Dose-dependent clozapine-induced skin picking and self-injurious behaviour in treatment-resistant schizophrenia

Clozapine is a second-generation antipsychotic used for treatment-resistant schizophrenia. Obsessive-compulsive symptoms induced by clozapine is a known entity. Skin-picking is closely related to obsessions and excoriation disorder is now categorised under obsessive-compulsive and related disorders. Skin-picking associated with clozapine dose increments has been reported in a young male from India. Apart from this, skin-picking and self-injurious behaviour associated with clozapine use are not well described in the literature. Here we report a young Sri Lankan male with treatment-resistant schizophrenia presenting with self-injurious behaviour that is related to clozapine-induced compulsive skin-picking. Due to the partial response, clozapine dose of the described patient was increased above 550 mg/day. Skin-picking was seen only above this dose and the addition of risperidone helped to resolve the psychotic symptoms and keep the clozapine dose at the previous level. The current report is unique in the sense that the self-injurious behaviour was associated with clozapine dose increments.