Hassan Herrera: By saying “Anxiety processes can at times escalate all the way to psychosis.” You mean, for example a OCD’er getting through the fear of going psychotic can start experiencing psychotic symptoms coming out of the anxiety process? I catch sight of a post of you setting apart core process and where the symptoms come from. I hope i got myself across.
Never seen a case of Schiz OCD going all the way to psychosis, although I know a woman with schizophrenia and Schiz OCD in which the two sort of go together but not completely. She still has delusions that she does not doubt. She also hides symptoms a lot, which is very hard to figure out, though I can sometimes do it.
I don’t think the Schiz OCD went into the Schizophrenia, but the Schizophrenia dx obviously played into the Schiz OCD. It’s an extremely complex case. Never seen a case of Schiz OCD going all the way to psychosis, although I know a woman with schizophrenia and Schiz OCD in which the two sort of went together but not completely. She still has delusions that she does not doubt. She also hides symptoms a lot, which is very hard to figure out, though I can sometimes do it. I don’t think the Schiz OCD went into the Schizophrenia, but the Schizophrenia dx obviously played into the Schiz OCD. It’s an extremely complex case.
There is a Psychotic OCD but I have never seen a single case of it, and I have seen more OCD’ers than 95% of clinicians will ever see. I have seen cases that I worried were Psychotic OCD, but when you got it all untangled, they still had reality testing intact more or less, at least in terms of overvalued ideas. There is a sub-diagnosis of OCD with Overvalued Ideas.
The OCD symptoms in this case were extremely bizarre, and phenomenologically, they looked a lot like the sort of thing you see in Psychotic OCD. His symptoms appeared so psychotic that when I mentioned them to a retired clinician, she insisted that this person was psychotic and would not accept that they were not. Unfortunately I am not allowed to share the very interesting symptoms on here.
Psychotic OCD has a sort of a “look” to it along with typical delusions that are present in a lot of cases – it is a syndrome, in other words.
A classic case of Psychotic OCD would be a case where the obsessions have escalated into delusions. The people are typically not dangerous, as fear is a freezing agent, and OCD’ers tend to be shy or very shy, passive, introverted, and remarkably nonviolent. A classic case is a man sitting in a chair all day shaking like a leaf and going on about his obsessions, which have now reached delusional intensity. The old view was that Psychotic OCD’ers never got too far gone psychosis-wise, and it was quite easy to pull them out of the psychosis. A typical case might last three weeks.
However, we now have recent cases of Psychotic OCD going on for years that did not respond to treatment. Some responded to ERP oddly enough. Some of these people are so ill that they have become the homeless mentally ill like a lot of schizophrenics, carting their belongings around in a suitcase.
The main thing to note is that Psychotic OCD is rarely seen. However, when OCD is very bad, they can appear psychotic. Hence, OCD’ers are often misdiagnosed with psychosis of one form or another and put on antipsychotic drugs, which generally do not help them. I get clients all the time coming to me with a diagnosis of some form of psychosis. Once I figure out they are not psychotic and are usually instead Schiz OCD’ers with what I call fake delusions and fake hallucinations, I tell them to fire their psychiatrist and go doctor shopping until you find an MD who understands that you have OCD and not psychosis.
A lot of psychiatrists continue to misdiagnose OCD’ers with psychosis. The phenomenology of OCD is not understood well by many clinicians, and the fact that OCD when severe looks like psychosis but is not results in a lot of misdiagnosis.
I think a Schiz OCD’er would be the last person to go psychotic, as the condition is predicated on continuous worry and doubt that they are going psychotic. If you have spent any time around psychotic people, that’s clearly not what’s going on. In psychosis the person never worries whether they are psychotic, nor are they are aware they are psychotic.
If you are worried about or are aware of being psychotic, then you cannot possibly be psychotic. That’s a rule out for psychosis right there. This is exactly what is going on in Schiz OCD, hence Schiz OCD is never psychotic by definition.
