1. Evan Leibu M.D. Assistant Professor Mount Sinai School of Medicine
Psychosis and Obsessive Compulsive Disorder: Determining Difference and Overlap
Evan Leibu M.D.
Assistant Professor
Mount Sinai School of Medicine

2. Disclosures and Conflicts of Interest
None to Disclose

3. Outline of Presentation:
Learning
Objectives
History of Psychosis and OCD
Delusional OCD
Schizophrenia /
Schizo-Obsessive Disorder
Antipsychotics and OCD
Neuroimaging Review

4. Learning Objectives Understand the history of OCD and psychosis
Understand the rational for the split between Delusional OCD and Schizo-obsessive Disorder
Understand the issues with treatment and the use of anti-psychotics in OCD with psychosis
Understand some of the neurobiological similarities in OCD and Schizophrenia

5. Significant debate has existed since the beginning about OCD and psychosis

6. Esquirol Reasoning monomania France 1838 History
First medical description of OCD
Case report of 34 year old woman with “kleptophobia” (fear of stealing) with checking and reassurance seeking rituals as well as avoidance.
Esquirol
Reasoning monomania
France 1838

7. Esquirol Reasoning monomania France 1838 History continued
“recurrent or persistent idea, thought, image, feeling or movement which is accompanied by a sense of subjective compulsion and a desire to resist it, the event being recognized by the individual as foreign to his personality, and into the abnormality of which he has insight”
Esquirol
Reasoning monomania
France 1838

8. Westphal Zwangs-vorstellung 1878 History continued
Coined the term “compulsive disorder”
Believed the disorder was characterized by “irrationality and insanity”
Although the name stuck the idea that OCD is marked by insight remained.
Westphal
Zwangs-vorstellung
1878

9. Ego alien
Early psychiatrists noted that OCD was marked by obsessions being prevalent but were resisted and felt to be ego alien
Janet
Schneider
Observation that this is not always the case have been prevalent since at least the 1930’s
Belief rises and falls with the threat level that the patient believes they are under.

10. History - Modern DSM-III 1980 - OCD DSM-IV 1994 – OCD
“the person recognizes that his or her behavior is excessive or unreasonable”
DSM-IV 1994 – OCD
Poor insight specifier
“This specifier can be applied when, for most of the time, during the current episode, the individual does not recognize that the obsessions or compulsions are excessive or unreasonable.”

11. Recent understanding
“OCD represents a psychopathological spectrum varying along a continuum of insight”
Insel, Akiskai, 1986

12. Unclear terminology - The overlap in symptoms
Obsessions
recurrent and persistent ideas, thoughts, impulses, or images that are experienced at least initially as intrusive and senseless”
Overvalued ideas
unreasonable and sustained belief or idea that is maintained with less than delusional intensity.
Differs from an obsessional thought in that the person does not recognize its absurdity and thus does not struggle against it

13. Unclear terminology - The overlap in symptoms
Delusions
A false personal belief based on an incorrect inference about external reality and firmly sustained in spite of what almost everyone else believes

14. Psychosis and OCD - Two main subtypes
Delusional OCD
Delusional OCD without a formalized thought disorder
Schizo-Obsessive Disorder
Delusional OCD with a formalized thought disorder
Schizophrenia with Obsessive Compulsive Symptoms

15. Delusional Obsessive Compulsive Disorder [i.e. OCD with poor insight]

16. Delusional OCD Marked by it’s “fixedness”
In the absence of formalized thought disorder or Hallucinations
Phenotypically close in presentation to Body Dysmorphic Disorder and Anorexia Nervosa
Effects more males?
Constitutes about 5% of the OCD population

17. The fixedness of an obsession can often alter with time
Timing
Maybe transient worsening of a preexisting obsession lasting weeks or months
May develop into a permanent worsening, often insidiously
Usually marked by social isolation.
No formal retrospective longitudinal studies have noted pattern of progression, if there even is one
The fixedness of an obsession can often alter with time

18. A Brief Word on Delusional Disorder
Delusional OCD symptoms cannot be defined as a delusional disorder
Part E of delusional disorder:
The disturbance is not attributable to the physiological effects of a substance of another medical condition and is not better explained by another mental disorder such as BDD or OCD.
However, you can certainly have both.

19. Schizophrenia, Schizophrenia with Obsessive Compulsive symptoms and Schizo-Obsessive Disorder

20. Schizophrenia Defined
Schizophrenia Primer
Schizophrenia Defined
Schizophrenia is not defined by delusions.
Schizophrenia is defined by disorganization.
These symptom present in the absence of a formal mood disorder

21. Word of warning from the DSM-5:
Schizophrenia Primer
Word of warning from the DSM-5:
It is a range of symptoms
No single symptom is pathognomonic
“Constellation of signs and symptoms”
Heterogeneous disorder

22. Formal thought disorder
Disorganization in thinking – inferred from disorganized speech
Disorganization in behavior

23. Schizophrenia & OCD:An Unclear History
Early Theories
Obsessive compulsive symptoms in schizophrenia are rare
FALSE
OCD with Schizophrenia indicates a less severe course
LIKELY NOT TRUE

24. Current understanding
Current cross-sectional studies
Rates between 7 and 55%
Variability somewhat due to study power and length of questionnaire
Always higher than what would be attributed to chance
Most studies report 25-45%

25. Current understanding
Current “consensus” is about 1/3 of schizophrenia patients have obsessive compulsive symptoms
Meta-analysis is mixed but most studies are unable to find a correlation between presence of symptoms and the severity of the condition

26. Schizo-obsessive Disorder
Best used to describe Schizophrenia patients who are also affected by Obsessive-Compulsive symptoms or who also meet the criteria for OCD.
Unclear if it is a unique diagnostic entity or due to comorbidity
Schizo-obsessive disorder
Poyurovsky M. (2013) . Schizo-Obsessive Disorder (1st ed.) Cambridge UK

27. This is later than what would be expected
Onset differences
Higher proportion of individuals with Schizophrenia and OCD have onset of OCD symptoms at or after the development of psychosis
This is later than what would be expected

28. Second Generation Antipsychotics and OCD

29. OCD and second generation antipsychotics
Evidence is limited
Theories related to serotonin blockade from SGAs.
Case studies exists that point to second generation anti-psychotics inducing OCD

30. Serotonin Blockade Hypothesis
Stahl, S. M. (2008). Essential Psychopharmacology Online. Retrieved March 10, 2017 from

31. Clozapine and Serotonin blockade
Stahl, S. M. (2008). Essential Psychopharmacology Online. Retrieved March 10, 2017 from

32. Risk of SGA induced OCD
Treatment with clozapine in patients with schizophrenia is associated with a higher prevalence of OCS
Especially when patients have been taking clozapine for 6 months or longer.
Olanzapine and risperidone also correlate with a higher incidence of obsessive compulsive symptoms.
J Clin Psychiatry Nov;73(11):

33. Choose a SGA that blocks D2 > 5HT-1A
Treatment Options
Add an SSRI
EXTREME CAUTION IF ADDING FLUVOXAMINE TO CLOZAPINE
Fluvoxamine inhibits CYP1A2
Choose a SGA that blocks D2 > 5HT-1A
Switch to a typical antipsychotic

34. Neuroimaging in Schizophrenia and OCD

35. Neuroimaging findings in OCD and Schizophrenia

36. Neurobiology
OCD the circuits primarily affected are Cortical-Striatal circuits involving orbitofrontal (OFC), anterior cingulate (AC), and prefrontal cortex (PFC).
SZ primarily involves dorsolateral (dl) PFC circuits.
Both disorders involve hyperactivity in these circuits. Cortical-Striatal circuits in other regions appear to be spared.
Shepherd Nat Rev Neurosci Apr; 14(4): 278–291

37. Frontal cortex physiology

38. Striatum physiology

39. The many roles of the Striatum
Jahanshahi M, Obeso I, Rothwell JC, Obeso JA (2015) A fronto–striato–subthalamic–pallidal network for goal-directed and habitual inhibition Nature Reviews Neuroscience 16, 719–732

40. Neuroimaging findings in OCD
1: Cortical changes
Abnormal frontal activity seen by fMRI;
2: Cortico-Striatal changes
Increased fronto-striatal connectivity;
3: Striatal changes
particularly in ventral striatum;
4: Changes at Cortico-Striatal synapses in mouse models of OCD
5: Thalamic abnormalities
increased activity & thalamocortical dysrhythmia. 
Shepherd Nat Rev Neurosci Apr; 14(4): 278–291

41. Neuroimaging findings in Schizophrenia
6: Cortical changes
Reduced thickness & functional connectivity with PFC cortex and striatum, with abnormal rhythms
7: Thalamic abnormalities
Thalamo-cortical dysrhythmia;
8: Striatal changes
Reduced volume
Shepherd Nat Rev Neurosci Apr; 14(4): 278–291

42. What leads to what?
Curr Psychiatry Rep Nov;16(11):510. doi: /s

43. Thank you!

44. References
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). Washington, DC
Berrios GE (1989) Obsessive-compulsive disorder: its conceptual history in France during the 19th century. Comprehensive Psychiatry. 30(4):
Insel TR, Akiskal HS (1986) Obsessive compulsive disorder wit psychotic features a phenomenological analysis. American Journal of Psychiatry 143,
Fonseka TM, Richter MA, Muller DJ (2014) Second Generation Antipsychotic-Induced Obsessive-Compulsive Symptoms in Schizophrenia: A Review of the Experimental Literature. Current Psychiatry Reports 16(11):
Shepherd GMG. Corticostriatal connectivity and its role in disease. Nature Reviews Neuroscience. (2013)14(4):
Albertine A, Scheltema Beduin MD, Marije Swets MD, Marise Machielsen MD, Nikie Korver MsC;, The Genetic Risk and Outcome of Psychosis Investigators (2012); 73(11):
Stahl, S. M. (2008). Essential Psychopharmacology Online. Retrieved March 10, 2017 from
Poyurovsky M. (2013) . Schizo-Obsessive Disorder (1st ed.) Cambridge UK
Kozak MJ, Foa EB. (1994) Obsessions, overvalued ideas, and delusions in obsessive-compulsive disorder. Behaviour Research and Therapy 32(3):343-53
Jahanshahi M, Obeso I, Rothwell JC, Obeso JA (2015) A fronto–striato–subthalamic–pallidal network for goal-directed and habitual inhibition Nature Reviews Neuroscience 16, 719–732
Cunill R, Castells X, Simeon D. (2009) Relationships between obsessive-compulsive symptomatology and severity of psychosis in schizophrenia: a systematic review and meta-analysis. Journal of Clinical Psychiatry 70(1):70-82