The most serious cases of OCD can develop psychotic symptoms.
All people have ever had an obsessive thought, a thought, fear or doubt that we cannot get out of our head even if we want to. Also, most have at some point had thoughts that we do not feel ashamed or dislike, such as wishing someone else not to get what we want for us or the temptation to give four shouts to the unscrupulous who is talking on the phone at the movies. Most people don’t care about them.
However, for those affected by an Obsessive-Compulsive Disorder, these ideas generate great anxiety about their possible implications and their possible consequences, so they try to perform different ritual actions to control their thoughts and regain control.
Most people with OCD consider and acknowledge that deep down these thoughts and fears have no basis that they should really be concerned about and have no real effects on the world. Others do not. Among the latter we can find cases in which the obsessive ideas turn into delusions and that they can even have hallucinations. Although it is something very unusual, there are cases of Obsessive-Compulsive Disorder with psychotic episodes. We will talk about this in this article.
Obsessive-Compulsive Disorder or OCD is called the condition characterized by the continued presence over time of obsessions, mental content or ideas that appear intrusively in the subject’s mind without being able to control them but which are recognized as their own and that in most cases they are generators of a high level of anxiety. Frequently, together with these ideations, a set of acts or rituals called compulsions appear that are carried out with the aim of reducing the anxiety generated by the ideas or avoiding the possibility that the obsessive thoughts occur or have consequences in real life.
It is one of the mental disorders that generates the greatest suffering in those who suffer from it, since in most cases the subject is aware that he cannot control the appearance of his thoughts and that the acts he performs as a ritual do not they have a real effect beyond a brief, temporary reassurance, actually reinforcing the future emergence of new thoughts. In fact, a vicious circle is established between obsession and compulsion that increasingly aggravates the anxiety that the subject suffers, feeding back the symptoms of the disorder.
The feeling is of lack of control over their own thinking, or even of confinement within a dynamic from which they cannot escape. Much of the problem is in fact the excessive attempt to control thought and actively avoid the appearance of the thought that generates anxiety, which indirectly reinforces its appearance. Thus, we are faced with an egodistonic disorder.
It is common for there to be a certain level of magical thinking and thought-action fusion, unconsciously considering that it is possible that one’s thoughts may have an effect in real life despite consciously recognizing that this is not the case.
This disorder has serious repercussions on the daily life of those who suffer from it, since the repeated presence of obsessions and compulsions can require a lot of hours and limit their personal, work and academic life. Personal relationships can deteriorate, the subject also tending to isolate themselves to avoid social rejection, and their work and academic performance and performance can be greatly diminished by dedicating much of their attention and cognitive resources to avoiding the obsession.
OCD with psychotic episodes: an atypical side
In general, the subject with Obsessive-Compulsive Disorder is aware and they recognize that their obsessive thoughts and the compulsions that they perform are not based on a real basis, and they can come to consider them stupid without being able to control them. This fact generates an even higher level of discomfort and suffering.
However, there are cases in which obsessive ideas are considered true and in which the subject is completely convinced of their veracity, not putting them in doubt and turning them into explanations of reality. In these cases, the ideas may be considered delusional, with OCD acquiring psychotic characteristics.
In these cases, considered and also called atypical obsessives or schizo-obsessives, it is observed that the insight necessary to detect that their behaviors do not have a real effect on what they intend to avoid is not present. Also in these cases the compulsions may not be experienced as something annoying or egodistonic but simply as something to do, without it appearing intrusive or forced. Another option is that the continued suffering of an obsessive idea ends up reactively triggering hallucinations or delusions as a way of trying to explain the functioning of the world or the situation experienced.
Three great possibilities
The comorbid presence of obsessive and psychotic symptoms is not particularly common, although in recent years there seems to be a certain increase in this joint pattern. The studies carried out speak that there are three great possibilities:
1. Obsessive disorder with psychotic symptoms
We are facing the most prototypical case of Obsessive-Compulsive Disorder with psychotic episodes. In this clinical presentation, people with OCD may present transitory psychotic episodes derived from the transformation and elaboration of their ideas, in an understandable way based on the persistence of the obsessive ideation. These would be episodes that will occur in a reactive way to mental exhaustion generated by anxiety.
2. OCD with lack of insight
Another possibility of an obsessive disorder with psychotic symptoms is derived from, as we have said previously, the absence of the ability to perceive the non-correspondence of the obsession with reality. These subjects would have stopped seeing their ideas as anomalous and would consider that their ideas do not contain an overvaluation of their influence and responsibility. They generally tend to have a family history of severe psychopathology, and it is not surprising that they only express anxiety about the consequences of not performing compulsions and not about the obsession itself.
3. Schizophrenia with obsessive symptoms
A third possible comorbid presentation of psychotic and obsessive symptoms occurs in a context where obsessive compulsive disorder does not really exist. It would be those patients with schizophrenia who during the illness or already before the presence of psychotic symptoms present obsessive characteristics, with repetitive ideas that they cannot control and a certain compulsiveness in their performance. It is also possible that some obsessive symptoms appear induced by the consumption of antipsychotics.
What Causes This Disorder?
The causes of any type of Obsessive-Compulsive Disorder, both those with psychotic characteristics and those without, are largely unknown. However, there are different hypotheses in this regard, considering that OCD is not due to a single cause but because it has a multifactorial origin.
At a medical and neurological level, through neuroimaging it has been possible to observe the presence of hyperactivation of the frontal lobe and the limbic system, as well as an involvement of the serotonergic systems (which is why drug treatment is usually based on antidepressants in those patients who need it) and dopaminergic. Involvement of the basal ganglia in this disorder has also been observed. Regarding those modalities of Obsessive-Compulsive Disorder with psychotic episodes, it has been observed that the neuroimaging level tends to have a smaller left hippocampus.
At a psychosocial level, OCD is more frequent in people with a sensitive nature who have received an education or excessively rigid or very permissive, which has generated in them the need to be in control of their own thoughts and behavior. They tend to be hyper-responsible for what happens around them and to have a high level of doubt and / or guilt. Nor is it uncommon to suffer from bullying or some type of abuse that has induced them to need, initially in an adaptive way for them, to control their thoughts. The association with psychotic symptoms may also be due to the suffering of traumas or experiences that have generated a break with reality, together with a predisposition to this type of symptomatology.
An existing hypothesis regarding the functioning of OCD is Mowrer’s bifactorial theory, which proposes that the cycle of obsessions and compulsions is maintained by double conditioning. In the first place, a classical conditioning occurs in which the thought is associated with the anxious response that in turn generates the need to flee from it, and later, through operant conditioning, maintain the avoidance or escape behavior through compulsion. Thus the compulsion is associated with the reduction of immediate discomfort, but does not have an effect on the actual aversive stimulus (the content of the thought). In this way, the appearance of future obsessive thoughts is not prevented but in fact facilitated.
- American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth edition. DSM-5. Masson, Barcelona.
- Rincón, DA and Salazar, LF (2006). Obsessive-compulsive disorder and psychosis: a schizo-obsessive disorder? Colombian Journal of Psychiatry, 35 (4).
- Toro, E. (1999). Psychotic Forms of OCD. Vertex, Revista Argentina e Psiquiatría; 37: 179-186.
- Yaryura-Tobias, JA & Neziroglu, F- (1997). Obsessive-Compulsive Disorders Spectrum. Washington DC, American Psychiatry Press.