A case of obsessive compulsive disorder with psychotic features that suffered from sexual trauma

Introduction: Although the relationship between obsessive compulsive disorder (OCD) and psychosis is a noteworthy phenomenon, the limits of the two disorders have not been defined. Eisen and Rasmussen (1993) evaluated a total of 475 patients with OCD and 14% were identified as having psychotic symptoms in addition to OCD. They classified the patients into 4 groups: 6% OCD without insight, OCD and schizophrenia (4%), OCD and delusional disorder (2%), OCD and schizotypal personality disorder (3%) (1). In clinical observation it is seen that, the shift from an obsession to a delusion is described when insight into obsessive signs is lost and resistance abandoned. These delusions do not signify a schizophrenic diagnosis but represent reactive affective or paranoid psychoses (3).

Case: A 32 year old single man, who has not been a soldier, presented with aggressive, contamination, sexual, need for symmetry, somatic obsessions; checking, washing, counting, need for confession compulsions; thinking he was followed by the secret service, sense of anal burning, and inability to sleep. His mood and affect were anxious, speech increased, and associations were dispersed. He had a history of sexual abuse by his brother. Obsessive symptoms started at the age of 12, feeling some problems about his gender, anxiety about his future, sleeplessness and not talking to people at 16. After 15 days he had talked about the sexual abuse with her mother, who died because of a myocardial infarction and he started to blame himself. He lost 15 kg in 6 months and started to experience auditory and visual hallucinations. He was treated with many antipsychotics, SRIs, TCAs, and benzodiazapines. He had a hypomanic attack under the treatment of aripiprazole. In the Rorschach test he showed schizoid reactions and dissociation in 2003. He was hospitalized 2 times. At his last visit his treatment was sertraline 200 mg/day and olanzapine 5 mg/day. The appearance of the psychotic symptoms occurred, when the depressive symptoms started. Olanzapine was increased to 10 mg/day after sleeplessness and psychotic symptoms şared up. The last Rorschach test assessed the patient as being in pregenital organization and requiring close control of affective and psychotic symptoms.

Discussion: The clinical observations emphasize the interest in OCD patients with psychosis, who are neglected often. The shift from an obsession to delusion is triggered by stress and is generally transient (2). The strong association between psychotic features and depressive features in OCD may also have important implications in the treatment strategies (3). OCD represents a psychopathological spectrum varying along a continuum of insight and requires careful clinical observation and treatment.

References:

1. Eisen JL, Rasmussen SA. Obsessive-compulsive disorder with psychotic features. J Clin Psychiatry1993; 54(10):373-379.
2. Özerdem A. Obsesif-Kompulsif Bozukluk ve Psikoz Üzerine Bir Gözden Geçirme. Klinik Psikiyatri 1998;2:98-102
3. Khess CDJ, Das J, Parial A et. al. Obsesive Compulsive Disorder with psychotic features.Hong Kong J Psychiatry1999;9(1): 21-25 Bulletin of Clinical Psychopharmacology 2011;21(Suppl. 2):S166-7