Towards the DSM-6: The intersection of OCD and psychosis. Expert perspectives on insight in the diagnosis of OCD.

In 1994, the DSM-IV added the specifier "with poor insight" to the diagnostic criteria of obsessive-compulsive disorder (OCD). The DSM-5 went one step further and now allows clinicians to diagnose OCD "with absent insight/delusional beliefs," thereby blurring the long-standing distinction between OCD and psychosis. The present study surveyed OCD experts as to their opinions on the insight specifier and the future classification of OCD. The final sample comprised 60 OCD experts, with a subgroup of 35 experts with verified identity and at least 6 years of clinical and/or research experience ("verified experts"). While most experts supported the inclusion of the insight specifier for OCD, verified experts were split on the question of whether, in the case of full absence of insight, a diagnosis of OCD should be accompanied by an additional diagnosis (e.g., delusional disorder). A relative majority of the full sample (48.4 % yes vs. 36.7 % no) and an absolute majority of verified experts (51.4 % vs. 34.3 %) recommended removing the term "delusional beliefs" as a specifier; most were concerned that including delusional beliefs as a symptom of OCD might foster the prescription of antipsychotics and skepticism about the efficacy of psychotherapy for OCD. An absolute majority (56.7 % of full sample, 60.0 % of verified experts) agreed that at least some doubt or partial insight into the excessiveness of one's obsessional beliefs should be present for a diagnosis of OCD. In addition, most experts opposed the reclassification of OCD as an anxiety disorder. Looking ahead to the development of the DSM-6, we recommend that (1) the criteria should emphasize that full absence of insight is rare in OCD and that (2) the term "delusional beliefs" should be dropped.