The relationship between insight and control in obsessive-compulsive disorder: implications for the insanity defense

In this paper the authors examine the relationship between insight and control in patients with obsessive-compulsive disorder (OCD) in an effort to better understand the concept of volitional control of behavior especially as it relates to changes in the insanity defense that were recommended by the American Psychiatric Association (APA), specifically that the volitional prong be dropped. Yale-Brown Obsessive Compulsive Scale ratings in 56 subjects with OCD were reviewed with specific attention to items measuring the patients' subjective sense of decreased volitional control over their compulsions and their insight into their behavior. No statistically significant correlation was found between the control over compulsions item and the insight item. The authors conclude that the experience of volitional control in patients with OCD is not significantly related to the level of insight they have into the irrationality of their behavior. The authors then review cognitive therapy literature and show that though cognition and volition may appear to be dissociated in some disorders, even in the absence of insight, a relatively gross measure of legally relevant cognitive disturbance, subtle cognitive changes can be identified in patients with seemingly purely volitional disorders such as OCD.