patients with obsessive compulsive disorder ( ocd ) have been traditionally described as having a good insight into their symptoms ; they perceive their obsessive - compulsive ( oc ) symptoms as excessive , unreasonable , and distressing .
the dsm iv field trial demonstrated that about a quarter of the patients were uncertain about whether their symptoms were unreasonable or excessive , indicating that a broad range of insight exists among patients with ocd .
it is now well - recognized that patients with ocd may present with varying degrees of insight , including poor and complete lack of insight into their oc symptoms.[24 ] pathological beliefs appear to be placed along an 
symptom component properties , they determine obsessions at one end , where beliefs are recognized as irrational .
overvalued ideas lie somewhere in the middle , and delusions where the beliefs are considered rational , lie at the other pole .
it can be a phenomenological challenge when the thin line of separation between these becomes difficult to discern .
ms . s , a 35-year - old , married lady presented with a one - year history of marked social withdrawal , muttering to herself , and suspiciousness . on clarification with her husband regarding her  suspiciousness it was found that she kept enquiring from him whether their acquaintances had visited her or not , subsequently she would report about her belief that she felt her acquaintances were not visiting her often , and hence , they could possibly be cheating her , but would not elaborate further .
she firmly held on to these beliefs in spite of her husband telling her otherwise . for the last two weeks
there had been a worsening of illness , characterized by crying spells , along with two suicidal attempts of high intentionality and lethality . after hospitalization , she was found to be tearful and withdrawn , reported of being fearful and expressed death wishes .
an initial impression of psychosis , with a phenomenological inference of delusion of persecution , was made as per the longitudinal course of the illness from the available information , and she was started on tablet risperidone 2 mg .
she continued to express fearfulness and did not show much improvement with risperidone . during the course of hospitalization
, she was noticed to be repeatedly asking others to forgive her for  a mistake she had committed . on further clarification
, she elaborated that she had been getting repeated thoughts that she had done something wrong , which could be the reason for her feeling that her acquaintances were not visiting her often .
suspicious behavior. she would get these repetitive , anxiety provoking thoughts so often that she started wondering whether she had actually done something wrong .
the level of conviction regarding this thought was quite high and she did not feel that this thought was in anyway irrational . hence , she had started feeling 
, she would constantly ask reassurance from others , would check with her husband as to why a particular acquaintance had not visited her , and would keep repeatedly muttering to herself about this issue .
the thoughts were very repetitive , stereotyped , and distressing , while they remained uncontrollable .
as the frequency of these thoughts increased , she started feeling sad throughout the day , along with ideas of hopelessness , guilt , and suicidal ideas .
subsequently , her diagnosis was revised to obsessive compulsive disorder ( ocd ) , with obsessions of intrusive thoughts / images and compulsion of reassurance seeking as denoted in the yale brown obsessive compulsive scale ( ybocs ) symptom checklist .
the ybocs obsession score was 16 and compulsion score was 10 ( ybocs total score of 26 ) .
she was started on fluoxetine 20 mg / day , which was increased to 40 mg per day in a week .
after two months follow - up , she had significant improvement in her symptoms with the ybocs total score decreasing to 10 .
this case demonstrates the importance of eliciting psychopathology in greater detail for specific diagnosis and treatment decisions , especially in the absence of a clear history .
the presentation of the case with suspiciousness as the major symptom raised the possibility of psychosis .
as there was no morbid illogical reasoning for the belief / thought , delusion was ruled out . additionally , the repetitive nature of the thought , which was stereotyped , causing severe distress , pointed toward a possibility of obsessions .
this was supplemented by the compulsive nature of reassurance seeking , which provided some temporary relief to the anxiety caused by the thought . however , the difficulty here was the lack of insight of the patient into this thought phenomenon . even though traditionally viewed as a condition with , 
egodystonic thoughts recognized as illogical by patients , ocd could present with lack of insight .
furthermore , depressive ruminations were usually associated with negative emotions regarding some past event , while in this case the event appeared like an intrusive meaningless thought when it originated .
insight in ocd had therapeutic implications such as poorer response to medications and prognostic implications , wherein , schizophrenic spectrum symptoms could lead to worse prognosis .
the continuity model between obsessions , overvalued ideas , and delusions seems to be more satisfactory , although it calls for a careful analysis of the phenomenon in clinical settings , for prudent treatment choices .
 obsessive compulsive disorder ( ocd ) is commonly regarded as a disorder with good insight . 
 however , it has now been recognized that insight varies in these patients . 
 pathological beliefs seem to lie on a continuum of insight , with full insight at one end and delusion at the other . 
 this can indeed pose a considerable challenge , especially in a scenario where the phenomenon is difficult to discern . 
 we report a case of ocd , which was initially diagnosed as psychosis . 
INTRODUCTION
CASE REPORT
DISCUSSION