When re-evaluation redefines diagnosis and treatment: a case of obsessive-compulsive disorder with poor insight mistaken for psychosis

Abstract

Obsessive–compulsive disorder can be deceptively difficult to identify when insight is limited and compulsions take the form of marked avoidance. This case describes a 32-year-old woman with an 18-month course of worsening daily functioning, including reduced intake, neglected personal care, social isolation, and sleep disruption. Her presentation was dominated by firm fear that routine activities such as eating or washing could invite divine retribution or endanger family members, leading to an initial diagnosis within the psychosis. But, Failure to improve with antipsychotic treatment prompted re-evaluation, which revealed recurrent intrusive thoughts with marked anxiety and avoidance functioning as compulsions, without hallucinations or formal thought disorder. The diagnosis was revised to OCD with poor insight, and targeted treatment led to gradual, steady improvement. This report highlights the diagnostic challenge of poor-insight OCD and emphasizes the value of clinical re-assessment to ensure appropriate management. Bang J Psychiatry 2024;38(2): 64-66