfizer Pharma GmbH, Bristol-Myers Squibb GmbH & CoKGaA, Astra Zeneca, Eli-Lilly and Janssen Cilag.

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  1. Department of Psychiatry and Psychotherapy, Medical Faculty Mannheim, Central Institute of Mental Health, University of Heidelberg, Mannheim, Germany

    Frederike Schirmbeck Dipl.-Psych. & Mathias Zink M.D.

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  1. Frederike Schirmbeck Dipl.-Psych.
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  2. Mathias Zink M.D.
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Correspondence to Mathias Zink M.D. .

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  1. Sha'ar Menashe Mental Health Center, Hadera, 38814, Israel

    Michael S. Ritsner

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Schirmbeck, F., Zink, M. (2013). Obsessive-Compulsive Syndromes in Schizophrenia: A Case for Polypharmacy?. In: Ritsner, M. (eds) Polypharmacy in Psychiatry Practice, Volume II. Springer, Dordrecht. https://doi.org/10.1007/978-94-007-5799-8_12

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