OCD and Schizophrenia: The Similarities, Differences, and Concurrent Presentations
OCD and schizophrenia are unique disorders with separate symptoms and presentations. But they share certain causes and risk factors and they cooccur roughly 12% of the time.
This article will explore the details of each as well as what makes them similar and the important differences.
First up, OCD!
The Specifics of OCD
OCD, or Obsessive Compulsive Disorder, is a neurobiological mental illness marked by intrusive, egodystonic, and anxiety-provoking thoughts (obsessions) and simple or complex rituals aimed at modulating discomfort (compulsions).
OCD presents in cycles, which is why it’s a disorder marked by repetition. The most classic example of an OCD cycle appears in compulsive handwashing. For example, someone with Contamination OCD who suffers from intrusive thoughts surrounding germs may fear that their hands are contaminated because they touched a public doorknob. In an effort to regulate this anxiety, they will wash their hands vigorously (sometimes using scorching hot water or bleach). This reduces their anxiety and brings them comfort.
Unfortunately, this relief is always short-lived; sometimes, the fear returns in a matter of seconds. For instance, someone who touches a public doorknob might walk into a bathroom and compulsively wash their hands. But, as they go to leave, their OCD may convince them that their hands still aren’t clean or that they didn’t scrub thoroughly enough. This compels the OCD sufferer to return to the sink and rewash. It’s not unusual for those with OCD to get “stuck” inside washrooms, scrubbing over and over again.
Other times, the compulsion is successful in reliving the anxiety of the original thought but the fear returns because of something else. For example, someone who compulsively washes their hands after touching a public doorknob may feel assured that their hands are clean. But their contamination fears will return if they grab a handle on a city bus, touch a counter at a deli, or push a shopping cart across a grocery store parking lot. Once these fears reappear, the sufferer engages in compulsive washing again. As a rule, OCD is never satisfied. In other words, no amount of washing results in continuous reassurance.
The OCD cycle is a vicious and life-interfering one and the fears are so powerful that OCD sufferers will ignore their responsibilities and everyday practicalities (such as going to school or arriving on time for work) in order to perform their rituals.
But the OCD cycle isn’t merely time-consuming; it’s empowering to the underlying disorder. Each time someone with OCD engages in their compulsions, they validate their intrusive thoughts, buying into OCD’s lies and making the condition worse. Compulsions might provide temporary relief but they provide long-term damage along the way.
The “Flavors” of OCD
While OCD is largely believed to be a disease that involves a preoccupation with illness, germs, or organization, that’s only part of the story (and, in many cases, it’s none of the story). Some people suffer from “flavors” of the disorder that have nothing to do with germs or tidiness.
Overall, some of the most common types of OCD include:
- Contamination OCD: This involves intrusive thoughts of germs and contamination
- Self-Harm OCD: This involves intrusive thoughts of harming one’s self
- Harm OCD: This involves intrusive thoughts of harming others accidentally or intentionally
- Scrupulosity OCD: This involves intrusive thoughts of committing blasphemy or hating God
- Sexual Orientation OCD: This involves intrusive thoughts of being homosexual (when straight) or heterosexual (when gay)
- Health Anxiety OCD: This involves intrusive thoughts of illness
- Relationship OCD: This involves intrusive thoughts of a spouse or partner leaving
- Pedophilia OCD: This involves intrusive thoughts of sexually harming children
- Just Right OCD: This involves intrusive thoughts of something bad happening because things are not right, symmetrical, or perfectly aligned
The intrusive thoughts experienced by people with OCD are found in the general population as well. The difference is that OCD sufferers take these thoughts seriously while those with normal brains discard them as nonsense.
The meaning applied to these thoughts by OCD sufferers triggers the thoughts to appear more often and more potently.
What Causes OCD?
OCD has no main cause (or at least not one that is yet known). It’s believed to be the result of several interweaving factors, including:
Genes: 25% of people with OCD have an immediate family member who has it. Having an immediate family member with autism also increases the risk for OCD.
A hyperactive amygdala: The amygdala is the part of the brain that scans the environment for threats. When it’s overactive, it perceives threats when no threats exist or amplifies low-risk events (two things omnipresent in OCD).
Abnormal brain structures: Studies suggest that those with OCD are more likely to have decreased grey matter volume in the frontal eye fields, medial frontal gyrus, and the anterior cingulate cortex. They are also more likely to have increased grey matter in the lenticular nucleus, the caudate nucleus, and a small area of the right superior parietal lobule.
Abnormal brain function: In the OCD brain, there is often impaired communication in the frontal parts of the brain as well as the deeper parts.
Low levels of certain neurotransmitters: OCD sufferers often have lower-than-normal levels of dopamine and serotonin. They may also have a mutation in hSERT, the serotonin transporter gene.
High levels of glutamate: Though a relatively new suspected cause of OCD, there is some evidence that people with OCD have naturally higher levels of glutamate and that glutamate-free diets may help control symptoms. Too much glutamate is linked to amplified pain, anxiety, and restlessness.
Learned behavior: While not a technical “cause” of OCD, the compulsions sufferers engage in (a type of learned behavior), solidifying it as a disorder. This is because compulsions keep the cycle going; effectively, OCD needs the obsession-validating rituals in order to survive.
In addition to the above, OCD sufferers have brains especially prone to dysfunctional beliefs. These include:
- Hyperresponsbility: Those with OCD believe and/or fear that they are responsible for things outside their control.
- Perfectionism: Perfectionism is found in about a third of the general population and in nearly everyone with OCD (at least to some degree).
- A desire to control thoughts: Any attempt to control OCD thoughts tends to make the thoughts worse.
- Thought-action fusion (magical thinking): This is the belief that thinking about something is the same as doing it or the belief that something can happen simply because you thought about it.
- Manufacturing threats: People with OCD not only see threats when no threats exist but they also significantly overestimate the danger of legitimate threats. For example, going to dinner during a pandemic is a risk but, in the OCD mind, this risk may translate into a 100% guarantee of infection.
- An inability to tolerate uncertainty: The need for certainty is the foundation of OCD. That is why the disorder requires sufferers to be 100% sure their obsessions haven’t come/won’t come true. In OCD, being 99% sure is not sure enough.
Treatment for OCD
The “gold standard” for OCD treatment is cognitive behavioral therapy with exposure response prevention. This is a type of therapy where sufferers expose themselves to their intrusive thoughts and then refrain from engaging in their compulsions. When done successfully, this takes the power away from OCD by showing the sufferer that intrusive thoughts are meaningless and worthy of being ignored. The more ERPs are practiced, the more the sufferer is able to see OCD for the liar that it is.
Because ERPs cause a great deal of anxiety for the OCD sufferer, therapists usually start their patients out on lower level exposures before moving onto the more difficult ones.
Other things that may be used to treat OCD include:
- Acceptance and Commitment Therapy (ACT)
- Mindfulness-Based Reduction Therapy
- Medication, including SSRIs (such as Zoloft), SNRIs (such as Pristiq), tricyclic antidepressants (such as Anafranil), and off-label prescriptions (such as Ketamine)
- Lifestyle changes (such as exercise, cutting out caffeine, and maintaining a regular sleep schedule)
- Transcranial magnetic stimulation (TMS), which is used in severe cases
The Specifics of Schizophrenia
Schizophrenia is a mental illness that causes sufferers to misinterpret reality, affecting their ability to function in daily life. This misinterpretation causes problems with cognition, impulsive behaviors, and dysregulated emotions.
The symptoms of schizophrenia include the following:
Hallucinations: Sufferers may see things that are not there, smell things that aren’t there, or hear voices that don’t exist. Hallucinations can affect any of the senses, but auditory hallucinations are the most common.
Delusions: Sufferers may experience paranoia brought on by delusional thinking. For example, someone with schizophrenia may assumed they’re being followed, harassed, spied on, or that something bad is about to occur. For example, someone with schizophrenia may see a fellow passenger smile at them on the subway and assume this means that person is in love with them or they may see a fellow passenger frown at them and take it as a sign that person is going to harm them in some way.
Compromised motor behavior: Sufferers may exhibit abnormal behavior, including acting like a child, unexplained agitation, a refusal to follow instructions, odd posture, extreme movement or restlessness, or unresponsiveness.
Impaired functioning: Sufferers may experience negative symptoms that influence their ability to function normally. These include neglecting hygiene, failing to make eye contact, an inability to hold a conversation, speaking in monotone, a failure to change facial expression, a lack of interest in everyday activities, and a failure to experience joy.
Symptoms can ebb and flow and psychotic episodes may come in phrases or appear only once or twice. At illness onset, symptoms are typically severe and sudden though sufferers may still understand distinct parts of reality.
The Types of Schizophrenia
There are several types of schizophrenia, including:
- Paranoid schizophrenia: As the name implies, this type of schizophrenia is marked by paranoia. Sufferers may fear they’re being followed by the CIA or the FBI and they may believe their phone is being tapped or that the authorities are spying on them through their television, radio, or Alexa (in modern day).
- Catatonic schizophrenia: In this type of schizophrenia, the sufferer completely shuts down and goes into a catatonic state. Because the sufferer essentially becomes paralyzed, unable to eat, drink, or use the bathroom, catatonic schizophrenia is a medical emergency when it continues for several hours.
- Undifferentiated schizophrenia: This type of schizophrenia presents with vague symptoms as the sufferer may appear to be paranoid or grow silent and unable to express themselves. They may also come across as indifferent to things like personal hygiene, failing to brush their teeth or take a shower.
- Schizoaffective disorder: This disorder is diagnosed in those who exhibit paranoia, hallucinations, or deluded thinking along with symptoms of a mood disorder. They may appear delusional, manic, or depressed.
What Causes Schizophrenia?
Like with so many mental illnesses, there is no smoking gun that causes schizophrenia. Rather, it appears to manifest as a combination of several factors, including:
Genetics: Schizophrenia tends to run in families and those who have an immediate family member with the illness are at higher risk than members of the general public. If one identical twin has schizophrenia, the other has a 50/50 chance of developing it as well. This proves true even if the twins are raised in separate environments.
Still, no single gene has been identified as the main cause and, in those with or without inflicted family members, schizophrenia remains rare. Scientists believe that part of its rareness is likely due to the required involvement of numerous genes.
Brain development: Several people with schizophrenia demonstrate brain abnormalities. These include reduced grey matter in the medial temporal, prefrontal areas, and superior temporal. There may be impaired connectivity within the amygdala as well.
Interaction of neurotransmitters: Just as they are implicated in OCD, serotonin, dopamine, and glutamate play a role in schizophrenia. Those with schizophrenia are believed to have higher than normal levels of serotonin, dopamine, and glutamate as well as decreased levels of norepinephrine.
Complications in utero: There are a handful of pregnancy-related complications that can leave someone predisposed to schizophrenia. These include low birth weight, a lack of oxygen during birth, and being born premature.
In addition to the above, there are several triggers that may lead to a schizophrenic episode. While these don’t cause the disease, they can increase symptoms or awaken a dormant disorder.
Some of these include:
Stress: An episode may be triggered by the death of a family member, a divorce or end of a relationship, the loss of a job, trauma, or physical or emotional abuse.
Drugs: Some drugs can act as triggers, particularly LSD, cocaine, or meth. Cannabis, though it’s more benign than the aforementioned substances, can act as one too. Drugs are often implicated in relapses.
Life transitions: Transitions can cause an episode as well, even when they’re positive experiences. For example, getting married, moving into a new home, or starting a new job may dramatically affect symptoms.
Treatment for Schizophrenia
People with schizophrenia require intervention their entire lives. While therapy may help, medication is the cornerstone of treatment. The goal of medication management is to relieve symptoms with the lowest dose and least bothersome side effects as possible.
The most common medication prescribed include:
First-generation antipsychotics: These aren’t used as often because they pose a risk of neurological side effects, including movement disorders. However, they are cheaper than second-generation meds, which may be a factor when deciding which to use. First-generation drugs include Haloperidol, Chlorpromazine, Perphenazine, and Fluphenazine.
Long-acting injectables: Because those with schizophrenia don’t always realize they have a disease (and might refuse medication as a result), injections may be preferred over pills. These are administered every 2-4 weeks and include Aripiprazole, Paliperidone, and Risperidone.
Outside of medication, other inventions are frequently used, including:
- Family therapy
- Social skills training
- Vocational training
- Employment support
- Support for everyday functioning
- Hospitalization (when symptoms are severe)
- Electroconvulsive therapy (this is usually reserved for those who do not respond to medication)
The Similarities Between OCD and Schizophrenia
OCD and schizophrenia are distinct mental illnesses. While they may appear concurrently in some people, having OCD does not mean you’re schizophrenia and being schizophrenic does not mean you have OCD.
Nonetheless, there are some overlapping characteristics, including:
- Both are lifelong disorders that must be managed rather than cured.
- Both involve symptoms that fluctuate over time and within the environment.
- Both are typically diagnosed in young people. In OCD, the disease most often appears during early adolescence (for boys) or late adolescence (for girls). Schizophrenia most often occurs in the early twenties (for men) or late twenties (for women). Onset of either disease is rare after 45.
- Both are uncommon though schizophrenia is about half as common as OCD. OCD appears in roughly 2.3% of the population while schizophrenia appears in 1.1.%. Of course, these figures are approximate as OCD and schizophrenia are prone to misdiagnosis.
- Both have a genetic component and people affected demonstrate brain irregularities.
- Both have similar triggers, including transitions and stress.
- Both are debilitating and dramatically affect the sufferer’s life.
- Both are widely misunderstood by society. In OCD, laypeople generally paint the disorder as something minor and driven by personal preference or anal-retentiveness. In schizophrenia, laypeople assume those affected are dangerous or violent. In reality, violence is the exception and not the norm. Studies suggest that schizophrenics are at a significant increased risk of behaving violently only when their disorder is combined with alcohol or illicit drugs. In general, all those with mental illness are far more likely to be victims of violence rather than perpetrators of it.
- Both may involve higher than normal levels of glutamate.
- Both disorders are difficult to diagnose. When OCD does not present with classical symptoms (such as handwashing), clinicians may misinterpret intrusive thoughts as latent desires. Schizophrenia, along these lines, may be misdiagnosed as drug-induced psychosis.
- Both involve irrational thinking and modified behavior around those thoughts. However, this similarity also encompasses the biggest difference between the two diseases (more on that below).
The Differences Between OCD and Schizophrenia
By and large, the biggest difference between OCD and schizophrenia is the irrational thinking noted above. OCD sufferers experience intrusive thoughts that compel them to perform repetitive rituals. But, deep down, they’re aware that they’re being irrational. They perform their compulsions because of OCD’s need for 100% certainty but they don’t buy into their thoughts all the way. On some level, they recognize their thoughts as ridiculous but they ritualize just in case.
Schizophrenia does not come with this kind of insight and sufferers are unable to recognize the absurdity of their behavior. What’s more, schizophrenia is not limited to intrusive thoughts; sufferers experience visual, auditory, or olfactory hallucinations and concrete delusions (none of which are experienced in OCD). As a result, they are unable to differentiate what is real from what is not. They act on their delusions not on a “just in case” basis but because they believe them.
Other differences between the two include:
- Impaired functioning: While OCD is a debilitating disorder, schizophrenia usually has more potential to impair everyday functioning. In many cases, those with schizophrenia need continual assistance and help with everyday life. In some instances, they may be unable to live alone.
- The role of certain neurotransmitters: Both OCD and schizophrenia involve abnormal levels or responses to dopamine and serotonin. But the levels in each disease are opposite of each other. In OCD, sufferers are believed to have too little serotonin and dopamine. In schizophrenia, sufferers are believed to have too much.
- Compulsiveness versus impulsiveness: While OCD is marked by compulsive behavior, schizophrenia involves impulsive behavior. Some people with schizophrenia demonstrate OCD or OCD-like symptoms, suggesting a cooccurrence but schizophrenia, on its own, does not involve the rituals that define OCD.
- “Acting” on a thought: In OCD, sufferer do not act on their thoughts (other than to perform compulsions around them). For example, someone with Scrupulosity OCD who is afraid they will curse God in the middle of a crowded church never engages in this behavior; they only fear they will. Schizophrenics, on the other hand, may act on their thoughts because they believe that they’re real. For example, a sufferer who believes they’re being followed by someone walking behind them on a city street may confront that person and demand to be left alone.
- Hospitalization: Schizophrenia is more likely to lead to hospitalizations than OCD. This is due to the rupture from reality.
- Treatment: Schizophrenia and OCD are treated differently, with the former focusing on antipsychotics and the latter focusing on ERP therapy.
- Lifelong care: While both OCD and schizophrenia require lifelong care, it’s different in terms of intensity. In OCD, sufferers can go off their medication as long as their obsessions are under control and their practicing ERPs. Some sufferers may get their disorder under such control that they are no longer “diagnosable” by psychological standards. People with schizophrenia typically require more intensive treatment and often need to stay on their medications for life, even if their symptoms subside.
- Compliance with treatment: People with OCD are aware they have a disorder and are generally willing to get help and take medication. People with schizophrenia may not believe there is anything wrong and thus be less likely to comply with treatment. The medications prescribed to schizophrenics can also come with very potent side effects, making compliance more challenging.
When OCD and Schizophrenia Occur Together
As previously noted, OCD and schizophrenia may overlap approximately 12% of the time. When they do, treatment is particularly tricky as drugs that treat OCD can worsen schizophrenia and vice versa.
Studies indicate that it’s important to address the schizophrenia first and then move onto the obsessive compulsive symptoms. Studies also suggest that those with schizophrenia may be more responsive to OCD meds than those with OCD alone, allowing for lower doses. They may be especially responsive to drugs that inhibit glutamate.
The drawback is that antipsychotic drugs and OCD medications can interact with each other or exacerbate underlying symptoms of either disorder, which is why careful monitoring is always required.
As for therapy, while ERP definitely works with OCD, there isn’t much evidence testing its efficiency when OCD and schizophrenia occur together. One pilot study did find that using ERP to address schizophrenic hallucinations didn’t change the frequency of the hallucinations but it did give patients a better sense of control, ultimately reducing the anxiety these hallucinations caused.
Other modalities, including ACT and mindfulness practices, may be helpful as well as adopting an overall healthier lifestyle. For instance, getting on and maintaining a routine is beneficial to both OCD symptoms and schizophrenic ones.
It’s also important to avoid alcohol and drugs. OCD sufferers on antidepressants are advised of this but many ignore the warnings because the interaction between alcohol and antidepressants is normally moderate (as opposed to major). But those with OCD and schizophrenia should abstain from alcohol and drug use completely, not only because of the inclusion of antipsychotics but because alcohol can worsen schizophrenic symptoms while making the antipsychotics less effective.
Overall, anyone suffering from concurrent disorders should look for a doctor who specializes in both OCD and schizophrenia and someone with experience in treating them together.