The management of schizophrenia with anxiety disorders, such as obsessive-compulsive (OC) and panic symptoms, is challenging. The underlying biological mechanisms responsible for this comorbidity are unknown. Clinically, the treatment may be different for schizophrenia with and without comorbid anxiety disorders. For this reason, Dr. Hwang noted that a diagnosis of schizophrenia with anxiety disorders is necessary for the successful treatment of this disease.

Dr. Hwang explained that, prior to the DSM-III-R, underdiagnosis or misdiagnosis of this disorder might have occurred because diagnostic conventions precluded simultaneously diagnosing schizophrenia and anxiety disorders. As a result, obsessive-compulsive disorder (OCD) and panic disorder (PD) in schizophrenia were initially believed to occur rarely and have no significant clinical implications. Today, schizophrenia with co-existing anxiety symptoms may be conceptualized categorically, e.g., as reflecting the presence of two distinct disorders, or dimensionally, e.g., as representing one of many phenomenological symptom dimensions in schizophrenia. Further studies are needed to determine the exact classification of this disease.

Recent clinical studies have shown significantly worse clinical courses among patients with schizophrenia and comorbid OCD and PD. These studies suggest that optimal outcome may be obtained when schizophrenic patients with comorbid anxiety disorders receive in-depth clinical evaluation and individualized approaches to treatment. This is important because the incidence of schizophrenia with OCD has increased from 3% in the 1920's to 9% or more in the 1990's.

Clinical management of schizophrenia with OCD is treated with the tricyclic antidepressant, clomipramine. Clomipramine treats the OCD symptoms and does not affect schizophrenia. Dr. Hwang mentioned that some patients benefit from this treatment, while others do not. For the treatment of PD in schizophrenia, a positive response may be obtained with an anti-panic regimen. Medications commonly used with PD and schizophrenia are selective serotonin reuptake inhibitors (SSRIs). These drugs should be started t a low dosage and increased slowly over the course of weeks.

Dr. Hwang presented his recent work on new onset new-onset psychosis and the frequency of anxiety disorders. These authors reported a greater rate of OCD and PD in patients with new onset psychosis than previously seen. The data indicate PD is most frequently associated with major depression (MDD) while OCD is most commonly associated with SZ/SA or MDD.

These data emphasize the need to accurately assess comorbid conditions, treat the associated symptoms and develop a positive rapport with the patient.

(abstract Symposia No. 6B)