New-Onset Psychotic Symptoms Associated With Neuromodulation in a Patient With Severe OCD

We report the case of a 26-year-old man with severe obsessive-compulsive disorder (OCD) who developed new-onset psychotic symptoms following neuromodulation therapy. He had a longstanding history of contamination obsessions, "just-right" phenomena, repeating compulsions, and severe avoidance, with minimal response to multiple trials of Serotonin Reuptake Inhibitors (SRIs) including clomipramine. Following initiation of deep transcranial magnetic stimulation (dTMS) using a modified intermittent theta burst (iTBS) protocol, he developed auditory hallucinations and persecutory delusions. Subsequent transcranial direct current stimulation (tDCS), using an adapted protocol targeting both OCD and psychotic symptoms, led to further worsening of the psychosis. Symptoms resolved with antipsychotic treatment. We describe the clinical course and discuss putative mechanisms underlying the emergence of psychosis with neuromodulation in OCD.