OCD and Psychosis

woman close-up

When my son Dan’s OCD became severe, he was in college, fifteen hundred miles away from home.  We arranged for him to see a psychiatrist near him, who telephoned us (with our son’s permission) after he met with Dan. He certainly didn’t sugarcoat anything. “Your son is suffering from severe OCD, and he is borderline psychotic.”

I knew very little about OCD at that time, but I knew what psychotic meant: out of touch with reality. I was terrified. Psychosis made me think of schizophrenia, though that illness was never mentioned. In fact, after I united with Dan and we met with the psychiatrist together, there was no more reference to psychosis.

So what was going on? A recent post on Psychiatric Times discusses the fact that OCD with poor insight should not be mistaken for a primary psychotic disorder, and a thorough history of the patient is warranted. There is also a good deal of discussion in the article regarding medication, because antipsychotics which are often prescribed in these cases have been known to induce and/or exacerbate symptoms of OCD. In addition, research has shown that these antipsychotics often do not help those with severe OCD who are dealing with poor insight, or borderline psychosis.

One of the criteria for the diagnosis of obsessive-compulsive disorder is the sufferer’s realization that their obsessions and compulsions are irrational or illogical. When Dan was first diagnosed with OCD, he did indeed have this good insight. But by the time he met with this psychiatrist his OCD had gotten so bad that he was at the point of borderline psychosis. At least at that moment. It should be noted that OCD sufferers insight into their disorder can fluctuate. For example, while calmly discussing a particular obsession and compulsion, those with OCD might realize their thoughts and behaviors are unreasonable. But when they are panic-stricken and in the middle of what they perceive as danger, they might totally believe what they had previously described as nonsensical.

So did Dan have something else going on aside from OCD? Thankfully, no. Once his OCD was treated, any possible issues related to psychosis resolved. This scenario reminds me of his misdiagnosis of ADHD. The same thing happened: When his OCD was treated, his symptoms that had been attributed to ADHD also disappeared.

Certainly there are lessons to be learned from Dan’s experiences. Things are not always what they seem. And in the case of mental illness, where we’ve categorized certain behaviors as belonging to specific illnesses, we really need to be careful not to jump to conclusions in reference to diagnoses and subsequent treatments. In the case of obsessive-compulsive disorder, maybe the best way to proceed is by treating the OCD first, and then reassessing the situation. Once OCD has been reined in, we might be surprised to find that symptoms typically associated with other disorders have fallen by the wayside as well.

I’d love to hear if others have had similar experiences.

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26 Responses to OCD and Psychosis

  1. Wow! Janet. Thank you for this powerful post. I have a couple of ways I connect with this one. First, before we knew Blake had OCD there were those who were certain he had ADHD (because he was distracted), petit mal/absence seizures (again because he seemed distracted and zoned out) and autism. All of these diagnoses were considered before the age of 7. None of them fit.

    As a professional, I’ve actually been asked by other professionals if my patients might be psychotic (for example because they feared they might cause harm while sleepwalking during the night). In moments of calm and clarity, the OCD sufferer knows the reality, but even professionals can get confused by the worried confessions that happen in moments of panic. One very young patient was prescribed an anti-psychotic because of her OCD thoughts. Thankfully, the parents got another opinion first.

    • Thanks so much for sharing Angie, and for illustrating how confusing OCD can be, even for professionals. Your comment also brings up the fact that parents shouldn’t just accept whatever diagnosis is thrown at them. You know Blake the best, and knew none of those early diagnoses fit. Also, I’m glad the young patient you mention did not take that antipsychotic. Dan took those meds at one point and they only harmed him.

  2. Hi there, having been psychotic in the past, and now with an OCD diagnosis I can often distinguish between the 2, although it isn’t easy. This was a really interesting post to read, and, I think, an important point about misdiagnosis. All the best

    • Thanks for sharing and for your continuing support. Misdiagnosis is certainly an important topic, for all of us. I know you have a good therapist, so that is really helpful, of course, to have someone who really knows you well. Wishing you all the best too!

  3. My son has severe and persistent OCD and one of his compulsions is to keep his feet on the ground. So he stands up to 12 hours a day and he does not sleep in a prone position – rather he sleeps in a chair so his feet can stay on the ground. He has been doing this for over 7 years and as a result his feet remain quite swollen, he has varicose veins and he has had open sores on his feet for 3 years now that do not heal and grow bigger each day. He is homebound and does not move much, exercise or go outside. He has poor circulation and I worry that he will die from a blood clot. He refuses to get help for his condition. A top leading psychiatrist in this field, Dr. Michael Jenike has made two home visits to try and help my son but he has been resistant to Dr. Jenike attempts. In Jan. of this year my son was Baker Acted and put in a hospital for 72 hours and then transported to a mental health facility for 2 weeks. My son was diagnosed with cellulitis in both feet which is a bacterial infection as well as MRSA and the doctors told him he was lucky the infection was not in his bones or else they would have had to amputate both feet. My son was not compliant the whole time and would not admit to needing help and would refuse treatment so they let him out. However, they gave him a diagnosis of OCD and psychosis of an unspecified origin and paranoia and they gave him a shot of Haldol which is an anti-psychotic medication. The whole time my son was there I was constantly telling the doctors, social workers and psychiatrists that my son only had OCD and not a psychosis and yet they would not listen to me. Dr. Jenike told me to have the doctors call him so he could explain my son’s diagnosis but they would not do that. Dr. Jenike would tell me to tell the doctors that with OCD the thoughts are “intrusive” and not “insertive” like they are with psychosis and there is a big difference in these diagnosis’s as well as the corresponding treatments. Dr. Jenike told me to have the doctors start my son on 20mg of Prosaz and then move it up to 80 mg in a week’s time. He said this would help my sons compulsions to lesson and make a difference . The doctors did agree with this treatment, but unfortunately my son would not take the meds. This is has been the most challenging and heartbreaking experience for me as I watch my son deteriorate even though his condition is treatable.

    • Oh, Gwenne, I am so sorry to hear how difficult things have been for you and your son. You certainly are doing everything you can and of course Dr. Jenike is the best there is. I have never heard of “intrusive” versus “insertive” thoughts, but that seems like a good way to describe the difference between OCD thoughts and psychosis. I wish I could make things better for you and your son, and I am so sorry for your heartache. I will keep you both in my thoughts and sincerely hope your son will decide to pursue treatment in the near future. Thank you so much for sharing your story.

    • Gwenne, your story breaks my heart, and I will be thinking of and praying for you and your son tonight.

  4. Janet, this is a great and informative post. I was never considered borderline psychotic, but I can understand that at times I certainly had poor insight into my OCD and how it was affecting me. I agree that a careful diagnosis is key–we shouldn’t jump to conclusions because certain symptoms seems to align themselves with certain conditions.

    It’s not psychosis, but I often wonder about the fact that I have both an OCD and a depression diagnosis. They seem so intertwined, and I cannot remember which came first. I do believe that when my depression is well treated and under good control, my OCD gets better.

    • Hi Tina, I was looking at this old post of mine, and saw I never replied to your comment. So sorry! 😦 I always appreciate your insight and contributions to my blog. Hope you are doing well!

  5. Alicia says:

    I am currently going through ERP, and I completely relate to what you are saying. It has become very hard for me to leave the house, because I’m so afraid of losing something. I have to look back every couple of seconds to make sure I haven’t dropped anything, even when I know that I didn’t bring anything with me and I checked the mirror to make sure nothing was stuck to me.

    When I’m in my normal, calm, relaxed state of mind, I feel like the ERP exercises should be easy, because if there’s nothing on me, I KNOW I’m not going to lose anything. But it’s COMPLETELY different when I’m in the thick of the panic and compulsions. The OCD takes over, and any rational thoughts just go by the wayside. When I think about it later on, I see just how ridiculous the thoughts were, and I wonder what could have possessed me to believe them in the moment. I keep thinking, no more, I KNOW this is ridiculous and I am not going to let these thoughts control me again…but then they always do.

    “Psychotic” to me seems like a derogatory term – one of my former neighbors called me “psychotic” and “weird” when he caught me performing a compulsion, and I was about as offended by that as I’d ever been by anything. I don’t think people with OCD are psychotic, but when they are in the moment, dealing with the compulsions, they certainly don’t have much of a grasp of reality, as you said. I’m sure you would agree that (unless there is another disorder there), the OCD drives any psychosis that is there in the moment, and it’s not the PERSON who is psychotic.

    Your son’s experience is very encouraging, and I hope that my panicked “psychotic” moments start to go away as well once I make more progress with the ERP.

    • Hi Alicia, Thank you so much for sharing. Hearing from you firsthand about how it feels when your OCD takes over is invaluable to those of us who do not have the disorder. And I agree with you that being called psychotic is certainly no compliment! Good luck as you move forward with your ERP therapy..I’m rooting for you!

  6. This is great piece, which explains very well how that blurring can occur. I will be sharing this with a work colleague, who was only recently trying to persuade me that all mental health conditions had an element of psychosis to them.

  7. The Hook says:

    I’m afraid i don’t have anything helpful to add, but your family is an inspiration; you refuse to surrender to despair and you simply love each other – no matter what.

  8. CannotSay2013 says:

    First, an introduction. This is cannotsay2013 from Mad In America. I told my story here http://www.madinamerica.com/2013/01/ny-times-invites-readers-to-a-dialogue-on-forced-treatment/#comment-19770 .

    Several years after my own ordeal with psychiatry happened, because of a diagnosis of OCD, I have to say that the label “OCD” is as false as all the other DSM labels are.

    What I mean by this is not to deny that some people in some cases worry more about certain things than other people. However, that is hardly an “illness”. Just as it happens with other fears, like fear of flying, not everybody has the same degree of fear, or reacts the same way, to the things he/she fears most.

    In the case of the HIV infection, the leaders of Cuba during the 80s seemed to have the same level of fear that I have because they implemented a quarantine policy that turned out to be extremely effective in containing the HIV epidemic in Cuba. To this day, Cuba remains one of the countries with the lowest HIV prevalence worldwide http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2688320/ .

    To be clear, I am not defending that the US adopts a Cuban policy with respect to HIV/AIDS. All I am saying that that to call exaggerated fear of HIV/AIDS “OCD” is preposterous. It is yet another invented label which serves no purpose other than stigmatizing those whose fear of HIV/AIDS is beyond what the medical establishment finds “appropriate”.

    My CBT therapist tried to convince me that my fears were irrational, and then I showed to him the Cuba situation. He became less condescending.

    We have to stop calling “irrational” a level of fear or concern that somebody else has but that we don’t have. From where I stand, irrational is to spend 14 billion dollars a year treating a disease that would not be transmitted if people were a little bit more “rational”. And yet, that’s the annual expenditures on HIV programs (including medicaid/medicare) by the US government alone.

    • Hi There, Thank you so much for commenting. I just read your story and it sounds like a nightmare. I am sorry you had to endure such horrible experiences. I could certainly relate to what happened to you with meds as my son had similar physical side-effects from his medications. We are thankful to have gotten him off of those heavy-duty drugs.
      I disagree, however, that “OCD is false.” I cannot, of course, comment on whether you have OCD or not, but I know my son does. I am also not one for labels, and to me it doesn’t matter what it’s called. I know he had a debilitating condition that literally stopped his life, and ERP therapy brought him back to himself. I’d also like to point out that I don’t believe the purpose of his CBT was to convince him his fears were irrational. Instead, it was to teach him to be able to live his life with the uncertainty that his fears actually “might” come true (as unlikely as that was), and that he could face whatever comes his way.
      Thank you again for sharing. Your post brings up so much of what is wrong with psychiatry. I wish you the very best as you move forward.

      • CannotSay2013 says:

        Hi Janet,

        Thank you very much for publishing my message and for your reply.

        Just a small clarification on language. I do not have “OCD” anymore than a gay person has “homosexuality”. Meaning, just because you can describe with more or less accuracy a pattern of behavior, it doesn’t make that pattern of behavior a “disease”. Check this video, a summary of a 1967 special by Mike Wallace, on homosexuals https://www.youtube.com/watch?v=-AXAOT_swIE . Listen to the first two minutes. When somebody tells me that I “have OCD”, it sounds like those dehumanizing comments, especially the psychiatrist that shows up around minute 1:23.

        And yes, I was “dehumanized” http://www.madinamerica.com/2013/09/psychiatric-diagnosis-process-qualify-degradation-ceremony/ with an OCD label by an American psychiatrist, the top expert on the matter in my local area. Psychiatry is a fraudulent endeavor, and so are all its invented labels, including OCD.

      • CannotSay2013 says:

        And one more thing. This notion of “OCD” or any other psychiatric label as an “illness” has implications beyond the dehumanizing aspect, which onto itself is problematic. It has legal implications in the US and elsewhere. Being assigned a “psychiatric label” follows you for the rest of your life in a way that a diagnosis of diabetes doesn’t. And these legal implications, which as I said are beyond the social stigma, exist because psychiatry is a fraud.

        Psychiatry denies the existence of free will once it assigns somebody a label. You suddenly become “the label” and what psychiatry thinks people with that label should be. Your individuality is removed forever. The type of hurting language that the psychiatrist shown in the Mike Wallace video is what allows psychiatry to have unparalleled coercive powers.

  9. You obviously have had terrible experiences with psychiatry and feel strongly about your convictions. I respect your opinions and certainly agree there are many things wrong with the “system” as it is. Thank you for sharing.

  10. Kay Zeaman says:

    Gwenne Gorman I am praying for your son’s complete recovery soon of OCD.
    My son and I are currently writing a book about how OCD and depression affected our lives. I have germ contamination fears. At times it has completely immobilized me.
    The second part of the book is about therapies I’ve used to treat my OCD successfully. I had EMDR therapy for trauma for one year. My counting rituals began the day of my dad’s funeral when I was 11 years old and he suddenly died in a car accident. My germ contamination fears because during a traumatic event when I was 21 and in an intense relationship with a man. The prefrontal cortex of the brain, the amygdala, the basal ganglia, and the thalamus are all involved with OCD in creating an “endless loop” of repetitive obsessions and compulsions. EMDR moves the anxiety in the brain to the hypocampus of the brain where it can successively be treated and released..
    Also hypnotherapy has helped me lower my anxiety level dramatically.
    The third part of our book is all about the latest research discoveries on how the brain functions. This knowledge is leading to much more effective for brain disorders such as OCD.
    Our book will be published next year. The title will be “Out of the Darkness and into the Light.”
    Best wishes for getting your son the help he needs so desperately.

    • Thank you for all this info, Kay, and I’m glad you’ve found ways toward healing. I too hope that with all the advances being made in the understanding of the brain that there will eventually be more ways for people to better fight their OCD.

    • gwennegorman says:

      Kay, thank you for much for your prayers. I am going to Georgia next month to a healing ministry called Be In Health (beinhealth.com) and they have been highly successful with OCD. I would love to talk to you on the phone if possible. I too, am writing a book that will be published next year. It is a self-help book for parents of children with OCD. The working title is “The Compassionate Parent – how to be a healing presence as your child struggles with OCD”. I like what you had to say and would like more information. Please let me know how we can connect.Thank you.

  11. marzia says:

    Hi! My mom keeps telling me OCD can turn into psychosis. But is it true? I’ve read many topics on the internet and each of them said it can’t, but i want to know what you think…

    • Hi Marzia, I am not a doctor or a therapist but what my post is talking about is how OCD with poor insight might be mistaken for psychosis. Certainly the best thing to do would be to connect with a health care professional who specializes in treating OCD to discuss your issues. I can’t really answer your question one way or the other. Sorry. Wishing you all the best!

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