Descriptive Psychopathology: The Signs and Symptoms of ...

298 Section 3: Examination domainsWhen genital mutilation (e.g. “amputee fetish”) 36 or limb amputation (e.g. “bodyintegrity identity disorder”) 37 occur, patients may be misdiagnosed as psychotic.The case literature of these extreme forms of self-mutilation, however, is superficialand there is little evidence presented in the published reports that a carefuldifferential diagnosis was considered.OCD and psychosisMany patients with the DSM diagnosis of schizophrenia are reported to haveone or more OCD features, and about 10% are reported to meet DSM criteriafor OCD. Such patients are also reported to have additional features of anxietydisorder. 38 An association between schizotypal and OCD behaviors has also beenreported. 39 The co-occurrence is explained by data implicating frontal lobe dysfunctionin both conditions. In schizophrenia dorsolateral prefrontal cortex (DLPC)dysfunction is reported, while in OCD ventro-medial prefrontal cortex (VMPC)dysfunction is recognized. 40 In patients with both features, overlapping braininvolvement is suggested. Functional MRI studies done in patients with schizophreniawith OCD features report reduced activation in prefrontal areas. 41The reported relationship between OCD and psychosis, however, is weak.Severe obsessions and compulsive rituals can be misunderstood as signs of apsychotic disorder, interpreted to be delusions, stereotypes or catatonic mannerisms,leading to the incorrect diagnosis of schizophrenia. Patients with OCD aremore likely to recognize their behavior and to understand it as abnormal.Psychotic patients often deny illness (anosagnosia), or are unaware of some oftheir symptoms or consider some necessary.The simplistic use of DSM-based checklists to identify psychopathology alsoencourages over diagnosis of co-occurrence. Schizophrenic patients reported tohave OCD are said to be less emotionally blunted and to have more depressivefeatures than those without OCD. They experience more compulsions thanobsessions. 42 The pattern suggests that many of the “OCD” features observed inthese psychotic patients are catatonic features and not OCD, and the patients tobe manic-depressive. Discrete episodes of obsessions and compulsions are alsolikely atypical presentations of mood disorder and may respond to electroconvulsivetherapy. 43 There are also several reports suggesting an association betweenatypical antipsychotics, especially clozapine, and the development of “obsessive–compulsive symptoms” in psychotic patients. 44 Drug-induced movement disorderis a well-known adverse effect of antipsychotic agents.There is, however, some association between OCD features and manicdepression.45 Patients with OCD and associated manic-depression are reported,and these patients exhibit an increased prevalence of mood disorder in their firstdegreerelatives and an OCD course reported to begin earlier in life, 46 and that is