Childhood obsessive-compulsive disorder presenting as schizophrenia spectrum disorders

Obsessive compulsive disorder (OCD) is a highly heterogeneous disorder, presenting with a wide array of symptoms. Sometimes, OCD can appear to be psychotic in nature, with periods of loss of insight or the emergence of paranoid ideas. Likewise, individuals with schizophrenia spectrum disorders (SSDs), including schizophrenia or schizo-affective disorder, can have obsessive-compulsive or "obsessive-compulsive like" symptoms. The complexities of differentiating obsessive-compulsive symptoms from true psychotic symptoms have been recognized in adults. However, in the child and adolescent OCD literature, this has just begun to be explored. In children, limited insight regarding their obsessions and compulsions often makes it more difficult to differentiate OCD from psychotic disorders, including schizophrenia. This report describes 2 adolescents who were initially diagnosed with "difficult-to-treat" SSDs, leading to the use of third-line antipsychotic treatments such as clozapine. Once the core symptoms were recognized as obsessions and compulsions, and appropriately treated, the apparent "psychosis" resolved and did not return over extended follow up. Awareness of the possibility of OCD presenting as if it were a schizophrenia spectrum disorder can facilitate proper diagnosis and treatment.