Intravenous Clomipramine for a Schizophrenic Patient With Obsessive-Compulsive Symptoms

Ms. A, a 25-year-old woman who had had schizophrenic disorder, paranoid type (according to DSM-IV), since the age of 17 years, was hospitalized twice because of acute psychotic exacerbation. After treatment with various antipsychotics, she was stabilized with perphenazine (8 mg/day). Ms. A also manifested ego-dystonic checking and cleaning rituals related to an obsessive fear of contamination. The subsequent addition of fluvoxamine (250 mg/day for 12 weeks) and fluoxetine (40 mg/day for 8 weeks) to the neuroleptic treatment failed to control her obsessive-compulsive symptoms. Further deterioration of the compulsive behavior resulted in her rehospitalization. At this point, in addition to the previously observed rituals, Ms. A was exercising compulsively for 12–14 hours per day. Despite her awareness of the irrationality of her behavior, our attempts to stop the exercising caused her severe anxiety. We initiated a course of intravenous clomipramine (75 mg in 1500 cc of normal saline) in addition to the ongoing perphenazine (8 mg/day); we repeated the 4-hour infusion procedure 24 hours later. Five days after the second infusion, Ms. A's score on the Yale-Brown Obsessive Compulsive Scale dropped from 19 to 4, an indication that her compulsive behavior had almost completely disappeared. This was the first notable improvement since the onset of her obsessive-compulsive symptoms. In addition, Ms. A's score on the Brief Psychiatric Rating Scale dropped from 41 to 29, and her monitored ECG, pulse, and blood pressure were within normal limits. The only side effect was mild sedation. We subsequently gave Ms. A prescriptions for oral clomipramine (150 mg/day) and perphenazine (8 mg/day) and discharged her from the hospital. We observed no recurrence of her obsessive-compulsive or schizophrenic symptoms during a 6-month follow-up.