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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 2  |  Page : 140-146

A comparative study of psychopathology and functioning in patients of obsessive–compulsive disorder with good and poor insight from a tertiary care center in North India


Department of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission26-Dec-2019
Date of Acceptance15-Feb-2020
Date of Web Publication23-Jun-2020

Correspondence Address:
Dr. Bandna Gupta
MD (PSY), Associate Professor, Department Of Psychiatry, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_297_19

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  Abstract 


BACKGROUND: Degree of insight in Obsessive Compulsive Disorder (OCD) varies with different symptom dimensions of OCD and not much of studies are done in this area. There is need to study insight in more detail in patients of OCD along with psychopathology and functioning.
AIMS: To study and compare Psychopathology and Functioning in Patients of Obsessive Compulsive Disorder with Good and Poor Insight.
METHOD: This is a cross sectional study and 94 patients fulfilling diagnostic criteria for OCD on the basis of the ICD10-DCR were assessed on Yale- Brown obsessive compulsive scale (Y-BOCS), Dimensional Yale- Brown obsessive compulsive scale (DY-BOCS), Brown Assessment of Belief Scale (BABS) and Social and Occupational Functioning Assessment Scale (SOFAS).
RESULTS: A total of 94 patients of OCD were assessed and 76 (81 %) patient had good insight (BABS < 12) where as 18 (19%) had poor insight (BABS ≥ 12). Duration of illness (P = 0.007) and duration of untreated illness (P = 0.006) was significantly longer in poor insight group. Compulsions subscale score (P = 0.003), mean total score (P = 0.014) and SOFAS mean score (0.001) was significantly higher in poor insight. Mean score of clinical severity in dimension of aggression, sexual and religious obsession was significantly higher (P = 0.001) in good insight group.
CONCLUSION: Majority of patient with predominant symptoms as aggression, sexual and religious obsessions belonged to good insight group. Patients with poor insight had higher severity of illness, longer duration of illness and duration of untreated illness.

Keywords: Functioning, insight, obsessive–compulsive disorder, psychopathology


How to cite this article:
Prasad C, Gupta B, Nischal A, Agarwal M, Singh S. A comparative study of psychopathology and functioning in patients of obsessive–compulsive disorder with good and poor insight from a tertiary care center in North India. Indian J Health Sci Biomed Res 2020;13:140-6

How to cite this URL:
Prasad C, Gupta B, Nischal A, Agarwal M, Singh S. A comparative study of psychopathology and functioning in patients of obsessive–compulsive disorder with good and poor insight from a tertiary care center in North India. Indian J Health Sci Biomed Res [serial online] 2020 [cited 2020 Aug 11];13:140-6. Available from: http://www.ijournalhs.org/text.asp?2020/13/2/140/287417




  Introduction Top


As per epidemiological data, obsessive–compulsive disorder (OCD) is the fourth most common psychiatric disorder, characterized by obsessions and compulsions.[1] Obsessions are defined as persistent ideas, thoughts, impulses, or images that are experienced as intrusive and repetitive and cause distress while compulsions are defined as repetitive acts, behaviors, or mental activities done to counteract anxiety associated with obsessions.[2] The most common symptom is contamination and cleaning, and other symptoms are pathological doubts and checking, symmetry and arranging, obsession of aggression, sexual and religious content, and mental compulsions.[2] Symptoms are recognized by patients as irrational and egodystonic. Often, these symptoms are accompanied by feeling of shame and secrecy.[3] Various theories have been proposed which lead to the development of OCD. Personality factors – studies have shown that 15%–30% of patients have premorbid Obsessive Compulsive personality traits such as excessive concern for details and perfectionism.” perfectionism.[4] Initially, it was presumed that OCD patients have good insight and are fully convinced that their thoughts are senseless and irrational, but on further studies,[5] it was found that some of the patients are not fully convinced about irrationality of their thoughts and they recognize that the thoughts may or may not be true, and such patients tend to have fair to poor insight. Thus, insight lies along continuum, where good insight patients tried to resist their thoughts and so are more distressed. Thus insight lies along continuum, where good insight patients tried to resist their thoughts and so are more distressed, on the opposite end poor insight patients do not recognize their symptoms as senseless and attempt less to resist and control their thoughts and behavior.[6],[7]

Insight in OCD is better conceptualized in cognitive terms and is evaluated along several dimensions, measured by scales to assess belief system.[8],[9] Insight varies with respect to different demographic factors such as age, year of education, occupation, and clinical variables such as age of onset, duration and course of illness, and family history of psychiatric, thus influencing severity and duration of illness.[10],[11],[12],[13],[14],[15],[16] Studies reveal that insight also varies among different symptom dimensions of OCD.[10],[12],[14],[17] OCD is a debilitating disorder causing significant impairment in social and occupational functioning and reduces the quality of life of patients as well as their family members.[1],[15],[18] Various studies reveal that response to treatment is influenced by level of insight and insight improves with treatment. The degree of insight varies with different symptom dimensions of OCD and not many studies are done in this area. There is a need to study insight in more detail in patients of OCD along with psychopathology and functioning. Hence, this study was conducted to study psychopathology, insight, and functioning in patients of OCD and to see association among these variables in the same population.


  Methodology Top


Study design

This was a cross-sectional, noninterventional study. All the participants enrolled in the study had given informed consent before inclusion in the study. The study was carried out from September 2018 to August 2019 and was approved by the Institutional Ethics Committee.

Sample

All symptomatic patients of OCD attending the adult psychiatry outpatient department (OPD) of the department of psychiatry of a tertiary care center from North India on specified OPD days were screened on the selection criteria. Patients who were in the age group of 18–60 years with a diagnosis of OCD as per the International Classification of Diseases-10 diagnostic criteria for research[19] having the Yale–Brown Obsessive–Compulsive Scale (Y-BOCS)[20] score equal or more than 16 were included, and those having medical illness requiring priority management, mental subnormality, or presence of any comorbid psychiatric disorder except nicotine dependence were excluded from the study. First, two patients satisfying selection criteria were included in the study after taking written informed consent. The Mini-International Neuropsychiatric Interview 6.0.0[21] was applied to rule out other psychiatric illnesses except nicotine dependence.

Procedure

A total of 94 patients of OCD were recruited in the study. Patients were assessed using a comprehensive set of clinical rating scales. Dimensional Y-BOCS (DY-BOCS)[22] was applied for the assessment of different dimensions of OCD and its clinical severity. DY-BOCS is a reliable and valid instrument for assessing multiple aspects of OCD symptom severity. This scale measures the presence and severity of obsessive–compulsive (OC) symptoms within six distinct dimensions that combine thematically related obsessions and compulsions. The self-report consists of an 88-item self-report checklist. The severity of each dimension is measured on three ordinal scales with six anchor points (0–5). The Brown Assessment of Beliefs Scale (BABS)[8] was applied for assessment of insight. The BABS is a semi-structured clinician-administered scale. This scale is based on the fact that insight exists as continuum and it itself has different dimensions. Seven items are assessed on scale rated from 0 (least pathological) to 4 (most pathological or delusional) with higher scores indicating poorer insight. The Social and Occupational Functioning Assessment Scale (SOFAS)[23] was applied for the assessment of social and occupational functioning. The SOFAS is a global rating of current functioning ranging from 0 to 100, with higher the score, better is functioning and lower scores representing poorer functioning.

Sample size calculation and statistical analysis

The sample size was calculated using the following formula: N = 2SD2 (Zα/2+ Zβ/2) 2/d2 by Charan and Biswas, 2013.[24] Z1-α/2 is standard normal variate (at 5% Type 1 error and P < 0.05) and it is 1.96. Keeping proportion of 30% from reference studies,[6],[7],[10],[11],[13],[25],[26] P = 0.3, (1 − p) = 0.7, with margin of error to be 10%: D = 0.1, a sample size of 80.67 was obtained as per the formula. With the decision of taking not less than the above-calculated value, a sample size of minimum 81 was taken.

The data collected were tabulated using computer software and statistically evaluated using SPSS v20 (IBM Corporations, Somers, New York, USA). The Kolmogorov–Smirnov test was used to check whether the given dataset could have been drawn from normal distribution and the data were found to be normally distributed. Descriptive statistics were used to calculate means, standard deviation, and frequencies. Fisher's exact and Chi-square tests were used to compare categorical variables, and independent t-test was used to compare continuous variables. Pearson's correlation analysis was used to assess the linear relation between variables where applicable. All P values reported are two-tailed. Statistical significance was set at 0.05.


  Results Top


In this study, 94 patients were recruited. In our sample, patients were categorized in good and poor insight based on the BABS score [Table 1]. About 81% of patients had good insight (BABS <12), whereas 19% had poor insight (BABS ≥12). [Table 2] depicts the comparison of sociodemographic variables between the two groups of OCD with poor and good insight. Statistical tests such as Fisher's exact test, Chi-square test, and independent t-test were applied where applicable. No statistically significant difference was found between both the groups of insight.
Table 1: Categorization of sample in two groups of obsessive-compulsive disorder with poor and good insight groups (n=94)

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Table 2: Comparison of sociodemographic variable between two groups of obsessive-compulsive disorder with poor and good insight

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[Table 3] depicts the comparison of clinical variables between both the groups of insight. The duration of illness was significantly (P = 0.007) longer in the poor insight (8.0 ± 4.61) group as compared to good insight (4.89 ± 4.94). Similarly, a comparison of duration of untreated illness was significantly longer (P = 0.006) in the poor insight (5.72 ± 4.40) group as compared to good insight (2.87 ± 3.73). [Table 4] depicts that no significant difference was found in mean obsession score between the two groups of insight; however, the compulsion score was significantly higher (P = 0.003) in the poor insight (16.00 ± 5.93) group as compared to good insight (12.00 ± 4.72). Furthermore, the mean total score was significantly higher (P = 0.014) in the poor insight (30.56 ± 6.21) group as compared to good insight (26.91 ± 5.41), which signifies that poor insight patients had more compulsions and overall more severity of illness. Furthermore, a statistically significant (0.001) difference in mean of SOFAS was found in the poor insight (66.67 ± 10.14) and good insight (53.09 ± 8.94) groups, indicating that patients with poor insight have better functioning in their life as compared to good insight.
Table 3: Comparison of clinical variable in two groups of obsessive-compulsive disorder with poor and good insight

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Table 4: Comparison of mean of total and subscale score of Yale-Brown Obsessive-Compulsive Scale and Social and Occupational Functioning Assessment Scale in two groups of obsessive-compulsive disorder with poor and good insight

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[Table 5] shows that the mean score of clinical severity in dimension of aggression was significantly higher (P = 0.001) in good insight (9.33 ± 2.56) as compared to poor insight (3.00 ± 0.00). Similarly, the mean score of clinical severity in dimension of sexual and religious obsession was significantly higher (P = 0.001) in good insight (9.10 ± 3.17) patients as compared to poor insight (3.83 ± 0.75). No significant difference was found in clinical severity in other dimensions of DY-BOCS between the two groups.
Table 5: Comparison of mean score of clinical severity in different dimensions of Dimensional Yale-Brown Obsessive-Compulsive Scale in two groups of obsessive-compulsive disorder with poor and good insight

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[Table 6] shows weak positive correlation between insight and severity of illness on compulsion subscale score (r 0.293; P 0.004) and total score (r 0.224; P 0.030), thereby indicating that with increasing severity of illness on Y-BOCS, insight gets worsen. There was moderate negative correlation between SOFAS and severity of illness on obsessions subscale score (r - 0.621, P 0.001*) and total score (r - 0.308, P 0.003*), signifying that functioning is reduced with increasing severity of illness. P value is statistically significant in obsessions and total score and indicates a moderate negative correlation of Y-BOCS with SOFAS, signifying that functioning is reduced with increasing severity of illness.
Table 6: Correlation of Yale-Brown Obsessive- Compulsive Scale with Social and Occupational Functioning Assessment Scale

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  Discussion Top


In our study sample, out of total 94 patients, 18 patients (19%) were found to have poor insight. This is consistent and well within the range described by many previous studies, where poor insight in OCD patients is reported to vary from 4% to 45%.[6],[7],[10],[11],[13],[25],[26] Majority, that is, about 86% of patients, belonged to 18–40 years of age group, which is consistent with other studies as illness begins in early age around 20 years.[20],[27] There is no significant difference in gender between both the groups of insight, which is consistent with the finding of Jakubovski et al. and Fontenelle et al.[14],[15] In our study sample, majority, that is, 45% of patients, were educated up to graduation, but we did not find any significant difference in educational status of poor and good insight OCD patients, which is consistent with the finding of Fontenelle et al.[15] In contrast, a study by Alonso et al. has revealed that patients having poor insight have less year of education.[12] In our study sample, majority of the patients (71%) belonged to nonearning group which comprised unemployed patients (24%), students (24%), and homemakers (52%). This can be explained by the fact that majority of them were either homemakers or students who were dependent on their family income. A study done by Alonso et al. reported that poor insight of patients has a higher rate of unemployment,[12] but we did not find any such difference in the two groups of OCD patients. No significant difference was found when all the sociodemographic variables were compared between both the groups of poor and good insight OCD patients, which is consistent with previous studies done to compare demographic variable such as age,[12],[14],[15] gender,[14],[15] marital status,[14] and religion[15] with insight groups.

Our study found that patients with poor insight had a significantly longer duration of illness. This is consistent with the finding of Ravi Kishor et al. and Solyom et al.[10],[28] This can be explained by the fact that patients with poor insight respond less to pharmacotherapy and behavior therapy, and since they have less awareness of their illness, adherence to medication is also questionable. Another reason may be due to the early age of onset in poor insight patients, so their duration of illness is prolonged. Our study found that poor insight patients had a significantly longer duration of untreated illness. This is consistent with the finding of Belloch et al.[29] who reported that poor insight patients are less aware of their illness complying with the obsessions and compulsions. They do not appraise the interference and behavioral changes associated with the illness and thereby do not attempt to resist or control and seek medical treatment late in their course of illness that too may be on persuasion by a family member or caregiver.[29] In our study, about 74% of patients had no family history of psychiatric illness, whereas 26% of patients had a family history of psychiatric illness. Catapano et al.[5] reported that poor insight patients have a higher chance of schizophrenic spectrum disorder among the first-degree relatives. This is not consistent with our study as there is no statistical difference regarding positive family history of psychiatric illness between both the groups of insight. In our study sample, the mean of obsession score was almost the same in both the groups, but the compulsion score and total mean score were significantly high in the poor insight group as compared to the good insight group. Thus, poor insight patients are more involved in compulsions regardless of its irrationality and so have increased severity of illness. Our results are found to be consistent with many other studies done in this area.[5],[11],[12],[15] This can be explained as poor insight patients have less resistance and control for their symptoms so that they are involved in more compulsions, and by doing the same, it actually feeds obsession by negative reinforcement. Our finding is in contrast to a study done by Jacob et al.[26] which revealed that insight does not mediate the relationship between resistance and control of symptoms and symptom severity. A comparison of mean of clinical severity scores in different dimensions of DY-BOCS was done, and scores in aggression and sexual and religious dimension of DY-BOCS were significantly higher in the good insight group as compared to the poor insight group. This is consistent with the findings of Cherian et al.[17] which showed that obsessions of aggression and sexual and religious nature maintain good insight for these symptoms. This can be explained as, in our Indian culture, talking about sex is still prohibited by society and if one has repetitive forbidden thoughts of sexual nature, this becomes very distressing to patients. They are more egodystonic, so probably, a patient maintains good insight for sexual beliefs, and another forbidden thought is of religious content, since belief about God is divine in nature, and in most of the families, this is strongly influenced by holy books such as Gita and Quran. Similarly, thoughts of aggression, that is, unwanted thoughts of harming self or familiar persons, are considered as irrational and more egodystonic. Individuals who have obsession of aggression and sexual and religious content have good insight and are more involved in mental compulsions, which is done to neutralize and reduce distress caused by these obsessional thoughts.[25] This is supported indirectly by the findings of Jacob et al.[26] who reported that poor insight patients have lesser neutralizing mental compulsions.

A study by Jakubovski et al.[14] reported that hoarding was associated with poor insight; however, this was not replicated in our study sample as only 14% of patients reported hoarding symptoms.

There was a statistically significant difference between SOFAS scores of the poor and good insight groups, that is, poor insight patients have better functioning as compared to good insight patients. This can be explained as poor insight patients make less effort to resist and control their symptoms and justify their compulsion to avoid some disastrous event. Thus, they are not much distressed by their thoughts, thereby causing less impairment in their personal and occupational life. However, such patients face difficulty in familial life as they perceive more expressed emotions and critical comment by family members. Our finding is not consistent with the result of Rasmussen and Eisen[27] who reported that insight has no role in functioning of patients.

There was a statistically significant weak positive correlation between compulsion and total score of YBOCS with BABS. This implies that poor insight patients have more compulsions and increased severity of illness, which is consistent with the finding of Ravi Kishor et al.[10] On correlation of YBOCS with SOFAS, a statistically significant moderate negative correlation was found between obsession and total score of YBOCS with SOFAS. This implies that as the severity of illness increases, the functioning decreases, and patients have more impairment in their personal, social, and occupational life.


  Conclusion Top


The study sample consisted of 81% of patients with good insight and 19% with poor insight. No significant difference was found among sociodemographic variables in the two groups of OCD patients with poor and good insight. Majority of the patients who had their predominant symptoms such as aggression and sexual and religious obsessions belonged to the good insight group. Patients with poor insight had a longer duration of illness and also long duration of untreated illness as compared to the good insight group. Patients with poor insight had a higher severity of illness as they scored more on compulsion subscale and total score of Y-BOCS. Dimension-wise clinical severity of illness was more in the dimension of aggression and sexual and religious content in the good insight group than the poor insight group. However, no difference was found in severity in other dimensions of DY-BOCS between the two groups. Patients with poor insight revealed a better level of functioning on SOFAS as compared to the good insight group. A weak positive correlation was found between scores of Y-BOCS and BABS, signifying that with increasing severity of illness, insight gets poor. Moderate negative correlation was found between scores of SOFAS and Y-BOCS, signifying that functioning is reduced with increasing severity of illness. A moderate positive correlation was found between BABS and SOFAS, signifying that as insight gets poor, the level of functioning improves probably due to lack of cognitive appraisal of symptoms and less distress.

Limitations of the study

The sample size in the present study was small because of time constraints and stringent selection criteria, and a larger sample would have been desired. To get a homogeneous sample, other psychiatric comorbidities were excluded. However, in naturalistic setting, OCD is frequently found to be comorbid with other psychiatric disorders such as depression and other anxiety disorders. Furthermore, the study was done in a tertiary care center, so the finding cannot be generalized. This is a cross-sectional study; however, a longitudinal study would have assessed treatment outcome as a change in psychopathology and also change in insight with treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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