Diagnostic and therapeutic difficulties in patients with obsessive-compulsive disorder

Introduction: Obsessive-compulsive disorder has essentially been characterized by symptoms that are perceived by the patients to be excessive or unreasonable. However, there is growing recognition of the extent to which insight into symptoms varies in OCD individuals. Some OCD patients do not regard their symptoms as unreasonable or excessive, and their ideas can be characterized as overvalued or delusional. Indeed, a subtype of "poor insight" has been introduced into the DSM-IV criteria for OCD.

The diagnosis of OCD, may be difficult in patients who briefly relinquish the struggle against their symptoms, which appear to shift from unwanted and distressing intrusion to psychotic delusion. OCD patients with poor insight may have a different response or different course than do patients with better insight.

The purpose of this study is the management of OCD patients with poor insight.

Patients and Method: 21 patients (8 males and 13 females) were admitted to Psychiatric Hospital of Thessaloniki. They were between the ages of 22 and 63 years (mean±SD age 41,5±11,6 ). They met the DSM-IV criteria for Obsessive-Compulsive Disorder, diagnosed by clinical interview but also had a variety of comorbid disorders including major depressive episode (n=5), bipolar disorder (n=2), schizotypal personality disorder (n=2), hypohondriasis (n=1).

The diagnosis of OCD was confirmed by Y-BOCS scale, (Yale-Brown Obsessive-Compulsive Scale). The total score of all patients was above 16.

All patients had received anti-depressant therapy in adequate doses for the proper duration of time and low doses of anti-psychotic therapy in doses lower than the therapeutic range. Some cases received additionally anxiolytics. Clinical improvement was judged by clinical interview and confirmed by Y-BOCS scale.

Results and Discussion: Among the twenty one patients of the study, sixteen patients (76,4%) had been diagnosed as psychotic before admission to the hospital and they had been prescribed anti-psychotics. These patients showed "poor insight" into their OCD symptoms.

The result of the Y-BOCS had a mean score of 29,9±5,5 in the population of sixteen patients. The rest five patients that had a good insight into their OCD symptoms had a similar average of 31,2±6,7. All patients had either failed to respond clinically or appeared residual symptoms that caused markedly functional decline.

All patients were clinically improved after the prescription of both anti-depressant and anti-psychotics. Even in the cases of the patients with "good insight" the prescription of low dose of anti-psychotics, improved additionally the clinical status.

In the current study a number of patients with "poor insight" showed an improvement of insight to fair or good in parallel with the improvement of OCD severity as well as the improvement of functional level.

The conclusions of this study are:

  1. that a significant percentage of patients with the diagnosis of obsessive-compulsive disorder have poor insight and that's the main reason that these patients are misdiagnosed as psychotic,
  2. the OCD patients with poor insight have a lower level of function comparatively to the OCD patients with good insight, because of the severity of their symptoms. As a result they are often admitted to psychiatric wards,
  3. that treatment of OCD patients with poor insight often lead to a swift to good insight with concomitant improvement of OCD severity. The best combination of the prescribed medication is that with low doses of anti-psychotic drugs plus to high doses of anti-depressant drugs.

Key words: Diagnostic difficulties, therapeutic difficulties, obsessive-compulsive disorder.