Institute of Psychiatry and Maudsley Hospital, London
![]() |
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Correspondence: Professor I. M. Marks, Maudsley Hospital, De Crespigny Park, Denmark Hill, London SE5 8AZ
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To present cases with unusual OCD, in order to re-evaluate the issue of delusions and OCD.
Method The cases of five subjects with delusions in the course of obsessive-compulsive disorder are presented to illustrate delusional OCD. The management and outcome of these cases are discussed.
Results Fixity and bizarreness of beliefs in OCD occur on a continuum from none to delusional intensity and may fluctuate within subjects.
Conclusions The idea that these cases may represent a form of OCD has implications for management, as, if this is correct, they should be able to respond to appropriate behavioural and/or pharmacological strategies used in OCD.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
CASE PRESENTATIONS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Before his admission to hospital, obsessions and compulsions affected every area of his life. Before performing any action he felt compelled to imagine the letter L and the phrase X away, power back for up to 20 minutes. He felt unable to sit on chairs or walk on grass or leaves, and slept with his feet uncovered for fear of the power being transferred to some object from which he might be unable to retrieve it. On leaving home he constantly retraced his steps to place his foot on a crack in the pavement or a leaf that he felt he had trodden on and so lost some of the power. If he saw the black dot leave his body (about 20 times a day) he had to touch the object it had entered and superimpose the letter L and the phrase X away, power back in his mind until he saw the black dot return.
From age 18, Z also had recurrent depression, hopelessness and suicidal urges, with deliberate self-harm (overdoses and wrist-slashing) when he was in a depressed mood. He said he harmed himself to appease the power or as a wish to die "when everything was perfect" after a day of ritualising.
Case 2
Y developed beliefs about a power at age 13. He felt that
everyone had a certain quality or goodness which
was stored in the brain as a power. He believed that other
people drained the power from him and replaced it with their own rubbish
(faeces and urine). The exchange of power was triggered by an image in his
mind of a face or object. When it happened he felt distressed,
dirty and horrible. He could only regain the power
by doing complex rituals. He imagined the person's face and that he had
detached their head from their body and sucked the power from the major
vessels of their neck or from their eyes. He then transferred the power back
into himself by banging his palm on a particular spot on his forehead, and
breathing out repeatedly. This made him feel relieved and good,
but as the events recurred up to several times a minute the relief was
short-lived. He felt compelled at times to get revenge on people
who stole his power by drawing with his finger on a wall a deformed and ugly
representation. If he touched anything he left a power trace
behind and so had to touch it repeatedly to get the power back.
Y's belief in the experience was absolute. He knew it might seem strange to
others but believed that if they experienced it, they would understand.
From age 17 he also had recurrent depression, hopelessness and suicidal urges requiring hospital admission.
Case 3
At the age of 8, X had transient counting rituals associated with fear of
harm coming to others. When she was 15, after a relative died, she feared that
harm would befall her family and friends unless she completed specific tasks.
She thought a supernatural power inserted unpleasant thoughts
into her mind, e.g. "if you read that book a relative will die".
She believed unshakeably that the power was supernatural, but could not
explain it. To appease the power and the thoughts, she developed
complex counting rituals pervading her daily activities. She also did
ritualistic hand-washing and checking. She avoided specific numbers, colours
and clothes and counted from 0 to 8 on her fingers and toes throughout the
day. She repeated rhymes, avoided multiple numbers she associated with death
or harm, and brushed her hair hundreds of times a day. She felt unable to
resist the rituals, as her belief in negative consequences was absolute.
Before she was admitted to hospital, rituals took all of her time until she
fell asleep.
X had two episodes of moderate depression at age 25 and 34, both associated with worsening of her OCD. She had never harmed herself.
Case 4
At the age of 7, W developed fear of harm coming to relatives. He engaged
in hand-washing and touching rituals to prevent this. Gradually he began to
believe that spirits or an outside force reminded
him to carry out his rituals lest harm should result. He associated the
numbers 13 and 66 with harm and, if he saw them, believed they were placed by
an external force to remind him to carry out his rituals. He defended his
belief absolutely but said he could not be 100% sure "because one can
never be sure about anything". He was unable to resist his rituals, as
his belief in the negative consequences of not doing so was absolute. His
rituals centred around numbers, complex counting, and avoidance of specific
numbers. At age 31 he developed fear of contamination associated with many
rituals of avoidance and hand-washing. Prior to admission he was homeless and
had thrown away all his contaminated possessions, carrying all
he owned in two carrier bags.
Case 5
For 20 years V had had a fear of being transported into another world. At
age 17 he worried that reflections in mirrors represented another world, and
had complex checking rituals involving mirrors. This gradually spread to all
reflective surfaces. He believed that turning on electrical switches, using
the television remote control or hearing car engines turned on could cause him
to be transported and constantly checked to make sure this had
not happened. He believed that if he ate while in another world, he would be
forced to stay there, and so either avoided eating, or ate with complex
rituals, or induced vomiting. Other rituals involved switching electrical
switches on and off and wearing particular clothes. The other
world was tangibly the same as the real one, but felt different
- he felt that friends and family, although appearing the same, were
different and might have been replaced by doubles.
The symptoms gradually worsened, occupying all of his time prior to admission
to hospital.
When he was 27 he suffered severe depression requiring in-patient care, and again at age 30. He had no history of self-harm.
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Fixity of beliefs
The DSM-IV diagnosis of OCD assumes that the patient at some time
recognises that the obsessions or compulsions are excessive or unreasonable.
DSM-IV acknowledges that patients show varying degrees of insight into the
validity of their belief, and specifies "with poor insight" for
subjects who "for most of the time" do not recognise that their
symptoms are excessive or unreasonable. It thus recognises that a given
patient's strength of belief may fluctuate over time. Patients may logically
repudiate their belief while in the safety of the therapist's office, but when
in a dangerous situation may be 100% convinced of the fact.
DSM-IV further suggests that where the obsession reaches "delusional proportions", delusional disorder or psychotic disorder not otherwise specified should be diagnosed in addition to OCD ("poor insight being reserved for those cases who fall between obsession and delusion"). There is no sharp divide between the delusional and non-delusional state. Schizophrenia is diagnosed where the ruminative delusional thoughts and bizarre behaviours are "not ego-dystonic and are not subject to reality testing". ICD-10 states that obsessive symptoms in the presence of schizophrenia should be regarded as part of the disorder.
Strength of belief in OCD was studied by Lelliott et al (Lelliott et al, 1988) in 49 typical OCD patients with compulsive rituals. Obsessive beliefs were assessed regarding fixity and bizarreness, resistance, and controllability. Fixity of belief was rated on three items: (a) how strongly the patient believed in the consequences of not ritualising; (b) the explanation of why others did not share their belief; and (c) how convinced they remained in the face of evidence to the contrary. On analysis, a third of the patients firmly believed that if they did not ritualise, the feared consequence would actually occur, 9% were convinced that only ignorance prevented others from sharing their belief, 11% firmly defended their belief in the face of contrary argument and evidence, and 12% never tried to resist their urges.
Scores on the three fixity items correlated significantly. Of the correlations between fixity, bizarreness, resistance and controllability, only that between fixity and bizarreness was significant (r=0.47, P<0.001). The findings support Lewis's view that recognition that the obsession is senseless is not an essential aspect of an obsession and that recognition of its absurdity is not always present (Lewis, 1935).
The fixity of belief in a third of the subjects in the study by Lelliott et al (1988) meant that they all met the criteria for psychosis and delusional disorder in DSM-IV. To us this appears inappropriate, given that the subjects were otherwise indistinguishable from other OCD subjects in the study and responded similarly to treatment by exposure and ritual prevention.
Bizarreness of content
The five OCD patients discussed above had particularly bizarre content of
thoughts and associated behaviours. DSM-IV defines delusions as
"bizarre" when they are clearly implausible, are not
understandable, and do not derive from ordinary life experiences (an example
is a belief that a stranger has removed one's internal organs and replaced
them with someone else's without leaving any scars; a less bizarre delusion is
that one is under surveillance by the police). We believe that the above
subjects' symptoms were bizarre in that they are not readily understandable
and do not derive from common life experiences usually described by OCD
subjects, such as a belief that they may develop AIDS or that harm may come to
their family. The bizarre content is indistinguishable from that of other
psychotic processes. In fact, DSM-IV includes bizarreness of delusional
content as a diagnostic criterion for schizophrenia, and allows a diagnosis of
schizophrenia based on the presence of a "bizarre" delusion.
Clinicians may intuitively empathise with this concept, but DSM-IV was
recently criticised for including "bizarreness" in the definition
of delusions (Maj, 1998). The
content of the thoughts and types of behaviour of these subjects was
particularly bizarre but does not indicate that they had a psychotic
disorder.
A diagnosis of OCD
A key feature in these cases that suggests obsessive-compulsive rather than
psychotic psychopathology is the clear logical link between the thoughts and
the rituals. The rituals are all cued by intrusive thoughts concerning a
central belief, the patient feels compelled to carry them out to relieve
associated distress, and they are all carried out
ritualistically. The patients are severely disabled by the
illness but are otherwise intact. In particular, none of the subjects had
other forms of thought disorder. Case 1 had transient perceptual
abnormalities, but these were clearly related to his obsessional phenomena. No
other subject had other psychotic symptoms.
Response to treatment
Most of the patients had several medications. None had improved
significantly with antipsychotic drugs, although several had improved somewhat
on antidepressant selective serotonin reuptake inhibitors (SSRIs) or
noradrenergic medication. Case 1 improved markedly with exposure and ritual
prevention after a stormy and protracted course, with a temporary reemergence
of severe depression. As his rituals reduced, so his belief in the
power weakened; he began to doubt its existence, and his
perceptual abnormalities disappeared. His OCD symptoms improved independently
of his mood. Case 2 had had adequate antipsychotic drugs, including clozapine,
none of which had helped. With SSRIs he improved moderately in mood, but only
to a limited extent in his OCD. He did not respond to a cognitive-behavioural
intervention. Case 3 had failed to respond to several antipsychotics. Her mood
improved with electroconvulsive therapy and SSRIs, but this did not help her
other symptoms. She refused to "risk" ritual prevention. Case 4
was twice admitted to hospital for exposure and ritual prevention. He improved
70% the first time, but relapsed two months after discharge (his belief
regarding external beings had not developed by then). During his second
admission (eight years later) he did not improve or change his belief. Case 5
had three admissions for behaviour therapy. He did not improve during his
first admission; but during the second and third (a further five years later)
improved 25-30% and his beliefs weakened. He could not tolerate clomipramine
and had not had an antipsychotic.
Diagnostic issues
The five patients described above form a rare group who had features
consistent with OCD and also had delusions related to their rituals. Their
features resemble those of an OCD sub-group noted by Solyom et al
(1985), characterised by an
earlier onset age, more severe illness, and poorer prognosis. Other writers
(Fear & Healy, 1995) also
described a sub-group of OCD subjects who had unusual, fixed beliefs, more
affective symptoms and a singular theme to their obsessions. Fear & Healy
thought that these subjects had both obsessive and delusional features in the
way that DSM-IV allows a "dual" diagnosis. Insel & Akiskal
(1986) argue against a dual
diagnosis in such cases, saying that psychotic-type symptoms may emerge at the
more severe end of the OCD spectrum, and regard such patients as having OCD
"with psychotic features".
The diagnostic issues posed by these patients are not unique to OCD. Anorexia nervosa subjects may believe with absolute certainty that they are fat, despite evidence to the contrary. These beliefs, despite their fixity, are generally called "overvalued ideas" (McKenna, 1984), the distinction from delusions perhaps being that the content of the belief is not alien beyond normal understanding, although some would argue that the disturbance is of "delusional proportions" (Bruch, 1962). Patients with body dysmorphic disorder also have a range of beliefs from obsessional at one end of the spectrum to delusional at the other end. These are classified as separate disorders in DSM-IV (body dysmorphic disorder and delusional disorder - somatic type) although this separation is controversial (Phillips et al, 1995). These cases highlight the artificial nature of current diagnostic boundaries, and the limitations of Kraepelinian dichotomy in understanding and treating these disorders.
Implications for management
How one labels the psychopathology in these OCD subjects is of more than
mere academic interest. A diagnosis of schizophrenia or delusional disorder
may lead to a lifetime of antipsychotic medication and a reluctance to
consider other, more effective, interventions. These subjects usually respond
poorly to antipsychotic medication but may improve with clomipramine or SSRIs.
Despite a view that fixity of belief adversely influences outcome with
behaviour therapy (Foa, 1979),
the marked improvement of Case 1 with exposure and ritual prevention
(Lelliott & Marks, 1987) and to a lesser extent of Case 5 suggests that the OCD of such subjects can
respond to behaviour therapy. Moreover, in these cases, and in those reported
by Lelliott et al
(1988), belief normalised as
the obsessive-compulsive features responded to treatment.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Bruch, H. (1962) Perceptual and conceptual disturbance in anorexia nervosa. Psychosomatic Medicine, 24, 187-194.
Eisen, J. & Rasmussen, S. A. (1993) Obsessive compulsive disorder with psychotic features. Journal of Clinical Psychiatry, 54, 373-379.[Medline]
Fear, C. & Healy, D. (1995) Obsessive compulsive disorders and delusional disorders: notes on their history, nosology and interface. Journal of Serotonin Research, 1 (suppl. 1), 1-13.
Foa, E. B. (1979) Failures in treating obsessive-compulsive disorder. Behaviour Research and Therapy, 17, 169-176.[CrossRef][Medline]
Insel, T. R. & Akiskal, H. S. (1986) Obsessive-compulsive disorder with psychotic features: A phenomenologic analysis. American Journal of Psychiatry, 143, 1527-1533.[Abstract]
Lelliott, P. & Marks, I. (1987) Management of obsessive-compulsive rituals associated with delusions, hallucinations and depression: A case report. Behavioural Psychotherapy, 15, 77-87.
Lelliott, P., Noshirvani, H. F., Basoglu, M., et al (1988) Obsessive-compulsive beliefs and treatment outcome. Psychological Medicine, 18, 697-702.[Medline]
Lewis, A. (1935) Problems of obsessional illness. Proceedings of the Royal Society of Medicine, 29, 325-336.
Maj, M. (1998) Critique of the DSM-IV operational diagnostic criteria for schizophrenia. British Journal of Psychiatry, 172, 458-460.[Medline]
McKenna, P. J. (1984) Disorders with overvalued ideas. British Journal of Psychiatry, 145, 579-585.[Abstract]
Phillips, K. A., Kim, J. M. & Hudson, J. I. (1995) Body image disturbance in body dysmorphic disorder and eating disorders obsessions or delusions? Psychiatric Clinics of North America, 18, 317-334.[Medline]
Rosen, I. (1957) The clinical significance of obsessions in schizophrenia. Journal of Mental Science, 103, 773-785.
Solyom, L., Di Nicoal, V. F., Phil, M., et al (1985) Is there an obsessive psychosis? Aetiological and prognostic factors of an atypical form of obsessive-compulsive neurosis. Canadian Journal of Psychiatry, 30, 372-379.[Medline]
World Health Organization (1992) International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). Geneva: WHO.
Received for publication June 15, 1999. Revision received September 24, 1999. Accepted for publication September 28, 1999.