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Introduction: Both obsessions and delusions are based on wrong, absurd and extreme ideas and it is thought that they could be separated on the basis of the presence of insight. Between obsessions and delusions there is the protection of insight and the ability to resist compulsive thoughts and/or behaviors. The insight of obsessive patients against obsessions may be protected or completely lost (1). In this paper, the diagnostic process in a patient with OCD, who also had delusions, is discussed.
Case: A 30 year-old, married, female patient applied to the hospital with complaints of unhappiness, suspiciousness, self-reproach, thoughts of death, hearing noises and insomnia. The patient had a four year medical history. She considered her 6 year-old son as her "love." Four years ago she had sexual feelings towards her female collegues and she thought that her feelings were mutual and her thoughts could be read by them. During psychiatric examination, her thought content had Schneiderian symptoms such as paranoia, thought withdrawal, thought insertion, and reference delusion. Just after the hospitalization and evaluation, the patient was medicated with 6 mg/day risperidone and 2 mg/day biperiden for a preliminary diagnosis of schizophrenia. Later the preliminary diagnosis was changed to atypical obsessive-compulsive disorder and her treatment was changed to sertraline 200 mg/day, quetiapine 300 mg/day and clonazepam 2 mg/day. Due to the fact that after a 10-day period of improvement, her reference delusion and fear of death had restarted, and inappropriate affect was detected, a treatment regimen of pimozide 2mg/day, sertraline 200mg/day, clomipramine 75mg/day, clonazepam 2mg/day had been prescribed. The difference between the facts and the idea had been discussed through a cognitive approach. After 12 days, her affect recovered and obsessive thoughts decreased, therefore the patient was discharged from hospital on the previously mentioned treatment. After 2 months, there had been no psychotic symptoms, she had been able to cope with distress better and her psycho-social functioning had been fine.
Discussion: The frequency of psychotic symptoms in OCD was detected at the ratio of 0.7-12.3% in a former study and 14% psychotic symptoms and 4% schizophrenia was reported in another study. Thomsen and Jensen demonstrated that 5% of 135 OCD patients, who applied to the hospital for the first time, were later diagnosed as schizophrenic (3). Despite the psychotic nature of OCD that has been noticed for a long time, modern classification systems still refer to OCD as an anxiety disorder. Although the DSM-IV mentions poor insight in OCD, there has been no objective description for what degree of insight should be accepted as poor. The diagnostic criteria and treatment of schizo-obsessions and whether the patients who have schizophrenia and OCD comorbidity should be considered as schizo-obsessive disorder are still under discussion(2).
References:
1. Aydyn A. Ceylan ME. Türkcan A. ?izofrenide Obsesif Kompulsif Fenomenler: Bir Gözden Geçirme. Klinik Psikofarmakoloji Bülteni 2008;18:222-234
2. Demir EY. Aslan S. ?izo-Obsesif Bozukluk: Tany, Synyşandyrma ve Tedavi. Türkiye' de Psikiyatri 2005;7(1):38-43
3. Güleç G. Güne? E. Yenilmez Ç. Obsesif Kompulsif Belirtileri Olan ?izofreni Hastalarynyn ?izofreni ve Obsesif Kompulsif Bozukluk Hastalary Yle Kar?yla?tyrylmasy. Türk Psikiyatri Dergisi 2008;19(3):247-256 Bulletin of Clinical Psychopharmacology 2011;21(Suppl. 2):S177