Inherent Characteristics of Obsessive-Compulsive Symptoms Associated with Clozapine Treatment in Schizophrenia / 신경정신의학

ABSTRACT

OBJECTIVES: Despite stockpiled case reports of obsessive-compulsive symptoms (O-C symptoms) in schizophrenic patients associated with clozapine, it is still difficult to explain the complex interplay between psychotic symptoms, O-C symptoms and clozapine. The main difficulty lies in building an integrated hypothesis for a complex manifestation as O-C symptoms accompanied by psychotic symptoms. Thus we assumed that O-C symptoms shown in schizophrenic patients have diverse mechanisms in symptom formation, and that O-C symptoms developed after clozapine administration have various mechanisms as well. METHODS: We reviewed charts of all the DSM-IV schizophrenic patients from the Refractory Schizophrenia Clinic of Seoul National University Hospital, who are currently using clozapine or has previously used clozapine. Then, we classified the patients into four types implicating different mechanisms of O-C symptom formation. RESULTS: O-C symptoms of first two cases implicating diverse mechanisms in symptom formation clearly showed clinical discrepancies, mainly the relationship with psychotic symptoms, responsiveness to clozapine use and therapeutic approach to O-C symptom per se. And the other two cases implying various mechanisms in O-C symptoms newly developed during clozapine use, also showed obvious differences in the relationship with psychotic symptoms, dose-dependent pattern of O-C symptom during clozapine use and timing of onset of O-C symptom after clozapine administration. CONCLUSIONS: In order to explain the diversity of clinical manifestations of these 4 cases, we have paid attention to inherent characteristics reflecting the differentiation process of symptom structure rather than the complex phenotype of O-C symptoms, and made explanatory model by applying and integrating several useful concepts, the 'symptom conceptualization' proposed by Berrios, 'personal illness hierarchy' proposed by Foulds and 'structural dynamics of O-C phenomena' proposed by Shoda. By proposing this model, we intend to describe the interplay between O-C symptoms, psychotic symptoms and clozapine treatment. This study is based on interpretations of the cases selected out of a great number of patients, and so it is hard to generalize. But we think it is worthwhile to build a hypothetical model for understanding the intricate manifestations of O-C symptoms in light of not only the phenotype but also the internal symptom structure.