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Letters   |    
Paliperidone-Induced Obsessive Symptoms
Thomas Paparrigopoulos, M.D.; Elias Tzavellas, M.D.; Dimitris Karaiskos, M.D.; Ioannis Liappas, M.D.
The Journal of Neuropsychiatry and Clinical Neurosciences 2011;23:E46-E46.

To The Editor: The therapeutic effect of the atypical antipsychotic paliperidone is attributed to a combination of D2 and postsynaptic 5-HT2A receptor antagonism,1 which, in turn, exerts an inhibitory effect on the mesolimbic dopaminergic system.2 Paliperidone also antagonizes α1 and α2-adrenergic and H1-histamine receptors. It is indicated for the treatment of schizophrenia and manic or mixed episodes of bipolar i disorder.1 we report on a patient who benefited in terms of psychotic symptom reduction but developed severe obsessive thoughts.

A 32-year-old man suffering from paranoid schizophrenia was referred for excessive weight gain attributed to risperidone, resistant to a dietary regimen. The patient had a first episode with auditory hallucinations and persecutory delusions 8 years ago. He had been medicated with risperidone, and symptoms were well-controlled. After an unsuccessful reduction of risperidone, the patient was stabilized on 4 mg/day. A gradual switch to paliperidone 9 mg/day was tried. Positive symptoms, that is, prominent hallucinations or formal thought disorder, were adequately contained, but, after 2 months, the patient complained of uncontrollable, invasive thoughts of harming his parents, which had never been present beforea. The patient recognized the irrational nature of his thoughts, and these produced excessive anxiety that he could not manage. A switch back to risperidone led to full remission of obsessive thoughts in 2 weeks.

Paliperidone-induced obsessive-compulsive symptoms (OCS) have not been reported. De novo surfacing of OCS by atypical antipsychotics during schizophrenia treatment has been documented in numerous cases.3,4 Pertinent hypotheses have been proposed, such as the following: 1) overt psychosis may mask OCS; 2) obsessions may represent a residual form of psychosis; 3) OCS and psychosis may be two discrete phenomena; and 4) obsessions may be adverse effects of antipsychotic medication.5 Although underlying pathophysiology is not well understood, 5-HT2 receptor antagonism, particularly in the basal ganglia, seems to play a key role in the emergence of OCS in schizophrenic patients. It is noteworthy that, in our case, obsessions had never been previously present, although the patient was on risperidone for 8 years. These symptoms surfaced when paliperidone, an active metabolite of risperidone, was administered, which suggests a potential different mechanism of action in the cortico-striato-thalamic loop. The observation that paliperidone may induce OCS corroborates the key role of the interplay of serotonin and dopamine in their emergence in schizophrenic patients.2 Monitoring of patients on paliperidone is needed because of the possibility of their developing OCS.

 Invega (paliperidone) [package insert].  Titusville, NJ:  Janssen LP;  April2007
 
Kapur  S;  Remington  G:  Serotonin-dopamine interaction and its relevance to schizophrenia.  Am J Psychiatry 1996; 153:466–476
[PubMed]
 
Sareen  J;  Kirshner  A;  Lander  M  et al:  Do antipsychotics ameliorate or exacerbate obsessive-compulsive disorder symptoms? a systematic review.  J Affect Disord 2004; 82:167–174
[PubMed]
[CrossRef]
 
Lykouras  L;  Alevizos  B;  Michalopoulou  P  et al:  Obsessive-compulsive symptoms induced by atypical antipsychotics: a review of the reported cases.  Prog Neuropsychopharmacol Biol Psychiatry 2003; 27:333–346
[PubMed]
[CrossRef]
 
Poyurovsky  M;  Weizman  A;  Weizman  R:  Obsessive-compulsive disorder in schizophrenia: clinical characteristics and treatment.  CNS Drugs 2004; 18:989–1010
[PubMed]
[CrossRef]
 
References Container
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References

 Invega (paliperidone) [package insert].  Titusville, NJ:  Janssen LP;  April2007
 
Kapur  S;  Remington  G:  Serotonin-dopamine interaction and its relevance to schizophrenia.  Am J Psychiatry 1996; 153:466–476
[PubMed]
 
Sareen  J;  Kirshner  A;  Lander  M  et al:  Do antipsychotics ameliorate or exacerbate obsessive-compulsive disorder symptoms? a systematic review.  J Affect Disord 2004; 82:167–174
[PubMed]
[CrossRef]
 
Lykouras  L;  Alevizos  B;  Michalopoulou  P  et al:  Obsessive-compulsive symptoms induced by atypical antipsychotics: a review of the reported cases.  Prog Neuropsychopharmacol Biol Psychiatry 2003; 27:333–346
[PubMed]
[CrossRef]
 
Poyurovsky  M;  Weizman  A;  Weizman  R:  Obsessive-compulsive disorder in schizophrenia: clinical characteristics and treatment.  CNS Drugs 2004; 18:989–1010
[PubMed]
[CrossRef]
 
References Container
+
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