Interfacing delusion and obsessive thought: two case reports

Abstracts

As dificuldades psicopatológicas de distinção entre pensamento delirante e pensamento obsessivo impõem reflexões. Na clínica, é comum a sobreposição de sintomas, o que promove dificuldades na distinção de categorias tão diversas. Discutem-se dois casos em que ambos os diagnósticos, pelos critérios do Manual de Diagnóstico e Estatística das Perturbações Mentais, são possíveis. Aplicam-se as escalas PANSS (Positive and Negative Syndrome Scale) e Yale-Brown Obsessive-Compulsive Scale, que não esclarecem as diferenças. Na busca de uma melhor formulação diagnóstica, é proposto um diálogo com as idéias de Carol Sonenreich em contraponto com as classificações dos códigos, manuais e literatura contemporânea.

Comportamento obsessivo; delírio; psicopatologia; diagnóstico diferencial

CASE REPORT

Interfacing delusion and obsessive thought: two case reports

Andres Santos Jr.^I; Débora Pastore Bassitt^II

^IPsychiatrist. Head of the Psychiatric Outpatient Clinic and Preceptor of Residence in Psychiatry, Hospital do Servidor Público Estadual de São Paulo (HSPE/SP), São Paulo, SP, Brazil. Head of the Psychopathology Course, HSPE/SP

^IIPsychiatrist. PhD. Preceptor of the Psychiatry Outpatient Clinic and Professor of the Graduate Program, HSPE/SP. Head, Nursing, Projeto Terceira Idade (PROTER), Hospital de Clínicas, Universidade de São Paulo (USP), São Paulo, SP, Brazil

Correspondence

ABSTRACT

In psychopathology, the difficulties in distinguishing between delusion and obsessive thought require some reflection. There is a significant degree of uncertainty and complexity surrounding these categories, the symptoms of which seem to overlap each other. Two cases are presented in which both diagnoses are plausible using criteria of the Diagnostic and Statistical Manual of Mental Disorders. The Positive and Negative Syndrome Scale and Yale-Brown Obsessive Compulsive Scale were applied, but did not help clarify the differences. In search for the best diagnosis, a dialogue with the studies of Carol Sonenreich is herein proposed in a counterpoint to code classifications, guides and the state-of-the-art literature.

Keywords: Obsessive behavior, delirium, psychopathology, diagnosis, differential.

Introduction

This article studies the concepts of delusional and obsessive thought. It aims at discussing controversies in the psychopathological area, illustrating with two cases studied in clinical practice, based on our considerations. Our choice is to have a dialogue with the ideas by Carol Sonenreich. As a counterpoint to the classification categories of codes, current manuals and contemporary literature, Sonenreich conceives the difference between delusional and obsessive thought in the relationship between physicians and their patients based on logical communication. Loss of the latter would determine failure in personal experience of delusional individuals, which does not occur in obsessive-compulsive cases. We propose that a better diagnosis can aim at a more adequate therapeutic project, contributing to clinical practice.

Method

Two patients were assessed. Respective diagnoses were performed in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The following scales were also applied: Structured Clinical Interview for DSM (SCID), Positive and Negative Syndrome Scale (PANSS), and Yale-Brown Obsessive-Compulsive Scale (Yale-Brown). A review of psychopathology will be performed. The discussion will be based on selected articles addressing the dialogue between delusional and obsessive thought.

Clinical cases

The cases below have similar characteristics: they are both patients from a private clinic, with previous diagnoses performed by mental health professionals. Authorizations for this study were provided by the patients.

Case 1: Mr. R.

R. was 22 years old when he was admitted to the clinic, referred by his sister, a psychologist, who had formulated the hypothesis of an obsessive-compulsive disorder. R. was a senior student of agronomics. He was a reasonable, medium-performance student, and was preparing to take over his father's farm management after graduating. He enjoyed going to a spiritualist umbanda center and was a good friend of the psychic running this center. One evening, after a religious séance, before his 22nd birthday, he had a sudden malaise. He leaned against a tree and had the following vision, in his own words:

Everything was dark for a moment and I couldn't see anything, then I looked up at the tree and I saw Jesus Christ crucified on its trunk. He was naked and looking at me. I saw him from a lower perspective and so his penis was swinging in my direction. When I stared at it, I noticed His penis was growing and bending backward, penetrating His anus until forming a strange curve, like en elephant snout when it's eating. I stared for a long time and then I guess I blacked out. I only woke up in the following morning when an officer awakened me and took me to the student's house I lived, and there my friends called my mother, who came to pick me up.

These facts occurred about 10 days before his first appointment. After R. had that vision, he felt obliged to perform certain rituals: running away from people dressed in white - such as the psychics at the spiritualist center - praying on his knees for hours and hours, drinking his own urine to purify himself, fasting, and not sleeping in bed to do penance. These actions were noticed by his family without any explanations by R.

He then reported that everything had started after an abortion to which his girlfriend was submitted. The "spirit" of the baby obliged him to do certain things he did not want to. He suffered because of this, but knew it was irreversible; therefore, he would have to do penance for the rest of his life.

We started administering an antipsychotic drug, sulpiride 600 mg/day, and there were improvements in sleep and hostile behavior since the first days. After he became more peaceful, he was able to report us what had occurred to him:

I used to go to the spiritualist center and listen to the psychic talk about sins that are paid through reincarnations. Then I started hearing voices that revealed me my past: I was God, the one who had created the God everyone knows. I had created a plan in which all the violence and misery in the world would end, we just had to plant more manioc and throw away all metals! The manioc would feed everyone and with no metals, money and guns would no longer exist. The angels and archangels were so happy with these revelations that they deposed the old God and elected me in His place!

He then "remembered" that, like God, he should be asexual or bisexual, moment in which he had the vision of Jesus Christ and the collapse. R. was born in a medium-high class family, and was raised in good conditions of information and university study. Between 13 and 14 years of age, he started a homosexual activity with a close cousin, of whom he liked very much. He always played the submissive role, which pleased him. When he was 19, his 17-year-old girlfriend got pregnant and had her pregnancy interrupted against R.'s will.

He described himself and was seen as a sensitive and loving young man, which would explain his great success with women. His religious interest arouse when he was 21, short before his acute state. He started praying when he knew his parents' marriage would probably be over. He used to go to a spiritualist center almost daily, he made promises for his parents to stay together. He started developing certain rituals that he considered safe to achieve his goal.

He collected the melted wax from a candle on a clean piece of paper and, after cooling, he should shape it like a cross, kiss it and lick it, then melt it again mixing it with feces and urine for purification. After all that, the cross was thrown in the toilet. He had to do it nine times a day, because "only novenas" would work.

Fasting and praying were other forms of making the spirits obey him: he used to eat a lettuce leaf with some earth, thus honoring Mother Nature; he drank his urine for "internal cleansing" and slept on the floor beside his bed.

He spoke to everyone very peacefully and serenely, as an attempt to make them understand his new divine condition; he knew he was the chosen one, since he himself had chosen him to save humanity.

He could not masturbate; this would make him develop miraculous strength. He postulated chastity as an exit to humanity's sexual perversions. The spirits guided him and told him exactly what to do, he only had to obey them.

We formulated a few hypotheses and used scales to diagnose the patient. R., according to the DSM-IV, is compatible with persistent delusional disorder, but also with obsessive-compulsive disorder (OCD). We cited thoughts, impulses or recurrent and persistent images that, at some time during the disorder, are experienced as intrusive and inadequate and caused marked anxiety or suffering. Thoughts, impulses or images are not mere excessive concerns about real life problems. The person tries to ignore or suppress such thoughts, impulses or images, or to neutralize them with another thought or action (diagnostic criteria for F42.8-300.3, obsessive-compulsive disorder, according to the DSM-IV, 1994).¹ Such elements could explain the hypothesis of OCD.

Application of the scales PANSS² and Yale-Brown³ showed, respectively:

PANSS (scores):

- General: 56

- Positive: 35 (delusions = 6; hallucinatory behavior = 4)

- Negative: 19

Yale-Brown (19 items): 52

Clinical course confirmed the psychopathological presentation of delusion. He responded to the antipsychotics and the proposed psychotherapy showed rupture of logical communication and impossibility of acting or working in second alternative. This form of conceiving delusion will be discussed later.

Case 2: Mr. A.

The patient A. sought us in the office in 1988, referred for assessment by a colleague, who is a psychoanalyst and suspected of paranoid schizophrenia. He was 28 years old, Caucasian, single, information technology (IT) engineer, and had good general appearance. His complaints were vague: he said he felt bad for his engagement and was pressed to get married. He could not sleep well, was not focused at work, always had the impression that something bad would happen to him. He suspected everyone around him: they seemed to laugh at his back and sometimes he had the impression of hearing voices that called him, mixed with his own thoughts; despite being absurd, he recognized that this was a product of "his mind."

He considered himself and was recognized as an excellent professional. His main job was to search for knowledge and proper techniques abroad with the aim of enhancing the Brazilian IT industry. He described his sexual activity as satisfactory. He started his sexual life at the age of 18, an age which he considered to be good. He was not comfortable with the subject and avoided being more clear or explicit. He never used drugs. He drank alcohol very moderately. His parents were both alive, with good health, he was an only son and there was no previous history of disease in the family.

He was unable to provide any explanation to his malaise and, in the first meetings, he was willing to collaborate, but could not do it effectively.

The following description is a synthesis of several meetings with the patient. We tried to maintain the chronological order of his revelations, adapting them to a more adequate format to our purposes. The grammar and vocabulary were slightly changed.

Mr. A's significant report started as follows:

Yesterday I got a film at the video store that I was too afraid to watch when it was on at the cinema. It is "The Exorcist," and in this film the guy saves a possessed girl; possessed, doctor! Can you imagine that? She even masturbates with a crucifix; a crucifix, dear God. Only God could understand how someone gets like that. I'm glad the priest goes and saves the girl. The priest dies in her place.

We asked him: "Why are you repeating certain words - 'exorcist,' 'possess,' 'crucifix'? Are there any reasons for that?" He was visibly disoriented, started trembling, twisting his hands, in movements expressing the moment of great anxiety through which he was going, and finally said that he "had to talk like that" so that nothing bad would happen to him: "I have a delusion, doctor."

To explain his attitudes or the reason for his malaise, after some resistance, he said:

This started a long time ago; I was about 14 and was on an intense masturbatory phase! One evening, my parents went out and I was alone at home, then I decided to masturbate in their own bed, masturbate in their own bed! I had taken a piece of toilet paper from their bathroom, but I was so excited that the sperm fell from the paper and went all over me, in my hands and belly. 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:

I prayed so much that one day I was enlightened: the chaplet is part of the rosary.

It has 5 mysteries, that is, it is repeated 5 times: 1 Our Father, 10 Hail Mary and 1 Gloria be to the Father, equal to 5 + 50 + 5.

The rosary is 3 times the chaplet, thus: 15 + 150 + 15.

Both sums added: 60 + 180 = 240.

Adding the numbers, 6 + 0 = 6 and 1 + 8 + 0 = 9, as well as the rosary is prayed to huge sins, due to the large amount of time it requires, it (the rosary) brings men closer to God, and God prefers those who pray more, and the chaplet is for lazy people, since it takes much less time.

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.

Since men are weak and sin a lot, adding 6 + 9 = 15, which, adding the numbers is 5 + 1 = 6: again the number of the devil.

In conclusion: 6 equals 1 (devil), 9 equals zero (God).

Thus: 6 (devil) + 1 (men) = 7 = number of sins.

On the other hand: 9 (God) + 1 (men) = 10 = even, multiple of 2 and with the zero of 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!

Based on that discovery, a new stage in Mr. A.'s life started: In his own words:

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). He was given amitriptyline in growing doses, from 25 to 75 mg/day, in 2 weeks he recovered his sleep, and the somatic manifestations of anxiety were perceptibly reduced. 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. A. met all of them (remarkable subjective certainty, impermeable to logical argumentations, unlikely case report).

Despite the possible delusional status, we certainly did not believe that he could be classified as schizophrenic. According to the DSM-IV criteria, his condition could be compatible with both OCD and persistent delusional disorder.

The application of PANSS and Yale-Brown scales showed the following result:

PANSS (scores):

- General: 55

- Positive: 32

- Negative: 17

Yale-Brown (19 items): 52

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. We agree with Araújo⁴ that neither of them has diagnostic purposes. 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.^5,6

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. A. had the diagnosis of OCD. Our option after therapeutic test should be considered, which is evidently not specific. Therefore, we will present the difference between delusion and obsessions/compulsions proposed by psychopathology to clarify our discussion.

Psychopathological conceptions on delusion and obsessive thought

Delusion

In 1913, the book General Psychopathology, by Karl Jaspers⁷ 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. (p.118)

Since the implementation of new mental disease codes - the American DSM-III, in 1980, and the International Classification of Diseases (ICD-10),⁸ in 1993, edited by the World Health Organization - delusion has been defined as:

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). (p.96)

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.⁹ In 1950, the I International Congress of Psychiatry had delusion as its main theme. Afterward, delusion became the key element for the diagnosis of schizophrenia. After the publication of the DSM-III in 1980, 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. The same occurred for paranoid schizophrenia, although this diagnosis is present both in the ICD-10 and in the DSM-IV. 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.¹⁰ defined delusion as a pathology characterized by loss of logical communication, described as follows:

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.

To Jaspers, delusion is a phenomenon that can be observed based on the observer/observed relationship, such as every other symptom. 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.

Obsessive thought

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 (1903), in France, and Sigmund Freud (1895), in Austria were almost simultaneously put forward.

Freud, in 1895, proposed obsessive neurosis with mechanisms almost opposed to hysteria.

Janet, in 1903, 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 1911.

The French alienists preferred the concept of anxious or emotive constitution by Duprè, in 1909, rather than psychasthenia, in which obsessive manifestations are described on the border of chronic delusional disorders (Sérieaux & Capgras, 1909; Clérambault, 1923; Ceillier, 1924). Between 1945 and 1980, 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 1980 contemporary international classifications (DSM-III, DSM-IV, ICD-10) 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.¹²

Current conception of icd-10 f42-f42: obsessive-compulsive disorder

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-10, 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 et al., based on Pierre Janet, consider obsessions and compulsions as a wider spectrum, which has also included phobia. Sonenreich proposes the study of this chapter in psychological terms, "as a result of conflicts, insufficient or improper investments to respond to situations" (p. 123).

Discussion

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-10 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. R., who believed he was illuminated and chosen by God (i.e., a delusional patient), executes repetitive acts - of an evidently symbolic character - compulsively, certain that he can better perform what that Lord tells him to do and knowing that he will be punished if he does not.

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.e., that is belongs to him?

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.¹³

Portela Nunes,¹⁴ in his dissertation and further book published in 1976, 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.,¹⁵ the transition between OCD and delusion varies as a spectrum in terms of the patient's ability to have insights.

Fear & Healy¹⁶ claim that, in obsessive and delusional patients assessed by them, those with obsessive disorder surprisingly responded less "normally" than delusional patients, weakly supporting the idea that something in common between both pathologies could serve to better understand them.

Phillips et al.¹⁷ believe that, differently from DSM-III-R, it makes no sense to exclude or encapsulate psychosis in chapters separated from the other conditions. 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.

Kitis & Akdede,¹⁸ in an article published in 2006, claimed that cognitive dysfunctions in patients with OCD, compared with schizophrenic patients, had the same relationship with overvalued ideas. 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.¹⁹

A proposal to distinguish between obsession, compulsion and delusion

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.e., the patient being aware of his disorder - perceiving that the thought belongs to him - points to psychasthenia (OCD) in the current update proposed by Sonenreich.

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. As previously said, the DSM-IV and ICD-10 criteria and some of the most widely used scales to screen for delusion or obsession/compulsion, which use symptoms as reference, resulted in overlapping of ideas, diagnostic confusion. 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. (case 1) isolates himself autistically, or even better, solipsistically, and can only manage to talk about delusional themes, with no concern about any proof of reality and sharing. 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." Since they are unable to get rid of ideas and compulsions, which we believe are associated with phobias, obsessive patients wear out their existence in a continuous and endless battle, resulting in unavoidable weakening and burnout and, therefore, psychasthenia. 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.

Conclusions

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.

Acknowledgments

We thank Professor Dr. Carol Sonenreich, director of the Psychiatry Service at Hospital do Servidor Público Estadual de São Paulo, who helped us with guidance and suggestions.

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Publication Dates

• Publication in this collection
  01 Dec 2008
• Date of issue
  Apr 2008

History

• Accepted
  10 Mar 2008
• Received
  25 Feb 2008