Abstract
Background:
Obsessive-compulsive disorder (OCD) is a chronic psychiatric disorder characterized by persistent, distressing obsessive thoughts and compulsive behaviors. In OCD, the level of insight is classified as good, poor, or absent. Poorer insight is associated with a more complex clinical presentation and a poorer prognosis.
Aim:
The aim of our research was to investigate the relationship between the level of insight in individuals with OCD and various neuropsychological and psychopathological factors.
Materials and Methods:
This cross-sectional study recruited a total of 100 participants diagnosed with OCD. The Brown assessment of beliefs scale (BABS) was used to evaluate the insight of the patients. Psychopathology was assessed using the Yale–Brown obsessive compulsive scale (YBOCS) and Hamilton depression rating scale (HDRS). Neuropsychological assessments included the Stroop test, digit span test, controlled oral word association (COWA) test, trail making test, and Wisconsin card sorting test.
Results:
The majority of the patients had good insight (54%), mild depression (48%), and moderate symptom severity (47%). Patients with poor insight had significantly higher scores on the YBOCS and HAM-D. They also performed significantly worse on the WCST and TMT-A. Patients with comorbid depression (mild/moderate) showed significantly poor performance on the WCST compared to those without depression.
Conclusion:
The findings of our study indicate that patients with poor insight exhibit more severe forms of OCD, display greater psychopathology, and show more pronounced neuropsychological dysfunction.
Keywords: Insight, neuropsychological, OCD, psychopathological
Obsessive-compulsive disorder (OCD) is a debilitating psychological condition characterised by intrusive thoughts (obsessions) and repetitive behaviours (compulsions) that severely affect daily functioning and quality of life. An estimated 2%–3% of the population experiences the crippling symptoms of OCD at some point in their lives.[1] Although OCD symptoms can emerge at any age, they most often manifest in adolescence or early adulthood. The onset and progression of OCD symptoms can be gradual and unpredictable. A key factor that complicates both the clinical presentation and treatment of OCD is the level of insight the patient has regarding the irrational nature of their obsessions and compulsions. OCD with poor insight presents unique challenges in both diagnosis and treatment.
Neuropsychological testing of OCD has shown impairments in several cognitive areas, including memory, motor speed, executive functioning, and visuospatial ability. Abnormalities in other cognitive areas, such as memory, visuospatial abilities, and executive functions, are inconsistent with clinical findings that suggest basic processing deficiencies.
Insight in OCD is a critical psychopathological feature that varies among individuals, impacting treatment outcomes and the severity of the disorder. Insight, defined as the recognition that one’s obsessions and compulsions are unreasonable, ranges from excellent to absent, with the latter sometimes linked to delusional beliefs.[2] The psychopathological influences on insight in OCD are complex, involving the interplay of cognitive, emotional, and neurobiological factors.
This study aimed to examine the relationship between the level of insight in individuals with OCD and various neuropsychological and psychopathological factors.
MATERIALS AND METHODS
The institutional ethics committee approved the study (letter no. 768/IEC/IGIMS, dated 06/10/2022). A consent statement was provided by each participant. Participants’ confidentiality and privacy were upheld in accordance with Declaration of Helsinki.
Study design and participants
This cross-sectional study, conducted from October 2022 to February 2024, involved a total of 100 patients with OCD who visited the outpatient department of a tertiary care hospital. After providing written informed consent, participants were selected consecutively from the psychiatry department. Based on the prevalence of OCD,[1] we initially calculated a sample size of 45. However, considering the heterogeneity of OCD presentations, the need for greater statistical power, and the broader scope of our objectives, we increased the sample size to 100. A purposive sampling approach was employed for the study.
Eligibility criteria
Patients aged between 18 and 45, diagnosed with OCD according to the ICD-10 DCR, and currently under treatment were included in the study. Patients with any medical, neurological, or major comorbid psychiatric disorders (except mild or moderate depression) were excluded, as assessed using the MINI scale. Patients with severe depression were not included in the study.
Data collection tools and procedure
All individuals who met the inclusion criteria were enrolled after providing their informed written consent. Clinical and sociodemographic information for all enrolled participants was documented on a self-prepared sociodemographic pro-forma. The Brown assessment of beliefs scale (BABS) was used to evaluate the patient’s insight.
Neuropsychological functions were assessed using the Stroop test, Wisconsin card sorting test (WCST), controlled oral word association (COWA) test, digit span test, and the trail making test (TMT). Psychopathology was assessed using Yale–Brown obsessive compulsive scale (YBOCS) and Hamilton depression rating scale (HDRS). The YBOCS measures the severity of obsessions and compulsions, with scores ranging from 0 to 40. The HDRS scale was used to assess the presence and severity of depression and to exclude severe depression.
Data analysis
For data analysis, SPSS version 20.0 was used. The study’s findings were presented using the mean and standard deviation for continuous variables and frequencies and percentages for categorical variables. The relationships among the study variables were explored using the analysis of variance (ANOVA) test and the t-test. P values less than 0.05 were considered statistically significant.
RESULTS
Overall, 100 patients with OCD were analyzed in our study. The mean age was 29.47 (±8.27) years, with mean years of education 13.79 ((±2.92) years and a mean duration of illness 5.59 (±5.62) years. The majority of patients (62%) were in the younger age group (18–30 years), with 66% being male, 61% unemployed, and 55% from a rural background. Nearly equal proportions of patients were single (48%) and married (52%). The most common obsessions were contamination (70%), followed by pathological doubt (53%) and intrusive thoughts (47%). The most common compulsions were washing (71%) and checking (51%) [Table 1]. The majority of the patients had good insight (54%), mild depression (48%), and moderate severity (47%) [Table 2]. Patients with a longer mean duration of illness exhibited significantly poorer insight. Patients with poor insight showed significantly higher scores on YBOCS and HAM-D. They also performed significantly worse on the WCST and TMT-A [Table 3]. Patients with comorbid depression (mild or moderate) showed significantly poorer performance on the WCST compared to those without depression [Table 4].
Table 1.
Sociodemographic and Clinical Profile of the Patients with OCD
| Variables | Patients with OCD (n=100) Mean (±SD) |
|---|---|
| Age (years; range 18–45) | 29.47 (±8.27) |
| Means years of education | 13.79 ((±2.92) |
| Duration of illness (years; range 1–25) | 5.59 (±5.62) |
|
| |
| n (%) | |
|
| |
| Age group (years) | |
| 18–30 | 62 (62%) |
| 31–40 | 22 (22%) |
| 41–45 | 16 (16%) |
| Sex | |
| Male | 66 (66%) |
| Female | 34 (34%) |
| Employment status | |
| Employed | 39 (39%) |
| Unemployed | 61 (61%) |
| Marital status | |
| Single | 48 (48%) |
| Married | 52 (52%) |
| Residence | |
| Rural | 55 (55%) |
| Urban | 45 (45%) |
| Types of obsessions | |
| Contamination | 70 (70%) |
| Pathological doubt | 53 (53%) |
| Intrusive thoughts | 47 (47%) |
| Symmetry | 6 (6%) |
| Miscellaneous | 18 (18%) |
| Types of compulsions | |
| Washing | 71 (71%) |
| Checking | 51 (51%) |
| Arranging | 25 (25%) |
| Miscellaneous | 25 (25%) |
| Duration of illness (years) | |
| 1–5 years | 70 (70%) |
| 6–10 years | 16 (16%) |
| >10 years | 14 (14%) |
Table 2.
Scores obtained on various assessment tools
| Assessment Tool | Mean (±SD) |
|---|---|
| Brown Assessment of Belief Scale | 6.68 (±3.82) |
| Yale Brown Obsessive Compulsive Scale | 23.35 (±5.41) |
| Hamilton Depression Rating Scale | 10.10 (±4.31) |
| WCST Total Error Score | 24.08 (±11.56) |
| WCST Perseverative Error | 14.83 (±10.02) |
| WCST Categories Completed | 2.71 (±1.29) |
| Trail Making Test- A | 27.09 (±5.88) |
| Trail Making Test- B | 57.09 (±19.11) |
| Digit Span Forward | 7.88 (±1.82) |
| Stroop Test | 110.39 (±7.30) |
| Controlled Oral Word Association Test | 29.80 (±6.33) |
| n (%) | |
| Insight (BABS) | |
| Excellent Insight | 15 (15%) |
| Good Insight | 54 (54%) |
| Fair Insight | 22 (22%) |
| Poor Insight | 9 (9%) |
| HAM-D Categories | |
| Normal | 30 (30%) |
| Mild | 48 (48%) |
| Moderate | 22 (22%) |
| Severe | - |
| YBOCS Categories | |
| Mild | 6 (6%) |
| Moderate | 47 (47%) |
| Severe | 38 (38%) |
| Extreme | 9 (9%) |
Table 3.
Neuropsychological and psychopathological correlates of insight in OCD
| Variables Mean (±SD) | Insight (BABS) |
F | P | |||
|---|---|---|---|---|---|---|
| Excellent Insight | Good Insight | Fair Insight | Poor Insight | |||
| Duration of Illness (years) | 1.93 (±1.03) | 3.59 (±3.11) | 8.59 (±6.04) | 16.33 (±4.77) | 35.756 | <0.001 |
| YBOCS | 24.00 (±3.74) | 21.61 (±5.22) | 24.77 (±5.58) | 29.22 (±3.07) | 7.609 | <0.001 |
| HAM-D | 9.40 (±3.62) | 8.53 (±4.04) | 12.18 (±3.55) | 15.55 (±1.81) | 11.995 | <0.001 |
| WCST total error scores | 16.20 (±4.61) | 20.85 (±8.50) | 30.18 (±12.41) | 41.66 (±9.73) | 20.065 | <0.001 |
| WCST perseverative error | 10.00 (±4.91) | 12.20 (±7.67) | 17.68 (±11.52) | 31.66 (±5.50) | 17.025 | <0.001 |
| WCST categories completed | 3.66 (±1.11) | 2.96 (±1.06) | 2.09 (±1.34) | 1.11 (±0.33) | 13.417 | <0.001 |
| TMT-A | 24.20 (±4.70) | 26.57 (±6.12) | 28.40 (±5.44) | 31.77 (±4.11) | 3.936 | 0.011 |
| TMT-B | 61.73 (±9.46) | 55.29 (±10.38) | 53.72 (±13.18) | 68.33 (±54.40) | 1.758 | 0.160 |
| Digit span (Forward) | 7.66 (±1.29) | 7.98 (±1.94) | 7.90 (±1.84) | 7.55 (±1.94) | 0.216 | 0.885 |
| Stroop test | 109.33 (±8.81) | 109.77 (±6.47) | 111.59 (±8.08) | 110.39 (±7.75) | 0.774 | 0.511 |
| COWA | 30.00 (±6.70) | 29.12 (±6.77) | 31.68 (±5.82) | 28.88 (±3.14) | 0.914 | 0.437 |
Table 4.
Correlation with HAM-D scores
| Variables | HAM-D Mean (±SD) |
t | P | |
|---|---|---|---|---|
| Normal n=30 | Depression (Mild/Moderate) n=70 | |||
| WCST total error | 18.20 (±7.61) | 26.60 (±12.07) | -3.516 | <0.001 |
| WCST perseverative error | 8.80 (±4.57) | 17.41 (±10.61) | -4.268 | <0.001 |
| WCST categories completed | 3.40 (±1.06) | 2.41 (±1.26) | 3.724 | <0.001 |
| TMT-A | 27.36 (±6.65) | 26.97 (±5.57) | 0.306 | 0.760 |
| TMT-B | 55.93 (±10.41) | 57.58 (±21.86) | –0.394 | 0.694 |
| Digit span (forward) | 7.96 (±2.26) | 7.84 (±1.61) | 0.310 | 0.757 |
| Stroop test | 108.70 (±6.44) | 111.11 (±7.57) | –1.524 | 0.131 |
| COWA | 28.96 (±7.76) | 30.15 (±5.63) | –0.861 | 0.392 |
DISCUSSION
The age distribution in our study revealed that 62% of patients with OCD were aged 18 to 30, indicating a higher prevalence among younger adults. This suggests that OCD is more commonly diagnosed or symptomatic in this age group, while older individuals may display OCD less frequently.[3] According to the gender analysis, there were more male patients (66%) than female patients (34%). This gender disparity suggests that males may be either more prone to developing OCD or more likely to seek diagnosis and treatment. In accordance with Jaisoorya et al. (2003),[4] who investigated gender variations in OCD, men experienced an early onset of the disorder.
A significant portion (70%) of the patients in our study had OCD for 1 to 5 years, indicating a relatively recent onset in many cases. These findings highlight the importance of early detection and intervention to prevent long-term chronicity. A study by John Pollitt et al. (1957)[5] on 141 patients with OCD found that 25% of patients sought medical attention only after ten years of suffering, while 50% did so five years after the onset of the illness. However, the duration of illness spanned up to 25 years, reflecting the chronic nature of OCD for some individuals. These findings highlight the importance of early detection and intervention to prevent long-term chronicity.
Our study sample was slightly more rural (55%) than urban (45%). In rural locations where resources may be limited, this distribution emphasizes the critical need to provide access to mental health treatments. A study by Gupta et al. (2023) in India noted a similar pattern, with 60% of participants from rural areas. The findings of our study may be due to the fact that, in the last few decades, psychiatric awareness has increased in rural areas.[6] In contrast, Manchanda et al. (1978)[7] revealed that 83.3% of patients with OCD in their study were from urban areas. These findings suggest that OCD affects individuals across different living environments, highlighting the need for widespread outreach and support services.
The most prevalent obsession in our study was a fear of contamination (70%), followed by pathological doubts (53) and intrusive thoughts (47%). This finding is consistent with a study that found pathological doubt (42%) and contamination (50%) to be the most prevalent obsessions.[8] Furthermore, our research is corroborated by an Indian study conducted in 1975 by Akhtar S et al.,[9] which found that the most prevalent obsession was the fear of contamination.
The washing compulsion was the most frequently reported compulsion (71%), followed by the checking compulsion (51%), in our study. Research by Rasmussen et al. (1988) showed that checking (61%), washing (50%), and counting were the more common compulsions. However, our findings are consistent with several Indian studies where washing compulsions were more common than other categories.[10]
In this study, we found a significant relationship between a longer duration of illness and poor insight. Similar findings were reported in a study by Kishore et al. (2005).[11]
Our findings reveal a significant relationship between poor insight and severe OCD symptoms, consistent with earlier research by Turksoy et al. (2002)[12] and Solyom et al. (1985)[13] Ottoni et al. (2022)[14] identified symptom severity as the primary predictor of poor insight, suggesting it reflects the most severe end of the OCD spectrum. Similarly, Catapano et al. (2010)[15] linked poor insight to extreme symptom severity, while Visser et al. (2017)[16] found higher rates of OCD and reduced treatment responsiveness in individuals with poor insight.
In our study, patients with poor insight exhibited significantly higher HAM-D scores, indicating greater depressive symptom severity. This aligns with the findings of Turksoy et al., (2002)[12] who also reported a higher prevalence of depressive symptoms in patients with poor insight.
Our findings indicate impaired performance across all WCST categories among patients with OCD with poor insight. This is consistent with a substantial body of research, including studies by Olley et al. (2007),[17] demonstrating that the WCST is a sensitive measure of executive dysfunction in OCD. Set shifting, the ability to adapt to changing task demands, is a critical executive function. The WCST is widely considered the gold standard for assessing executive function due to its robust association with frontal and prefrontal cortex activation. Previous research, including our findings, has consistently demonstrated impaired WCST performance in patients with OCD. This difficulty likely stems from deficits in organisational skills, as the test requires flexible attention to stimulus attributes, categorisation, and rule application.
Our findings showed significantly higher scores on the TMT-A in patients with poor insight, with no notable differences in TMT-B performance. This aligns with prior investigations by Manarte et al. (2021)[18] and Kashyap et al. (2012),[19] which reported impaired TMT performance in these patients. The association between poor insight and severe OCD symptoms suggests that individuals may struggle with sustained attention and cognitive flexibility—core executive functions often compromised in treatment-resistant OCD, a group typically characterised by poor insight.
Our Stroop test results align with previous research, showing no significant difference between patients with OCD and healthy controls. While the Stroop task is sensitive to executive function deficits, particularly response inhibition, which is often impaired in OCD, our findings suggest that these deficits may not be universally present in the OCD population.
Limitations
This cross-sectional study, conducted at a single centre, limits our capacity to establish casual relationships and generalise the outcomes to a larger population. The absence of a control group hinders our ability to definitively isolate the specific impact of insight on executive functioning.
CONCLUSION
The significant relationship between poor insight and severe OCD symptoms, as well as elevated depressive symptom severity, suggests that poor insight is a crucial factor in understanding the severity of OCD. Impaired executive functions, as demonstrated by performances on the WCST and TMT, further illustrate the cognitive challenges patients face, particularly those with poor insight. Further research is recommended to investigate these associations in larger and more diverse populations to enhance the fundamental information established by this study.
Authors’ contributions
All authors were involved in study design, data collection and preparing the entire manuscript.
Data availability statement
Data can be made available on reasonable request.
Ethical statement
The institutional ethics committee approved the study (letter no. 768/IEC/IGIMS, dated 06/10/2022). A consent statement was provided by each participant. Participants’ confidentiality and privacy were upheld in accordance with Declaration of Helsinki.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data can be made available on reasonable request.
