Abstract
Follow-up studies of patients with an initial diagnosis of obsessive–compulsive disorders found that a relatively high percentage of them developed delusion in the course of the illness [1]. These delusions do not signify a schizophrenic processes and are generally transient. In this group of patients, the cardinal features of insight and resistance may be minimally present. For instance, patients may recognise the obsession as ego-dystonic and irrational, but they fail to struggle against their urges and thus become incapacitated by the symptoms. Insel and Akiskal [1] described this group of patients as having ‘obsessive–compulsive psychosis’. We present here a case of severe obsessive–compulsive disorder who falls into this category.
A 49-year-old married supervisor presented to the psychiatric clinic with 2 months history of fearfulness in relation to the number 3 and other numbers consisting of the numeral 3. He would stop or avoid all activities associated with these numbers. His daily activities were restricted and he was almost house-bound. He could not drive properly because he would stop driving or drive his car very fast when he encountered certain times such as 8.03, 8.13, and 8.31. He was also scared to pass road signs such as those showing 30 km/h speed limit. He would not eat because he was scared that it would coincide with the ‘bad times’; sometimes he ate fast to avoid such times. He lost about 10 kg in 2 months. He became aggressive if somebody forced him to cease these activities. He also had poor sleep, lost interest in daily activities and neglected his personal hygiene.
The problem started following the Security Commission investigation for his alleged involvement in cheating the balloting process of the initial public offer (IPO) of several listed companies in the Kuala Lumpur Stock Exchange about 5 months ago. Following this, his bank account was frozen. Three months later, while watching his watch in a state of frustration, he could not resist the thought that he would be ‘in trouble’ if he fought against the numbers 3 and 13. Since then he completely lost the ability to resist these thoughts and he was scared to fight against number 3 and other numbers related to it. He believed that 3 and 13 were bad or unlucky numbers. He also believed in superstitions, although he knew that this was against Islamic teaching.
Mental status examination revealed a restricted affect. His personal hygiene was poor. He had persecutory delusion toward number 3 and other related numbers. There was no perceptual disturbance. His attention, concentration, judgement and insight were poor. The diagnosis of obsessive–compulsive disorder with poor insight was entertained [2]. He was subsequently admitted and treated with perphenazine and fluvoxamine in addition to a behaviour modification program. He slowly regained the confidence to fight against the ‘bad numbers’. He was discharged well after 2 months in hospital.