Self-report screening instruments differentiate bipolar disorder and borderline personality disorder.

BACKGROUND: Bipolar disorder (BD) and borderline personality disorder (BPD) share overlapping phenomenology and are frequently misdiagnosed. This study investigated the diagnostic accuracy of the Mood Disorder Questionnaire (MDQ) and McLean Screening Instrument for Borderline Personality Disorder (MSI) in a clinical inpatient setting and whether individual screening items could differentiate BD from BPD. METHODS: 757 sequential inpatients admitted to a Mood Disorder Unit completed both the MDQ and MSI. Screen positive for the MDQ was defined as ≥7/13 symptoms endorsed with concurrence and at least moderate impact. Screen positive for the MSI was defined as a score of ≥7. The clinical discharge summary diagnosis completed by a board-certified psychiatrist was used as the reference standard to identify concordance rates of a positive screen with clinical diagnosis. Individual items predicting one disorder and simultaneously predicting absence of other disorder by odds ratio (OR>and <1) were identified. RESULTS: Both screening instruments were more specific than sensitive (MDQ 83.7%/ 67.8%, MSI 73.2% / 63.3%). MDQ individual items (elevated mood, grandiosity, increased energy, pressured speech, decreased need for sleep, hyperactivity) were significant predictors of BD diagnosis and non-predictors of BPD diagnosis. Whereas MSI subitem, self-harm behaviors/suicidal attempts predicted BPD in the absence of BD; distrust and irritability were additional predictors of BPD. CONCLUSION: While this study is limited by the lack of structured diagnostic interview, these data provide differential symptoms to discriminate BD and BPD. Further work with larger datasets and more rigorous bioinformatics machine learning methodology is encouraged to continue to identify distinguishing features of these two disorders to guide diagnostic precision and subsequent treatment recommendations.

Mirtazapine's effect on the QT interval in medically hospitalized patients.

INTRODUCTION: Mirtazapine is generally well tolerated in medically ill patients with and without formal psychiatric comorbidity to target sleep, appetite, nausea, and pain. However, there is little data regarding mirtazapine's potential to prolong the corrected QT interval (QTc) in this population. METHODS: From a retrospective cohort of patients hospitalized on a variety of medical units for whom a psychiatric consult recommended mirtazapine, electrocardiogram (ECG) data were extracted for ECGs obtained up to 3 days before and 6 days after the initial consult. Descriptive statistics were used to characterize the QTc changes and adverse cardiac outcomes, including incident ventricular tachycardia, torsades de pointes, and sudden cardiac death. Multiple linear regression models were completed to assess the effect of potential confounding variables on QTc changes. RESULTS: Complete premirtazapine and postmirtazapine ECG data were available for 61 patients, and the average change in QTc was -0.31 ms (SD = 36.62 ms). No incidental adverse cardiac outcomes were found. QTc changes were not significantly affected by patient age and sex, initial and maximum mirtazapine dose, days between ECGs, number of concomitant QTc prolonging medications, Charlson comorbidity scores, and electrolyte abnormalities. Due to incomplete potassium, magnesium, and ionized calcium data, electrolytes were excluded from the final regression model. DISCUSSION: Despite the limitations of this retrospective study, these data suggest that modest doses of mirtazapine may not significantly affect the QTc in medically ill patients. Retrospective cohorts are more feasibly analyzed, but prospective controlled trials could more systematically assess QTc changes with higher doses of mirtazapine in medical settings.

Prescribing Practices for Patients With Borderline Personality Disorder During Psychiatric Hospitalizations.

This study aimed to understand prescribing practices during acute psychiatric hospitalization in a large cohort of patients (N = 569) with borderline personality disorder (BPD) at a tertiary care psychiatry unit from January 1, 2013, through January 1, 2015. The mean number of hospitalizations per patient was 1.5 (range, 1-7). The odds of being prescribed antidepressants, antipsychotics, mood stabilizers, hypnotics, or anxiolytics were higher at discharge than at admission. The rate of psychotropic prescriptions was also higher at discharge than at admission (incidence rate ratio, 1.9). This pattern was true for the combined psychotropic and nonpsychotropic ("medical") prescriptions. Further guidelines are needed regarding optimal psychosocial, medical, and psychopharmacological care of patients with BPD during acute psychiatric hospitalizations.

Difficult Conversations: Training Medical Students to Assess, Educate, and Treat the Patient with Chronic Pain.

OBJECTIVE: Chronic pain, along with opioid abuse and misuse, continues to be a prevalent problem across the USA. Medical students have minimal training in biopsychosocial treatment of chronic pain and often lack the knowledge and skill necessary to address chronic pain with their patients. While there are a variety of treatment options available, research repeatedly has demonstrated that biopsychosocial treatment is the most effective option for chronic pain. Engaging patients in this type of treatment requires training and education. METHODS: The authors implemented a simulation workshop with standardized patients to educate medical students on the physical, psychological, and social aspects of chronic pain and also train students on the most effective ways to discuss chronic pain and educate their patients. Outcomes were measured by a pre- and post-test survey of knowledge, attitudes, and confidence in treating chronic pain, as well as satisfaction with the learning experience. RESULTS: Test and survey results indicated improvements in knowledge, attitudes, and confidence in treating chronic pain. Additionally, students were satisfied with the experience as evidenced by high post-workshop ratings. CONCLUSIONS: Chronic pain training during medical school is associated with students feeling more prepared to provide non-opioid biopsychosocial pain treatment. Additionally, training with standardized patients allows students to learn how to effectively educate their patients, reduce negative confrontations, and maintain a positive physician-patient relationship.

Addressing clozapine under-prescribing and barriers to initiation: a psychiatrist, advanced practice provider, and trainee survey.

Clozapine use has declined, despite its superior antipsychotic efficacy in treatment-resistant schizophrenia. Implications for clozapine underutilization include suboptimal treatment outcomes and increased hospitalizations. Many barriers preventing the use of clozapine have been described in the literature, including suboptimal knowledge and poor perceptions. The aim of this study was to assess psychiatry prescribers' perception and knowledge of clozapine. A survey was distributed to advanced practice providers, psychiatrists, and trainees (i.e. residents and fellows) at 10 medical centers within the US and Canada. The survey asked respondents about their perception of clozapine use and assessed their pharmacotherapeutic knowledge of clozapine. Two hundred eleven individual submitted completed surveys of a possible 1152; a response rate of 18.3%. There were no statistically significant differences between the advanced practice provider plus psychiatrist groups and the trainee group for most perception (eight of nine) and knowledge (eight of nine) questions. The knowledge questions with the lowest scores pertained to clozapine reinitiation and myocarditis. The majority of all respondents (144, 68.2%) felt that clozapine prescribing was a burden. Findings of this study support the need for continued clozapine education regardless of a prescriber's age/experience. Future studies to assess barriers to clozapine prescribing should extend beyond academic centers.

Effect of In-Class vs Online Education on Sexual Health Communication Skills in First-Year Medical Students: a Pilot Study.

OBJECTIVE: Online education is effective for knowledge acquisition, but its effect on clinical skill development is not well characterized. We aimed to compare communication skills of 50 first-year medical students who learned to assess and treat patients through an online learning module vs an in-class lecture. METHODS: Twenty-six students were randomized to learn about antidepressant-induced sexual dysfunction in class and 24 learned the same content through an online module. Students were individually observed conducting an interview with a standardized patient with antidepressant-induced sexual dysfunction. Students were assessed by faculty raters blinded to the student's learning mode. Standardized patients were asked about their willingness to have the student as their physician. RESULTS: More students who learned in class vs online demonstrated appropriate verbal empathy (18 [69%] vs 8 [33%]; P = 0.01), defined as completing each task in the "verbal empathy" assessment domain, as measured by a faculty rater. Other assessed variables were not significantly different. Standardized patients' willingness (vs unwillingness; P = 0.01) to have the student as their physician was associated with the demonstration (by faculty appraisal) of a number of basic skills: using open-ended questions, asking one question at a time, using gender-neutral terminology when asking about the patient's relationship, and using appropriate sexual-health terminology. CONCLUSIONS: This study, although limited by a single-site design and the small number of participants, offers preliminary evidence that, if confirmed, may suggest that in-class learning from a psychiatrist (vs from an online module) is associated with greater verbal empathy in the assessment of SSRI-related sexual dysfunction.

Effectiveness of Electroconvulsive Therapy in Patients With Major Depressive Disorder and Comorbid Borderline Personality Disorder.

OBJECTIVE: Previous research suggests that electroconvulsive therapy (ECT)-the criterion standard for the treatment of severe depression-is not as effective when the patient has comorbid borderline personality disorder (BPD). The ECT outcomes of patients with and without BPD were compared in a retrospective chart review to test this claim. METHODS: We enrolled 137 patients with a diagnosis of major depressive disorder who completed the McLean Screening Instrument for Borderline Personality Disorder. Twenty-nine patients had positive screening scores for BPD. The difference in Patient Health Questionnaire (PHQ-9) scores before and after ECT was compared between patients with and without BPD. Follow-up PHQ-9 scores determined after treatment were collected and analyzed. RESULTS: Electroconvulsive therapy equally improved symptoms of depression as measured by PHQ-9 score in both patients who screened positive and patients who screened negative for BPD. No difference in the increase in PHQ-9 scores between these 2 groups was noted 1 month after treatment (P = 0.19). CONCLUSIONS: These data showed that a positive BPD screen does not necessarily predict a poorer response to ECT, nor does it predict greater symptom recurrence after ECT. This does not suggest that ECT is necessarily an appropriate treatment for major depressive disorder in patients with a comorbid BPD, given the limitations of screening instruments.

A cross-sectional study of learning styles among continuing medical education participants.

PURPOSE: Experiential learning has been suggested as a framework for planning continuing medical education (CME). We aimed to (1) determine participants' learning styles at traditional CME courses and (2) explore associations between learning styles and participant characteristics. MATERIALS AND METHODS: Cross-sectional study of all participants (n = 393) at two Mayo Clinic CME courses who completed the Kolb Learning Style Inventory and provided demographic data. RESULTS: A total of 393 participants returned 241 surveys (response rate, 61.3%). Among the 143 participants (36.4%) who supplied complete demographic and Kolb data, Kolb learning styles included diverging (45; 31.5%), assimilating (56; 39.2%), converging (8; 5.6%), and accommodating (34; 23.8%). Associations existed between learning style and gender (p = 0.02). For most men, learning styles were diverging (23 of 63; 36.5%) and assimilating (30 of 63; 47.6%); for most women, diverging (22 of 80; 27.5%), assimilating (26 of 80; 32.5%), and accommodating (26 of 80; 32.5%). CONCLUSIONS: Internal medicine and psychiatry CME participants had diverse learning styles. Female participants had more variation in their learning styles than men. Teaching techniques must vary to appeal to all learners. The experiential learning theory sequentially moves a learner from Why? to What? to How? to If? to accommodate learning styles.

Pain, psychiatric comorbidities, and psychosocial stressors associated with Klippel-Trenaunay syndrome.

BACKGROUND: Klippel-Trenaunay syndrome (KTS) is characterized by the triad of capillary malformation, venous malformation with or without lymphatic malformation, and limb overgrowth. Patients with KTS have lower scores in general in mental health, physical function, and quality of life than the general population. OBJECTIVE: To determine the prevalence of pain and psychiatric comorbidity in patients with KTS. METHODS: A retrospective review of 410 patients with KTS evaluated during 1976-2012 was conducted to identify the presence of pain, psychiatric comorbidities, and psychosocial stressors. RESULTS: Pain was reported by 260 patients (63.4%) and was associated with any KTS complication (P < .0001) and venous malformations of the lower extremities (P = .0008) and feet (P = .0007). Ninety-five patients had a diagnosed psychiatric condition (23.2%), most commonly depression (15.1%) and anxiety (5.1%). Pain (P = .0016), superficial thrombosis (P = .0269), deep embolic/thrombotic events (P = .0005), gastrointestinal complications (P = .0085), genitourinary complications (P = .0163), and capillary malformation of the hands (P = .0040) were associated with having a psychiatric diagnosis. LIMITATIONS: This is a retrospective study that relied on physician detection and reporting of variables. CONCLUSION: Pain and psychiatric conditions, particularly depression and anxiety, are common in patients with KTS. Awareness of the psychosocial impact of KTS and appropriate screening are important.

Antidepressant Use by Class: Association with Major Adverse Cardiac Events in Patients with Coronary Artery Disease.

BACKGROUND: To assess use of antidepressants by class in relation to cardiology practice recommendations, and the association of antidepressant use with the occurrence of major adverse cardiovascular events (MACE) including death. METHODS: This is a historical cohort study of all patients who completed cardiac rehabilitation (CR) between 2002 and 2012 in a major CR center. Participants completed the Patient Health Questionnaire (PHQ-9) at the start and end of the program. A linkage system enabled ascertainment of antidepressant use and MACE through 2014. RESULTS: There were 1,694 CR participants, 1,266 (74.7%) of whom completed the PHQ-9 after the program. Depressive symptoms decreased significantly from pre- (4.98 ± 5.20) to postprogram (3.57 ± 4.43) (p < 0.001). Overall, 433 (34.2%) participants were on antidepressants, most often selective serotonin reuptake inhibitors (SSRI; n = 299; 23.6%). The proportion of days covered was approximately 70% for all 4 major antidepressant classes; discontinuation rates ranged from 37.3% for tricyclics to 53.2% for serotonin-norepinephrine reuptake inhibitors (SNRI). Antidepressant use was significantly associated with lower depressive symptoms after CR (before, 7.33 ± 5.94 vs. after, 4.69 ± 4.87; p < 0.001). After a median follow-up of 4.7 years, 264 (20.9%) participants had a MACE. After propensity matching based on pre-CR depressive symptoms among other variables, participants taking tricyclics had significantly more MACE than those not taking tricyclics (HR = 2.46; 95% CI 1.37-4.42), as well as those taking atypicals versus not (HR = 1.59; 95% CI 1.05-2.41) and those on SSRI (HR = 1.45; 95% CI 1.07-1.97). There was no increased risk with use of SNRI (HR = 0.89; 95% CI 0.43-1.82). CONCLUSION: The use of antidepressants was associated with lower depression, but the use of all antidepressants except SNRI was associated with more adverse events.

Clozapine-induced cardiomyopathy and myocarditis monitoring: A systematic review.

The use of clozapine requires monitoring the absolute neutrophil count because of the risk of agranulocytosis, but other potentially fatal adverse events associated with clozapine (specifically, myocarditis and cardiomyopathy) do not have mandatory procedures. We performed a systematic review of English-language articles to synthesize an evidence-based approach for myocarditis and cardiomyopathy monitoring. Articles published from January 1988 through February 2017 were identified through a search of Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Web of Science, Scopus, and Google Scholar. Selected articles were required to relate to myocarditis or cardiomyopathy in humans from exposure to clozapine. A total of 144 articles were included. Recommendations varied widely. Some authors recommended baseline laboratory monitoring, with or without follow-up testing, for C-reactive protein, creatine kinase MB, and troponin. Electrocardiography was commonly recommended, and echocardiography was less commonly recommended. The expense of monitoring was a consideration. A unanimous recommendation was to stop the use of clozapine and seek a cardiovascular consultation if myocarditis or cardiomyopathy is suspected. Although there is general agreement on which tests to perform for confirming myocarditis and cardiomyopathy, preemptive screening for these clozapine-induced conditions is controversial, and cost and barriers for the use of clozapine are concerns. For asymptomatic patients receiving clozapine, testing could include baseline electrocardiography, echocardiography as part of a cardiac consultation if patients have cardiac disease or risk factors, and monitoring of C-reactive protein and troponin as indicated.

Validation of a Teaching Effectiveness Assessment in Psychiatry Continuing Medical Education.

OBJECTIVE: Little is known about factors associated with effective continuing medical education (CME) in psychiatry. The authors aimed to validate a method to assess psychiatry CME teaching effectiveness and to determine associations between teaching effectiveness scores and characteristics of presentations, presenters, and participants. METHODS: This cross-sectional study was conducted at the Mayo Clinic Psychiatry Clinical Reviews and Psychiatry in Medical Settings. Presentations were evaluated using an eight-item CME teaching effectiveness instrument, its content based on previously published instruments. Factor analysis, internal consistency and interrater reliabilities, and temporal stability reliability were calculated. Associations were determined between teaching effectiveness scores and characteristics of presentations, presenters, and participants. RESULTS: In total, 364 participants returned 246 completed surveys (response rate, 67.6%). Factor analysis revealed a unidimensional model of psychiatry CME teaching effectiveness. Cronbach α for the instrument was excellent at 0.94. Item mean score (SD) ranged from 4.33 (0.92) to 4.71 (0.59) on a 5-point scale. Overall interrater reliability was 0.84 (95% CI, 0.75-0.91), and temporal stability was 0.89 (95% CI, 0.77-0.97). No associations were found between teaching effectiveness scores and characteristics of presentations, presenters, and participants. CONCLUSIONS: This study provides a new, validated measure of CME teaching effectiveness that could be used to improve psychiatry CME. In contrast to prior research in other medical specialties, CME teaching effectiveness scores were not associated with use of case-based or interactive presentations. This outcome suggests the need for distinctive considerations regarding psychiatry CME; a singular approach to CME teaching may not apply to all medical specialties.

Concurrent Electroconvulsive Therapy and Bupropion Treatment.

BACKGROUND: Bupropion is associated with a dose-dependent increased risk of seizures. Use of concomitant bupropion and electroconvulsive therapy (ECT) remains controversial because of an increased risk of prolonged seizures. This is the first systematic evaluation of the effect of bupropion on ECT. METHODS: A case group (n = 119), patients treated with concomitant ECT and bupropion, was compared with an age and gender frequency-matched control group (n = 261), treated with only ECT. Electroconvulsive therapy treatment data including seizure length, number of treatments, and concurrent medications were extracted. Longitudinal mixed models examined ECT versus ECT + bupropion group differences over the course of treatments measured by seizure duration (electroencephalogram [EEG] and motor). Multivariable models examined the total number of treatments and first and last seizure duration. All models considered group differences with ECT treatment measures adjusted for age, gender, benzodiazepine treatment, lead placement, and setting. RESULTS: Electroconvulsive therapy treatment with bupropion led to shorter motor seizure duration (0.047) and EEG seizure duration (P = 0.001). The number of ECT treatments (7.3 vs 7.0 treatments; P = 0.23), respectively, or the probability of a prolonged seizure (P = 0.15) was not significantly different. Benzodiazepine use was significantly more common in control subjects (P = 0.01). LIMITATIONS: This is a retrospective analysis limited in part by unavailable variables (seizure threshold, nature of EEG and motor seizure monitoring, type of ECT device, dosing and formulation of bupropion, and duration of the current depressive illness). CONCLUSIONS: This study revealed a significantly shorter duration in seizure length with ECT + concomitant bupropion, but not in the number of required treatments in those treated compared with ECT without bupropion. There remains a critical need to reevaluate the efficacy of concomitant use of psychotropic medications + ECT.

Acute suicidal affective disturbance: Factorial structure and initial validation across psychiatric outpatient and inpatient samples.

BACKGROUND: A new clinical entity, Acute Suicidal Affective Disturbance (ASAD), was recently proposed to characterize rapid-onset, acute suicidality including the cardinal symptom of behavioral intent. This study examines the proposed ASAD criteria factor-analytically and in relation to correlates of suicidal behavior and existing psychiatric disorders in samples of psychiatric outpatients and inpatients. METHODS: Two samples of psychiatric outpatients (N=343, aged 18-71 years, 60.6% female, 74.9% White) and inpatients (N=7,698, aged 15-99 years, 57.2% female, 87.8% White) completed measures of their ASAD symptoms and psychological functioning. RESULTS: Across both samples, results of a confirmatory factor analysis supported the unidimensional nature of the ASAD construct. Additionally, results provided evidence for the convergent and discriminant validity of ASAD, demonstrating its relation to, yet distinction from, other psychiatric disorders and correlates of suicide in expected ways. Importantly, ASAD symptoms differentiated multiple attempters, single attempters, and non-attempters, as well as attempters, ideators, and non-suicidal patients, and was an indicator of past suicide attempts above and beyond symptoms of depression and other psychiatric disorders. LIMITATIONS: This study utilized cross-sectional data and did not use a standardized measure of ASAD. CONCLUSIONS: ASAD criteria formed a unidimensional construct that was associated with suicide-related variables and other psychiatric disorders in expected ways. If supported by future research, ASAD may fill a gap in the current diagnostic classification system (DSM-5) by characterizing and predicting acute suicide risk.

Continuation phase intravenous ketamine in adults with treatment-resistant depression.

BACKGROUND: Little is known about the antidepressive effects of repeated intravenous ketamine infusions beyond the acute phase of treatment in patients with refractory depression. METHODS: Twelve subjects with treatment-resistant non-psychotic unipolar or bipolar major depression and suicidal ideation were given repeated (up to 6) thrice-weekly acute-phase intravenous infusions of ketamine (0.5mg/kg, administered over 100min). Those who remitted during acute-phase treatment received continuation-phase treatment that consisted of 4 weekly ketamine infusions, followed by 4 weeks of post-continuation phase follow-up (during which no further ketamine infusions were administered). Clinical measures were assessed at baseline, at 24h following each infusion, at the last acute-phase observation, and during continuation and post-continuation follow-up (acute phase remitters only). RESULTS: Of the 12 enrollees, 5 (41.7%) remitted and 7 (58.3%) responded to ketamine treatment during the acute-phase. All five subjects who remitted during the acute-phase experienced further depressive symptom improvement during continuation-phase treatment. Four subjects lost remission status during the post-continuation phase, but all were still classified as positive treatment responders at the end of the post-continuation phase. Adverse effects were generally mild and transient during acute- and continuation-phase treatment; however, one subject developed behavioral outbursts and suicide threats during follow-up while hospitalized, and one subject died by suicide several weeks after the end of follow-up. LIMITATIONS: This was an uncontrolled feasibility study with a small sample size. CONCLUSIONS: The continuation-phase administration of ketamine at weekly intervals to patients with treatment-resistant depression who remitted during acute-phase ketamine treatment can extend the duration of depressive symptom remission. The antidepressive effect of ketamine persisted for several weeks after the end of continuation-phase treatment. Our results highlight the need for close monitoring of subjects who are at high baseline risk for suicide but do not respond clinically to ketamine. CLINICALTRIALS. GOV IDENTIFIER: NCT02094898.

Mixed mania associated with cessation of breastfeeding.

BACKGROUND: This case chronicles the unique presentation of psychotic mixed mania in a female 5 months after parturition and 1 week following breastfeeding discontinuation, highlighting a rarely recognized mania risk factor that is temporally delayed from parturition: breastfeeding discontinuation. CASE PRESENTATION: A 25-year-old G1P1 female with a past psychiatric history of a depressive episode in adolescence presented to the Emergency Department with her 5-month-old daughter, fiancée, and family 1 week after breastfeeding cessation. She endorsed sleep-deprived energy enhancement, unfulfilled goal-oriented productivity, hyper-talkativeness, hyper-sexuality and increased nicotine use. Concurrent depressive symptoms included hopelessness, worthlessness, poor concentration, lack of appetite, and ego-dystonic intrusive thoughts that she may kill herself or her child. She exhibited pressured speech, affective lability, expansiveness, distractibility, and tangential, grandiose, delusional self-referential content. Transient thoughts of self-harm and harm to her child were not associated with intent. Her family history was significant for a deceased mother who had bipolar I disorder. The patient was hospitalized for 5 days and diagnosed with bipolar disorder, type I, current episode manic with psychotic features with a mixed-feature specifier. Olanzapine and lithium were initiated and the patient's acute episode of mania resolved prior to discharge. CONCLUSIONS: This case extends the limited literature on mania following weaning and highlights the role of rapid serum dopamine rise following breastfeeding cessation in mania.

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

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.