A 42 year-old man with a past medical history of schizoaffective disorder, hyperlipidemia, and gastrointestinal reflux disease was admitted to an adult psychiatric unit secondary to intrusive thoughts that were sexual, homicidal, and suicidal in nature. Similar thoughts with tics were first reported 2 decades prior to the current hospital admission; however symptoms of depression were most prominent then and he was initially diagnosed with only major depressive disorder. During the following years there were documented reports of “paranoia and delusions related to contamination” as well as continued reports of intrusive violent thoughts also believed to be delusions. This led to a diagnosis of schizoaffective disorder; and antipsychotics became the primary modality of treatment over the next decade. Documented antipsychotics trials included aripiprazole, olanzapine, lurasidone, and quetiapine, all of which were associated with a lack of adequate improvement or adverse events. Records indicated that haloperidol combined with fluvoxamine did result in partial improvement. Antidepressants were also utilized intermittently over this 20-year period to target mood symptoms. Historically, the antidepressant trial with the highest documented relative dose was paroxetine 60 mg. It was during this time period with paroxetine that there was documented improvement of the patient's intrusive thoughts. Side effects limited use of the paroxetine 60 mg, and after it was decreased the violent intrusive thoughts worsened.\nInevitably the patient's outpatient provider after years of suboptimal response to antipsychotics initiated clozapine to target what was continued to be described as psychotic symptoms in the medical record. However, as the clozapine was gradually increased to 400 mg the patient noted a severe worsening of intrusive thoughts causing secondary depressed mood, anxiety, and suicidal ideation leading to hospitalization at our facility. It was during this admission that there was exploration of the patient's intrusive thoughts, which were clearly obsessions in that they were persistent, unwanted, egodystonic thoughts. Efforts by the patient to suppress or ignore these thoughts were futile, resulting in significant anxiety and distress. Yet while these obsessions occupied a significant amount of time during the day, impacting his social and work functioning, he denied any ritualistic behaviors or compulsions. Family history was found to be positive for an aunt and mother with hoarding disorder and a cousin with OCD. As the obsession were not attributable to the use of substances, a medication condition, or other mental disorders, the diagnosis of OCD was given for the first time based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition []. With the patient now diagnosed with OCD, he was appropriately treated; and there was a plan to initiate fluoxetine with a goal dose of 80 mg. Given the historical nature of the schizoaffective diagnosis, clozapine was continued taking into account there had been improvement during the hospitalization and that it would need to be slowly tapered as an outpatient to avoid adverse effects. The patient was safely discharged with minimal intrusive thoughts and it was recommended to the patient's outpatient provider that clozapine be discontinued after a slow taper. However, in the following months, the patient's outpatient provider had increased clozapine to 700 mg. This was associated again with a subsequent worsening and exacerbation of distressing intrusive thoughts leading to another hospitalization. Serum clozapine and norclozapine levels upon admission were found to be 453 ng/mL and 464 ng/mL, respectively. Clozapine was rapidly discontinued due to the association with OCS, as well as the patient's clinical presentation after each clozapine escalation. Clozapine was tapered over approximately 2 weeks without complications such as cholinergic rebound, catatonia, serotonin syndrome, or withdrawal dyskinesias [–]. More importantly there was no emergence of psychotic symptoms, strengthening the likelihood that the patient did not have schizoaffective disorder based on DSM-5 criteria.\nIn review of records and after discussion with the patient, it was determined that the past fluvoxamine trial did not reach an adequate dose for the treatment of OCD. Fluvoxamine was started and increased to 200 mg after clozapine had been allowed to wash out. Low-dose aripiprazole was also initiated to augment the fluvoxamine given the severity of the presentation, the benefits of this antipsychotic in treatment resistant OCD, and the low risk of inducing OCS []. The patient was discharged with resolution of intrusive thoughts and improvement in mood and still without emergence of psychotic symptoms. Following this hospitalization the patient began to see a therapist who specialized in exposure and response prevention therapy to address his OCD. Longitudinally, the patient struggled with depression and anxiety associated with residual obsessions resulting in fluvoxamine being changed to clomipramine. The last known dose of clomipramine was 150 mg and reported as having reasonable control of OCS as an outpatient. Up to a year following the second reported hospitalization at our facility there were no patient reports or documentation noted of criteria sufficient for a diagnosis of schizoaffective disorder or other psychotic disorders.
A 28-year-old, Caucasian, male patient, with a diagnosis of residual schizophrenia, treated for 2 years with clozapine 100 mg/day was admitted because of the worsening of his psychotic symptoms. His OCS first was seen at age of 13. He had control and symmetry obsessions and compulsions. After 5 years of OCS, he had psychotic symptoms. He reported that he could not leave the house for the last 2 years, due to his persecution delusions, skepticism, and resentment. He was on a treatment of clozapine 100 mg/day for 2 years.\nHe was hospitalized with a dose of 10 mg/day aripiprazole added on to his ongoing 100-mg/day clozapine treatment. The plasma level of clozapine and norclozapine were lower than therapeutic level at the admission. At the end of the second week, clozapine dose increased to 200 mg/day and aripiprazole to 30 mg/day gradually. The clozapine, norclozapine, aripiprazole doses and the clinical rating scale scores are given at Table \n. During discharge, his scores of PANSS was 49 (78 at admission), BPRS was 27 (39 at admission), and Y-BOCS was 15 (40 at admission).