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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 15  |  Issue : 2  |  Page : 295-299

Schizophrenia with obsessive-compulsive symptoms - neuropsychiatric manifestation in the context of underlying brain pathology: A case report from rural tertiary health-care center from Maharashtra


Department of Psychiatry, Jawaharlal Nehru Medical College (Deemed to be University), Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India

Date of Submission03-Feb-2020
Date of Decision15-Feb-2020
Date of Acceptance26-Feb-2020
Date of Web Publication21-Dec-2020

Correspondence Address:
Dr. Ajinkya Ghogare
House Number 4, Shree Colony, Daryapur, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_34_20

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  Abstract 


Obsessive–compulsive symptoms (OCS) and obsessive–compulsive disorder (OCD) occur frequently in schizophrenia. Comorbid OCS or OCD can influence the course of schizophrenia. Comorbid OCS or OCD is associated with an increased severity of schizophrenia and poorer prognosis. Lacunar infarcts though not always, but often considered benign as they do not usually cause clinically significant neuropsychiatric or neurological deficits. In the current case report, we highlight a rare case of a 23-year-old male who presented with schizophrenia with OCS in the background of lacunar infarct in the left corona radiata on computed tomography of the brain, which later followed by focal ischemic changes in the subcortical left temporal, peritrigonal, and periventricular regions on magnetic resonance imaging of the brain. In the current case report, index patient suffering from schizophrenia showed a temporal association between the worsening of findings on neuroimaging and worsening of OCS, depicting the growing importance of neuroimaging in the field of psychiatry.

Keywords: Corona radiata, lacunar infarct, neuroimaging, obsessive–compulsive disorder, obsessive–compulsive symptoms, peritrigonal region, periventricular region, schizophrenia, subcortical left temporal region


How to cite this article:
Ghogare A, Chowdhury D, Patil P, Vankar G. Schizophrenia with obsessive-compulsive symptoms - neuropsychiatric manifestation in the context of underlying brain pathology: A case report from rural tertiary health-care center from Maharashtra. J Datta Meghe Inst Med Sci Univ 2020;15:295-9

How to cite this URL:
Ghogare A, Chowdhury D, Patil P, Vankar G. Schizophrenia with obsessive-compulsive symptoms - neuropsychiatric manifestation in the context of underlying brain pathology: A case report from rural tertiary health-care center from Maharashtra. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Jan 16];15:295-9. Available from: http://www.journaldmims.com/text.asp?2020/15/2/295/304257




  Introduction Top


Evidence suggests that schizophrenia with obsessive–compulsive disorder (OCD) has a poor prognosis. However, the effect of OCD on the psychopathology of schizophrenia is quite unclear.[1] The co-occurrence of obsessive–compulsive symptoms (OCS)/OCD and schizophrenia symptoms has been a challenging task for psychiatrists both in understanding the phenomenology and in managing the patients with such presentation.[2] The lifetime prevalence of schizophrenia is 1%,[3] whereas that of OCD is 2.3%.[4]

In patients suffering from schizophrenia, the prevalence of OCS ranges from 10% to 52%, whereas the prevalence of OCD ranges from 7.8% to 26%.[5],[6] Comorbid OCS or OCD is associated with an increased severity of schizophrenia and poorer prognosis. In majority of the patients with comorbid OCD and schizophrenia, OCS precede initial psychotic symptoms in about 40% of the patients, may succeed psychosis in 40%, and occur concurrently with psychotic symptoms in around 20%.[7] In the current case report, we present an index patient suffering from schizophrenia showing a temporal association between worsening of findings on neuroimaging and worsening of OCS, depicting the growing importance of neuroimaging in the field of psychiatry.


  Case Report Top


The index patient was a 23-year-old unmarried Hindu male, from nuclear family and rural background, with no family history of psychiatric disorders. He had been premorbidly extrovert and stubborn. He presented with continuous illness of 5-year duration. He started complaining of throbbing headache which was more on the bilateral temporal regions and felt like “his mind was not working and he was going to be mad”. These complaints lasted for about 2 weeks. He was more irritable than usual; hence on the advice of a few villagers, parents took the patient to faith healers. As there was no improvement in his symptoms, parents took him to a physician who advised computed tomography (CT) of the brain. CT of the brain was suggestive of “tiny lacunar pinhead size infarct in left corona radiata” [Figure 1]a and [Figure 1]b, after which the patient was advised to undergo magnetic resonance imaging (MRI) of the brain. For financial reasons, parents decided to continue the treatment from faith healers. The patient then grew suspiciousness that his neighbors had done black magic on him and wanted to kill him. Family members noticed that the patient began muttering. On interrogation, the patient would deny that he was talking to himself and would become irritable and verbally abusive. Because of suspicion of possible harm, he stopped going outside his house. Then, he began refusing food served by the family members.
Figure 1: (a) Computed tomography of the brain showing tiny lacunar pinhead size infarct in the left corona radiata. (b) Tiny lacunar infarct in the left corona radiata on computed tomography of the brain

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After about 7 months, he started washing his hands repeatedly for about 20–25 times a day and taking about 5–10 min for each handwashing incident. On asking him why he was washing hands repeatedly, the patient would not reply. He started spending about ½ h for brushing his teeth. He started spending about 1–2 h in bathing, using one full soap for each bath. Later, he started drinking about 5 l of water every day. Because of increased water intake, his urinary frequency increased, to an extent that he would pass urine in his clothes even during daytime while on the way to the washroom. He showed repetitive acts such as rubbing his palm of the right hand over his left cheek, then on the right cheek, followed by rubbing the tip of the nose with the index finger of the right hand and acted as if he was coughing. He engaged in such repetitive acts whenever anyone tried to talk with him. He would repeatedly switch on and off electricity buttons. He would walk in a peculiar manner, taking few steps forward and take few steps backward repeatedly as if he was in doubt what to do. His suspiciousness, fearfulness, and muttering continued throughout the illness. As per the available documents, 3 years back, he received tablet olanzapine 10 mg at bedtime by a psychiatrist, which he took for only 15 days. The reason for the poor compliance with treatment and follow-up was refusal from the patient to take the medicines as he grew suspiciousness against treating psychiatrist. For last 9 months, he was socially increasingly withdrawn, refusing to talk even with his family members. He had sleep disturbance and poor appetite. Five years ago, he worked as a laborer in a textile mill along with his brother for about 2 years. He stopped working since last 5 years, i.e., after the onset of illness.

The mental status examination revealed withdrawn behavior, with neat, tidy, and hygienic appearance; increased blinking rate and blunt affect; increased reaction time with low volume and monotonous speech (was only giving answer to the question regarding his name and family members' name), and performing repetitive movements as described in the history, whenever anyone tried to interact with him.

After the hospitalization, he was given oral trifluoperazine 5 mg/day which was gradually increased to 15 mg/day. He was prescribed fluoxetine 20 mg/day which was gradually increased to 60 mg/day. After 3 weeks of treatment, the patient's sleep and appetite improved. His hallucinatory behavior, suspiciousness, and fearfulness also reduced. His repetitive handwashing was reduced from 20–25 times every day to 10–15 times each day. His water intake reduced from 5 l/day to 2½–3 l/day. His compulsive behaviors of handwashing and sliding his right hand across his cheeks, followed by coughing whenever anyone tried to talk with him were also reduced. The Nurses' Observation Scale for Inpatient Evaluation (NOSIE) was used to assess an improvement in psychotic features.[8] The NOSIE consists of a total of thirty items. The NOSIE consists of six factors, of which three are positive and three are negative factors. Positive factors consist of social competence, social interest, and personal neatness. Negative factors consist of irritability, manifest psychosis, and retardation. The NOSIE is usually administered 72 h after initial hospitalization and weekly thereafter. Each item is rated from 0 to 4, but item numbers 3, 14, 18, and 23 do not usually contribute to the total score. The total scale score ranges from 0 to 208. For the total scale score or final score, either the sum of the total scores of two raters or doubling the score of a single rater is recommended. On NOSIE, total patient assets (TOT) is calculated by the following equation: 96 + total positive factors score − total negative factors score.[8] In the index patient, on NOSIE, TOT progressively increased indicative of improvement in symptoms with time. Scores at initial assessment, at the end of the 1st week, at the end of the 2nd week, at the end of the 3rd week, and at the end of 4th week were 39, 60, 80, 96, and 107, respectively [Table 1]. Progressively, scores of positive factors increased, whereas scores of negative factors decreased.
Table 1: NOSIE scoring in the index patient

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The Yale–Brown Obsessive–Compulsive Scale (YBOCS) was used to categorize the severity of OCD.[9] YBOCS score reduced from 34 to 14, indicating reduction of OCD severity from extreme to mild.

Later on, his MRI of the brain was done which was suggestive of focal ischemic changes in the subcortical left temporal, peritrigonal, and periventricular regions [Figure 2], [Figure 3], [Figure 4]. The opinion of neurophysician was taken, and neurophysician advised to continue the same line of management and advised to keep a close observation on the patient, as at that time the patient had silent ischemic changes in the various parts of the brain without any focal or nonfocal neurological signs and symptoms, except for neuropsychiatric manifestations.
Figure 2: Focal ischemic change in the subcortical left temporal region on magnetic resonance imaging of the brain

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Figure 3: Focal ischemic change in the peritrigonal region on magnetic resonance imaging of the brain

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Figure 4: Focal ischemic change in the periventricular region on magnetic resonance imaging of the brain

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Ethical Clearance

Date-22/2/2019. Ref No-DMIMS(DU)/IEC/2019-20/7111.


  Discussion Top


This case highlights the occurrence of neuropsychiatric manifestations in the context of the underlying pathology of brain parenchyma.

Probably, because of the well-defined neural circuitry in OCD and the overlap in these circuits with some of those implicated in schizophrenia, there has been informed speculation about potential overlap in the underlying pathology of schizophrenia and OCD. It does appear that the prevalence of OCS and OCD in schizophrenia exceeds the prevalence in the general population, with estimates of up to a third of people with schizophrenia having comorbid OCD.[10]

OCS in patients with schizophrenia are not merely a result of chronic illness or due to antipsychotic treatment.[11] The current case report also depicts the same fact that the index patient had the onset of OCS a way ahead of the onset of treatment with antipsychotic medicines. There is a high prevalence of OCS from 2.7% to 37% and of OCD from 1.5% to 30% in patients with high risk of psychosis, in the prodromal phase of schizophrenia, and in patients with “first episode drug naïve schizophrenia.”[11] In one study, 65% of the patients had developed OCS before antipsychotic use.[7] The index patient had silent corona radiata infarction on CT of the brain without any manifestations of stroke, and later on developed focal ischemic changes in the subcortical left temporal, peritrigonal, and periventricular regions which were evident on MRI of the brain. The initial change that was evident on CT of the brain occurred before the onset of neuropsychiatric manifestations. Furthermore, as the severity of neuropsychiatric manifestations increased with time, the patient developed more extensive ischemic changes in other areas of the brain. It might suggest that as the extent of underlying brain parenchyma pathology increased, the severity of neuropsychiatric manifestations also increased in the present case, indicating the vital role of underlying brain pathology in the development of neuropsychiatric manifestations. Fujikawa et al. concluded that half of the presenile onset depression and majority of senile onset major depression might be organic depression related to silent cerebral infarction.[12] A case report from Malaysia found that the patient had depressive symptoms after right corona radiata infarct, and the same patient later on developed psychotic as well as depressive symptoms after bilateral infarcts of the corona radiata and lentiform nucleus.[13]

In a case report by Farid et al., a 38-year-old male with new-onset psychosis was found to have a lacunar infarct of the left putamen.[14] The emergence of psychotic symptoms in two patients after lacunar infarcts in the internal capsule thalamus, bilateral basal ganglia, and the right lentiform nucleus has also been described.[15]

In terms of cost-benefit consideration, due to low yield, it may not be possible and affordable to image the brains of each and every patient who present with psychiatric symptoms. There is also a lack of quality evidence which can depict clinical advantages of neuroimaging in the field of psychiatry. Hence, the outcome from an economic view remains quite unclear.[16] However, the present case depicts the emerging importance of neuroimaging in the field of psychiatry for understanding the underlying psychopathology of mental illnesses.[17],[18],[19],[20],[21]


  Conclusion Top


The current case highlights the occurrence of neuropsychiatric manifestations in the context of underlying brain parenchymal pathology. If the neuroimaging findings are positive in patients with psychiatric manifestations, then appropriate consultation-liaison services can be utilized for further treatment. It can also help the clinician to understand the underlying psychopathology of psychiatric manifestations in more depth. Initially, it was thought that psychiatric disorders have a nonneurological functional origin, but because of the use of neuroimaging in the field of psychiatry, it is now thought that psychiatric disorders may have some underlying neurological origin too.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient and parents have given the consent for the images and other clinical information to be reported in the journal. The patient and the parents understand that name and initials will not be published, and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Honigfeld G, Klett CJ. The nurses' observation scale for inpatient evaluation: A new scale for measuring improvement in chronic schizophrenia. J Clin Psychol 1965;21:65-71.  Back to cited text no. 8
    
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Zink M, Schirmbeck F, Rausch F, Eifler S, Elkin H, Solojenkina X, et al. Obsessive-compulsive symptoms in at-risk mental states for psychosis: Associations with clinical impairment and cognitive function. Acta Psychiatr Scand 2014;130:214-26.  Back to cited text no. 11
    
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Fujikawa T, Yamawaki S, Touhouda Y. Incidence of silent cerebral infarction in patients with major depression. Stroke 1993;24:1631-4.  Back to cited text no. 12
    
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Abdullah KH, Saini SM, Sharip S, Rahman AH. Psychosis post corona radiata and lentiform nucleus infarction. BMJ Case Rep 2015. pii: bcr2014208954.  Back to cited text no. 13
    
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Farid F, Mahadun P. Schizophrenia-like psychosis following left putamen infarct: A case report. J Med Case Rep 2009;3:7337.  Back to cited text no. 14
    
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Srivastava S, Agarwal MP, Gautam A. Post stroke psychosis following lesions in basal ganglion. J Clin Diagn Res 2017;11:VD01-2.  Back to cited text no. 15
    
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Albon E, Tsourapas A, Frew E, Davenport C, Oyebode F, Bayliss S, et al. Structural neuroimaging in psychosis: A systematic review and economic evaluation. Health Technol Assess 2008;12:iii-iv, ix-163.  Back to cited text no. 16
    
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Patel A, Barot CK, Vankar G, Pal S. Acting on Delusions in Patients Suffering from Schizophrenia. Arch Psychiatr Psychotherapy 2019;21:52-61. Available from: https://doi.org/10.12740/APP/109009. [Last accessed on 2019 Nov 22].  Back to cited text no. 17
    
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Adarsh T, Avasthi A, Grover S, Sharma E, Bhaveshkumar M. Lakdawala M. Thirunavukarasu, Amitava Dan, et al. “Gender Differences in Obsessive-Compulsive Disorder: Findings from a Multicentric Study from India. Asian J Psychiatr 2018;37:3-9. Available from: https://doi.org/10.1016/j.ajp.2018.07.022. [Last accessed on 2019 Nov 22].  Back to cited text no. 19
    
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