Analysis of the form of obsessions revealed the following pattern of occurrence: doubts (66.7%), imageries (40%), ruminations (33.3%), thoughts (26.7%), urges (26.7%), and fear (20%). Analysis of obsession content revealed the following pattern of occurrence: sex (26.7%), contamination (26.7%), and others (46.7%).

There were 5 patients with washing compulsions and 4 with checking compulsions. Other compulsions such as writing compulsions, compulsions to follow symmetry, and compulsions to indulge in sexual activity were also seen in these patients.

Analysis of delusions showed the following pattern of occurrence: persecution delusion in 13 patients (86.7%), reference delusion (60%) in 9 patients, and delusional misinterpretation in 5 patients (33.3%). There were 8 patients (53.3%) with first-rank symptoms. Hallucination analysis showed the following pattern of occurrence: third-person auditory hallucinations occurred in 3 patients (20%), second-person auditory hallucinations occurred in 7 patients (46.7%), olfactory hallucinations occurred in 2 patients (33%), and visual hallucinations occurred in 1 patient (6.67%).

Tables 1, 2, and 3 indicate the patients’ treatment profiles. All 15 patients were treated with a combination of a neuroleptic and an antiobsessional drug. Initially, 7 patients were treated with an adequate dosage of either of the 2 drugs alone. There was either no response or selective response to the corresponding symptoms.

There were 2 patients who did not follow up, whereas 13 patients had a minimum follow up of at least 8 weeks. Of these, 3 patients showed near total improvement, and 7 patients showed a 60% to 80% improvement within a 4- to 8-week period. Differential improvement of psychotic symptoms, with minimal improvement in OC symptoms, was found in 2 patients. One case did not improve.

Discussion

This is one of the very few reports (4,6,7) that discuss the phenomenology of patients with OCD and psychotic symptoms. These patients can be classified further into 3 groups, depending upon the relation between the onset of the symptoms: patients with OCD developing before psychotic symptoms (Table 1), patients with psychotic symptoms developing

before OCD (Table 2), and patients with OCD and psychotic symptoms developing simultaneously (Table 3).

Some interesting features in the phenomenology of these patients merit discussion. OC symptoms involving the need for symmetry were found in 2 patients in the third group. These patients seem to have lost their goal directiveness in favour of completing a given subroutine perfectly. The basal ganglia control motor planning; therefore, they coordinate motor subroutines and what MacLean has termed the master routine (8). Of these 2 patients, 1 patient developed severe akathisia and extrapyramidal symptoms with minimal doses of antipsychotics. This is interesting, particularly within the context of shared hypothesized neural circuits.

Risperidone had been used in 10 cases (7 cases showed significant improvement, 1 case did not improve and 2 cases did not follow up further). There were no cases documented wherein risperidone worsened the OC symptoms. This is interesting in the context of many case reports of risperidone-induced or aggravated OC symptoms in patients with psychosis (9,10).

Behaviour therapy in the form of exposure and response prevention had been tried in 3 cases. It helped to improve OC symptoms in 2 cases. In one case, psychotic symptoms worsened with the introduction of behaviour therapy, which needed dosage escalation of antipsychotics.

Given the retrospective nature of the analysis, one has to be cautious in interpreting the above series. One major problem in studying the association between OC symptoms and schizophrenia is the phenomenology of the OC symptoms. Clearly, these symptoms may be overlooked in patients who experience persistent psychotic symptoms, in part because severe obsessions and compulsions resemble psychosis symptoms (6). Analysis of the phenomenology of this small patient group raises interesting questions. Do these patients having OCD with psychotic symptoms form a distinct group, a subgroup of OCD, or a subgroup of psychosis? Given the recently reported high prevalence of OC symptoms in cases of schizophrenia (20% to 50%) (11–14), comorbidity per se would be unusual, because the prevalence of OCD in the general population is less than 3% (15). Do OC symptoms represent an additional dimension to the existing positive, negative, and disorganization dimensions of schizophrenia?