Obsessive-Compulsive disorder and criminal responsibility: clinical management of a severe OCD-hoarding case and forensic-medico-legal implications

Background. In Italian forensic psychiatry, criminal responsibility is assessed according to the presence of a total or partial “mental defect” as defined by Articles 88 and 89 of the Italian Criminal Code ^{1, 2}. Obsessive–compulsive disorder (OCD) is rarely considered central in medico-legal evaluations because reality testing is typically preserved; however, under specific conditions-severe symptom burden, partial insight, comorbidity, and intense family conflict-OCD-related phenomena may substantially compromise volitional capacity and contribute to disruptive or unlawful behaviors.
Case presentation. We describe a patient with severe contamination-focused OCD in comorbidity with Hoarding Disorder, whose symptoms markedly worsened during the COVID-19 pandemic, culminating in an episode of psychomotor agitation and hetero-directed aggression within a highly dysfunctional family context, followed by criminal reporting under Italian law. Neuroimaging and EEG were unremarkable. The patient showed partial insight, ruminative preoccupation with contamination/cleaning themes, and no overt psychosis or significant cognitive deficits. Pharmacological management required high-dose SSRI trials with poor adherence, followed by inpatient stabilization and a combined regimen including clomipramine and antipsychotic augmentation, along with psychoeducation and psychological support.
Forensic evaluation and implications. The medico-legal analysis focused on functioning at the time of the offense, symptom–conduct nexus, illness severity and persistence, comorbid hoarding with reduced insight, and the absence of alternative criminogenic drivers. The findings supported a significant impairment of volitional capacity (capacity to “will”), with preserved capacity to understand and participate in proceedings and no current social dangerousness.
Conclusions. Although OCD is not a common diagnosis in forensic caseloads, severe OCD-especially when comorbid with Hoarding Disorder and embedded in a destabilizing interpersonal environment-may become forensically relevant. Clinicians should address not only evidence-based treatment but also risk reduction, psychoeducation, and the psychiatrist’s duty of care (“posizione di garanzia”) when symptom escalation may precipitate behavioral dyscontrol.

INTRODUCTION

Obsessive-compulsive disorder (OCD) is characterized by intrusive, unwanted thoughts, images, or urges (obsessions) and repetitive behaviors or mental rituals (compulsions) performed to neutralize distress or prevent feared outcomes. While reality testing is typically preserved, OCD can be profoundly disabling, with marked deterioration in quality of life, interpersonal functioning, and occupational performanc ³. Hoarding Disorder (HD), recognized as a distinct diagnosis in DSM-5, is defined by persistent difficulty discarding possessions regardless of their value, driven by a perceived need to save items and distress associated with discarding. HD often follows an early onset and chronic course, frequently accompanied by executive dysfunction (planning, categorization, decision-making), avoidance, procrastination, and impaired organization ^4,5,6.

From a medico-legal perspective, OCD is commonly considered less relevant than psychotic or severe mood disorders because it does not usually entail loss of reality testing. Nonetheless, under specific clinical configurations-severe symptom intensity, partial or poor insight, comorbidity (particularly HD), and high interpersonal stress-OCD-related internal conflict, overwhelming anxiety, and ritual disruption may precipitate episodes of behavioral dyscontrol, including intimidation, hetero-directed aggression, or conduct that becomes legally significant. In the Italian legal framework, criminal responsibility is evaluated according to Articles 88 and 89 of the Criminal Code, which address total and partial mental defect. Importantly, forensic psychiatry does not equate diagnosis with non-imputability; rather, it assesses functioning at the time of the alleged offense, including the causal link between psychopathology and the conduct in question, with particular attention to the capacity to understand (capacity to “intend”) and the capacity to control one’s behavior (capacity to “will”) ^7,8.

This paper presents a severe OCD case comorbid with Hoarding Disorder, emphasizing clinical management, risk mitigation, and the main medico-legal implications, including the psychiatrist’s duty of care (“posizione di garanzia”) when symptom escalation may increase the likelihood of harmful behaviors.

BACKGROUND

Hoarding Disorder and OCD Comorbidity

Hoarding Disorder typically begins in childhood or adolescence, with a chronic and progressively impairing course. Clinical distress is often linked to a strong emotional attachment to objects, safety beliefs associated with possession, and inflated responsibility about the potential usefulness of items. In patients with reduced insight, impairment may be minimized or denied, becoming apparent primarily to relatives or cohabitants. Neurocognitive models frequently emphasize executive dysfunction, working memory burden, and altered fronto-limbic regulation ⁴.

Comorbidity between OCD and HD is clinically meaningful and is often associated with greater severity, broader impairment, and more rigid behavioral patterns. In some presentations, saving/accumulating behaviors may acquire ritualistic features aimed at neutralizing obsessions (e.g., contamination-related fear), thereby blending the phenomenology of OCD compulsions with hoarding-related avoidance and distress intolerance ⁹.

CASE PRESENTATION

Referral and timeline

The patient is a celibate male of 54 years old, graduated from to the Conservatory and employed as music teacher. He lives alone. He was first evaluated in July 2022. The onset of psychopathology was reported around age 25, with contamination obsessions and washing/cleaning compulsions. Initially, symptoms were intermittent and partially managed through psychological support.

Pandemic-related exacerbation

During the COVID-19 pandemic, the patient experienced a marked symptom escalation, including increased distress, functional impairment, and progressive interpersonal conflict. Hoarding behaviors intensified and became a major source of household tension. This culminated in an episode of psychomotor agitation and hetero-directed aggression in the domestic context, leading to a criminal report. The 572 article C.p.p regulates configuration of the crime of Maltreatment against family members and cohabitans. In this case, the reiteration of the crime, the most important element of patient’s behaviour has determined the legal complications.

Affective and behavioral features

No episodes consistent with primary impulse-control disorder were documented. Mood was characterized by depressive tone congruent with ideational content, in the context of chronic anxiety and family stress. The family system appeared highly dysfunctional. the patient has not agitated violence in other contexts, in the familiar environment however the patient has always found a climate of antagonism, and recognition of symptoms (van Noppen et al 1991) increasing anger and loneliness feelings and consequential acting out.

DIAGNOSTIC ASSESSMENT AND TREATMENT

Investigations: brain MRI and EEG were unremarkable.

Pharmacological treatment: an initial trial of fluvoxamine was titrated up to 300 mg/day with inadequate response and poor adherence. Due to persistent severity and risk-related instability, two voluntary inpatient admissions were required. Stabilization was achieved through combined pharmacotherapy including risperidone 3 mg/day, clomipramine 150 mg/day, and benzodiazepines as needed as titration schedule the clomipramine has been started at 25 mg every three days during hospitaliazion and Risperidone as 0, 5 ml with monitoring of ECG/QTc every three days at beginning and then once a month.The possible side effects as constipation and high plolactine blood levels, as metabolic profile have been monitoring during the time (Sthal et al.) ¹⁰.

Psychological intervention: psychoeducation and supportive psychological interventions were provided, with emphasis on symptom understanding, family accommodation, and relapse prevention CBT-ERP is the first line of treatment in OCD by modifying dysfunctional thoughts and emotions and by exposition, however with difficulties of rigid thinking. The combined approach led to partial clinical stabilization.

FORENSIC PSYCHIATRIC OBSERVATION

The forensic interview was conducted in an unstructured format and video-recorded. The patient was cooperative and oriented, with no frank psychotic phenomena. Thought processes were characterized by circumstantiality and marked perseveration on contamination and cleaning themes. Insight was partial. No significant memory impairment was detected, and no overt disinhibition was observed during the interview.

FORENSIC RELEVANCE OF SEVERE OCD

The literature describes that a subset of patients with severe OCD may develop sudden episodes of anger, affective dysregulation, and aggressive behavior-often in association with intense frustration when rituals are interrupted, coercive family dynamics, or chronic exposure to perceived threats. In forensic contexts, OCD may become relevant for:

• fitness for interrogation and the reliability/validity of statements;
• compatibility with detention conditions (risk of decompensation, self-neglect, behavioral escalation);
• evaluation of criminal responsibility and mitigating circumstances, particularly regarding volitional impairment;
• assessment of risk factors associated with symptom-driven family conflict and intimidation ^11,12.

MEDICO-LEGAL EVALUATION AND DISCUSSION

Anamnestic, documentary, and interview data supported:

• recurrent depressive disorder (to be specified: diagnosis, course, treatment);
• contamination-focused OCD with washing/cleaning rituals;
• severe Hoarding Disorder.

In Italian forensic psychiatry, functioning is paramount: even severe psychiatric diagnoses do not automatically exclude criminal responsibility. The evaluation must examine the subject’s mental state at the time of the offense and the causal relationship between psychopathology and conduct. Hoarding Disorder, especially when accompanied by poor insight and chronicity, is often resistant to treatment and may contribute to maladaptive escalation within family systems, including coercive or confrontational interactions.

In the present case, the long-standing nature of symptoms, OCD-HD comorbidity, partial response to treatment, and need for inpatient care supported a structured and entrenched clinical picture. Medico-legal reasoning emphasized that obsessions may impose themselves against the individual’s will and that compulsive pressure, combined with distress intolerance and partial insight, may particularly compromise the capacity to will, while the capacity to understand may remain relatively preserved. When symptoms take on egosyntonic features, critical appraisal may decline further, with a consequent reduction in behavioral flexibility ^{13, 14,15,16}.

Elements supporting a partial mental defect at the time of the offense included:

1. severe and active psychopathology at the time of the alleged conduct;
2. absence of antipsychotic augmentation before the index event;
3. documented need for continuous specialist care;
4. partial and fluctuating response to subsequent treatments;
5. lack of alternative criminogenic drivers or primary antisocial trajectory. In the clinical history in this case, in fact, It is not present history of antisocial episode during adolescence and time or other conduct disorders and legal implications.

Overall, the evaluation supported a significant impairment of volitional capacity consistent with partial mental defect (Art. 89 c.p.), preserved capacity to participate in proceedings, and absence of current social dangerousness.

CONCLUSIONS

Although OCD is not frequently central in forensic caseloads, severe OCD - particularly when comorbid with Hoarding Disorder, partial insight, and destabilizing environmental factors - may lead to clinically and legally relevant behaviors. Clinicians should combine evidence-based pharmacotherapy with structured psychoeducation, risk mitigation, and a well-defined care network, recognizing the psychiatrist’s duty of care when symptom escalation increases the likelihood of harmful acts. In parallel, forensic experts must ground their conclusions in a rigorous analysis of functioning at the time of the offense, risk factors, and the causal nexus between symptoms and conduct, which remain indispensable for criminal responsibility assessment.

Conflicts of interest statement

The authors declare that they have no conflicts of interest related to this manuscript.

Funding

This research received no external funding.

Authors’ contribution

C. Ceparano, F. Domestico, D. Formisano, L. Iacuaniello, D. Silvestro, A. Tramontano, C. Tucci, M. Boccardi: conceptualization, literature review, clinical and forensic-medico-legal data interpretation, manuscript drafting, critical revision of the manuscript, and final approval of the version to be published.

Ethical consideration

The manuscript was prepared in accordance with ethical standards for case-report publication. All clinical and medico-legal information was anonymized to protect patient confidentiality. No identifiable personal data are reported. The study did not involve experimental procedures or interventions beyond routine clinical and forensic-medico-legal assessment.