The Connection Between OCD and Psychosis

Obsessive-compulsive disorder is characterized by recurrent and disturbing thoughts (obsessions) and repetitive, ritualized behaviors (compulsions).

Obsessions can also take the form of intrusive images or unwanted impulses. Compulsions tend to interfere with a person’s daily life, including activities and interactions.

This is a rather general picture of what OCD looks like, but there’s not just one type of thought or behavior you might experience with OCD.

Symptoms of OCD vary from person to person, and obsessions and compulsions can change over time.

If you have OCD, the types of obsessions you have could relate to include:

• harm
• losing control
• perfectionism
• religion
• sexual thoughts

Some common compulsions may relate to:

• checking
• cleaning and washing
• repeating (like rewriting or repetitive body movements)
• mental repetitions or reviews

Not everyone with OCD will develop psychosis, but for some people, it’s possible to experience symptoms of psychosis.

Psychosis is when you lose some contact with reality. When you experience symptoms of psychosis, you may have difficulty understanding what’s real and what is not.

Experiencing psychosis with OCD is more common when OCD symptoms or anxiety levels are particularly high.

DSM-5 diagnosis

Even before the connection between OCD and psychosis was fully realized, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) outlined that “obsessional thoughts, impulses, or images are a product of the person’s mind” in OCD.

In other words, awareness that obsessions and compulsions are products of your mind is considered a characteristic of OCD.

Previously, it was believed that people with OCD should not be experiencing symptoms of psychosis.

According to the DSM-5, OCD has specifiers that show if a person has:

• good or fair insight: recognizes that beliefs are definitely or likely not true
• poor insight: feels that beliefs are probably true
• absent insight or delusional beliefs: thinks that all beliefs are true

Someone who’s considered to have OCD with poor or absent insight might not readily acknowledge their thoughts and behaviors as problematic or unreasonable. This can be considered psychosis.

OCD with poor or absent insight is when symptoms of psychosis might appear.

How prevalent is OCD?

OCD is a fairly common condition that affects adults and children of all races, genders, ethnicities, and backgrounds. About 1 in 100 U.S. adults have it.

According to the International OCD Foundation, OCD symptoms first appear between ages 8 and 12 or between late teens and early adulthood.

Typically, OCD is diagnosed by age 19. OCD can still be diagnosed later in adulthood, but it’s less common.

How is OCD diagnosed?

Behaviors and thoughts associated with OCD exist in most people to some extent. But showing harmless or mild symptoms of OCD is not enough for a diagnosis.

To be diagnosed with OCD, your symptoms must:

• get in the way of your daily functioning
• cause a great deal of distress
• consume excessive amounts of energy or time

To measure whether your symptoms meet the requirements for an OCD diagnosis, you’ll likely need to be interviewed by a trained mental health professional.

The list of potential OCD symptoms is fairly long. No two people will have the same symptoms at the same time.

The main two OCD symptoms are obsessions and compulsions. Some examples include:

• Obsessive fear of contamination: compulsive handwashing, avoiding physical contact, doing laundry excessively
• Fear of death or harm: compulsively checking that doors are locked, checking that appliances are turned off, unreasonable avoidance of certain activities
• Fear of discarding something: saving useless items
• Fear of violating religious rules: compulsively praying, repeatedly confessing perceived sins
• Fear of asymmetry: a need to arrange items so they’re perfectly aligned, mentally plotting the arrangement of objects on a grid or streets on a map

What psychosis feels like

When you experience symptoms of psychosis, your brain processes information in a way that causes a permanent or temporary disconnect from reality.

Psychosis isn’t necessarily its own disorder but can be a symptom of a mental health condition or from medical events, such as injuries and some illnesses.

Usually, the onset of psychosis requires immediate medical attention.

The signs and symptoms of psychosis may include:

• difficulty concentrating
• depressed mood
• sleeping too much or not enough
• anxiety
• paranoia
• withdrawal from family and friends
• delusions
• hallucinations
• disorganized speech, such as switching topics erratically
• suicidal thoughts or actions

Some signs of psychosis may overlap with other conditions (like depressed mood, anxiety, or sleep difficulties), but if you believe you’re having symptoms of psychosis, consider seeking help right away.

While OCD is considered a mental health condition, psychosis is not. Psychosis describes a mental state in many other conditions, including OCD.

While someone with OCD can experience psychosis, this does not mean that OCD is a psychotic disorder. This distinction is important to make, especially when seeking treatment.

Misdiagnosis of OCD with psychosis

Occasionally, poor insight with OCD may be mistakenly attributed to a psychotic disorder and misdiagnosed.

In a 2012 case study, one woman had a 1-year history of symptoms including social withdrawal, muttering to herself, and feeling extremely suspicious. She firmly held onto delusions about her acquaintances, despite her husband telling her otherwise.

Since her grasp of reality seemed distorted, doctors ruled that her behaviors showed signs of psychosis.

But after she was hospitalized, it became clear that her symptoms of psychosis accompanied OCD symptoms, including repetition of thoughts (obsessions) and behaviors (compulsions).

Recognizing her patterns in obsessive thoughts and compulsive behaviors eventually led to a correct diagnosis.

There are many treatment options for managing symptoms of OCD, including therapy and medications.

People with OCD may have to work with a therapist and try multiple strategies to develop the right treatment plan.

According to the International OCD Foundation, 7 out of 10 people with OCD will benefit from cognitive behavioral therapy known as exposure response prevention (ERP).

Many people can also benefit from medication in addition to therapy.

Support groups can also help people with OCD feel more connected to others living with the same condition.

Many mental health centers and hospitals offer outpatient day programs that may help support people with OCD. With day programs, you can attend treatment during the day for up to 5 days a week.

Aside from medication and therapy, you can do several other things to feel better.

If you have OCD, you can practice specific self-care techniques at your own pace and in the comfort of your own home to help you manage stress and relieve symptoms associated with your condition:

• Mindfulness. Because intrusive thoughts are common in OCD, practicing mindfulness can help you recognize thought patterns and work to rethink them.
• Journaling. Writing may help you note unwanted or intrusive thoughts, as well as discover rituals and compulsions used to combat these thoughts.
• Self-talk. Positive self-talk like affirmations may help change an obsessive inner monologue so you’re kinder and more compassionate to yourself.
• Sleep. A consistent sleep routine and peaceful sleep environment may help reduce symptoms of psychosis (and benefit overall health).
• Exercise. Some research suggests that exercise can help soothe symptoms of psychosis in people with OCD.

If you’re living with OCD, your symptoms can be wide-ranging and even change over time. You may also develop symptoms of psychosis.

There are numerous strategies for coping with OCD (with and without psychosis), including:

• therapy
• medication
• self-care

With the support of a therapist or other healthcare professionals, you can explore treatment options to find what works best for you.

For more resources and information on OCD and psychosis, you can visit the International OCD Foundation.