Obsessive compulsive disorder with psychotic features

Background: The purpose of this study was to systematically identify and characterize the demographic and clinical features of patients with obsessive compulsive disorder (OCD) and psychotic symptoms. Method: From a total of 475 patients with DSM-III-R OCD evaluated and/or treated in an outpatient OCD clinic, 67 patients (14%) were identified as having psychotic symptoms in addition to OCD. Psychotic symptoms were defined as hallucinations, delusions, and/or thought disorder. Clinical and demographic data on these probands were collected from semistructured interviews and compared with data collected on the nonpsychotic OCD probands. Results: We identified 27 (6%) of 475 probands with DSM-III-R OCD whose only psychotic symptom was lack of insight and high conviction about the reasonableness of the obsessions ('OCD without insight'). The remainder of the patients with psychotic symptoms and OCD met criteria for distinct DSM-III-R psychotic disorders as well as OCD: 18 probands (4%) had OCD and schizophrenia, 8 probands (2%) had OCD and delusional disorder. Fourteen patients (3%) met criteria for both OCD and schizotypal personality disorder. Compared with the OCD patients without psychosis, probands with OCD and psychotic features were more likely to be male, be single, have a deteriorative course, and have had their first professional contact at a younger age. The data suggest that these differences were largely due to those patients with OCD and schizophrenia- spectrum disorders and not those probands whose only psychotic symptom was complete conviction and lack of insight about their obsessions. Conclusion: There appears to be considerable heterogeneity in the clinical features of OCD patients who also have psychotic symptoms. The implications of these findings for understanding delusional states and for diagnostic classification are discussed.