I got up, went to their bathroom and washed my hands, dried myself in their towel and checked the bed many times to see if there was something there. I went to bed and quickly fell asleep, I didn't even hear them coming. I woke up in the middle of the night and I was very scared: I knew [patient's highlight] that I had committed a sin, such a big sin that I would certainly be punished.
On the following day, everything seemed normal. After some days, I almost forget what had happened, or at least I didn't think about it no more. Some time later, we were awakened by a phone call in the middle of the night, and I heard my father speaking loudly and my mother started to cry.
Immediately, it all came to my mind. Some thing had happened and it should be my fault, sin and punishment, I repeatedly thought: sin and punishment.
The news came from an uncle's wife that had found him dead, suicide by hanging, and was asking for my father's help. We all went to the funeral. His children were a little older than me, I tried to talk to them or play a little but it didn't work out, it seemed as if they were looking at me in a different way, and I started thinking they knew it.
Despite knowing it was an absurd, I started being sure that God, yes, God only could be punishing me. I was responsible for that guy's death, someone I really liked and who had never done me anything wrong, never! The first reaction to that guilt was a decision: I'd never masturbate, and so I'd eliminate any further danger! I totally stopped masturbating. I couldn't sleep well, I was no longer focused at school, and my performance, which had been good so far, was disappointing.
I quit the guitar and English lessons and started going to church quite often. I had painful erections almost every night and I avoided sleeping facing down, my favorite position, to reduce the excitement I felt. The solution found by the patient is briefly described, since it consisted of many pages, with long and complex equations:.
Laziness is one of the capital sins, which are 7, and the devil prefers the chaplet, and the devil knows that only a chaplet is not enough for large sins.
Six is the number of the chaplet, which is also the number of the beast the beast as described in the Bible. Nine is the number of the rosary, which is the number that represents God, because it is as absolute as God. Final: everything that is even is God, the highest indication of even is zero, because it's absolute, it doesn't need men, zero or even is God, and 1 or odd is the devil, imperfect being that needs men to sin.
All unity belongs to the devil! When I solved the divine equation, everything changed for me. One day when my parents were absent, I went to their bedroom and again I masturbated in their bed! Thus, I solved the problem of my solitary pleasure: I just had to masturbate twice. I became a good friend of everything that's even, and enemy of odd numbers, but after some time, that initial freedom became my condemnation. I was and am afraid of everything that's not double or that cannot be annulled.
In addition to psychotherapy, we chose to use symptomatic drugs to treat the patient's anxious manifestations and the repetition to which he was submitted arithmomania. Psychotherapy was also essential for the treatment. Our diagnostic difficulties were present since the beginning: the obsessive-compulsive component, evident phobic elements, in addition to delusional ideas diagnosed prior to our contact with the patient.
When the criteria for delusional thought proposed by Jaspers were considered, Mr. Despite the possible delusional status, we certainly did not believe that he could be classified as schizophrenic. It is worth making an observation here not as to scale inaccuracy, whose aim is well established in research : both patients had very similar scores, both in the PANSS and in the Yale-Brown. They do not discriminate reliably differences between obsessive-compulsive symptoms, depression and anxiety in patients with OCD, as well as in delusional patients.
We may add that PANSS was developed to suppress the absence of scales with a better psychometric standardization. Dichotomy in positive and negative symptoms is also questionable, and even rejected by some authors. Considering the known diagnostic criteria, scales and patients' course, we reached the conclusion that clinical observation, pharmacotherapy and psychotherapeutic follow-up of cases were superior to confirm our initial hypotheses: Mr.
R was diagnosed with persistent delusional disorder, and Mr. Our option after therapeutic test should be considered, which is evidently not specific. In , the book General Psychopathology , by Karl Jaspers 7 defined delusion as it is still accepted by the psychiatric community:. Vaguely, delusion-like ideas are all false judgments that have the following external characters to a certain degree - not precisely determined: 1st - The extraordinary conviction with which the subjective certainty, incomparable, is adhered to them; 2nd - The impossibility of influencing part of the experience and constringent thinking; 3rd - The impossibility of content.
A false belief based on incorrect inference about external reality that is firmly sustained despite what almost everybody else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary.
When a false belief involves a value judgment, it is regarded as a delusion only when the judgment is so extreme as to defy credibility. Delusional conviction occurs on a continuum and can sometimes be inferred from an individual's behavior.
It is often difficult to distinguish between a delusion and an overvalued idea in which case the individual has an unreasonable belief or idea but does not hold it as firmly as is the case with a delusion. Jaspers was a type of watershed for the definition of delusion. His conception expressed a kind of apex for a series of proposals, especially from the Anglo-Saxon, German and French schools.
Afterward, delusion became the key element for the diagnosis of schizophrenia. After the publication of the DSM-III in , delusion as a nosological entity delusional disorder has its modest place in codes. In the contemporary literature, terms such as paranoia, paraphrenia and chronic systematized delusions no longer have their previous relevance. Current classifications classify delusion as a morbid belief. A higher interest in course of dementia and delusion in the diagnosis of schizophrenia left no more room for paranoia as reference pathology.
It has been globally replaced by the concept of persistent delusional disorder. Sonenreich et al. Defining delusion by loss of ability to communicate logically means to approach this concept not as a symptom, but as a form of interacting with others. The statements we make aim at informing the other, convince him, occasionally make him share thoughts and actions with us. Therefore, they need to be performed properly for the other, acceptable by him. The notions and terms should mean the same thing to us.
Delirious patients, in that assumption, would say things that do not convince in a way that is not convincing. They do not follow norms formulated as logic to transmit their communication. Sonenreich supports that the essential characteristic of logic is to allow for the understanding and collaboration between interlocutors. Communicated thought needs to be submitted to certain norms, assure the identity of terms, coherence. The difference in postulates on delusion and the evident novelty of Sonenreich's proposition seems remarkable.
Piaget's studies of children showed that the logic form of thinking is not spontaneous, and it is only acquired around 10 years of age.
Sonenreich proposes the diagnosis in the relationship: a way of being with others. The logic is ruptured in delusion because it is a quality that is acquired late, and is consequently more vulnerable. Efforts are required to maintain it; therefore, it remains if acquired results are satisfactory. Since the delusional patient cannot reach his goals, he abandons logic, because it is no longer a communication instrument.
From the historic perspective, 11 obsessions and compulsions have been studied by medicine since the 19th century, mostly in the 20th century, when the proposals by Pierre Janet , in France, and Sigmund Freud , in Austria were almost simultaneously put forward. Janet, in , described psychasthenia as a pathology of psychological origin including obsessive ideas, forced agitations: compulsions, phobias, panic attacks and stigmas, which would be personality diseases, correlated to reduction in psychological tension, incompleteness and loss of reality function - theoretical notion that had a great influence on Bleuler's concept of autism in Between and , the obsessive neurosis described by Freud prevailed in French texts and classifications, while psychasthenia was simply reduced to personality disorder, along with the "anal" character.
In contrast, since contemporary international classifications DSM-III, DSM-IV, ICD and the studies of obsessive disorder comorbidities with other anxiety disorders, depressive disorders, cyclothymia, and obsessive-compulsive disorder have seemed to validate Janet's points of view. This disorder is basically characterized by obsessive ideas or by recurrent compulsive behaviors. Obsessive ideas are thoughts, representations or impulses that interfere with the individual's awareness in a repetitive and stereotyped manner.
In general, they are very disturbing for the individual, who frequently tries to resist them, but is not successful. However, the individual recognizes that those are his own thoughts, but strange to his will, and usually unpleasant. Compulsive behaviors and rituals are repetitive, stereotyped activities. The individual has no direct pleasure in performing these acts, which, on the other hand, do not lead to useful tasks per se. Compulsive behavior aims at preventing some objectively unlikely event the individual fears from happening, implying damage to himself or being caused by him.
The individual usually recognizes the absurd and usefulness of his behavior and makes repetitive efforts to resist against it. This disorder is almost always followed by anxiety. Such anxiety is worsened when the individual tries to resist his compulsive activity.
In the definitions of psychiatry manuals, such as DSM-IV and ICD, there is no psychopathological contribution to the understanding or even distinction between obsessive thoughts in their limits and delusions, although clinical practice makes us think about this issue. Sonenreich proposes the study of this chapter in psychological terms, "as a result of conflicts, insufficient or improper investments to respond to situations" p.
Both cases described above may indicate difficulties found in clinical practice between delusional psychopathology and obsessive thought. The diagnostic criteria proposed by DSM-IV and ICD allow us to formulate the hypothesis of both delusional and obsessive compulsive disorder in both of them. We believe that psychopathological difficulty forces us to go beyond the concepts of comorbidity, which may facilitate diagnosis by symptoms, but do not inspire deeper thoughts.
One patient, Mr. Are insight criteria in delusion, 7 that is, that the idea does not belong to the individual, enough to distinguish it from obsessive thought, in which the patient does not know that the idea is autochthonous, i. Many publications have stressed the difficulty in distinguishing between OCD and delusional symptoms and found that some cases of OCD are confounded by delusional disorders.
Portela Nunes, 14 in his dissertation and further book published in , suggested a difference between delusion and obsession based on wider categories such as psychosis and neurosis. For that author, these concepts can be misinterpreted if analyzed outside the major reference syndromes.
To Palomo Nicolau et al. Phillips et al. They concluded that changes in body image in dysmorphic sizes and food changes can be credited to both delusions and obsessions. Insight variability would occur within a spectrum. They also stated that, according to the DSM-IV - based on empirical evidence - the boundaries between delusional and non-delusional are even less clear than in the previous revision. In addition, they considered that clinical observations show an overlapping between schizophrenia and obsessive disorder in the field related to thought changes, which would involve obsessions, overvalued ideas and delusions.
There is no psychopathological characterization to distinguish these thought changes. The conclusion is that, in OCD, cognitive dysfunctions similar to those found in delusional patients could be related. Authors studying the differences between delusional and obsessive-compulsive disorders found difficulties and possible confusions between these diagnostic categories.
In current studies of psychopathology there was no clear reference to facilitate a distinction between these two categories, which would imply distinct therapeutic conduct. According to Jaspers, a delusional patient could never admit being sick. The insight criteria Jaspers , i. According to that author, the criterion of loss of logic communication drives us to delusion. Being with other people is a construction based on experiences of success and failure; the speech, with psychic maturity, is enhanced, increases in possibilities and ability of abstraction and acknowledgment.
For a delusional patient, this is absolutely lost. The descriptive criterion adding symptoms does not end the discussion. It does not help separating into diagnostic categories proposed by manuals and codes that place delusion among cognitive disorders, and OCD as an anxiety disorder.
Recent studies, mentioned above, have stressed the difficulty in characterizing the differences in cognition for delusional and obsessive patients. The same patient could be considered delusional or obsessive-compulsive. The Yale-Brown scale the most frequently used seems to be imprecise, since it confounds obsession and phobia. In the assessment scale of obsessive symptoms, fear comes in first place: fear of being hurt, of hurting others, of saying obscenities, of stealing, of executing impulses, which seems to be the main reason for the condition.
Even without having the intention to lead to a diagnosis, there is no clear separation between these symptoms. We then chose to think about the way the patient is with us.
What we named rupture of logical communication could be a way of living that abolishes the other and the basic logic of communication; there is no argumentation or willing to convince. The patient R. The rupture with the other, failure in considering a second possibility, speech full of jargons, common places, and inability to recognize failure in oneself make the differences between obsessive-compulsive psychopathology and delusion clearer.
We have no doubt that there is anxiety, but it is restricted to the delusional theme with any type of questioning. The second case reminds us of Ey, 20 who described obsessive patients as having "anxiety as their law of existence. This could be another difference: the fact that the delusional patient preserved psychic energy that falls away easily in obsessive patients.
It if is possible to think of a formula for the existence of obsessive individuals, it would be the following: I cannot control my ideas and my conducts, and as a result there is an unbearable anxiety. Psychopathological difficulty forces us to go beyond the concept of comorbidity, which may facilitate diagnosis by symptoms, but do not inspire deeper thoughts. Since this is a study of debate in psychopathology, our results aimed at clarifying the state-of-the-art concepts of delusional and obsessive thought.
In delusion, an impossibility of recognizing failure with loss of logical communication is prevalent. The main characteristic of obsessive individuals is the impossibility of controlling their ideas and conducts, resulting in anxiety. Appraisal of its application in psychiatric diagnosis may enlighten the most common questions regarding differential diagnosis, pointing to new proposals and, consequently, to more effective conducts.
It has also been noted that in many people who later develop schizophrenia, their first clinical symptoms are often an OCD-like presentation, and the schizophrenia diagnosis becomes clearer over time. While not yet an official psychiatric term in the Diagnostic and Statistical Manual of Mental Disorders DSM , this potential diagnosis has begun to receive some study and attention.
One of the trickier parts of determining whether someone is struggling with schizophrenia versus OCD is trying to understand if the individual is experiencing a delusion or an obsession. People suffering from delusions are comfortable and accepting of their beliefs and see no need to question the presence of such a belief nor the content of it.
People with OCD usually have doubts that the content of their obsession is true, and they will usually question why they are having an obsessive thought in the first place. The mere presence of the thought makes them uncomfortable. Unfortunately, while these definitions sound very different, in clinical practice they can be difficult to distinguish. Additionally, m any patients have both ego-syntonic and ego-dystonic thoughts.
To qualify for this diagnosis, the patient must have symptoms of both disorders. Schizo-obsessive disorder is currently being conceptualized as a subtype of schizophrenia rather than a subtype of OCD.
Diagnostic criteria for this disorder have been proposed by Poyurovsky et al. According to these criteria, a person is not considered to have schizo-obsessive disorder if OC symptoms occur solely in the context of a delusion. In this example, to qualify as having schizo-obsessive disorder, such an individual would need to have other, separate obsessions and compulsions. OCD symptoms that occur in patients with schizophrenia do not present differently than in people with OCD alone; they present the same in both groups of patients.
There have been few studies focused on the treatment of people with schizo-obsessive disorder. That said, there is a good argument that ERP should still be considered the first treatment to try. In my clinical experience, patients with decreased insight into their obsessions i. The real challenge, in fact, is getting them to agree to participate in ERP treatment!
Another treatment approach would be to use medication. Unfortunately, OCD symptoms rarely respond to antipsychotic medications. To start, anti-psychotic medications can be used to treat the schizophrenia symptoms, and treatment for obsessions would be initiated after sufficient resolution of psychotic symptoms has occurred. The good news is that the same medication protocols used to treat individuals with OCD work the same way in individuals with schizo-obsessive disorder Borue et al Certain anti-psychotic medications, such as clozapine, are believed although not proven to induce obsessions in patients or worsen already existing obsessions.
Therefore, if possible, it is best to avoid this medication in someone who is schizo-obsessive. Also, increased cooperation in academic settings between schizophrenia researchers and OCD researchers, clinicians, and therapists should occur.
Finally, similar to issues that arise for co-occurring OCD and substance use disorders, schizophrenia and OCD programs should develop bridge programs to help educate people with schizophrenia and schizo-obsessive-like presentations and prepare them for exposure with response prevention treatment in OCD programs.
Schizo-obsessive spectrum disorders: an update. CNS Spectrums 22, Diagnostic and Statistical Manuel of Mental Disorders 5. American Psychiatric Association. Behav Res Ther March; 32 3
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