Is It Possible to Have OCD and Psychosis?

Although severe OCD may resemble psychosis, the truth is more complex. In other words, you can exhibit behaviors that look a lot like psychosis without having the true (diagnosable) form of psychosis.

What does that mean? It means you can exhibit psychotic behaviors – with OCD. This means that while you are displaying psychotic behaviors, your true mental health condition is severe OCD. For instance, ritualistically checking one’s front door several times before going to work is not “psychosis.” Why not? Because, the person realizes there is a difference between his or her thoughts and reality.

However, the thought of someone possibly breaking into the person’s home if the door is unlocked is so relentless that he or she feels compelled to check and recheck the front door until he or she feels like the house is secure. Checking the front door over and over again is annoying. It also causes this person to rush to get to work on time, but the urge is too strong.

Still, this person is “aware” that the behavior (obsessing over the security of the house and checking the front door multiple times) is useless and probably unnecessary, because a locked door will not prevent robbers from entering his or her home, if that is what they want to do. But, this person performs the action anyway to give him or her a “peace of mind.” There is an “awareness” there that is typically not present in psychosis.

What is Psychosis?

• Progressively jumbled and confused thinking
• Mental confusion
• Visual and auditory visions (hallucinations)
• Magical or unrealistic thoughts (delusions)

Understand that psychosis typically presents over time with the signs slowly indicating that a mental illness is emerging. These signs may involve a lack of hygiene, inappropriate emotions and insensitive reactions, mental confusion, inattention, an inability to decipher or understand one’s thoughts, poor work or school performances (i.e. productivity and quality), emotional detachment, and/or paranoia or suspicion.

Note: When asking if OCD can exist with psychosis, the more appropriate discussion should center on if OCD can accompany psychotic features. In which cases, yes, it can. However, psychotic features do not equate to having a full-blown diagnosable psychotic disorder like schizophrenia.

Dan’s Story

Dan was a “college kid” when his OCD became severe. He was approximately 1500 miles away from his mother, Janet, at the time. Janet scheduled an appointment for him to see a psychiatrist near his college. With Dan’s permission, the psychiatrist phoned Janet after the consultation and told her that Dan was not only suffering from severe OCD, but was also “borderline psychotic.”

Janet didn’t know the exact definition of psychosis at the time, but what she did know frightened her. She knew that it meant being “out of touch with reality.” In her mind, “borderline psychotic” meant that her son was suffering from schizophrenia. He was not. The psychiatrist did not mention schizophrenia or any psychotic disorder for that matter.

Once Janet arrived at the college, she and Dan met with the psychiatrist together – and the psychiatrist no longer believed that Dan had “borderline psychosis.” So, what was going on? What Janet’s son was experiencing was “OCD with poor insight or psychotic features” – not a true psychotic disorder.

OCD vs. Psychosis

For instance, Lucy is a beautiful, college-educated “social butterfly,” who truly believes that she is an ugly woman, who no one could love. Deep down inside, Lucy knows that isn’t true. She’s not a hideous unlovable monster, however, she can’t get these thoughts out of her mind. She has become obsessed with the belief that she’ll never get married or have the family she dreamt of.

As a result, she spends hours on her appearance each day to “make herself more appealing to others” (compulsions). Lucy cannot leave her house until she has “perfected” her appearance, because of a fear that others will shun her if they see the real her. Lucy realizes that she’s doing too much, but it eases her mind and calms her fears so she continues to do it. This is OCD.

On the flipside, Jim is a 20-something college student, who recently dropped out of school because he truly believes he is Nostradamus and can predict future events. In Jim’s mind, school is a waste of time because he already has all the answers to life. He believes he’s been alive for centuries and that he was sent from God to warn others about the end of time. Jim starts a “cult” and amasses 30 followers. He “tours” the US preaching about the error of human ways and the end of the world. This is psychosis. Jim can’t tell magical thinking from reality.

Understand, however, that if extreme OCD is left untreated, it can trigger psychosis in some people, especially if the person with OCD experiences chronic stress, emotional distress, anxiety, trauma, depression, or insomnia. But, this is rare. Because OCD treatments typically involve SSRIs, CBT, and/or antipsychotics aimed at reducing or eliminating intrusive thoughts (“mental tics”) and controlling psychotic behaviors. Thus, “OCD with psychotic features” is largely uncommon.

What Does “OCD with Poor Insight or Psychotic Features” Mean?

These individuals also realize that their behaviors are disrupting their lives and causing a host of problems (i.e. dry, cracked hands). But, they are unable to resist the urge (compulsion), so they continue to repeatedly wash their hands until they crack and bleed. Doing this eases their stress, fears, and anxiety.

So what does “OCD with poor insight or psychotic features” mean? Well, people with this condition do not believe that their inner thoughts and behaviors are necessarily illogical. As a result, they may view their obsessions and compulsions as “normal,” when they are not. These individuals may truly believe that these behaviors are necessarily to avoid harm.

According to the DSM-V, a person with OCD may be characterized as having “good insight,” “fair insight,” “poor insight,” or “absent insight/delusional thoughts.” Previous DSMs required that the individual have an “awareness” that their intrusive thoughts, images, fears and ritualistic behaviors (compulsions) are unfounded, possibly unnecessary, and irrational to be diagnosed with OCD.

The latest version of the DSM, the DSM-V, however, states that the individual can have “absent insight/delusional thoughts ” or psychotic features” and still be diagnosed with OCD. The previous criteria that stated that the individual must, at some point, recognize that his or her obsessions and compulsions are “extreme” or “unwarranted” to be diagnosed with OCD was removed from the DSM-V.

Keep in mind, however, that the degree of insight that people with OCD have fluctuates or varies, depending on the situation. For instance, at first Dan had “OCD with good insight.” He was “aware” that his obsessions and compulsions were unrealistic and highly unlikely to actually occur.

However, by the time Dan met with the psychiatrist, his OCD symptoms had worsened, causing him to have “OCD with poor insight or psychotic features.” That is why the psychiatrist originally diagnosed Dan with OCD and borderline psychosis. Later, the psychiatrist realized that Dan had “OCD with poor insight or psychotic features.”

So, as you can see, the degree of insight a person with OCD has can change. For instance, Mark, logically discussed a specific obsession (like making sure everything is neat and orderly) and compulsion (like his incessant need to constantly organize things) with his doctor.

During the session, he even acknowledged that his thoughts were not logical and his actions were unnecessary. However, 30-minutes later, he reverted back to illogical, irrational, and delusion thinking patterns. Once Mark got home, he was exposed to a “trigger.” A knife that is out of place in the drawer. The missing knife caused him to panic.

He truly believed that his wife, Belle, hid the knife and was planning to stab him to death once he fell asleep. So, Mark forced himself to stay awake because, in his mind, if he fell asleep his wife would kill him. This is “OCD with poor insight or psychotic features.”

Eric’s Story

Eric, a 20-year-old, has been feeling very nervous, worried, and anxious for the past few months. He admitted experiencing anxiety and fear, every so often, but, it usually went away within seconds. However, one day it did not go away. In fact, Eric, sweating profusely and crippled by fear, experienced a full-blown panic attack. He was afraid for his girlfriend, Samantha. He truly believed that there were “evil forces” outside that wanted to hurt her.

Eric begged her to stay home with him, but she refused. She had to go to work and she knew that there was nothing out there that would harm her. But, Eric was not convinced. She left and he locked the door and closed the blinds and curtains. He began taping the windows up with black tape to keep the “bad things” out. He also started cleaning because the “bad things” would happen if his home became “infected.”

After 6 hours and once he had completely sanitized and closed off his house, his panic attack started to subside, however, he was still on high-alert. Everything felt unreal to Eric but he couldn’t put into words why it felt that way. He grabbed his pistol and sat on the couch – waiting. He was tired and needed to sleep, but was unable to because he believed that if he fell asleep his house would get dirty and the evil would come inside.

So, he gots up and started cleaning again. He was experiencing disorganized thinking. He was confused. Eventually, Samantha came home from work, but was unable to enter the residence. Eric had pushed furniture up against the door as a barrier. He heard her knocking, but was unsure if he should let her in. Maybe it wasn’t not her. Maybe it was a clone. She had been “outside,” after all. He decided to clean his home again, because it was the only thing that eased his anxiety.

Samantha waited outside until Eric had finished cleaning and opened the door. Once inside, Eric instructed her to take a shower and throw out her clothes because they were “tainted.” Samantha, unable to take anymore of Eric’s delusions, left. This threw Eric back into a spiral and he began to vigorously clean again.

What if Samantha brought dirtiness and evil inside of his home? Exhausted, he passed out. When he awakened the next day, he looked around at his black-taped, closed curtain, dark home and winced. He placed his hands on his head and looked down at the ground. He noticed a speck of dirt and the cycle began again. Eric needed help, but was too afraid to tell anyone because he knew his thoughts and behavior were irrational.

So, was Eric suffering “OCD with psychotic features” or was he experiencing a full-blown psychotic disorder? Most likely, Eric was experiencing “severe OCD with psychotic features.” Why? Because at times he realized that his behavior was unrealistic and unreasonable.

Are OCD and Psychosis Connected?

Also, like OCD, psychosis can involve disorganized thinking. Why does this happen? This occurs when brain functions (the direct and/or indirect pathways of the basal ganglia) are disrupted. Basal ganglia pathways are important because they play a significant role in thought processes and movement.

It is important to distinguish between OCD and a psychotic disorder because the medications typically prescribed for psychosis (antipsychotics) may induce or aggravate OCD in some individuals. Haloperidol (Haldol) is a common antipsychotic medication that can “activate” the indirect pathway of the basal ganglia. So, if a person takes too much of it, it can negatively affect his or her thought processes (delayed or slowed thinking) and movement. This could be mistaken as OCD when it is actually a side-effect of the medication.

Studies suggest that antipsychotics are ineffective for severe OCD. In fact, researchers have concluded that for some people, antipsychotics can actually worsen OCD, leading to a host of serious physical and psychological side-effects. Thus, it is important that people with OCD, their loved ones, and the general public understand that it is possible to be misdiagnosed as having OCD and a psychotic disorder when in actuality, the person has “OCD with psychotic features or poor insight.”

So, the best way to address OCD and psychosis concerns is to first treat the OCD, and then, reexamine the situation. Once the OCD has been controlled, you may be surprised to discover that the person doesn’t really have a psychotic disorder – even if they appear to have one.

But, although OCD and psychosis can be connected, the primary difference between the two conditions is the presence of “awareness.” People who struggle with psychosis have experienced a break with reality. For instance, a person with a psychotic disorder honestly believes that his or her thoughts, images, urges, and behaviors are real and valid.

There is no “awareness” that these thoughts, images, urges, and behaviors are illogical or unreasonable. On the flipside, people with OCD are often aware (on some level) that what they are feeling, thinking and doing is unrealistic and irrational. And, although both conditions can involve problems with intrusive thoughts, hallucinations, delusions, and repetitive behaviors, people with a psychotic disorder may experience disturbing thoughts that manifest in peculiar language and loose associations.

How is “OCD with Poor Insight or Psychotic Features” Treated?

• Psychotherapy

  Psychotherapy may involve individual therapy, family therapy, and/or group therapy. The most common psychotherapy is cognitive-behavioral therapy (CBT). Individual, family, and/or group CBT can help you identify illogical and unrealistic thoughts, urges, and fears (obsessions) and unhealthy and destructive emotional responses (compulsions).

  A recent study found that CBT is highly effective in the treatment of anxiety disorders like OCD. Researchers concluded that its most beneficial component is exposure therapy for people experiencing extreme anxiety.

• Antidepressants and Antipsychotics

  Antidepressants and antipsychotics are used to ease OCD symptoms and reduce or eliminate the psychotic features. Common antidepressants include: Anafranil (clomipramine), Prozac (fluoxetine), Fluvoxamine, Paxil & Pexeva (paroxetine), and Zoloft (sertraline).

  

  In some cases, mental health professionals may also prescribe antipsychotics. Although, research suggests that these medications do not work well for people with severe OCD. Common antipsychotics include: Haldol (haloperidol), Loxitane (loxapine), Mellaril (thioridazine), Moban (molindone), Trilafon (perphenazine), Thorazine (chlorpromazine), Abilify (aripiprazole), Clozaril (clozapine), Risperdal (risperidone), Seroquel (quetiapine), and Zyprexa (olanzapine).

• Adjunctive Treatments

  Adjunctive treatments like exposure-based therapies and eye-movement desensitization and reprocessing (EMDR) can be used to treat “OCD with psychotic features.” These types of adjunctive therapies help reduce the intensity of the “trigger” or obsession, so you don’t feel compelled to perform certain actions to ease your stress, fear, urges, or intrusive thoughts.

• Holistic/Alternative Treatments

  Holistic/alternative treatments, primarily derived from Eastern practices, are often used to treat OCD, especially “severe OCD with psychotic features.” Mindful meditation, yoga, guided meditation, herbal supplements, CBD, acupuncture, and massage therapy can ease your stress and encourage calmness and relaxation.

In Summary

In this case, the psychosis is not the same as a true psychotic disorder. Regardless of the origin of the OCD, it is imperative that you receive a proper diagnosis and treatment for the psychotic features. Thus, it is quite possible for a person with severe OCD (that is untreated) to experience symptoms of psychosis.

Understand that the nature of OCD with psychotic features is different from a diagnosable psychotic disorder like schizophrenia. Severe OCD does not only trigger psychotic features, it can also exacerbate a person’s emotional distress. Moreover, OCD symptoms may actually worsen as a result of the psychotic features (symptoms). Thus, even if you have OCD-related psychosis that does not mean you have a true psychotic disorder. Still, more research is needed to find the best way to treat “OCD with psychotic features.”

References

• Good Therapy. (2020). Typical and atypical antipsychotic agents. Retrieved from https://www.goodtherapy.org/drugs/anti-psychotics.html
• Mayo Clinic. (2020). Obsessive-compulsive disorder (OCD). Retrieved from https://www.mayoclinic.org/diseases-conditions/obsessive-compulsive-disorder/diagnosis-treatment/drc-20354438
• Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A. J., & Hofmann, S. G. (2018). Cognitive-behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials. Depression Anxiety, 35(6), 502-514. Retrieved from https://pubmed.ncbi.nlm.nih.gov/29451967/
• Biria, M., Huang, F. X., Worbe, Y., Fineberg, N. A., Robbins, T. W., Fernandez-Egea, E. (2019). A cross-sectional study of impact and clinical risk factors of antipsychotic-induced OCD. Eur Neuropsychopharmacology, 29(8), 905-913. Retrieved from https://pubmed.ncbi.nlm.nih.gov/31303266/
• National Institute of Mental Health. (2020). What is psychosis? Retrieved from https://www.nimh.nih.gov/health/topics/schizophrenia/raise/what-is-psychosis.shtml
• Insel, T. R. & Akiskal, H. S. (1986). Obsessive-compulsive disorder with psychotic features: A phenomenological analysis. Am J Psychiatry,143(12),1527-33. Retrieved from https://pubmed.ncbi.nlm.nih.gov/3789205/
• Matsunaga, H., Kiriike, N., Matsui, T., Oya, K., Iwasaki, Y., Koshimune, K., Miyata. A., Stein, D. J. (2002).Obsessive-compulsive disorder with poor insight. Compr Psychiatry, 43(2),150-157. Retrieved from https://pubmed.ncbi.nlm.nih.gov/11893994/
• Marsden, Z., Lovell, K., Blore, D., Ali, S,. & Delgadillo, J. (2018). A randomized controlled trial comparing EMDR and CBT for obsessive-compulsive disorder. Clinical Psychology Psychotherapy, 25(1), e10-e18. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28752580/
• Benito, K. G., Conelea, C., Garcia, A. M., & Freeman, J. B. (2012). CBT Specific Process in Exposure-Based Treatments: Initial Examination in a Pediatric OCD Sample. Journal of Obsessive-Compulsive and Related Disorders, 1(2), 77–84. Retrieved from https://doi.org/10.1016/j.jocrd.2012.01.001
• Singer, J. (2018). The connection between OCD & psychosis. Psych Central. Retrieved from https://psychcentral.com/lib/the-connection-between-ocd-psychosis/
• American Psychiatric Association. (2020). What is obsessive-compulsive disorder (OCD)? Retrieved from https://www.psychiatry.org/patients-families/ocd/what-is-obsessive-compulsive-disorder
• Legg, T. (2020). What is considered a psychotic disorder and is that term appropriate? Healthline. Retrieved from https://www.healthline.com/health/psychotic-disorder
• Grohol, J. M. (2013). DSM-5 changes: Obsessive-compulsive and related disorders. Psych Central. Retrieved from https://pro.psychcentral.com/dsm-5-changes-obsessive-compulsive-and-related-disorders/