Comparison of obsessive compulsive disorder with and without schizophrenia in terms of insight, metacognitive beliefs and clinical features

Objective: The incidence of obsessive compulsive phenomenon in schizophrenia is 3-59,2%. Studies that find insight into obsessive compulsive symptoms (OCS) better in patients with obsessive compulsive disorder (OCD) accompanied by schizophrenia than pure OCD patients or studies that do not find a difference between groups suggest that the comorbidity of schizophrenia in OCD may not go together with impaired insight into OCS. Studies in which OCD patients with good insight have more pathological metacognitive activity than OCD patients with poor insight suggest that pathological metacognitive beliefs may not be in parallel with poor insight into OCS. However, there is no study examining how metacognitions are and their relationship with clinical features and the level of insight into OCS in patients with a diagnosis of OCD with schizophrenia. In this regard, this study aimed to compare the clinical characteristics, insight levels into OCS and metacognitive beliefs of OCD patients with and without schizophrenia. In addition, it was aimed to examine the relationship between the level of insight into OCS and metacognitive activity in both pure OCD patients and OCD patients accompanied by schizophrenia. Materials and Methods: Patients who applied to the outpatient clinic of Istanbul University, Istanbul Faculty of Medicine, Department of Psychiatry between 01.09.2018 and 01.09.2019 and who were being followed up in psychotic disorders and anxiety disorders outpatient clinics were evaluated with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV Axis I Disorders (SCID-I), and 30 patients diagnosed with OCD with schizophrenia and 30 patients with pure OCD were included in our study. Patients were evaluated with a semi-structured sociodemographic data form developed according to DSM-5 criteria, Yale-Brown Obsession Compulsion Scale (YBOCS), Brown Assessment of Beliefs Scale (BABS), Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), the Metacognition Questionnaire-30 (MCQ-30) and the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF). Results: There was no difference between the OCD with schizophrenia group and the pure OCD group in terms of the OCS severity, depression and anxiety severity, insight into OCS, metacognitive beliefs and quality of life. When the patients in the group with "good or very good insight" based on DSM-5, were separated from the others and all patients were divided into two groups regardless of the presence or absence of schizophrenia as "good insight" and "poor or no insight", no difference was found between the groups in terms of OCS and depression severity. Anxiety severity was higher in the "poor or no insight" group. Insight assessed by both the YBOCS item 11 and the BABS was worse in the "poor or no insight" group as expected, and it was shown that pathological metacognitive activity increased with the worsening of insight. Pathological metacognitive activity regarding positive beliefs about worry, uncontrollable and dangerous thoughts, and need to control thoughts; and total pathological metacognitive activity were found to be higher in the "poor or no insight" group. Quality of life was better in the group with "good insight". Conclusion: In our study, no difference was found between the OCD with schizophrenia group and the pure OCD group in terms of insight levels into OCS and metacognitions. Insight into OCS has been interpreted as a clinical phenomenon independent of the comorbidity of schizophrenia and a core symptom of OCD. Metacognitions are thought to be a clinical variable that can be evaluated separately in both schizophrenia and OCD, and overlaps can be seen in terms of metacognitions in two disease groups. However, when all patients were divided into two groups as "good insight" and "poor or no insight", it was found that patients in the "poor or no insight" group had increased non-functional metacognitive activity compared to the other group and the increase in non-functional metacognitive activity was associated with the worsening in insight. Thus, it was thought that the relationship between metacognitions and insight into OCS in OCD patients existed independently of the schizophrenia comorbidity.