Understanding Insight and Its Role in OCD

Not being able to recognize or acknowledge that OCD symptoms are irrational, commonly referred to as insight by mental health professionals, can present a major challenge for patients, treatment providers and family members. How does insight impact the diagnosis and treatment of OCD?

According to the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, one of the diagnostic criteria for OCD is that the person at some point in time has recognized that the obsessions or compulsions they experience are “excessive or unreasonable.” This acknowledgment of the irrational nature of the OCD symptoms has been coined "insight."

However, people who treat and study OCD have observed that people with OCD do not always seem to recognize or agree that their obsessions and compulsions do not make sense. In reality, it seems that insight into OCD symptoms exists on a continuum, with some people completely acknowledging that their symptoms do not make sense, and others having a very strong belief in the validity of their obsessions and compulsions. For this reason, the DSM-5 has been modified to include distinctions in levels of OCD insight, including "good or fair insight," "poor insight," and "absent/insight delusional," which means sufferers perceive their OCD symptoms as completely rational and true.

It is important to note that there are also situations where people with OCD recognize the irrationality of their specific obsessions and compulsions, but do not appear to understand or acknowledge the impact of OCD on their ability to function either at work or at home. This can be especially frustrating for family members.

A special situation is children with OCD since they typically don't have as much insight into their symptoms as adults simply because of their lack of life experience and are often unable to grasp the irrational nature of their thoughts or behaviors. Parents and therapists can often work together to help children get a different perspective on their symptoms.

Although there is some disagreement, poor or absent insight into OCD symptoms is generally thought to predict a worse response to both psychological and medical treatments for OCD. Poor or absent insight may make it difficult for the affected person to get up the motivation to do the hard work that therapy requires or to stick with taking a medication daily, especially if there are initial side effects that are unpleasant. People with less insight may also be less likely to attend regular appointments or to contact a healthcare provider in the first place.

In addition, it should also be kept in mind that insight into the excessive or unreasonable nature of obsessions and compulsions can fluctuate over time. For example, while obsessions or compulsions may at first seem completely reasonable or even helpful, over time the person may come to question these beliefs or behaviors.

Insight may also change from one situation to another. For instance, while someone with OCD may be perfectly able to acknowledge that their obsessions and compulsions do not make sense while sitting in the therapist's office, they may nevertheless feel they have to engage in these behaviors or thoughts when confronted with the actual feared situation. So, while someone may have intellectual insight, they may lack emotional insight.

Although difficult, insight into symptoms or their day-to-day impact can also change after treatment with either psychotherapy or medication. However, these changes usually occur slowly and can fluctuate over time.