Psychotherapeutic Approach to the Treatment of a Youth with Schizophrenia and OCD: A Case Report

Introduction

Stages of human development are a reference child and adolescent psychiatrists regularly use to guide the evaluation and treatment of patients. For instance, it can be helpful to know that the emergence of psychiatric conditions is most likely to occur in specific developmental stages. This is the case for schizophrenia and obsessive-compulsive disorder (OCD), which are often first detected during adolescence.^1,2 These illnesses also commonly co-occur. ³ Individually, they are some of the most complex and challenging to manage. When comorbid, selecting a treatment approach requires even more careful consideration in choosing modalities for them. Published case reports involving similar patients and successful outcomes are an educational tool available to clinicians in these scenarios. Recent ones are preferred and more likely to include contemporary standards of care. There is currently a lack of recently published case reports involving the treatment of children and adolescents suffering from OCD and schizophrenia. Therefore, the following case involving an adolescent suffering from both can serve as a useful addition to the scientific record and aid currently practicing clinicians treating patients with similar presentations.

Case Report

Jim is a 13-year-old boy whose parents immigrated to the United States from a Middle Eastern country a decade prior. At the time, Jim was about to complete his seventh grade year of school when he began voicing concerns that his band instructor was speaking poorly of him to other students when he was absent. In sharing these thoughts with his parents, they initially concluded he must just be sensitive to feedback from the instructor. However, over the following weeks, Jim’s concerns became more distressing and somehow evolved into paranoia about an array of other topics, one being fear that the United States was about to go to war and bombed on by an enemy nation. Then one evening, a month after Jim’s initial comments, his parents received a call from law enforcement. They were told that he had been apprehended a few blocks from their home when neighbors reported him knocking on their doors, entering uninvited, and insisting they take shelter from a bombing campaign that was about to be underway.

It was now clear that something was not right. Jim’s parents then took him to a nearby hospital. Over the coming months, he underwent numerous hospital stays, for medical evaluation and psychiatric stabilization. An extensive battery of tests screening for metabolic, immunologic, and infectious sources that could provoke neuropsychiatric symptoms were ordered, turning up no relevant findings. During this workup, Jim became increasingly withdrawn and difficult to engage with due to the distracting internal stimuli he was visibly responding to. When approached by family, he reacted with screams and throwing punches, often leaving holes in the drywall of their home. During this time, numerous psychotropic medication trials were undertaken. These only subdued Jim enough to limit his aggression from injuring him or others and did nothing to recover his reality testing.

Nearly six months after the onset of his psychiatric symptoms, Jim’s parents found a psychiatrist for him. However, with limited experience treating children like Jim, his psychiatrist instead referred him to an academic medical center, seeking consultation on further evaluation and treatment. Up to this point, four second-generation antipsychotic agents had been trialed. During his initial evaluation by the author of this case report, Jim did not respond to any interview questions. Instead, he spent the appointment whispering to himself and gazing around the room, rarely making direct eye contact with anyone in the exam room. By this point, Jim was unable to attend school, even from home. With the number of failed medication trials, it was apparent Jim had treatment-resistant schizophrenia (TRS). At the end of this first appointment at the university hospital, consent and assent were obtained from the patient and parents to obtain baseline laboratory tests and initiate a clozapine trial, the intervention with the strongest evidence for use in TRS.

Once started, Jim’s clozapine dose was gradually titrated upward. Between each dose change, he experienced an array of side effects: sialorrhea, constipation, enuresis, sedation, and hyperphagia, to name a few. Each one required treatment, often with another agent. After eight months of tedious medication adjustments, Jim’s symptoms had reduced in severity, so much so that he was remarkably able to take part in an online homeschool curriculum. Despite his return to school, though, he continued to report distress from persecutory auditory hallucinations. This was compounded by the fact that his clozapine dose could no longer be increased due to intolerable gait instability and fine motor tremors affecting his balance, and ability to write and feed himself, respectively. As a result, his dose was optimized in view of the side effects and remained unchanged for the remainder of the academic year.

By the next fall, his psychotic symptoms had improved enough for him to return to brick-and-mortar school to begin high school. Great efforts were taken to ensure adequate accommodations were in place to compensate for his still active auditory hallucinations (e.g., being allowed to wear an ear bud in one ear to distract him from the voices, preferential seating, extended time on tests). Jim fared well that first semester but had not quite returned to his high premorbid functioning, where he had consistently made all A’s and regularly took part in multiple after-school athletics. Instead, his grades were a mix of A’s and B’s, and by the end of the fall, he joined the school swim team while balancing his schoolwork. Once Jim entered the spring semester of his ninth grade year, his parents began reporting feeling confused about new behavior in him: daily and frequent reassurance for them to check his work, sometimes dozens of times in the afternoon, to screen for errors in his work, and to verify that he was correctly following directions in his assignments. They were perplexed because rarely were there errors in his work, and he clearly understood directions for each assignment. As time went on, a number of other signs and symptoms became apparent in Jim: intrusive thoughts about missing words when reading assignments, resulting in him rereading them over and over and erasing and rewriting his work a certain number of times, all until “it felt just right,” according to Jim. After investigating the duration of these symptoms, it was concluded that he met criteria for a diagnosis of obsessive convulsive disorder. It was initially thought to be secondary to clozapine, which has been known to provoke OCD symptoms as a side effect. However, Jim later reported having similar experiences dating back to grade school, suggesting a primary etiology.

To address this constellation of symptoms, the patient’s psychiatrist began a trial of exposure response prevention (ERP) psychotherapy. This involved a total of 15 sessions, each lasting 45 minutes, once per week. It was explained to Jim that this would begin with him ranking the level of distress he could imagine experiencing if he were not able to engage in each compulsive behavior. Then, under the guidance of his psychiatrist, he would be asked to gradually prolong the interval of time between each intrusive thought and subsequent compulsive behaviors. Each time the interval widened, he would experience a stress response that would subside once he engaged in the compulsion of concern. It was emphasized to Jim that as this exercise continued, the intensity of stress responses would reduce, making it easier to expand the time between each obsession and compulsion. The ultimate goal would be for him to reach a point where he would not feel the need to carry out compulsive behaviors to cope with intrusive thoughts he experienced in the future.

Jim’s list of obsessions and compulsions was extensive and contained a variety of themes (e.g., fear of harming self or others, concerns about morality, and fears of blurting out obscenities and of forgetting important information). When asked where he was comfortable starting, Jim elected to challenge his fears of forgetting academic course material, mentioned above, that he only felt relief after engaging in some of the following compulsive behaviors: rereading assigned reading, rewriting assignments, and asking for parents to check his work, all a certain number of times, or until he felt reassured that his memory of course content and assignment deadlines was intact. During this stage of his treatment, Jim met with his psychiatrist weekly and was given the following assignments to do: provide less and less time to the act of rereading passages and rewriting assignments. He was also asked to delay the amount of time it took him to seek reassurance from his parents. Each obsession was approached one at a time, until Jim was able to no longer have the urge to carry compulsions linked to each. As had been predicted, Jim’s stress level rose with each obsession he challenged. Due to the determination and devotion he gave to his treatment, he eventually experienced complete resolution of his previous symptoms, even those that were never specifically targeted with ERP.

By the end of this treatment trial, Jim had completed his first year of high school. Now, at age 15 years, his response to treatment had led to the recovery of nearly all the premorbid functioning he held before his first psychotic episode. However, Jim still felt unsatisfied with the amount of benefit he was getting from the clozapine, as it related to the auditory hallucinations he continued to experience throughout each day. Therefore, a decision was made to augment his treatment with electroconvulsive therapy (ECT). This intervention had been discussed during the previous school year. It had been delayed until the summer to prevent any potential memory impairment during the procedure from affecting his academic performance. By the end of his 12-session ECT index series, and the end of his summer break, the auditory hallucination voices were softer. His previously mentioned OCD symptoms were also stable and continued to stay in remission.

Conclusion

This case report highlights several important points. either previously missing from the scientific record or with limited mention. These include the prevalence of OCD in youth with treatment-resistant schizophrenia and the strong response these individuals have to the first-line treatment for OCD, ERP. It also highlights how youth with schizophrenia and other psychoses can benefit from psychotherapy, especially systematic cognitive psychotherapy techniques. This goes contrary to the pessimistic bias many in our field often associate with using psychotherapy with this more severely ill population.

To evaluate if these results are replicable and generalizable to this patient population, it is important that future studies be conducted. Until then, this case can serve as a point of optimism for clinicians who read it: that despite the poor prognosis often faced by those with early onset schizophrenia, if faced with co-occurring OCD, there exists a precedent of similar individuals responding to treatment for this psychiatric comorbidity.