Answered on Quora. A lot of the other answers are also very good if you are interested in psychiatry.
I work for the most part only with persons with OCD. I don’t even claim to be able to treat any other mental disorders. When I get people with other disorders, I refer them out, especially if they badly need help.
OCD seems to be poorly diagnosed. I get people who obviously have OCD who have been misdiagnosed as something other than OCD all the time. A lot of the time, the clinician simply does not know what is wrong with the person. At other times, they diagnosis is simply something like “anxiety,” which is not very helpful, as there is a lot more to OCD than just anxiety. The people given a diagnosis of “anxiety” in general were not being properly treated.
The second one I get a lot of is some form of psychosis. It is very common for people with OCD to get a misdiagnosis of some form of psychosis. I see a lot of “psychosis”, “mild psychosis”, “mild schizophrenia”, “psychotic depression”, “schizophrenia”, “manic psychosis”.
Almost all of these people are being treated with antipsychotic drugs, and in almost all cases, the drugs are not working or are even making them worse. I simply tell them that they are not psychotic, the diagnosis is in error, please fire your psychiatrist, and look around for another one until you find one who figures out that this is OCD.
The problem is that people with OCD quite commonly appear psychotic when the illness is bad. They “appear” psychotic, but if you examine them very closely, it becomes glaringly obviously that they are in fact not psychotic at all!
In addition there is a form of OCD called by its sufferers “Schiz OCD” in which the person worries and obsesses that they are going psychotic. They often worry that they are developing schizophrenia. I have seen more people with this problem than I can count. Some of them were properly diagnosed, especially by clinical psychologists, but many others were not.
The condition is further muddled by the fact that the person will start to develop a number of “psychotic-like” symptoms that can even include perceptual alterations. They develop “fake auditory hallucinations” where they think they are hearing voices but actually they are not. They are just misinterpreting ordinary sounds in the environment as hallucinations. They also develop “fake delusions” in which they worry that they believe crazy things when in fact they do not.
I am now very good at differentiating fake hallucinations from real ones and fake delusions from real ones and worrying that someone is psychotic from actually being psychotic. But it took me a long time to figure it out, and it’s not clear or obvious at all unless you are very good at diagnosing this particular condition.
Also the obsessions themselves or the illness itself can simply look like a psychosis. I could give you some examples, but space is limited here. Suffice to say that OCD can be a very strange, weird illness and the obsessions can look like delusions. You have to be good at differentiating between an obsession and a delusion, and the distinction is not clear at all.
However, an obsession that looks like a delusion has a particular “feel” about it that an actual delusion simply does not have. It’s more of a Gestalt, intuitive or impressionistic conclusion than a logical one.
Suffice to say that people with OCD often have a certain sameness about them. I like to say “they are all reading off the same script.” After you have seen enough of them, you can practically spot them 1/2 a mile away blindfolded at night, but few clinicians see that many people with OCD.
When OCD is extremely bad, it does indeed look like a psychosis, and the difference between severe OCD and “psychotic OCD” (which actually exists) is not clear at all. I had people who I mulled over for months whether they were actually psychotic. However out there they are though, generally reality testing is still somewhat intact.
You can start getting into the territory of some truly bizarre symptoms. I remember describing one girl’s symptoms to a retired LCSW with decades of experience. She said, “Well, this person is psychotic. That’s all there is to it.” I actually now believe that she was not, but if I told you the very weird ideas going through her head, you would probably immediately say psychosis too.
The problem is that in order to get good at this sort of micro-diagnosis, you have to see a lot of people with the disorder. After a while, you start seeing a common syndrome and a diagnostic picture develops. But a clinician who only sees people with those symptoms rarely if at all has little opportunity to hone his diagnostic skills.
If any clinicians are reading this, you can see that I am complaining that many clinicians do not understand this condition well, hence it is often poorly diagnosed and treated. I believe it is important for clinicians to understand this poorly understood disorder better. How to go about doing that, I do not know. That is for you to decide.
