Complex Presentation of Schizophrenia-Spectrum Psychosis with Obsessive-Compulsive Symptoms: A Psychiatric Case Report from Somaliland

Technical Summary: Complex Presentation of Schizophrenia-Spectrum Psychosis with Obsessive-Compulsive Symptoms

Problem Statement
The co-occurrence of schizophrenia-spectrum psychosis and obsessive-compulsive disorder (OCD), often descriptively termed "schizo-obsessive," presents significant diagnostic and therapeutic challenges. While literature suggests shared neurobiological pathways and high comorbidity rates, the condition is not a formal DSM-5 diagnostic subtype. This overlap complicates clinical differentiation, as obsessive-compulsive symptoms with poor insight can mimic delusional beliefs, while psychotic features may obscure the recognition and treatment of OCD. These challenges are exacerbated in low-resource settings like Somaliland, where limited psychiatric infrastructure, a scarcity of trained professionals, high stigma, and reliance on traditional healing practices often lead to delayed diagnoses and inappropriate treatments.

Methodology
This study is a single-case report of a 24-year-old Somali male presenting to a psychiatric outpatient clinic in Hargeisa, Somaliland, with a six-month history of auditory hallucinations, paranoid delusions, and severe compulsive rituals. The study adhered to the CARE guidelines for case reporting.

• Diagnostic Approach: The clinical team conducted a comprehensive assessment including routine psychiatric history-taking, collateral history from family, a mental status examination, and a DSM-5-informed clinical interview. Organic causes were excluded via normal physical and neurological examinations, routine laboratory investigations (CBC, liver/renal/thyroid function, infectious screening), and a normal brain CT scan.
• Severity Quantification: Baseline symptom severity was measured using the Positive and Negative Syndrome Scale (PANSS) and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS).
• Intervention Strategy: The patient received a multimodal treatment regimen over a 12-week period:
  1. Pharmacotherapy: Risperidone (an atypical antipsychotic) was initiated at 2 mg/day and titrated to 6 mg/day over two weeks. Concurrently, fluvoxamine (an SSRI) was started at 50 mg/day and increased to 200 mg/day over four weeks to target OCD symptoms.
  2. Psychotherapy: Cognitive-behavioral therapy (CBT) with a focus on Exposure and Response Prevention (ERP) was implemented. The hierarchy began with lower-anxiety triggers (e.g., reducing handwashing) and progressed to more distressing compulsions (e.g., lock-checking, counting).
  3. Support Systems: Psychoeducation and family engagement were integrated to support adherence, reduce stigma, and reinforce ERP strategies at home.
• Monitoring: The patient was monitored weekly for symptom changes using PANSS and Y-BOCS scores, as well as for adverse effects (extrapyramidal symptoms, metabolic changes, etc.).

Key Results
Over the 12-week follow-up period, the patient demonstrated marked clinical improvement across both psychotic and obsessive-compulsive domains:

• Symptom Reduction:
  • PANSS Score: Decreased from a baseline of 92 (severe) to 54 by week 8 and 42 by week 12.
  • Y-BOCS Score: Decreased from a baseline of 32/40 (severe) to 22 by week 6 and 14 by week 12.
• Clinical Observations: Auditory hallucinations (commentary voices) subsided by week 8 with no recurrence. Compulsive behaviors, including repetitive handwashing and lock-checking, were significantly reduced in frequency and distress.
• Functional Outcomes: The patient resumed household responsibilities, showed improved sleep patterns, and reduced social withdrawal. Insight into the irrationality of rituals improved, and adherence to medication was confirmed via self-report and pill counts.
• Safety: No major adverse effects, including extrapyramidal symptoms or metabolic issues, were reported during the treatment period.

Significance and Claims
The paper claims that this case highlights the feasibility of achieving meaningful short-term outcomes for complex schizophrenia-spectrum psychosis with obsessive-compulsive symptoms in low-resource settings through an integrated approach.

• Multimodal Efficacy: The authors assert that the combination of antipsychotic medication, SSRI therapy, ERP-based psychotherapy, psychoeducation, and family involvement is effective in managing this complex comorbidity.
• Contextual Relevance: The report contributes to the sparse literature on complex psychiatric comorbidities in low-resource environments (specifically Somaliland). It demonstrates that despite systemic barriers, culturally adapted, evidence-based care involving family engagement can be successfully implemented.
• Diagnostic Clarity: The case underscores the necessity of careful differential diagnosis to distinguish between poor-insight OCD and schizophrenia-spectrum disorders, particularly when symptoms overlap.

Limitations
The authors modestly note several limitations:

• As a single case report, findings cannot be generalized to all patients with this comorbidity.
• The three-month follow-up period is insufficient to establish long-term stability, relapse risk, or long-term medication tolerability.
• The concurrent introduction of multiple interventions (pharmacotherapy, ERP, psychoeducation) prevents the isolation of the specific contribution of each component.
• Some data relied on patient and family self-reporting.
• Cultural interpretations of symptoms may influence disclosure and help-seeking behaviors.