Understanding Insight and Its Role in OCD

Insight is an important component of understanding obsessive-compulsive disorder (OCD). When someone is unable to recognize or acknowledge that their OCD symptoms are irrational, it presents a major challenge for patients, treatment providers, and family members.

Here's how insight impacts the diagnosis and treatment of OCD.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), one of the diagnostic criteria for OCD is that at some point in time, a person has recognized that the obsessions or compulsions they experience are “excessive or unreasonable.”

However, people who treat and study OCD have observed that people with the condition do not always recognize or agree that their obsessions and compulsions are irrational.

In reality, it seems that insight exists on a continuum. Some people completely acknowledge that their symptoms do not make sense, while others have 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" (a person views their OCD symptoms as completely rational and true).

Insight also pertains to how a person views OCD in their day-to-day life. Someone with OCD may recognize the irrationality of their obsessions and compulsions but fail to understand or acknowledge that OCD has affected their ability to function.

They may struggle at work or school and have issues with responsibilities at home that can be frustrating for family members.

Children with OCD are a unique situation as they usually don't have as much insight into their symptoms as adults do. Children simply lack the necessary life experience for a high level of insight and are often unable to grasp the irrational nature of their thoughts or behaviors.

Parents and therapists can work together to help a child with OCD gain a different perspective on their symptoms.

While there is some disagreement, poor or absent insight into OCD symptoms is thought to predict a worse response to psychological and medical treatments.

Poor or absent insight can make it harder for someone with OCD to feel motivated, do the hard work that therapy requires, or stick to taking medication (especially if there are unpleasant side effects).

People with poor insight may also be less likely to attend regular appointments or contact a healthcare provider at all.

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, a person may come to question these beliefs or behaviors over time.

Insight can also change with a person's situation. 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.

Insight into OCD symptoms and the effect they have on functioning can also change after treatment with psychotherapy or medication. However, these changes usually occur slowly and can also fluctuate over time.