For about eight months in 1991, from March-November, I was about as crazy as I have ever been in life. I wasn’t psychotic, but I was getting some weird perceptual alterations, and my mind had seriously gone off. On the one hand, I was painfully aware of these things. On the other hand, I was pretty convinced that I was going psychotic, mostly because of the way I felt. I got into therapy within a few months. The psychologist did go round and round a bit about whether I was psychotic or not, but he and the psychiatrist agreed after a bit that I wasn’t psychotic. He said, “The only delusion you have is that you think you’re nuts.”
When OCD gets very bad, they can appear psychotic and they often feel like they are going psychotic themselves. They often present as being either afraid they are going psychotic or convinced that they have gone psychotic. It is not not uncommon for them to get a diagnosis of psychosis or even schizophrenia. I deal with people with this type of OCD or OD theme all the time. In fact, I currently have two clients with this theme and another one is waiting in the wings. There are others I am talking to who have not signed on.
It is best described as Fear of Psychosis, but on the OCD boards they call it “Schiz OCD.” That is a misleading name, but it means that they have OCD with the Schizophrenia or Psychosis theme. That theme translates into fear that they are schizophrenic or psychotic or that they are going to become that way soon.
I have had some OCD clients with Schiz OCD and a couple with the Harm and Pedophile themes who were all misdiagnosed as psychotic, and a few were misdiagnosed schizophrenic.
The Harm theme (Harm OCD) means they are afraid they will attack or kill other people or fear of harming others. The Pedophile theme (Pedophile OCD or POCD) is entails the fear that one is a pedophile.
Harm OCD’ers are generally completely harmless in spite of their creepy symptoms. These are simply completely harmless people who fear that they are murderers, rapists, or violent people, etc.
Pedophile OCD’ers are almost always not pedophiles at all. They are simply sexually normal people who fear that they are pedophiles. They are generally harmless to children, though I am familiar with a case where a woman with Pedophile OCD actually molested her three year old boy, though not seriously. Anyway, three year olds hardly remember anything that happened to them at that age. She was arrested and charged with child molestation, but the charges were dropped on the basis that she was in treatment. She has as whole team working with her, and the main thrust is to keep her from molesting the boy again.
Most of the psychosis diagnoses I have seen with my clients (see below for exceptions) were in error, and these folks simply had OCD. But if the clinician doesn’t understand how OCD can look like a psychosis but not be a psychosis, they might misdiagnose someone. It boils down to the difference between an obsession and a delusion. The two can be confused, and clinicians do misdiagnose obsessions as delusions. The difference can be a bit fine-tuned, but generally it is straightforward.
The problem is that many clinicians simply have no idea how to tell an obsession from a delusion. Obsessions can get unbelievably bizarre, and at first look, they can appear in content like the sort of delusions that psychotics get.
I did have two very ill people come to me, (call them Mr. A and Ms. B.), who seemed to have both OCD and schizophrenia, among other things. It took me a while to figure out that they actually had both conditions at once as opposed to one or the other alone, and Mr. A was a diagnostic confusion for a while. But both of them did seem to have some sort of psychotic process going on. Mr. A had had a clear psychotic break around age ~19-20, and another had gone through an obvious schizophrenic prodrome in late adolescence and early adulthood.
Ms. B was hallucinating most of the time, including a lot of visuals. Mr. A also appeared to be hallucinating, as he was experiencing his thoughts being broadcast out into the environment, and he was afraid people could hear them. Both were both functioning very poorly, were on disability, and working or in school. Mr. A was living at home and had had a conservatorship set up for him. This entailed some sort of trustee who doled out the monthly SSI check Mr. A as they saw it, so Mr. A had no control over his finances. Mr. A was also in and out of the hospital on involuntary hold on a pretty regular basis.
What is odd is that both of them so lucid during our email conversations you wondered how they could be psychotic.