Introduction: The comorbidity of obsessive-compulsive disorders (OCD) and schizophrenia has been documented by epidemiological investigations. Within the multiple pathogenetic factors leading to OCD in schizophrenic patients, treatment with atypical antipsychotics has been proposed for a significant subgroup of these patients. Herein, we report the case of a schizophrenic patient who developed clozapine-induced obsessive compulsive symptoms that responded to valproic acid augmentation.
Case Report: A 51-year-old male patient first developed paranoid delusions and auditory and visual hallucinations at the age of 23, fulfilling the diagnostic criteria of the DSM-IV for schizophrenia. He had been hospitalized several times and underwent various treatment regimens (including electroconvulsive therapy) in the past for acute schizophrenic episodes. He had been in remission with clozapine 500 mg/day for approximately one year before relapse occurred as a result of treatment noncompliance. He was admitted to hospital with exacerbation of positive symptoms. He was started on clozapine 50 mg/day and titrated up to 500 mg/day. A significant improvement was observed in positive symptoms. However, he developed compulsive hand washing behavior in the 3rd week of the treatment. He had been spending 5 to 8 hours a day washing his hands although he recognized that it was senseless. He did not have a history of obsessive-compulsive disorder. We assumed clozapine-induced obsessive compulsive symptoms and gradually decreased the dosage of clozapine which resulted in aggravation of positive symptoms and elevated mood. Therefore, valproic acid 1000 mg/day was added to the regimen of clozapine 500 mg/day. Two weeks after starting valproic acid, the patient`s positive symptoms and elevated mood were significantly reduced and his compulsive hand-washing disappeared. He was discharged and in a 3 month-follow-up, he was maintained well under a combined treatment with clozapine and valproic acid.
Discussion: Our patient developed hand-washing compulsion during treatment with clozapine,an atypical antipsychotic, which disappeared after augmentation of valproic acid. Although a few case reports have mentioned the efficacy of valproic acid in the treatment of OCD, there is only one case report showing alleviation of clozapine-induced OCD symptoms with valproic acid augmentation in a patient with schizophrenia. In light of our case report, we suggest that valproic acid may be a choice when treating OCD symptoms which may appear as an adverse effect of atypical antipsychotics in patients with schizophrenia. Case-controlled studies are required to establish the efficacy of valproic acid in the treatment of antipsychotic-induced OCD symptoms before definitive conclusions can be reached.