Category Archives: Schizophrenia

Schiz OCD Versus Psychosis: Differences and Interactions

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.

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Are Schizophrenic People Smart?

Although of course schizophrenics vary in IQ, the research shows that lower IQ is associated with schizophrenia. Typically the lower IQ was present before the schizophrenia hit. Whether these people already had pre-schizophrenia and the low IQ was a signal of that or whether lower IQ is an independent risk factor is not known. I suggest the former.

I am not sure if schizophrenia itself, once it hits, causes an IQ decline, but it would not surprise me. The process of developing schizophrenia involves considerable damage to the brain. It makes sense that this brain damage, in addition to causing the disorder, also lowered your IQ.

In summary, people with schizophrenia tend to have lower IQ’s than normals on average, but the difference may not be large. I think it was only ~3 points.

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How Can I Tell If I Have Paranoid Schizophrenia or Schizotypal Personality Disorder?

Answered on Quora.

Simple. If you had either one, you would probably not be asking this question right now.

If you had paranoid schizophrenia, you would not be asking this question because people with this illness do not recognize that they are ill, typically refuse to seek help, and also refuse to take medication. If you tell them they are ill, they will not agree.

If you had Schizotypal Personality Disorder (really mild schizophrenia) you would probably not be asking this either. These people probably do not believe there is anything wrong with themselves either, and they are typically too paranoid to go in for treatment. There is a forum for Schizotypals on the Net, and many of them are on there saying that they are too paranoid and distrustful to go to therapy.

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Borderlands: Obsession, Delusion and Their Differential Diagnosis

The Borderland between Obsession and Delusion

Anxiety processes can at times escalate all the way to psychosis. I have had some OCD clients who I had a very hard time figuring out if they were psychotic or not. With one, I told a retired therapist of their symptoms, and the therapist immediately said, “Well, they’re psychotic. That’s a delusion.” The things that they believed or almost believed did look like psychotic delusions. However, they did not entirely believe them. OCD with Overvalued Ideas was probably a better diagnosis. There are a few cases of Psychotic OCD. I have never seen one though, although this case was getting close.

When OCD gets very bad, they appear psychotic. However, they generally are not, and in 95% of cases, I can figure out that they are not psychotic. That is because Severe OCD That Looks Psychotic has this particular look, feel, or vibe (gestalt) about it where the cases all give off this particular vibe. It’s like they are all reading off the same script in a sense.

The Problem of Psychotic People Hiding Symptoms

You get a different look, feel, or vibe (gestalt) with an actively psychotic individual, but they can be hard to figure out too because sometimes they lie about their delusions.

I have caught them hiding symptoms from me.

Some people with psychoses learn to hide symptoms because they figure out that every time they say “The FBI is after me,” someone grabs them and hauls them off to the hospital. So they continue to believe the FBI is after them, but they learn to shut up about it.

You look at what the person is doing in reaction to the thoughts. They thought the neighbors were hacking into their computer so they disconnected their computer from the Internet? Delusion. A person who just had the fear or obsession that the neighbors were hacking in would not disconnect the computer, and their description of the fear would be full of all of these strange doubts and uncertainties.

The Difficulty of Differentiating between Thoughts and Voices

Psychotic people sometimes refer to thoughts as voices. I had one client who referred to thoughts telling him to do bad things, in this case, to kill animals. He had recently killed five puppies in response to these thoughts ordering him to kill these animals. I suspected these were more than thoughts, so I had him describe them, and he said, “It’s a thought, you know. You hear it like someone standing next to you and talking.” Ok if you hear it outside your body like that, it’s not a thought, it’s a voice.

Some people with schizophrenia hear their thoughts spoken out loud in the environment, and they fear or believe that others can hear their thoughts being broadcast out there. However, if you corner them on it, some will try to deny it by saying that they just have very loud thoughts in their heads, and the thoughts are so loud that they worry or fear that maybe others can hear them. That’s not quite precisely a delusion, and it’s not a hallucination like the thought broadcasting. It’s off into the obsession/delusion borderland.

Schiz OCD – OCD with the Fear of Psychosis Theme

There is a type of OCD where the person fears that they are going psychotic. OCD’ers have made up a term called Schiz OCD for this illness, which is really OCD with the Fear of Psychosis as the theme. Some clinicians have complained to me about these “hokey names” for the different OCD types and accused me of making them up. I didn’t make up any of them.

The sufferers make up these names for the different themes that they have. I feel that the sufferers have a right to own their symptoms and illnesses and call them whatever they want to call them. That’s their right as sufferers.

Who are we to tell them that their name for their symptoms is the wrong name? Do we have a better name? Of course not. “We” are just arrogant clinicians who think we know these illnesses better than the sufferers themselves know them. I realize Schiz OCD is a confusing name, but it’s the name they picked, and we don’t have a better one, so let’s go with it.

They develop all sorts of “psychotic” symptoms, including fake delusions, fake hallucinations, and even perceptual disturbances. Once again the Schiz OCD symptoms have a completely different quality – look, feel, vibe or gestalt – than you get with someone who has actual delusions and real hallucinations. In addition, all of the Schiz OCD symptoms have a very similar quality across many different people – once again, it’s like they are all reading off the same script.

The Problem of Misdiagnosis in Schiz OCD

I have now seen more people like this than I can count, and I’m an expert on this illness. But I still get people with this type of OCD coming to me all the time with diagnoses of various types of psychoses, schizophrenia, psychotic depression, etc. They received these diagnoses from qualified clinicians such as psychiatrists and clinical psychologists. They were misdiagnosed in 95% of cases, so you see even skilled clinicians can’t tell this OCD type from a psychosis in a lot of cases.

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Are People on the Schizophrenic Spectrum Less Intelligent?

Answered on Quora: 

Indeed, repeated studies have shown that schizophrenia is associated with a somewhat lower IQ – possibly 5–10 points. These studies showed that schizophrenics had lower IQ even before the schizophrenia developed.

Why schizophrenia is associated with lower IQ is not known, but schizophrenia is a disease of the brain, and it seems that whatever is causing the schizophrenia is also lowering the IQ.

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Schizophrenia and Autism: Similarities and Differences

JohnnyHG writes: There is evidence schizophrenia is developmental like Autism. I would exclude the cases of diagnosis of someone with a history of drug use or brief psychotic hallucinations from environment. The fuck up just gets delayed – it’s latent, which is why it happens in one’s teens/early 20s rather than toddlerhood. But there are signs lasting years leading up to it if I am correct, prodromal? It doesn’t happen overnight.

Experts have watched videos of children who later went on to develop the condition and could pick them out after a while. Often poorer school grades, abnormal movements, and irritable behavior could be found. Plus the negative and cognitive symptoms overlap heavily with Asperger’s/ASD or just Autism Disorder. I believe they bundled it all up because there is too much heterogeneity, hence the distinction between AS and Autism was a bit artificial.

Some things seem to be opposites: clumsiness in autism vs. stupor/stiffness in SCZ, repetitive literal speech or no speech in autism vs alogia or garbled speech in SCZ, obsessiveness with one topic in autism vs apathy in SCZ, but stereotypies are shared and so are bizarre habits. However, there is a different flavor to them, hard to describe.

Do you believe it is neurodevelopmental or stick with the old belief it’s degenerative?

Thanks for the excellent comment. I share your views. I have long believed that schizophrenia is developmental. Really they are born with it or born with the tendency. With enough stress or genetic loading, they get schizophrenia, and if they have little stress or low genetic loading, they either get schizotypal personality disorder (really just mild schizophrenia) or they may get schizophrenia with a later onset.

There really are two things they are seeing in the early symptoms.

The first are the early symptoms – clumsiness, oddness, poor grades, irritability, etc. Those are childhood symptoms.

Then there is the prodrome which hits in adolescence at some point. This causes a slow deterioration over a few years’ period leading to the classic onset from 16-24. I was best friends with a man with paranoid schizophrenia for a year. I hung out with him every day that year. It was a most interesting experience!

At the time, he was 27 years old and he was in the prodromal phase of paranoid schizophrenia. It had been going on maybe since age ~22, so five years. A long slow prodrome is common in paranoid schizophrenia. He was hearing voices the whole time, but his charming personality was quite intact. He was half-Black, very good-looking, and very charming, and he attracted White women everywhere we went together. He later got slowly worse and worse, and after a while, he was not even talking much. I haven’t heard much about him since, as my relatives are telling me to avoid him.

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A Few Words About Schizophrenia and Psychosis in General

I do not know much about schizophrenia. I have met two people who were schizophrenic who discussed their symptoms with me.

The young man was medicated but he was still too ill to work and lived off disability. The woman may also have been medicated and she also lived off disability. This is a typical outcome for this illness, sadly.

Her diagnosis was a true grab bag, and she had been diagnosed with everything in the book, including OCD and frequently Borderline Personality Disorder. I was not sure what her complete picture was, but in adolescence and early adulthood, she underwent what looked like a classic schizophrenic prodrome process. There’s nothing else that looks like that. Afterwards a lot of psychotic symptoms developed including visual hallucinations. Also she did not believe she was ill, which is typical of these folks.

I could not really see the Borderline PD. The problem with these schizophrenics is that the schizophrenic process is so complete and totalizing that it essentially swamps over all sorts of other or lesser symptoms.

 

 

The man also had an OCD process going on, and he denied his symptoms were caused by mental illness. He was also trying to hide symptoms from me, which they do sometimes after the illness goes on for a while. It’s not that they believe the symptoms are crazy – they think it is actually true that the man in the TV said, “It’s going to rain today” and that really is a secret message to them telling them to go to the store and buy a pack of cigarettes. Incidentally that is a common type of psychotic symptom and they are called delusions of reference and they are common in schizophrenia. I have someone close to me who had Bipolar 1 Disorder with prominent psychotic (schizophrenic-like) features who had symptoms exactly like that.

The thing is that even chronic psychotics are not stupid and are driven by the pleasure principle to avoid pain. Eventually these people often figure out that when they say certain things like that the CIA is after them, people tend to get alarmed, call the police and they get hospitalized. Being more rational than you would think, they learn to keep some of these symptoms to themselves if only to stay out of the hospital.

He had a lot more insight than a typical schizophrenic which may be due to the OCD, which would introduce a chronic doubting nature into the psychosis, which would be good for any psychosis, as they are based on hard belief. There are new theories about an illness called Schizo-obsessive Disorder which looked a lot like what this man had. Paranoia, Shneiderian symptoms, and a better prognosis are among the features. To give you an example of the Shneiderian features, for instance, this man heard his own thoughts spoken out loud in the exact same way as if you were to speak your thoughts out loud – how creepy! He was afraid to ride the buses as he feared that the others on the bus could hear his thoughts as he thought them as they sounded as loud and clear as if there were someone talking right next to you.

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Filed under Anxiety Disorders, Borderline, Mental Illness, Mood Disorders, OCD, Personality Disorders, Psychology, Psychopathology, Psychotic Disorders, Schizophrenia

Schizophrenia “Swamps out” Any Other Disorders in the Individual

The problem with schizophrenics is that the schizophrenic process is so complete and totalizing that it essentially swamps over all sorts of other or lesser symptoms.

All you see is the schizophrenia, and its hard to see if there are anxiety, mood (Axis 1 or symptomatic) or especially personality disorders (Axis 2) underneath there. It’s like there’s a tidal wave coming in (the schizophrenia), and you are running around your house looking for roaches (other disorders).  Well, the wave is going to swamp all those roaches, and even if they are there, at some point all you will see is the wave, and the only thing that will matter is the wave, as the roaches will be swamped out so to speak.

Also schizophrenia itself can feature prominent anxiety at times (for instance that the FBI is after them), although anxiety is not typical a primary feature of schizophrenia.

Schizophrenics are often depressed, but it seems like depression is part of the schizophrenia itself. Obviously when depression is part of core schizophrenia as a symptom, it makes it hard to tell that apart from a depression arising often from the depressing effects of the illness itself.

Axis 2 (personality disorder) problems are going to get swamped out too, not to mention the fact that having schizophrenia alone has a devastating effect on personality.

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Differential Diagnosis in Psychiatry – Separating “Symptomatic” Processes from “Core” Processes

In an anxiety disorder, the main thing you see or the “meat” of the illness is the anxiety – I call it an “anxiety process.” In this sense, even some anxiety disorders that have gone psychotic, say Psychotic OCD or Body Dysmorphic Disorder, are still basically anxiety disorders at their core and not psychotic disorders.

The primary disturbance or process if you will is anxiety and the psychosis is just growing out of that process.

What we are doing here is looking for the core essence of the problem – the Gestalt if you will. We are ignoring symptomatic features on the outside and looking underneath them to see what the core or basic process is underneath.

In the same sense, mood disorders that have gone psychotic or even resemble schizophrenia are better seen as mood processes. In Bipolar Disorder, the primary disturbance is one of mood. The psychotic features, if any, are only present during the mood disturbance – the depression or mania. The psychotic features are flowing out of the mood issue and not the other way around as in the case of some schizophrenic persons who get depressed due to the depressing nature of their illness.

If you clear up the mood process and the psychosis is still there, it tends to go over to Schizoaffective Disorder. This is a controversial category, but it is valid. No one quite knows what it is, but I believe the best explanation is that this is simply Schizophrenia and a mood disorder – Major Depression or Bipolar Disorder – occurring in the same person. Persons with Schizoaffective Disorder tend to be heavily loaded genetically for both mood disorders and schizophrenia, whereas someone with a core mood disorder will tend to have mood disorders in their family history and someone with schizophrenia will tend to have relatives with schizophrenia.

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Chronic Mental Illness and Personality

Axis 2 disorders (personality disorders) are hard to diagnose in schizophrenia because of the swamping nature of schizophrenia and because schizophrenia itself has a devastating effect on personality.

Even mood disorders often cause serious personality changes. When they hit in adolescence, maturity is often frozen at whatever the age the illness hit. This is why you see people with chronic mental illness in their mid-50’s who still act like teenagers. They act that way because the chronic illness hit in adolescence and their maturation process for all intents and purposes froze in place.

You really need to treat the mood disorder and then see if there is anything left on Axis 2.

I don’t believe in diagnosing personality disorders that are caused by an Axis 1 symptomatic process (anxiety or mood disorder) because this violates the basic theory of Axis 2 – that these are illnesses at the very core or essence of the person, at the soul itself if you will – that usually have roots deep in childhood and adolescence and are always apparent by adolescence or early adulthood. Pathological personality change in later life violates the principles of Axis 2, but maybe we need a new DSM category for that, as it does occur sometimes.

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