Insight:
• Obsessive-compulsive disorder (OCD) with poor insight should be considered a severe form of OCD and not be mistaken for a primary psychotic disorder; a careful history is required to ascertain for insight in previous OCD exacerbations
• OCD with poor insight may respond to treatment with an SSRI without the addition of an adjunctive antipsychotic, or preferentially to adjunctive antipsychotic added to an SSRI ; because some individuals with OCD take longer to respond to SSRIs, a therapeutic trial of an SSRI at optimized dosages for at least 8 to 12 weeks should be tried before the addition of adjunctive antipsychotic medication
Primary OCD Vs Secondary to atypicals:
• Primary OCD should be distinguished from de novo obsessive-compulsive sympoms (OCS) induced by atypical antipsychotics/serotonin-dopamine antagonists (SDAs); this highlights the importance of a careful history rather than mere cross-sectional examination
Evaluate Before Medication :
• Persons with schizophrenia should be evaluated for OCS/OCD before starting or switching to an SDA and monitored prospectively for the emergence of de novo OCS
Manage Induced Obsessive Symptoms:•
SDA-induced OCS may be dose-dependent; in managing treatment emergent OCS, whether to reduce the SGA dose, switch to a different antipsychotic, or continue the atypical antipsychotic and treat the de novo OCS is a matter of clinical judgment; the decision should entail a risk/benefit analysis that considers the degree of antipsychotic response to the SGA and the severity of treatment emergent OCS, among other factors
If Pure OCD is Co- Morbid with Schizophrenia:
• As with pure OCD, OCD comorbid with schizophrenia may respond to treatment with an SSRI and/or adjunctive cognitive-behavioral therapy; first-line treatment for patients who meet criteria for both disorders consists of an antipsychotic and an SSRI