Obsessive-compulsive disorder with poor insight
Abstract
Although a diagnosis of obsessive-compulsive disorder (OCD) can be made with the specification [ldquo ]poor insight[rdquo ] (PI), this subtype remains understudied. To investigate the subtype, 78 OCD patients were characterized by degree of insight, reevaluated after treatment, and compared with 20 schizophrenics with OCD (OCD+S). At the pretreatment assessments in OCD patients, 28 subjects with poor or delusional insight (PI; 36%) were distinguished from 50 subjects with fair or good insight (GI; 64%) using the insight question of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Compared to the OCD+S group, OCD patients were less likely to have PI, whereas OCD PI patients showed a similar degree of functional impairment as that observed in the OCD+S. After a 6-month combination of clomipramine with cognitive-behavioral treatment, 14 of 25 OCD PI patients no longer fell in the PI category, which was associated with reduced OCD severity and depressive status. Schizotypal personality disorder (SPD) was more common in patients whose insight remained poor even after the treatment. OCD patients demonstrate a range of insight with PI accompanied by significant dysfunction. Comorbid SPD in PI patients may be associated with worse prognosis.
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Clinical profile of schizophrenia comorbid with obsessive-compulsive symptoms: A comparative study
2023, EncephaleDescribe and compare the clinical profile of schizophrenic patients with and without obsessive-compulsive symptoms and obsessive-compulsive disorder (OCD) patients.
A descriptive and analytical cross-sectional study was carried out at the psychiatry department of Hassan II University Hospital in Fez over 12 months to compare three groups of patients: “schizo-obsessive” (n = 32), “schizophrenia” (n = 34), and “OCD” (n = 46). All participants (n = 112) were assessed using the mini-international neuropsychiatric interview (MINI), the Yale-Brown obsessive-compulsive scale (Y-BOCS), the Brown assessment of beliefs scale (BABS), the Hamilton anxiety rating scale (HAM-A), the Beck's depression inventory (BDI-II), the positive and negative syndrome scale (PANSS), and the clinical global impressions–severity scale (CGI-S).
The “schizo-obsessive” group differed from the “schizophrenia” group in: more severe psychotic symptoms (mean = 64.16 ± 17.049, P < 0.001), higher anxiety (mean = 8.87 ± 5,655, P < 0.001) and depression (mean = 7.50 ± 5.989, P < 0.001) scores, more prevalent suicide attempts (46.9%), higher illness severity score (mean = 5.13 ± 1.157, P = 0.02), and more professional disinsertion (78.1%). The “schizo-obsessive” group (mean= 14.47 ± 3.388) had significantly poor insight (P < 0.001) compared to the “OCD” group (mean= 8.35 ± 4.542). There were similarities in the obsessive and compulsive themes between the “schizo-obsessive” and the “OCD” groups, with no significant difference of severity (P = 0.26).
A careful assessment of obsessive symptomatology is essential in schizophrenia for better patient management and prognosis.
L’objectif de cette étude était de décrire et comparer le profil clinique des patients schizophrènes avec ou sans symptômes obsessionnels compulsifs et des patients ayant un trouble obsessionnel compulsif (TOC).
Une étude transversale descriptive et analytique a été réalisée au service de psychiatrie du CHU Hassan II de Fès sur une période de 12 mois pour comparer trois groupes de patients : « schizo-obsessionnel » (n = 32), « schizophrénie » (n = 34), et « TOC » (n = 46). Tous les patients (n = 112) étaient évalués par l’entretien diagnostique structuré « MINI », l’échelle d’obsession-compulsion de Yale-Brown (Y-BOCS), l’échelle d’évaluation des croyances (BABS), l’échelle d’anxiété d’Hamilton (HAM-A), l’inventaire de dépression de Beck (BDI-II), l’échelle des symptômes positifs et négatifs (PANSS), et l’échelle de sévérité de la maladie (CGI-S).
L’âge moyen était 36,33 ± 11,95 ans dans le groupe « TOC », 30 ± 8,13 ans dans le groupe « schizo-obsessionnel », et 32,26 ± 9,928 ans dans le groupe « schizophrénie ». La plupart des participants étaient des hommes dans les groupes « schizo-obsessionnel » (75 %, sexe ratio H/F = 3) et « schizophrénie » (76,4 %, sexe ratio H/F= 3,25). D’autre part, les femmes étaient majoritaires dans le groupe « TOC » (58,6 %, sex-ratio H/F = 0,7). Les antécédents familiaux de troubles psychiatriques étaient plus retrouvés dans les groupes « TOC » (n = 23, 50 %) » et « schizo-obsessionnel » (n = 19, 59,4 %) que dans le groupe « schizophrénie » (n = 5, 14,7 %). La schizophrénie et le TOC étaient les antécédents familiaux les plus fréquents dans les groupes « TOC » (n = 18, 39,2) et « schizo-obsessionnel » (n = 17,53,1 %), alors qu’aucun patient n’avait des antécédents familiaux de TOC dans le groupe « schizophrénie ». Le groupe « schizo-obsessionnel » diffère du groupe « schizophrénie » en présentant : des symptômes psychotiques significativement plus sévères (moyenne = 64,16 ± 17,049, p < 0,001), des scores d’anxiété (moyenne = 8,87 ± 5,655, p < 0,001) et de dépression (moyenne = 7,50 ± 5,989, p < 0,001) significativement plus élevés, des tentatives de suicide plus nombreuses (46,9 %), un score de gravité de la maladie plus élevé (moyenne = 5,13 ± 1,157, p = 0,02), et plus de désinsertion professionnelle (78,1 %). Le groupe « schizo-obsessionnel » (moyenne = 14,47 ± 3,388) avait un insight significativement pauvre (p < 0,001) par rapport au groupe « TOC » (moyenne= 8,35 ± 4,542). Il y avait des similitudes dans les thèmes obsessionnels et compulsifs entre les groupes « schizo-obsessionnel » et « TOC », sans différence significative de sévérité (p = 0,26).
Une évaluation minutieuse de la symptomatologie obsessionnelle est nécessaire dans la schizophrénie pour une meilleure prise en charge et un meilleur pronostic du patient.
Poor Insight in Obsessive-Compulsive Disorder as a Multifaceted Phenomenon: Evidence From Brain Activation During Symptom Provocation
2023, Biological Psychiatry: Cognitive Neuroscience and NeuroimagingPoor insight in obsessive-compulsive disorder (OCD) is associated with higher symptom severity, more comorbidities, and worse response to treatment. This study aimed to elucidate underlying mechanisms of poor insight in OCD by exploring its neurobiological correlates.
Using a symptom provocation task during functional magnetic resonance imaging, we compared brain activation of patients with poor insight (n = 19; 14 female, 5 male), good/fair insight (n = 63; 31 female, 32 male), and healthy control participants (n = 42; 22 female, 20 male) using a Bayesian region-of-interest and a general linear model whole-brain approach. Insight was assessed using the Overvalued Ideas Scale.
Compared with patients with good/fair insight and healthy control participants, patients with OCD and poor insight showed widespread lower task-related activation in frontal areas (subgenual anterior cingulate cortex, ventromedial prefrontal cortex, dorsolateral prefrontal cortex, ventrolateral prefrontal cortex, supplementary motor area, precentral gyrus), parietal areas (posterior parietal cortex, precuneus), and the middle temporal gyrus and insula. Results were not driven by interindividual differences in OCD symptom severity, medication usage, age of disorder onset, or state distress levels.
During symptom provocation, patients with OCD and poor insight show altered activation in brain circuits that are involved in emotional processing, sensory processing, and cognitive control. Future research should focus on longitudinal correlates of insight and/or use tasks that probe emotional and sensory processing and cognitive control.
Psychotic-like experiences in obsessive compulsive disorder
2023, European Journal of PsychiatryThe study aims to compare individuals diagnosed with obsessive-compulsive disorder (OCD) and healthy individuals in terms of psychosis-like experiences (PLEs) and investigate the relationship between PLEs and OCD severity.
Sociodemographic information form, Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the positive dimension of Community Assessment of Psychic Experiences (CAPE-P), Hamilton Depression Rating Scale (HAM-D), and Hamilton Anxiety Rating Scale (HAM-A) were applied to 83 OCD patients and 83 healthy individuals. The 11th item of Y-BOCS (Y-BOCS-11) was used to evaluate the level of insight. The OCD group was compared with the healthy control group in terms of sociodemographic information and CAPE-P score. In the OCD group, mediation analyses were performed to evaluate the factors affecting the relationship between OCD severity and PLEs.
The OCD group had higher CAPE-P scores than the healthy control group. CAPE-P scores were weakly correlated with Y-BOCS-11 and Y-BOCS total scores. It was found that the relationship between OCD severity and PLEs was mediated by poor insight; however, the scores of depression and anxiety did not.
The results show that the level of insight is a determinative factor for PLEs in OCD. The fact that PLEs are common in the OCD group and healthy individuals support the concept of the psychosis continuum. We emphasize that being aware of PLEs in OCD can provide new understandings of the phenomenon of OCD and psychosis.
Treatment-resistant OCD: Pharmacotherapies in adults
2023, Comprehensive PsychiatrySerotonin reuptake inhibitor (SRI) medications are well established as first-line pharmacotherapeutic treatment for Obsessive-Compulsive Disorder (OCD). However, despite the excellent safety profile and demonstrated efficacy of these medications, a substantial proportion of individuals with OCD fail to attain sufficient benefit from SRIs.
In this narrative review, we discuss clinical features of OCD that have been associated with poorer response to SRIs, and we present pharmacotherapeutic interventions that have been explored as augmenting or alternative treatments for treatment-resistant OCD. We additionally highlight non-SRI interventions for OCD that are currently under investigation.
Pharmacotherapeutic interventions were identified via expert consensus. To assess the evidence base for individual pharmacotherapies, targeted searches for relevant English-language publications were performed on standard biomedical research databases, including MEDLINE. Information relevant to ongoing registered clinical trials in OCD was obtained by search of ClinicalTrials.gov. Pharmacotherapies are grouped for review in accordance with the general principles of Neuroscience-based Nomenclature (NbN).
Clinical features of OCD that may suggest poorer response to SRI treatment include early age of onset, severity of illness, duration of untreated illness, and the presence of symmetry/ordering or hoarding-related symptoms. Based on evolving pathophysiologic models of OCD, diverse agents engaging serotonin, dopamine, norepinephrine, glutamate, and anti-inflammatory pathways have been explored as alternative or adjunctive therapies for treatment-resistant OCD and have at least preliminary evidence of efficacy.
Medications with dopamine antagonist activity remain the most robustly evidence-based of augmenting interventions, yet dopamine antagonists benefit only a minority of those who try them and carry elevated risks of adverse effects. Interventions targeting glutamatergic and anti-inflammatory pathways are less well evidenced, but may offer more favorable benefit to risk profiles. Ongoing research should explore whether specific interventions may benefit individuals with particular features of treatment-resistant OCD.
What is obsession? Differentiating obsessive-compulsive disorder and the schizophrenia spectrum: Obsession and differential diagnosis
2022, Schizophrenia ResearchObsessive-compulsive symptoms are frequent in schizophrenia-spectrum disorders and often cause differential diagnostic challenges, especially in first-contact patients. Drawing upon phenomenology of cognition, we critically review classic and contemporary psychopathological notions of obsessive-compulsive phenomena and discuss their relevance for differential diagnosis between obsessive-compulsive disorder (OCD) and schizophrenia-spectrum disorders. The classic psychopathological literature defines true obsession as intrusions with intact resistance and insight and regards these features as essential to the diagnosis of OCD. In schizophrenia, the classic literature describes pseudo-obsessive-compulsive phenomena characterized by lack of resistance and an affinity with other symptoms such as thought disorder and catatonia. By contrast, the notions of obsession and compulsion are broader and conceptually vague in current diagnostic systems and research instruments. Here, these phenomena overlap with delusions as well as various subjective and behavioral anomalies, which we discuss in detail. Furthermore, we examine a link between obsessive-compulsive phenomena and disturbances of basic structures of experience in schizophrenia-spectrum disorders addressed in contemporary psychopathological research. We suggest that these experiential alterations have relevance for differential diagnosis and early detection in this complex symptom domain.
Poor insight in obsessive compulsive disorder (OCD): Associations with empathic concern and emotion recognition
2021, Psychiatry ResearchInsight is currently considered to be responsible for 20% to 40% of the cases of ineffective obsessive-compulsive disorder (OCD) treatment. As 15% to 36% of patients with OCD have reduced insight, we aimed to identify some of the clinical determinants of insight in OCD.
Our sample consisted of 57 OCD patients, of which 34 men (59%) and 23 women (41%). All individuals completed a two-phase interview consisting of a clinical assessment, emotional awareness evaluation and insight measurement, using the Brown Assessment of Beliefs Scale (BABS). The insight score correlated significantly with negative emotion recognition (p < 0.0001) and empathic concern (p = 0.003).
Our results support the hypothesis that insight in OCD is related to emotional awareness, specifically emotion recognition and empathic concern. Future research should investigate the extent to which poor insight and impaired emotional awareness can be modified by psychological or pharmacological therapies and whether this will enhance treatment response.