Comparison of clinical characteristics in good and poor insight obsessive–compulsive disorder
Introduction
The problem of insight has been a key issue in the series of debates surrounding the definition of obsessive–compulsive disorder (OCD). First of all, obsessions and compulsions also occur in psychoses, and this calls for a clear-cut boundary between neurotic and psychotic obsessions and compulsions. The traditional gold standard in making the distinction has been presence of insight in the former (Reed, 1985, Snaith, 1981).
Secondly, as many authors addressing OCD have noted, presence and degree of insight may change considerably from one patient to another and over the course of the disorder (Freud, 1966; Insel & Akiskal, 1986; Kozak & Foa, 1993; Lelliott, Noshirvani, Basoglu, Marks, & Monteiro, 1988; Robinson, Winnik, & Weiss, 1976; Solyom, DiNicola, Phil, Sookman, & Luchins, 1985), making such a distinction difficult at times, if not altogether impossible.
And thirdly, it has been noted that patients with poor insight also respond to treatment poorly (Basoglu, Lax, Kasvikis, & Marks, 1988; Eisen & Rasmussen, 1993; Foa, 1979; Insel & Akiskal, 1986; Jenike, Baer, Minichiello, Schwartz, & Carey, 1986; Solyom et al., 1985), raising the question of whether there is a subgroup of “atypical” OCD patients whose symptoms are more severe. In case such a group exists, would it not be more appropriate to classify these patients under a separate entity or under psychoses? Hoch and Polatin described a case with “pseudoneurotic schizophrenia” in as early as 1949 (cited in Spitzer, Skodol, Gibbon, & Williams, 1981). Strauss (1948), Weiss, Robinson, and Winnik (1969) and also Solyom et al. (1985) offered “obsessive psychosis,” Insel and Akiskal (1986) offered “OCD with psychotic features,” and Rasmussen and Tsuang (1986) offered “chronic deteriorative OCD.” However, subpopulations defined by those terms are not necessarily identical.
Appropriateness of classifying some “atypical” cases with poor insight under the classical entity of OCD has been questioned by many authors in recent years. The first one to note that obsessive patients do not necessarily have insight into the senselessness of their beliefs was Lewis (1936) who, as Jakes (1996) pointed out, also employed the term “resistance” in a special way to broaden the definition of OCD. However, with the attempts to use uniform criteria in classification getting stronger in DSM-III (American Psychiatric Association, 1980), the definition became somewhat stricter. Still, it may be interesting to note that in the historical cases section of the official casebook for DSM-III, Spitzer et al. (1981) re-diagnosed a case with probably negative insight as OCD, arguing against the original diagnosis of “pseudoneurotic schizophrenia” offered by Hoch and Polatin. The tendency to broaden the definition gained ground in time and resulted in a loosening of the criterion “insight into senselessness” in DSM-III-R (American Psychiatric Association, 1987), which admitted that this “ … may no longer be true for people whose obsessions have evolved into overvalued ideas.” DSM-IV went even further by stating that obsessions or compulsions must be recognized as excessive or unreasonable not necessarily earlier, but “at some point during the course of the disease.” DSM-IV also stressed that the specifier “with poor insight” was added “in recognition that insight … occurs on a continuum” (American Psychiatric Association, 1994), in line with Kozak and Foa (1993) who had pointed out the difficulty of drawing lines between obsession and overvalued idea and overvalued idea and delusion, which can be distinguished only by the degree of insight present.
In this study, we investigated 94 OCD cases with varying degrees of insight and tried to find out whether these patients constitute a homogenous subgroup. We also tried to determine the other features that may help to characterize such a subgroup.
Section snippets
Subjects
Patients aged 18 or older presenting to the outpatient clinic in the Department of Psychiatry at the Istanbul University Istanbul Faculty of Medicine between May 1995 and July 1999 who agreed to participate in the study were included. Exclusion criteria were illiteracy, organic brain disease, and psychotic disorders (schizophrenia, delusional disorders, etc.) other than OCD without insight. Patients whose delusions pertained only to their specific obsessive–compulsive symptomatology and who had
Results
Of the 94 cases with OCD, 29 (31%) had poor insight defined according to DSM-IV criteria. There was no statistically significant difference between the groups for gender, marital status or education (Table 1). The poor insight group tended to include more males. No difference between the two groups was observed for the mean duration of the disease, age at onset, and age at assessment. When the dichotomous variable of insight was replaced by the more sophisticated Y-BOCS item 11, none of the
Discussion
Although insight has been a controversial issue, there is a paucity of studies which compare OCD patients with poor and good insight using structured instruments. We have been able to find five studies in relevant literature, two of which used structured instruments (Eisen & Rasmussen, 1993; Robinson et al., 1976, Solyom et al., 1985, Weiss et al., 1969; Weiss, Robinson, & Winnik, 1975). Selection criteria for atypical group in the study by Solyom et al. were similar to ours; but Eisen and
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