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.