Background
Recent evidence suggests that the high rates of comorbidity between obsessive-compulsive symptoms (OCS) and psychosis may warrant the diagnosis of a specific condition known as schizo-obsessive disorder. Nonetheless, the lack of official diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) for this condition and limited research on optimal management for the overlapping symptom presentations complicate both diagnosis and treatment.

Case Presentation
CM is an 18-year-old female with a history of five past psychiatric hospitalizations resulting in various diagnoses including obsessive-compulsive disorder (OCD); anxiety; hypothyroidism, psychosis, unspecified; and schizoaffective disorder. She was brought to the hospital by ambulance after a physical dispute with her mother following months of worsening agitation. Her history is also notable for severe anxiety preventing her from attending school, compulsions causing her to command her mother to perform repetitive actions (resulting in significant interpersonal conflict), command auditory hallucinations involving angels and the devil, and persecutory delusions of being watched in public. Treatment with fluphenazine and risperidone in two prior hospitalizations resulted in the development of extra-parkinsonism symptoms (EPS). She has repeatedly displayed non-adherence to medications including sertraline and levothyroxine between hospitalizations, reporting both side effects and ineffectiveness in managing her symptoms. Throughout this active hospitalization, CM has endorsed intrusive audio-visual thoughts and isolative behavior. She also displays avolition, anhedonia, flat affect, thought blocking, and negativism. CM continuously fluctuates between acknowledging and denying her symptoms, indicating poor insight into her condition. She is currently being transitioned from oral to intramuscular paliperidone to manage her symptoms of psychosis, as well as oral clomipramine to treat her OCS. She is under routine monitoring for EPS and signs of adverse drug interactions.

Discussion
CM’s significant history of recurrent psychiatric hospitalizations, her unstable relationship with her mother, and her poor insight into her condition may be partially explained by the inconsistencies in her diagnoses over time. With schizo-obsessive disorder, difficulties in distinguishing obsessive and compulsive symptoms from potential delusions secondary to psychosis can result in unstandardized, overcomplicated treatment plans. This can lead to adverse effects such as EPS, worsening of either OCS or psychotic symptoms, medication non-adherence, or deleterious drug interactions. Further research is warranted to better understand the intersection of OCD and psychotic disorders such as schizophrenia. In addition, more research should be conducted on improving therapeutic practices and pharmacological treatment plans that target the related symptomatology while minimizing adverse effects.

Alina Mitchell

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