Schizophrenia and

obsessive-compulsive disorder
DENISA-OANA CLIN1, TEFANIA TOT-BORNESCU1, SIMONA MACOVEI2

ABSTRACT:
The presence of obsessive-compulsive symptoms
(OCS) or obsessive-compulsive disorder (OCD) is common in patients with schizophrenia. The impact of OCS
and OCD on the severity of psychotic symptoms has been
assessed in several studies. There is growing evidence that
patients with comorbid obsessivecompulsive disorder
(OCD) and schizophrenia may represent a special category of the schizophrenia population. Contemporary investigators contend that there may be a specific pattern of
neurobiologic dysfunction in this subgroup of patients that
accounts for symptom co-expression. Accurate diagnosis
is important, given that current treatments for OCD and
schizophrenia differ and the choice of diagnosis made has
prognostic implications.
Key Words: obsessive-compulsive disorder, schizophrenia, comorbidity
REZUMAT:
Prezena simptomelor obsesiv-compulsive este
comun la pacienii cu schizofrenie. Impactul OCS i
OCD asupra severitii simptomelor psihotice a fost
prezentat n diferite studii. Exist tot mai multe dovezi care
susin c pacienii cu schizofrenie i tulburare obsesiv
compulsiv ar putea reprezenta o categorie special.
Studiile arat c ar putea exista un model specific de disfuncie neurobiologic la acest subgrup de pacieni, care s
determine co-expresia simptomelor. Un diagnostic corect
este important, deoarece tratamentele pentru OCD i pentru schizofrenie sunt diferite, iar diagnosticul ales are i
implicaii asupra prognosticului.
Cuvinte cheie: tulburare obsesiv compulsiv,
schizofrenie, comorbiditi.
INTRODUCTION
Schizophrenic patients may have obsessive-compulsive (OC) symptoms and patients that have obsessive-

compulsive disorder (OCD) may have psychotic symptoms. The lifetime comorbidity rate of schizophrenia and
OCD was reported to be higher than the individual lifetime
prevalence rate of each disorder and, therefore, researchers
suggest that there might be a psychopathological relationship between schizophrenia and OCD. Both disorders have
early age onsets. Both disorders have a chronic course and
affect males and females similarly. Both disorders are
characterized by disturbing thoughts and bizarre behaviour. A growing literature suggests that obsessive-compulsive symptoms (OCS) and obsessive-compulsive disorder
(OCD) occur in a higher proportion of patients with schizophrenia than was originally suspected .There is a common assumption that both disorders affect the same
anatomical pathways, and that afferent impulses are not
filtered adequately by the thalamus. Although the neurobiological basis of schizophrenia and OCD have been
explained with comparative studies and despite all supportive epidemiological and biological findings, the relationship between OCD and schizophrenia is not well
understood (Glcan et al., 2008, Kumbhani et al. 2010 ).
COMORBIDITY BETWEEN SCHIZOPHRENIA
AND OBSESSIVE-COMPULSIVE DISORDER
Co-occurrence of obsessivecompulsive symptoms
(OCS) and psychotic illness was first recognized over a
century ago (Bottas et al. 2005). Early descriptions of
obsessive-compulsive symptoms in schizophrenia can be
found in Bleulers monography on dementia praecox.
compulsive thinking (obsession) is the most common of
all the automatic phenomena, Bleuler stated, and further
described OCS in schizophrenia as automatisms, which
are comparable to auditory or visual hallucinations in that
they are hallucinations of thinking, striving, and wanting
. Confirming these observations, case reports and larger
systematic studies have since suggested that more than a
third of the persons with schizophrenia experience clini-

1 Resident physician in Child and Adolescent Psychiatry, Child and Adolescent Psychiatry Department, Prof. Dr. Al. Obregia Hospital of Psychiatry,
Bucharest
2 MD, Primary doctor in Child and Adolescent Psychiatry, Child and Adolescent Psychiatry Department, Prof. Dr. Al. Obregia Psychiatry Hospital,
Bucharest, Assistant Professor Child and Adolescent Psychiatry Department, University of Medicine and Pharmacy Carol Davila Bucharest, Romania

VOLUME 5, NUMBERS 3-4, DECEMBER 2011

27

D.-O. CLIN, T. TOT-BORNESCU, S. MACOVEI

cally significant OCS, while roughly 10% to 25% meet full

diagnostic criteria for obsessive compulsive disorder
(OCD) (Lysaker et al. 2009). Many patients with schizophrenia can distinguish the egodystonic OC symptoms,
perceived as coming from within, from the egosyntonic
delusions perceived as intruding from the outside. Followup studies demonstrate diagnostic stability over time and it
seems that the presence of OCD in schizophrenia predicts
a poor prognosis. The presence of OCD or significant OCS
in patients with schizophrenia has been associated with
more severe psychosis and depression, poorer social functioning, lesser likelihood of being employed, and poorer
prognosis. Due to the different (poorer) prognosis of
patients with schizo-obsessive symptoms, as well as preliminary data regarding their response to specific therapeutic intervention (i.e., the combination of antipsychotic and
antiobsessive medications), and taking into account the
high prevalence of this presentation, several researchers
have suggested that a schizo-obsessive category may be
considered. Schizophrenia patients with concurrent OCS
constitute an intriguing subgroup of individuals. Three
main types of interrelation between OCS and psychotic
disorder are described: 1) those whose OCS are independent from psychosis; 2) those whose OCS are partially related to their psychosis; and 3) those whose OCS represent a
continuum of their psychosis. Clinically and anamnestically, we are able to distinguish three main subgroups of
patients: 1) those who met the DSM-IV criteria for OCD
before the development of schizophrenic process; 2) those
who began to exhibit OC symptoms around the onset (i.e.
in prodromal phase) or at any time during the course of
schizophrenia; and 3) schizophrenic patients having transient OC symptoms on different stages of their disease, or
under specific circumstances (infections, i.e streptococcal;
iatrogenic, i.e. under some atypical neuroleptics, etc).
Existence of these three groups may explain (at least, in
part) the diversity in epidemiological data, clinical manifestations and course, neuropsychological correlates, outcomes of various prognoses and treatments. (Reznik et
al.,2004; Bottas et al., 2005, Lee et al., 2009, Kumbhani et
al. 2010 )
DIAGNOSTIC CHALLENGES
The differential diagnosis of a patient who presents
with both psychotic and obsessive-compulsive symptoms
can include comorbid schizophrenia and obsessivecompulsive disorder, OCD with poor insight, or schizophrenia with antipsychotic-induced obsessive-compulsive
symptoms. If the psychotic symptoms are subthreshold or
attenuated in form, the individual may have OCD and
putative prodromal schizophrenia. No biological markers
28

exist to differentiate between these possibilities, and there

is debate as to the relationship of schizophrenia and OCD,
especially early in the course of evolving symptoms.
However, accurate diagnosis is important given that current treatments for OCD and schizophrenia differ, and
first-line medications for one may exacerbate the symptoms of the otherthat is, antipsychotics can exacerbate
obsessive-compulsive symptoms, and SRIs may exacerbate psychosis . Also, the choice of diagnoses made has
prognostic implications. (Rodriguez et al., 2010)
When a patient presents with the hallmarks of schizophreniahallucinations, disorganized speech and behaviour, negative symptoms, and delusions (i.e., erroneous
beliefs that usually involve a misinterpretation of perceptions or experiences [DSM IV-TR])the diagnosis is
usually straightforward. Likewise, when a patient presents
with the hallmarks of OCDobsessions (recurrent or
persistent thoughts, impulses, or images[that are]
intrusive and inappropriate and that cause marked anxiety
or distress [DSM-IV-TR]) and compulsions (repetitive
behavioursor mental actsthat the person feels driven
to perform in response to an obsession[and]are aimed
at reducing distress or preventing some dreaded
event[DSM-IV-TR])and has good insight into the irrationality of his or her thoughts and the link between his or
her thoughts and compulsions, it is clearly OCD.
However, in the patient who does not have hallucinations
or disorganized speech but has psychotic beliefs and repetitive behaviours, it can be a challenge to distinguish the
delusion of schizophrenia from the obsession of OCD if
the patient has poor or no insight. Another challenge in
some cases is to distinguish the repetitive behaviours of
schizophrenia from the compulsions of OCD. Neither of
the challenge is uncommon. In the absence of biomarkers
or behavioural tests that can distinguish these features,
careful attention to four aspects of the clinical phenotype
can help in evaluation. (Rodriguez et al. 2010; DSM-IVTR).
OBSESSIONS VERSUS DELUSIONS
A long-standing challenge facing investigators and
clinicians is the difficulty in differentiating an obsession
from a delusion when the 2 symptoms appear to be connected. Obsessions and delusions are both thought distortions. However, the content and character of the distortions, as well as their relationship to repetitive behaviours,
can differ. In OCD, several common obsessive themes
have been described: contamination, symmetry or exactness, forbidden thoughts (aggressive, sexual, religious, and
somatic), and hoarding . These obsessional themes are typically associated with corresponding compulsions: cleanVOLUME 5, NUMBERS 3-4, DECEMBER 2011

PRESENT DEFICIENCIES AND FUTURE SKILLS IN CHILDREN WITH ASPERGER SYNDROME

ing, ordering and arranging, checking, and hoarding. In

contrast, the delusions seen in patients with schizophrenia
include persecutory, referential, somatic, erotomanic, and
grandiose themes . This is true even of the overvalued
ideas seen in patients who are in a putative prodromal
stage . Psychotic beliefs are more often bizarre (clearly
implausible and not understandable and do not derive from
ordinary experiences); however, bizarreness can be difficult to judge, especially across cultures. Although
somatic themes overlap between the two disorders,
somatic thoughts that are bizarre or represent loss of control over mind or body are more common in schizophrenia than in OCD with poor insight . Likewise, religious
themes can occur in both, but in OCD, patients are overly
concerned with sacrilege, blasphemy, or scrupulosity (i.e.,
excessive concern with right and wrong or with morality),
whereas in schizophrenia, patients may more commonly
have grandiose religious delusions (e.g., Im a divine
messenger). Furthermore, loss of control, or agency of
thinking, more commonly occurs in schizophrenia.
Patients with OCD often consider their obsessions as products of their own thinking, whereas patients with schizophrenia often believe that there is some external agency or
cause to what they are experiencing and thinking .This distinction, however, becomes blurred when considering individuals with attenuated psychotic symptoms in a putative
prodromal stage of schizophrenia or in patients with
schizophrenia whose psychotic symptoms are partially
remitted or residual. Also, a sense of permeation of ego
boundary is more typical of schizophrenia than of OCD,
although most patients with schizophrenia also have an
intact sense of ego boundary. However, the problem with
these distinctions is that they are less clear in prodromal or
evolving stages of illness or with partial remission of
symptoms during residual phases. For example, young
people at heightened risk for schizophrenia have attenuated psychotic symptoms and can retain insight that their
experiences are likely the product of their own imagination, although doubt may exist as to their source and
nature. (Rodriguez et al., 2010; Bottas et al., 2005).
COMPULSION VERSUS REPETITIVE
BEHAVIOURS
In adults with OCD, compulsive behaviours are typically performed in response to an obsession and to reduce
distress or prevent a dreaded event. In contrast, in schizophrenia, repetitive behaviours are often independent of
thought content. The presence of compulsions linked to
obsessions may be a useful guide in diagnosing comorbid
OCD in patients with schizophrenia. (Rodriguez et al. ,
2010; Bottas et al, 2005)
VOLUME 5, NUMBERS 3-4, DECEMBER 2011

TIME OF ONSET OF SYMPTOMS

Age at onset is similar for both OCD and schizophrenia, with 50% of OCD cases starting by age 19 and
20%40% of first psychotic symptoms in schizophrenia
starting by age 20. In both disorders, subsyndromal symptoms can start in adolescence. However, the time of symptoms onset in relationship to changes in medication can
exclude diagnoses. For example, if the first evidence of
obsessive-compulsive symptoms or an exacerbation of
existing symptoms occurs after initiating antipsychotic
treatment for psychosis, one should consider the possibility that the symptoms are medication induced. Similarly, if
psychotic symptoms worsen after initiating or titrating an
SRI, one should consider the possibility of medicationinduced psychosis (Rodriguez et al., 2010).
FAMILY HISTORY
Family history can help inform the differential
diagnosis. Although both schizophrenia and OCD are heritable disorders, with higher concordance rates in monozygotic twins than in dizygotic twins, they do not appear to
cosegregate. Families of patients with schizophrenia are
more likely to have members with schizophrenia spectrum
disorders, such as schizoaffective disorder and schizotypal
personality disorder . In contrast, families of patients with
OCD are more likely to have what are called OCD spectrum disorders (including tic disorder, Tourettes syndrome, skin picking) and comorbid mood and anxiety disorders . (Rodriguez et al., 2010)
DEVELOPMENTAL PSYCHOSOCIAL
FUNCTIONING
Both schizophrenia and OCD can lead to significant
functional impairment in the work, family, and social
domains. However, in contrast to OCD, social dysfunction
is a core feature of schizophrenia and functional impairment is one of the DSM-IV criteria required for diagnosis.
In schizophrenia, this social dysfunction is evident early .It
is first expressed subtly during the premorbid period in
childhood as difficulty in establishing relationships and
social overreactivity (social anxiety, acting out) in boys
and underreactivity (withdrawal) in girls . Likewise, adolescents at genetic risk for schizophrenia have poor peer
engagement and unpopularity with peers .Active social
withdrawal is a feature of the putative prodromal period in
schizophrenia . Lack of interpersonal relatedness (i.e.,
diminished capacity for others to feel engaged and relate
well to the individual) may also be characteristic of schizophrenia. In addition to social dysfunction, negative symptoms (e.g., flat affect, avolition, and alogia) are a key clin29

D.-O. CLIN, T. TOT-BORNESCU, S. MACOVEI

ical aspect of schizophrenia and can include social anhedonia. In contrast, lack of interpersonal relatedness and social
anhedonia are not characteristic of OCD, and social dysfunction is not required for an OCD diagnosis. On the
other hand, obsessive-compulsive symptoms can certainly
lead to social dysfunction. (Rodriguez et al., 2010)
SUGGESTIONS FOR IDENTIFYING OCS IN THE
PRESENCE OF PSYCHOSIS
1. The types of obsessions and compulsions observed
in schizophrenia are phenomenologically similar to those
present in pure OCD.
2. A repetitious act should be considered a compulsion only if it occurs in response to an obsession and not if
it occurs in response to psychotic ideation (e.g., repetitive
checking in response to paranoid fears does not constitute
a compulsion).
3. A recurrent, intrusive, ego-dystonic thought should
not be considered an obsession if it revolves exclusively
around current delusional themes (e.g., violent images,
which constitute a common type of obsession in OCD,
may represent an entirely different phenomenological entity in the context of psychosis). In the acute psychotic
phase it may be necessary to exclude questionable obsessions and reassess for these after the psychotic symptoms
have been treated.
4. OCS may be difficult to distinguish in the presence
of thought form disorder; it may therefore be necessary to
reassess for OCS once thought form has normalized.
5. Primary obsessional slowness may be mistaken for
prodromal schizophrenia or thought disorder; such patients
may be unable to articulate any obsessions and may exhibit no compulsions.
6. At times it may not be possible to determine if
apparent OCS in the presence of psychosis represent real
OCS; in such cases empiric treatment with a neuroleptic
and a serotonin reuptake inhibitor (the standard treatment
for OCD) may be necessary. (Bottas et al, 2005)
NEUROPSYCHOLOGICAL PROFILE OF OBSESSIVE- COMPULSIVE SCHIZOPHRENIA
OC-schizophrenia patients possess a distinct clinical
and neuropsychological profile that differs from that of
their non-OC schizophrenic counterparts. This profile
includes a worse clinical course with poor treatment
response, lower functioning levels, and greater impairment
of functions primarily subserved by the frontal lobes.
(Hwang et al. 2000). Co-occurrence of schizophrenia and
OCS reflects the presence of both the structural and functional abnormalities associated with schizophrenia and

30

OCD. Accordingly, it has been suggested that individuals

with schizophrenia and OCS/OCD may represent a group
of persons with particularly severe cognitive and functional deficits. Research supporting this hypothesis includes
studies linking OCS with deficits in several domains of
executive function, including abstract reasoning and
abstract flexibility (Lysaker et al., 2002, Kumbhani et al,
2009, Niendam et al, 2008)
NEUROBIOLOGY
Considerable work has been done to elucidate the
neurobiologic basis of both schizophrenia and OCD.
Serotonin and dopamine have most consistently emerged
as the principal neurotransmitters of interest in both disorders. In schizophrenia, the dopamine hypothesis has long
been regarded as the fundamental neurochemical premise;
this is most strongly supported by successful treatment of
the disorder with dopamine receptor antagonists.
However, the superior efficacy of the serotonindopamine
receptor antagonists in the treatment of schizophrenia
additionally supports the importance of the serotonergic
system in the pathophysiology of this disorder and may
reflect the modulation of dopaminergic systems by serotonin. Conversely, in OCD a somewhat opposing picture
has emerged with respect to neurotransmitter involvement.
The serotonin hypothesis of OCD is supported by successful treatment of the disorder with serotonin reuptake
inhibitors. Pharmacologic challenge studies with serotonin
agonists and cerebrospinal fluid neurotransmitter metabolite studies have provided further evidence for the involvement of the serotonergic system in OCD. However, not all
studies support a singular role for serotonin in OCD.
Typically only 40%60% of patients with OCD exhibit
response to monotherapy with selective serotonin reuptake
inhibitors, and the magnitude of response is often modest.
This observation suggests the involvement of other neurotransmitter systems in the pathophysiology of OCD, and
evidence supporting the role of the dopaminergic system
in this disorder has led to a proposed dopamineserotonin
hypothesis of OCD. Several lines of evidence implicate
the dopaminergic system in the pathophysiology of OCD,
including the role of dopamine in stereotypic behaviours in
animal models, the etiologic role of dopamine in
Tourettes disorder (which is frequently comorbid with
and shares neuroanatomic substrates with OCD), preclinical evidence of dopamines reciprocal modulatory effects
on the serotonin system and successful treatment of refractory OCD with dopamine receptor antagonists and serotonindopamine receptor antagonists. The latter observation (of the therapeutic utility of antipsychotic medications
in OCD) is difficult to interpret, given numerous reports of

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PRESENT DEFICIENCIES AND FUTURE SKILLS IN CHILDREN WITH ASPERGER SYNDROME

the emergence of de novo OCD or exacerbation of preexisting OCD in patients with schizophrenia who have
been treated with atypical antipsychotics. Such paradoxical findings are a testimony to the extreme complexity of
the neurotransmitter systems involved in each disorder.
(Bottas et al., 2005; Poyurovsky et al 2007, Hwang et al.
2000)
NEUROANATOMY AND NEUROCIRCUITRY
Several investigators have hypothesized that similarities in the neurocircuitry and specific anatomic structures
implicated in each disorder may account for symptom coexpression. The functional circuitry involved in the pathophysiology of OCD is generally believed to involve a cortico-striatal-thalamic-cortical circuit. Specific structures
involved in this pathway include the basal ganglia,
orbitofrontal cortex and anterior cingulate cortex. In schizophrenia, the dorsolateral prefrontal cortex circuit contains
anatomic substrates similar to those of the OCD
orbitofrontal circuit. Thus, the specific neuroanatomic
sites identified by structural and functional neuroimaging
studies performed in each of these disorders independently show considerable overlap in implicated structures,
including the basal ganglia, thalamus, anterior cingulum,
orbitofrontal cortex and regions of the temporal cortex,
although some of these findings are controversial. (Bottas
et al., 2005; Poyurovsky et al 2007)
NEUROIMAGING STUDIES
Neuroimaging studies suggest that there may be a
specific pattern of neuroanatomic dysfunction in the
comorbid subgroup. Aoyama et al performed MRI in subjects with juvenile-onset schizophrenia and OCS and
found significantly smaller left hippocampi in this group
than in subjects who had schizophrenia without OCS and
in control groups. These researchers also found an inverse
correlation between illness duration and frontal lobe size
in the group with both schizophrenia and OCS, but not in
the group with schizophrenia only. In another MRI study
of patients with juvenile-onset schizophrenia, investigators
demonstrated significant enlargement of the anterior horn
of the lateral ventricle and the third ventricle in patients
with OCS relative to those without OCS. In a study of
functional MRI performed on patients with schizophrenia
and various degrees of OCS, one subgroup exhibited a
negative correlation between activation of the left dorsolateral prefrontal cortex and OCS severity. Taken together,
these findings suggest specific neuroanatomic abnormalities in the overlap group that differ from what is observed
in each disorder individually. (Bottas et al., 2005)

VOLUME 5, NUMBERS 3-4, DECEMBER 2011

PRINCIPLES OF TREATMENT
A few studies have addressed how to treat patients
with both schizophrenia and OCD . Based on these studies, OCD treatment guidelines suggest that these patients
should first be stabilized on a second-generation antipsychotic and the obsessive-compulsive symptoms subsequently treated by the addition of an SRI. Whether these
patients require SRIs at the high doses needed in patients
with OCD without a comorbid psychotic disorder is
unclear: obsessive-compulsive symptoms in the context of
psychotic disorder have been found to respond to lower
doses of fluvoxamine (100200 mg/day) than typically
used in treatment of OCD (250300 mg/day). Poyurovsky
and colleagues proposed that those who do not respond to
the steps above be switched to another SRI or
clomipramine, to another second-generation antipsychotic,
or to a first-generation antipsychotic with an SRI or
clomipramine. If these strategies are ineffective, they propose clozapine at a low dosage (75300 mg/day), SRI augmentation of clozapine, and finally ECT . Combining
antipsychotics and SRIs (e.g., fluvoxamine and clozapine;
clomipramine and clozapine; paroxetine and risperidone or
a phenothiazine) requires careful monitoring for drug-drug
interactions and for possible exacerbation of obsessional
or psychotic symptoms . In patients with co-occurring
schizophrenia and OCD or obsessive-compulsive symptoms, if antipsychotic medication induces obsessive-compulsive symptoms, there are several options: waiting for
spontaneous resolution (46 weeks), gradually reducing
the dosage of antipsychotic, switching to another antipsychotic, adding an SRI to target the obsessive-compulsive
symptoms (e.g., fluvoxamine, clomipramine, sertraline),
or attempting a trial of exposure and response prevention .
The evidence base for these approaches is limited. Some
patients with both schizophrenia and OCD, remain symptomatic despite the treatment recommendations listed
above. Recent data have implicated glutamatergic abnormalities in the pathophysiology of schizophrenia, OCD,
and depression . Lamotrigine is an anticonvulsant typically used for seizure disorders and maintenance treatment in
bipolar disorder. In addition to its varied mechanisms of
action, lamotrigine inhibits glutamate release. In schizophrenia, there is preliminary evidence that lamotrigine (at
dosages of 200 mg/day and higher) might be effective for
psychotic symptoms when added to clozapine but not
when added to antipsychotics other than clozapine. In
OCD, an open-label study found that one of eight patients
responded to lamotrigine augmentation of an SSRI
(although the lamotrigine dosage was only 100 mg/day),
and there has been a case report of marked improvement
with lamotrigine augmentation (150 mg/day) of clomip-

31

D.-O. CLIN, T. TOT-BORNESCU, S. MACOVEI

ramine. Although no randomized clinical trials have yet

been conducted to evaluate the efficacy of lamotrigine for
patients with comorbid OCD and schizophrenia, these preliminary data suggest that glutamate modulators may be an
area of interest for treatment-resistant patients with both
psychotic and obsessive-compulsive symptoms. There are
as yet no consensus guidelines for the treatment of the
putative schizophrenia prodrome. Olanzapine has unclear
efficacy and problematic side effects and one study reported efficacy with risperidone when administered in combination with CBT . It remains unknown whether treating
obsessive-compulsive symptoms in a putative schizophrenia prodrome has an effect on the natural course of either
of these illnesses (Rodriguez et al, 2010).
CONCLUSIONS
Despite the growing evidence supporting the existence of an epidemiologic and biologic relation between
OCD and schizophrenia, the association remains poorly
understood. Although the distinction between obsessions
and delusions is often unclear, clinical evidence suggests
that OCS in schizophrenia represents more than just an
expression of enduring psychosis. The epidemiologic data
suggest a unique relation between these 2 disorders, given
the marked degree of comorbidity that has been observed.
Furthermore, the neurobiologic data on each disorder suggest the involvement of common brain regions and neurotransmitter systems. In patients with both schizophrenia
and OCD more severe impairment was generally revealed
than among patients who have schizophrenia and not OCD
(and patients who have OCD and not schizophrenia), which
suggests a specific and active interaction between these 2
disease processes. Further research focusing specifically on
this overlap group is essential and should clarify the nature
of this putative entity in the years to come.
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