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Case Reports in Psychiatry
Volume 2016, Article ID 2180748, 5 pages
http://dx.doi.org/10.1155/2016/2180748
Case Report

Psychosis or Obsessions? Clozapine Associated with Worsening Obsessive-Compulsive Symptoms

1Department of Hospital Pharmacy Services, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
2Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA

Received 1 March 2016; Revised 2 May 2016; Accepted 12 May 2016

Academic Editor: Toshiya Inada

Copyright © 2016 Jonathan G. Leung and Brian A. Palmer. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

One underrecognized adverse event of clozapine is the emergence or worsening of obsessive-compulsive symptoms (OCS). OCS, particularly violent thoughts, can be inaccurately described as psychosis and result in a misdiagnosis. We report a case of a 42-year-old man, initially diagnosed with schizoaffective, who was placed on clozapine for the management of “violent delusions.” However, clozapine led to a worsening of these violent thoughts resulting in suicidal ideation and hospitalization. After exploration of the intrusive thoughts and noting these to be egodystonic, clearly disturbing, and time consuming, an alternative diagnosis of obsessive-compulsive disorder (OCD) was made. Clozapine was inevitably discontinued resulting in a significant reduction of the intrusive thoughts without emergence of psychosis or adverse events. While an overlapping phenomenology between OCD and psychotic disorders has been described, clozapine and other antiserotonergic antipsychotics have been implicated with the emergence or worsening of OCS. Unique to our case is that the patient’s obsessions had been treated as psychosis leading to the inadequate treatment of his primary illness, OCD. This case highlights the potential for OCD to masquerade as a psychotic disorder and reminds clinicians that clozapine may worsen OCS.