Attribution and insight
Insight criterion
Patients suffering from OCD typically fulfill three symptom characteristics: (1) they attribute obsessions, impulsive symptoms, and compulsions to their own thinking, (2) declare with insight their unreasonableness, and (3) show some degree of resistance against them. In particular, the first two properties allow a differentiation from hallucinations and delusions
Uncertainty
Doubt
Typically OCD patients are in doubt, whereas deluded patients know for sure
Content
OCS not solely related to the psychotic content
For instance, cleaning or checking behavior should be diagnosed as compulsions only if it is accompanied by typical obsessions and not if the patient currently suffers from delusions of contamination, intoxication, or infection
Theme
Typical themes of obsessions are contamination, aggressive or sexual topics, or symmetry
Typical themes of delusions are persecution, ideas of reference, diminishing barriers between the person and surrounding, or grandiosity
Catatonic symptoms
Repetitive behavior or stereotypic actions should be discriminated from catatonic symptoms most importantly in patients with the so-called manieristic catatonia
Obsessions presented as pseudohallucinations
A subgroup of OCS patients who experience their obsessions as extremely aversive and burdening and use expressions such as “voices” or “foreign thought content,” but in most cases these phenomena can be characterized as pseudohallucinations
Association with schizophrenia symptoms
No association with schizophrenia symptoms: comorbid OCD
In most studies of patients with schizophrenia and comorbid OCD, a lack of association between the major OCD symptom categories and schizophrenia symptom dimensions is found
Association with schizophrenia symptoms: no comorbid OCD
Ruminations or stereotypic ego-dystonic cognitions with direct relation to the contents to psychotic thinking should not be diagnosed as obsessions
Time of occurrence
Antipsychotic-induced OCS
Patients without a previous history of OCS might develop these phenomena during antipsychotic treatment
Course
Reevaluation of OCS after remission of psychotic symptoms
If the first manifestation of OCS occurs simultaneously with the first psychotic exacerbation, the final decision whether there is a valid comorbid condition should be postponed until the remission of psychotic symptoms
Recently, Oulis et al. (2013) also listed the phenomenological features of typical obsessions/compulsions and delusions/repetitive delusional behaviors, respectively, and proposed a list of features that should be evaluated in differential diagnosis. This list can be kept in mind in evaluating the differential classification of these symptoms. They mention seven features concerning obsessions/delusions that may be of importance in differentiating these symptoms: (1) source or origin and sense of ownership of the thought, (2) conviction, (3) consistency with one’s belief system, (4) awareness of its inaccuracy, (5) awareness of its symptomatic nature, (6) resistance, and (7) emotional impact. They also propose five features of repetitive behaviors that are important in differentiating symptoms: (1) aim of repetitive behaviors, (2) awareness of their inappropriateness, (3) awareness of their symptomatic nature, (4) their immediate effect on underlying thought, and (5) their emotional impact. These clinical features may help to discriminate obsessions and compulsive rituals from delusions and delusional repetitive behaviors in patients with schizophrenia or related disorders. Throughout Oulis et al. stress the importance of the feature of mental reflexivity for understanding the nature of insight and the ambiguous diagnostic status of poor insight in OCD which may be either a marker of the chronicity of obsessions or a marker of their delusionality. With these notions we return to earlier-mentioned thoughts concerning “obsessions in the strict sense” and “obsessions in the broader sense” according to Jaspers (1973).
With the abovementioned aspects in mind, psychotic symptoms and OCS can often be clearly distinguished; however, relatively frequent there is a marked overlap between psychotic symptoms and obsessive-compulsive symptoms. Sometimes it is not possible to make a robust unequivocal distinction between OCS and psychosis. Given the similarities in neurobiology, pathophysiology, prognosis, and therapeutic response of “psychotic OCS” or “obsessive-compulsive psychosis,” this may not come as a surprise.
Taken together, a comprehensive assessment of the abovementioned aspects of OCS or psychotic symptoms helps to differentiate them, or at least, in cases were a robust unequivocal distinction between OCS and psychosis is not possible, they help to place them on a dimensional line between those classifications.
3.4 Clinical Presentation of OCS in Patients with Psychotic Disorders
Throughout this book, details will be given concerning the clinical presentation of OCS in patients with psychotic disorders. Here we will give a concise overview concerning the following aspects: (a) time of occurrence, (b) symptom structure, (c) course of comorbid OCS, and (d) association with schizophrenia symptoms. For more details concerning these aspects, we will refer to the relevant chapters.
3.4.1 Time of Occurrence
OCS may occur in schizophrenia patients as (1) preceding prodromal symptoms: (1.1) before the development of psychosis as an independent, coexisting syndrome that can be diagnosed as OCD; (1.2) before the occurrence of the first psychotic episode as part of the at-risk mental state (ARMS) in subjects with mild psychotic complaints; or as (2) comorbid condition, during a psychotic episode or during recovery form psychosis: (2.1) together with psychotic symptoms during the first psychotic episode; (2.2) during the course of chronic schizophrenia as a waxing and waning condition; (2.3) simultaneously with the first psychotic exacerbation; (2.4) during the course of chronic schizophrenia as a persistent morbidity; or (3) de novo associated with antipsychotic treatment, as markedly aggravated or de novo occurring after initiation of specific antipsychotic treatment (Hwang et al. 2009; Schirmbeck and Zink 2012, 2013).
3.4.2 Symptom Structure
Several researchers evaluated whether the symptom structure of well-described OCS in patients with schizophrenia is comparable to the symptom structure of OCS in patients with OCD.
Faragian et al. (2009) studied 110 patients who met DSM-IV criteria for both schizophrenia and OCD. They performed an exploratory factor analysis of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) checklist. They found a five-factor solution that accounted for 58.7 % of the total variance:
1.
Aggressive, sexual, and religious obsessions and counting
2.
Symmetry and ordering/hoarding compulsions
3.
Contamination and cleaning
4.
Somatic obsession and repeating compulsion
5.
Hoarding obsession and checking/repeating compulsions
Moreover, they evaluated the interrelationship between the resulting factors and schizophrenia symptom dimensions. Here they found no significant correlation between the Y-BOCS symptom dimensions and schizophrenia symptom dimensions. The five symptom dimensions are comparable to those revealed in “pure” OCD. The first three symptom dimensions identified in their study, namely, aggressive, sexual, and religious obsession and counting compulsion, symmetry/ordering, and cleanliness/washing, are remarkably similar to the OCD factors that emerged from a meta-analysis of the symptom structure in “pure” OCD and designated as forbidden thought factor, symmetry factor, and cleaning factor (Bloch et al. 2008). These findings are supported by a recent study in which Kim et al. (2012) found a high level of similarity between the nature of symptoms and dimensions identified in patients with antipsychotic medication-induced OCS and those revealed in OCD patients. Taken together, these similarities suggest the involvement of universal mechanisms in the pathogenesis of OCD regardless of the presence of schizophrenia. Moreover, the lack of intercorrelation between the major OCD symptom categories and schizophrenia symptom dimensions lends additional support to the independent nature of OCD in these patients suffering from schizophrenia and OCD. For more details concerning OCD subtypes and spectrum disorders, we refer the reader to Chap. 2.
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