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Prevalence and clinical correlates of obsessive–compulsive disorder in schizophrenia Sugnyani Devi a , Naren P. Rao a, b , Suresh Badamath a , C.R. Chandrashekhar a , Y.C. Janardhan Reddy a,⁎ a

Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India b Centre for Neuroscience, Indian Institute of Science, Bangalore, India

Abstract Obsessive compulsive symptoms frequently occur in a substantial proportion of patients with schizophrenia. The term schizoobsessive has been proposed to delineate this subgroup of schizophrenia patients who present with obsessive–compulsive symptoms/disorder. However, whether this co-occurrence is more than just co-morbidity and represents a distinct subgroup remains controversial. A striking variation is noted across studies examining prevalence of obsessive–compulsive symptoms/disorder in schizophrenia patients and their impact on clinical profile of schizophrenia. Hence, in this study, we examined the prevalence of obsessive–compulsive symptoms/disorder in a large sample of consecutively hospitalized schizophrenia patients and compared the clinical and functional characteristics of schizophrenia patients with and without obsessive–compulsive symptoms/disorder. We evaluated 200 consecutive subjects with the DSM-IV diagnosis of schizophrenia using the Structured Clinical Interview for DSM-IV Axis I disorders, Positive and Negative Syndrome Scale, Yale–Brown Obsessive–Compulsive Scale, Brown Assessment of Beliefs Scale, Clinical Global Impression-Severity scale, Global Assessment of Functioning Scale, Family Interview for Genetic Studies and World Health Organization Quality of Life scale. The prevalence of obsessive– compulsive symptoms in patients with schizophrenia was 24% (n = 48); 37 of them had obsessive–compulsive disorder (OCD) and 11 had obsessive–compulsive symptoms not amounting to a clinical diagnosis of OCD (OCS). Schizophrenia patients with OCS/OCD had an earlier age at onset of schizophrenia symptoms, lower positive symptoms score, higher co-morbidity with Axis II disorders, higher occurrence of OCD in family and better quality of life. Findings of the study indicate a higher prevalence of OCS/OCD in schizophrenia. Schizophrenia patients with and without OCS/OCD have comparable clinical profile with few exceptions. High rates of OCD in first degree relatives suggest possible genetic contributions and differences in neurobiology. Finally, evidence to consider schizoobsessive as a distinct diagnostic entity is inconclusive and warrants further studies. © 2014 Elsevier Inc. All rights reserved.

1. Introduction Although schizophrenia and obsessive compulsive disorder (OCD) are distinct nosological entities, they frequently coexist in a substantial proportion of patients. In some patients obsessive–compulsive symptoms are severe enough to qualify for a diagnosis of OCD and in others they do not amount to a clinical diagnosis of OCD, often referred to as OCS. In this paper, we refer OCS to obsessive–compulsive

⁎ Corresponding author at: Obsessive Compulsive Disorder Clinic, National Institute of Mental Health and Neurosciences, Bangalore, India. Tel.: +91 80 2699 5278; fax: +91 80 2656 4830. E-mail address: [email protected] (Y.C. Janardhan Reddy). http://dx.doi.org/10.1016/j.comppsych.2014.09.015 0010-440X/© 2014 Elsevier Inc. All rights reserved.

symptoms not reaching the clinical threshold for a diagnosis of OCD. Some studies have reported distinct profile of schizophrenia patients with OCS/OCD compared to schizophrenia patients without OCS/OCD and other studies have reported overlapping clinical characteristics and underlying neurobiology [1]. Some researchers have proposed a schizoobsessive subgroup of schizophrenia as a separate diagnostic entity [2]. However, whether this co-occurrence is more than just a co-morbidity and represents a distinct subgroup remains controversial. Several studies have examined the prevalence of OCS/OCD in schizophrenia patients but striking variation is noted across studies; a wide range between 10 and 64% for OCS [3–8] and 0 and 31% for OCD [3,9–12] are reported. In a systematic review of 36 studies, authors reported a weighted average of 25%

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prevalence of OCS and a 23% prevalence of OCD [4]. A metaanalysis of 34 studies reported prevalence of OCD in schizophrenia as 12.1% [13], a significantly higher rate than in the general population (2–3%). Studies regarding the impact of OCS/OCD on schizophrenia are conflicting with both higher and lower positive and negative symptoms [14] and greater [6] and lesser disability [15]. Some studies have reported longer periods of hospitalization [6], more social impairment [16], poor performance in neuropsychological tests [17,18], and poor quality of life [10] but others have reported better global functioning [19,20] and performance [21,22] and absence of difference [23]. In a previous study, we examined 50 schizophrenia patients with OCD and 50 schizophrenia patients without OCD and reported differences in clinical features [15]. In this study, we aimed to examine the prevalence of OCS/OCD in a bigger sample of consecutively hospitalized schizophrenia patients and compare the clinical and functional characteristics of schizophrenia patients with and without OCS/OCD. Based on our previous study findings, we hypothesized that the prevalence of OCS/OCD in schizophrenia patients will be higher than in the general population and schizophrenia patients with OCS/OCD will have lesser disability compared to those without OCS/OCD. 2. Methods 2.1. Subjects We recruited patients from the inpatient services of the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India between September 2010 and September 2011. Consecutively admitted patients with a diagnosis of schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR) criteria were screened for inclusion in to the study. A total of 238 patients were screened, of which we included 200 (104 men, 96 women) patients. Thirty eight patients (17 women and 21 men) were excluded for the following reasons: language incompatibility between the patient an interviewer (n = 22), logistic reasons (n = 10), refusal to give consent (n = 3) and inability to participate in assessment (n = 3). Those who were excluded did not differ from those who participated with respect to clinical characteristics such as age, gender, age at onset of schizophrenia, and duration of illness. Paranoid subtype was the commonest (n = 140) followed by undifferentiated (n = 51), disorganized (n = 5), catatonic (n = 2) and residual (n = 2) subtypes. The mean age (SD) was 33.10 (9.6) years and mean (SD) age at onset of schizophrenia was 25.08 (8.15) years with a mean (SD) duration of illness of 8.07 (6.71) years. Twenty nine (14.5%) patients were in first episode. All patients continued to receive treatment as prescribed by their treating psychiatrist. Patients were at different stages of illness and hence some received a combination of oral and long acting depot medication. Out of 200 patients, 87 received a combination of typical and atypical antipsychotics, 108

received atypical antipsychotics and 5 received only a typical antipsychotic. Forty patients were on treatment with clozapine. All patients with OCS/OCD were on treatment with serotonin reuptake inhibitors (SRI) in addition to antipsychotic(s). Information was collected from patients, their first degree relatives and from clinical records. The study was approved by the Institute Ethics Committee and written informed consent was obtained from all the subjects. 2.2. Clinical assessments Clinical status of patients was assessed using the Structured Clinical Interview for DSM-IV Axis I and II disorders (SCID I and II) [24], the Positive and Negative Symptom Scale (PANSS) [25] and the Yale Brown Obsessive–Compulsive Scale (Y-BOCS) [26]. A total score of ≥16 on the Y-BOCS was required for diagnosis of clinically significant OCD and a total score of b16 on the YBOCS and not fulfilling DSM-IV criteria for OCD was labeled as OCS. For brevity, obsessive–compulsive symptoms not amounting to OCD are referred to as just OCS. Schizophrenia patients with OCS/OCD were further evaluated for insight into OC symptoms using the Brown Assessment of Beliefs Scale (BABS) [27]. Poor insight is indicated by a total BABS score of ≥12 and a score of ≥3 on the “conviction” item (fairly or completely convinced that belief is true). Identifying obsessions and compulsions in the presence of psychotic symptoms can be difficult. We followed the suggestions by Bottas et al. [28] for identifying obsessions and compulsions in the presence of psychosis; a repetitive act was considered as compulsion only if it occurred in response to an obsession and not if it occurred in response to psychotic ideation (for example, repetitive checking in response to paranoid fears does not constitute a compulsion). A recurrent, intrusive thought was not considered an obsession if it revolved exclusively around delusional themes (e.g. persecutory or referential ideas). Current severity of illness was assessed using the Clinical Global Impression-Severity scale (CGI-S) [29] and global functioning was assessed using the Global Assessment of Functioning Scale (GAF) [30]. Family history of psychiatric illness was assessed using the Family Interview for Genetic Studies (FIGS). As FIGS does not cover family history of OCD, questions in the OCD module of SCID-I were asked in third person to patient and other informants to assess family history of OCD. Quality of life was measured using the World Health Organization Quality of life (WHOQOL-BREF) [31] which is an abbreviated 26 item version of the WHOQOL-100. The scores of WHOQOL-BREF were later transformed to percentages. All the assessments were performed by the principal author (SD) who was trained in administering the instruments by the senior consultant (YCJR). 2.3. Statistical analysis Data were tested for normative distribution using Shapiro–Wilk test. As the subgroup data (schizophrenia,

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Table 1 Sociodemographic variables of schizophrenia with and without OCS/OCD. Variable

Schizophrenia without OCS/OCD n (%)/mean (SD) (n = 152)

Schizophrenia with OCS/OCD n (%)/mean (SD) (n = 48)

Age Gender Male Residence Urban Rural Years of education

34.88 (9.70)

27.48 (6.99)

χ 2/z

p

5.014

b0.001

73 (48.0%)

31 (64.6%)

4.007

0.045

92 (60.5%) 60 (39.5%) 10.53 (5.16)

42 (87.5%) 6 (12.5%) 11.79 (3.23)

12.005

0.001

0.887

0.375

schizophrenia with OCS, schizophrenia with OCD) was not normatively distributed we applied Kruskal–Wallis test to compare three groups and Mann–Whitey U test to compare two groups for continuous variables and χ 2 test for categorical variables. Spearman's bivariate correlation was used to examine the relation between obsessive compulsive symptoms and schizophrenia symptoms and demographic variables. All tests were two tailed and significance was set at a conservative p value of ≤0.001 after Bonferroni correction for 50 correlation comparisons. Statistical analyses were conducted using Statistical Package for Social Sciences (SPSS) version 15.

3. Results 3.1. Prevalence of OCS/OCD The prevalence of OCS/OCD in patients with schizophrenia was 24% (n = 48); 37(18.5%) patients had OCD and 11 (5.5%) patients had OCS (total Y-BOCS score b16). Seven of 48 were in first episode of schizophrenia. Majority of the patients (46/48) had both obsessions and compulsions; one each had only obsessions or compulsions. The mean (SD) of YBOCS total, obsessions and compulsions score was 22.25 (9.52), 10.93 (5.16) and 11.33 (4.86) respectively. Contamination related obsessions (n = 33, 68.8%) were the most prevalent followed by pathological doubts (n = 27, 56.3%), aggressive (n = 20, 41.7%), religious (n = 16, 33.3%) and sexual (n = 14, 29.2%) obsessions. Cleaning compulsions (n = 31, 64.6%) were the most prevalent followed by miscellaneous (n = 31, 64.6%), checking (n = 26, 54.2%), repeating and counting (n = 26, 54.2%) compulsions. In an equal number (n = 19, 39.6%) of patients, OC symptoms preceded or succeeded the onset of schizophrenia symptoms. In 10 (20.8%) patients, OC symptoms and schizophrenia symptoms had simultaneous onset. In schizophrenia with OCS/OCD subgroup, the mean (SD) age at the onset of schizophrenia and OCS were 19.95 (5.014) and 19.88 (7.18) respectively. Thirty one of 48 (64.6%) patients developed obsessive–compulsive symptoms before the use of atypical antipsychotics. Though 15 schizophrenia patients with OCS/OCD were on treatment with clozapine, only 4 patients had onset of OCS/OCD

following clozapine use. Twenty six (54.1%) patients exhibited poor insight into OC symptoms. 3.2. Comparison between schizophrenia with OCS/OCD and schizophrenia without OCS/OCD The demographic and clinical profiles of schizophrenia patients with and without OCS/OCD are given in Table 1. Schizophrenia patients with OCS/OCD were significantly younger and had urban residence. Schizophrenia with OCS/ OCD had higher number of students possibly because of younger age of subjects. There was no significant difference in gender, marital status and years of education (Table 1). Schizophrenia patients with OCS/OCD had significantly younger age at onset of schizophrenia, lower PANSS positive score, lower conceptual disorganization and higher abstract thinking, better environmental QOL, greater comorbidity of personality disorders, anxiety disorders and alcohol dependence disorder and higher rate of OCD in firstdegree relatives (Table 2). 3.3. Comparison between ‘Schizophrenia with OCS’ and ‘schizophrenia with OCD’ and ‘schizophrenia without OCS/OCD’ We examined quality of life, global assessment of functioning, age at onset of schizophrenia and PANSS scores between three groups of patients (schizophrenia without OCS/OCD, schizophrenia with OCD, schizophrenia with OCS) to compare the differential effect of OCS and OCD on clinical symptoms, level of functioning and quality of life. As the data within the subgroups were not normatively distributed, we used Kruskal Wallis test to compare the three groups, followed by a post-hoc Mann– Whitney U test. The groups differed only in environmental QOL, age at onset of schizophrenia, PANSS positive score but not in GAF, physical QOL, psychological QOL, social QOL, PANSS negative symptoms or PANSS total score (Table 3). On post-hoc analysis, schizophrenia with OCD had significantly better environmental QOL (U = 1745; z = 3.59; p b 0.001), lower age at onset (U = 1242; z = 5.26; p b 0.001) and lower PANSS positive score (U = 2046; z = 2.57; p = 0.01) compared to schizophrenia without OCS/OCD. Similarly schizophrenia with OCS had lower age at onset of schizophrenia (U = 371; z =

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Table 2 Comparison of clinical characteristics of schizophrenia with and without OCS/OCD. χ 2/z

p

Variable

Schizophrenia without OCS/OCD n (%)/mean (SD) (n = 152)

Schizophrenia with OCS/OCD n (%)/mean (SD) (n = 48)

Age at onset of schizophrenia Duration of illness (years) Duration of untreated illness (months) First episode schizophrenia Subtypes of schizophrenia Paranoid Undifferentiated Disorganized Residual Catatonic Clinical Global Impression Severity Score (CGI-S) Global Assessment Of Functioning (GAF) Quality of life Physical Psychological Social Environmental PANSS positive score PANSS negative score PANSS general psychopathology score PANSS total score Depressive disorder Anxiety disorder Any anxiety Substance use disorder Alcohol dependence Axis II disorders Any Axis-II disorder Avoidant Obsessive–compulsive Paranoid Schizotypal Schizoid Borderline Antisocial Family history of psychosis Family history of depression Family history of mania Family history of alcohol use Family history of OCD

26.70 (8.30) 8.25 (7.057) 19.29 (30.01) 22 (14.5%)

19.96 (5.01) 7.52 (5.51) 21.86 (30.56) 7 (14.6%)

5.828 0.115 0.735 0.000

b0.001 0.909 0.462 0.985

102 (67.1%) 43 (28.3%) 1 (0.7%) 1 (0.7%) 0 5.12 (0.78) 32.40 (11.89)

38 (79.2%) 8 (16.7%) 1 (2.1%) 1 (2.1%) 0 5.02 (0.81) 34.94 (11.12)

2.527 2.594 0.749 0.749 0 0.689 1.602

0.112 0.107 0.387 0.387 0 0.491 0.109

40.34 (10.04) 34.32 (10.52) 18.37 (11.44) 53.91 (9.42) 23.95 (6.25) 25.12 (8.42) 32.72 (8.15) 81.04 (17.49) 2 (1.3%)

43.01 (9.91) 36.02 (10.37) 21.01 (11.53) 60.29 (9.00) 20.25 (6.99) 23.21 (7.65) 31.54 (6.20) 73.10 (18.37) 3 (6.3%)

1.614 0.842 1.989 3.795 3.230 1.553 0.367 2.311 3.644

0.107 0.400 0.047 b0.001 0.001 0.120 0.714 0.021 0.056

5 (10.4%) 6 (12.5%) 6 (12.5%)

11.939 2.276 11.883

0.001 0.131 0.001

15 (31.3%) 7 (14.6%) 2 (4.2%) 1 (2.1%) 0 (0.0%) 3 (6.3%) 3 (6.3%) 1 (2.1%) 19 (39.6%) 5 (10.4%) 3 (6.3%) 14 (29.2%) 5 (10.4%)

10.929 10.026 0.295 0.145 0.317 3.644 2.292 0.145 0.583 2.184 3.644 1.890 16.239

0.001 0.002 0.587 0.703 0.573 0.056 0.130 0.703 0.445 0.139 0.056 0.169 b0.001

1 (0.7%) 9 (5.9%) 2 (1.3%) 17 (11.2%) 4 (2.6%) 4 (2.6%) 2 (1.3%) 1 (0.7%) 2 (1.3%) 3 (2.0%) 2 (1.3%) 51 (33.6%) 7 (4.6%) 2 (1.3%) 30 (19.7%) 0.0%

3.08; p = 0.002) and lower PANSS positive score (U = 474; z = 2.39; p = 0.017) but no difference in environmental QOL (U = 584; Z = 1.677; p = 0.094) compared to schizophrenia without OCS/OCD. There was no difference between schizophrenia with OCS and schizophrenia with OCD on any of the three measures (p N 0.3). We also examined the difference between schizophrenia with OCS and schizophrenia with OCD on insight; there was no difference between the two groups on either YBOCS insight score (U = 155; z = 1.21; p = 0.22) or BABS total score (U = 147; z = 1.38; p = 0.16). 3.4. Correlations between obsessive–compulsive and schizophrenia symptom scores There was a significant positive correlation between YBOCS insight score and BABS total score (r = 0.92;

p b 0.001). YBOCS insight score had significant negative correlation with GAF (r = −0.59; p b 0.001) and significant positive correlation with PANSS negative score (r = 0.679; p b 0.001) and PANSS total score (r = 0.45; p = 0.001). Understandably, BABS total score had significant negative correlation with GAF (r = −0.621; p b 0.001) and positive correlation with PANSS negative score (r = 0.705; p b 0.001) and PANSS total score (r = 0.497; p b 0.001). PANSS positive subscale had significant negative correlation with social QOL (r = −0.316; p b 0.001) but not with other QOL sub scores. PANSS negative subscale, PANSS general psychopathology scale and PANSS total score had significant negative correlations with all subscales of QOL namely physical QOL, environmental QOL, psychological QOL and social QOL (all p b 0.001). There were no significant correlation between YBOCS obsessions score/compulsions

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Table 3 Comparison of clinical characteristics of schizophrenia without OCS/OCD and schizophrenia with OCD and schizophrenia with OCS a. Variable Global Assessment Of Functioning (GAF) Quality of life Physical Psychological Social Environmental Age at onset PANSS Positive Negative General Total a

Schizophrenia without OCS/OCD Mean Rank (n = 152)

Schizophrenia with OCS Mean Rank (n = 11)

Schizophrenia with OCD Mean Rank (n = 37)

z

p

96.83

111.00

112.47

2.57

0.27

96.81 98.58 96.11 91.82 113.88

92.95 111.73 90.64 121.41 60.45

117.91 105.04 121.46 129.93 57.42

4.19 0.82 6.57 14.59 33.98

0.12 0.66 0.04 0.001 b0.001

107.92 104.07 101.34 105.81

64.27 118.32 103.55 84.14

80.80 80.54 96.14 83.54

11.12 6.03 0.27 5.34

0.004 2.74 0.87 0.07

Kruskal Wallis test.

score/total score and PANSS total score/positive subscale score/negative subscale score/general psychopathology subscale score/GAF/QOL (p N 0.001).

4. Discussion We aimed to examine the prevalence of OCS/OCD in consecutively admitted patients and to compare the clinical and functional characteristics of schizophrenia patients with and without OCS/OCD. The prevalence of any obsessive compulsive symptoms was 24% and OCD was 19 % in our study. Schizophrenia patients with OCS/OCD had an earlier age at onset of schizophrenia symptoms, lower positive symptoms score, higher co-morbidity with Axis II disorders, higher occurrence of OCD in family and better quality of life. 4.1. Prevalence of OCS/OCD in schizophrenia The prevalence of OCS/OCD in our study is consistent with the results of most previous studies [4,5,19,32–35] but higher than that reported in some studies [13,36]. The frequency of subtypes of obsessions and compulsions is also in accord with findings from previous studies [16,32,37,38]. Our study findings together with findings from other studies suggest increased prevalence of OCD and OCS in schizophrenia compared to general population. Though atypical antipsychotics are known to induce de novo OCS/OCD [39–43] evidence from different lines of research suggest this increased prevalence of OCS/OCD in schizophrenia to be a true comorbidity and not due to the confounding effect of medication. Prevalence of OCD in first episode patients with less than 12 weeks of exposure to atypical antipsychotics is 14%, higher than the general population [36] and in our sample nearly 2/3 developed OCD before the use of antipsychotics and there was no difference in the number of antipsychotic trials between those with and without OCD suggesting that the onset of OCD is unlikely to be due to antipsychotic.

4.2. Impact of comorbid OCD/OCS on schizophrenia symptoms In our study, schizophrenia with OCS/OCD had lower positive symptoms, lower conceptual disorganization and better abstract thinking compared to schizophrenia patients without OCS/OCD. However, the two groups did not differ significantly with respect to PANSS negative and general psychopathology scores. Previous studies examining the effect of OCS/OCD on severity of schizophrenia symptom have reported inconsistent results [14]; while some studies found no difference is schizophrenia symptom severity between the groups [44]. Others have reported higher [9,18,45,46] or lower symptom severity in OCS/OCD patients [20,36]. A meta-analysis reported no difference in severity of psychotic symptoms when schizophrenia with OCD was compared to those without OCD [14]. However, in the same meta-analysis, those with OCS had significantly greater severity of positive, negative and global symptoms compared to those without [14]. In lieu with previous studies [17,36,47] there was no significant correlation between positive and negative symptoms of schizophrenia and obsessive compulsive symptoms. We also found younger age at onset of schizophrenia symptoms in schizophrenia patients with OCS/ OCD similar to previous studies [5,19,48]. In line with the previous findings [5,6,48,49] we found OCS/OCD group patients to have earlier age at onset of schizophrenia symptoms and younger age at assessment than schizophrenia patients without OCD/OCD. As distinct entities, both schizophrenia and OCD are neurodevelopmental disorders with adolescent onset though OCD has a slightly earlier age of onset [50]. It is thus possible that presence of OCS/OCD in schizophrenia exerts an influence on the pathophysiology of schizophrenia leading to an earlier age of onset. However the underlying mechanisms are not known at this stage and further studies are needed. 4.3. Impact of comorbid OCD/OCS on schizophrenia functioning Though the co-occurrence of OCS/OCD and schizophrenia symptoms are expected to cause double jeopardy and have poorer prognosis, majority of studies do not report such

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an effect [14]. In our study we found better environmental quality of life in patients with OCD compared to schizophrenia without OCS/OCD. We did not observe a differential effect of clinical OCD and OCS on level of functioning or schizophrenia symptoms. One potential reason for better QOL is lower severity of psychotic symptoms [51] but as OCS/OCD group had higher urban residence, it is difficult to comment whether the better environmental QOL is due to urban residence or lower symptom severity. The reason for these findings is not clearly known; it is hypothesized that the impact of OCS on schizophrenia may depend upon the stage of schizophrenia and it may have protective effect in early schizophrenia and deleterious effect in chronic schizophrenia [14]. However in our study, majority patients were having chronic schizophrenia with only a minority having first episode schizophrenia and hence does not explain the absence of negative impact. 4.4. Insight into OCD and relation to schizophrenia symptoms In our study, nearly half of the schizophrenia patients with OCS/OCD had poor insight into OCD which is greater when compared to primary OCD; earlier studies have reported poor insight in 15 and 36% of patients with OCD [52,53]. In our earlier study we reported 9% of patients to have poor insight [54]. Findings indicate the possibility that schizophrenia psychosis may have influence on insight in to OCD in these patients. Insight into OCS/OCD in schizophrenia is examined only by few studies and reports are inconclusive. While one study [53] reported majority to have poor or absent insight. Two other studies [55,56] reported majority to have good or fair insight into OCD, indicating that the presence of OCD does not substantially modify global awareness of illness. In the current study, we used a consecutive sampling in hospitalized schizophrenia patients who might harbor a more severe illness and hence higher proportion of those with poorer insight. In our earlier study we found a relation between insight and positive symptoms of schizophrenia [15]. However, in the current study we found an association between insight into OCD and negative symptoms of schizophrenia suggesting the higher the negative symptoms the poorer the insight. Interestingly, insight in to schizophrenia is also closely linked to negative symptoms. Considering the involvement of discrete but closely related frontal circuitries in insight, negative symptoms and OCS, one cannot rule out the possibility of intricate neurobiological link between absent insight and negative symptoms [57,58]. Since this study is cross-sectional, it is not known whether patients initially had better insight and then went on to lose insight to OC symptoms with onset of schizophrenia symptoms. These findings could have major implication in management as poor insight is associated with poorer outcome [59–61]. 4.5. Is schizo-obsessive a distinct diagnostic entity? The increased prevalence of OCS/OCD in schizophrenia together with findings from clinical and neurobiological

studies have prompted the investigators to propose schizoobsessive disorder as a distinct diagnostic entity [2]. While the higher prevalence of OCS/OCD in schizophrenia is well established, the impact of OCS/OCD on clinical profile of schizophrenia is inconclusive and many questions must be answered to determine if presence of OCS/OCD in schizophrenia warrants a distinct diagnostic entity of “schizoobsessive disorder”. Though the primary aim of present study was not to examine the nosological validity of the schizoobsessive disorder, the findings provide further data to this controversy. We observed a significantly higher rate of personality disorders in particular anxious avoidant personality disorder (AAPD) in schizophrenia patients with OCS/OCD than in those without. Importantly, significantly higher rate of OCD was observed in first-degree relatives of schizophrenia with OCS/OCD than schizophrenia without OCS/OCD, consistent with earlier study suggesting a possible genetic contribution. However, studies examining neuroimaging and neuropsychological profiles of schizophrenia patients with OCS and without OCS have not provided consistent evidence to support a separate diagnostic entity [1]. Hence put together, though OCS/OCD are frequent comorbidities in schizophrenia the evidence is preliminary at this stage and whether schizoobsessive disorder is a distinct diagnostic entity warrants further studies. 4.6. Implications and future directions Our findings have important clinical implications. Findings further highlight the importance of assessing OC symptoms in schizophrenia patients owing to high prevalence of OCS and OCD in subjects with schizophrenia. Poorer insight in to OC symptoms in schizophrenia may also pose a challenge in the management since poor insight may predict poorer treatment response to traditional methods of treatment [59]. The major implication of poorer insight would be in the selection of treatment for these patients as absent insight is associated with poorer outcome. Further studies are needed to evaluate the underlying neurobiology of this comorbidity and prospective studies are required for better understanding of the impact of OC symptoms on course of schizophrenia. 4.7. Methodological issues Findings of the study need to be considered in the background of few limitations. The cross-sectional design of the study does not allow us to evaluate the relationship between severity of OCD and symptoms of schizophrenia and the effect of OCD on course and outcome of schizophrenia. While the large sample size and consecutive sampling limit the recruitment bias, inclusion of only hospitalized patients limit the generalizability of the findings. Although the rater was well trained, and a single rater examined all subjects, inter rater reliability was not established which could have added to the methodological rigor.

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5. Conclusion Prevalence of OCS/OCD is high in patients with schizophrenia. Schizophrenia patients with OCS/OCD and without OCS/OCD have comparable clinical profile with few exceptions. High rates of OCD in first degree relatives suggest possible genetic contributions and differences in neurobiology. Finally, evidence to consider schizoobsessive as a distinct diagnostic entity is inconclusive and warrants further studies.

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