Case Presentation
A 20-year-old patient, high school student, lives with family. Nicotine addict, confirms occasional alcohol and marijuana use. In november 2019, the patient’s mental status was deteriorating. Patient was in ambulatory treatment with olanzapine and fluoxetine, but with no satisfactory results, which was the reason for the first psychiatric hospitalization in august 2020.
Symptoms
- Intrusive thoughts and behaviour
- There were hallucinatory voices commenting
- Decreased mood with suicidal thoughts
- Increased anxiety and isolation
- He spent most of his time in bed and neglected school activities
On the day of admission, the patient was correctly oriented auto- and allopsychically, in equilibrated mood and psychomotor drive. Logical verbal contact was preserved.
Medical History
- No family history with psychiatric burden
Physical Examination
- Using the MINI scale, with a score of 0, he was found to be at low risk for suicide.
- During the initial period of hospitalization, the patient had the following psychotic experiences: imperative commenting voices, unveiling thoughts, and pseudo hallucinations.
- The patient was in moderate psychomotor distress and ambivalent about the need for hospitalization.
- He reported the presence of intrusive thoughts and compulsive behaviours.
- Non-modulated affect was noted – significantly reduced emotional expressions observed.
- The patient periodically behaved in a bizarre, maladaptive manner.
- No delusional contents, but acknowledged the presence of commenting voices.
Clinical Examination
- Neurological consultation confirmed tics in the head, of which blinking was the most severe, as well as in the upper and lower extremities.
- Otherwise, no abnormalities on neurological examination.
- Magnetic resonance imaging of the head without focal changes.
- EEG examination showed abnormalities, including: generalized changes in the form of groups of delta-theta waves and few, usually abortive paroxysmal discharges of irregular slow waves with low voltage spikes, in addition, basal function was found to be slowed down to a slight degree, mainly over the frontal brain area.
- The neurologist recommended periodic neurological and EEG follow-up.
- Psychological testing revealed that the general intelligence quotient is at the level of borderline intellectual disability.
Treatment
During hospitalization the patient received clozapine and risperidone, and non-pharmacological interventions such as:
- Psychoeducation
- Individual psychotherapy
- Art therapy
Modification of the current therapy resulted in a partial improvement of mental status in the form of reduction of anxiety and obsessions, reduction of intensity of manufacturing symptoms, intensity of pseudo hallucinations and change of their content to friendly. A decrease in body weight was also noted, most likely related to the patient’s compliance with dietary recommendations.
Follow up
On the day of discharge, the patient was correctly oriented, in clear consciousness without behavioural disturbances, and did not spontaneously express delusional contents. Partial morbid insight was obtained. A narrowly modulated affect was noted. The patient’s drive and mood were equalized. The patient denied suicidal and auto-aggressive thoughts and tendencies. The patient was discharged at his own request before completion of the therapeutic process.
Conclusion
Patients suffering from both schizophrenia and severe forms of OCD, as well as both diseases at the same time, represent a challenge for physicians, due to problems with differentiation of disorders, making the right diagnosis, treatment not bringing the desired results, or unfavourable prognosis. Due to specific character of the disease, difficulties in diagnosis and treatment, there is a special need for individual therapeutic measures. Appropriate and targeted approach to the patient may be a chance for success in therapy.