Abstract
The differential diagnosis of obsessive–compulsive disorder (OCD) and schizophrenia-spectrum disorders can be difficult. In the current diagnostic criteria, basic concepts such as obsession and delusion overlap. This study examined lifetime schizophrenia-spectrum psychopathology, including subtle schizotypal symptomatology and subjective anomalies such as self-disorders, in a sample diagnosed with OCD in a specialized setting. The study also examined the differential diagnostic potential of the classic psychopathological notions of true obsession (‘with resistance’) and pseudo-obsession. The study involved 42 outpatients diagnosed with OCD at two clinics specialized in the treatment of OCD. The patients underwent semi-structured, narrative interviews assessing a comprehensive battery of psychopathological instruments. The final lifetime research-diagnosis was based on a consensus between a senior clinical psychiatrist and an experienced research clinician. The study found that 29% of the patients fulfilled criteria of schizophrenia or another non-affective psychosis as main, lifetime DSM-5 research-diagnosis. Another 33% received a research-diagnosis of schizotypal personality disorder, 10% a research-diagnosis of major depression and 29% a main research-diagnosis of OCD. Self-disorders aggregated in the schizophrenia-spectrum groups. True obsessions had a specificity of 93% and a sensitivity of 58% for a main diagnosis of OCD. In conclusion, a high proportion of clinically diagnosed OCD patients fulfilled diagnostic criteria of a schizophrenia-spectrum disorder. The conspicuous obsessive–compulsive symptomatology may have resulted in a disregard of psychotic symptoms and other psychopathology. Furthermore, the differentiation of obsessions from related psychopathological phenomena is insufficient and a conceptual and empirical effort in this domain is required in the future.
Highlights
IntroductionObsessive–compulsive-like phenomena have been described in schizophrenia since Kraepelin [36] and Bleuler [7]
The demarcation of obsessive–compulsive disorder (OCD) from schizophrenia-spectrum disorders [schizophrenia, other non-affective psychoses and schizotypal personalityElectronic supplementary material The online version of this article contains supplementary material, which is available to authorized users.Obsessive–compulsive-like phenomena have been described in schizophrenia since Kraepelin [36] and Bleuler [7]
According to DSM-5, 62% of the sample received a lifetime, main, research-diagnosis within the schizophreniaspectrum (schizophrenia (N = 6 (14%)), other non-affective psychoses (N = 6 (14%)) and Schizotypal personality disorder (SPD) (N = 14 (33%))). 38 (90%) patients fulfilled the criteria of a DSM-5 diagnosis of OCD but due to the diagnostic hierarchy less than 29% of the sample received OCD as main, research-diagnosis
Summary
Obsessive–compulsive-like phenomena have been described in schizophrenia since Kraepelin [36] and Bleuler [7]. In their description of OCD, they both emphasized that this diagnosis required the exclusion of schizophrenia and manio-depressive illness [8, 37]. The notion of compulsion in OCD required such underlying true obsession [11]. The true obsession was regarded as essential to the notion of OCD, contrary to obsessive–compulsive-like symptoms with ‘lack of resistance’ in schizophrenia or organic disorders [22, 44, 82]. For the evaluation of a possible underlying affective disorder, previous typical depressive or manic episodes and an episodic occurrence of obsessive–compulsive symptomatology were emphasized [9, 37, 82]
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