All people have ever had an obsessive thought, a certain thought, fear or doubt that we cannot get out of our head even if we want to. Additionally, most have at some point had thoughts that don’t bother or hate us, such as wishing someone else not to get what we want for ourselves or the temptation to hit four cries against the unscrupulous who speak on the phone in the films. Most people don’t give them more importance.
However, for those affected by obsessive-compulsive disorder, these ideas generate great anxiety about their possible implications and possible consequences, so that they try to perform different ritual actions to control their thoughts and regain control.
Most people with OCD consider and recognize that deep down, these thoughts and fears are nothing to really worry about and have no real effect on the world. Others don’t. Among the latter, we can find cases in which obsessive ideas become illusions and may even have hallucinations. Although this is a very unusual thing, there are cases of obsessive-compulsive disorder with psychotic episodes. We will talk about it in this article.
Obsessive Compulsive Disorder
It is called obsessive-compulsive disorder or OCD in the condition characterized by the continued presence over time of obsessions, mental content, or ideas that appear intrusively in the mind of the subject without the subject being able to control them but which are recognized as theirs and which, in most cases, generate a high level of anxiety. Along with these ideas often appear a set of acts or rituals called compulsions that are performed in order to reduce the anxiety generated by the ideas or to avoid the possibility that obsessive thoughts take place or have consequences in life.
It is one of the mental disorders which generates the most suffering for those who suffer from it, since in most cases the subject is aware that he cannot control the appearance of his thoughts and that the actions that he takes. it performs as a ritual have no real effect beyond a temporary and brief reassurance, which in fact reinforces the future emergence of new thoughts. In fact, a vicious circle is established between the obsession and the compulsion which aggravates the anxiety that the subject is suffering, by returning the symptoms of the disorder.
The feeling is to lose control of their own thinking, or even to withdraw into a dynamic from which they cannot escape. Much of the problem is actually the excessive attempt to control thought and to actively prevent the appearance of the thought that generates anxiety in them, which indirectly strengthens their appearance. So we are faced with a disorder of selfish character.
It is common for there to be some level of magical thinking and thought-action fusion, subconsciously considering that it is possible for the thoughts themselves to have an effect in real life while recognizing on a conscious level that this it’s not the case.
This disorder has serious repercussions on the daily life of those who suffer from it, as the repeated presence of obsessions and compulsions can demand a large number of hours and limit their personal, professional and academic lives. Personal relationships can deteriorateThe subject also tends to isolate himself to avoid social rejection, and his performance, work and school performance can be greatly diminished by devoting much of his attention and cognitive resources to avoiding “obsession”.
OCD with psychotic episodes: an atypical aspect
In general, the subject with obsessive-compulsive disorder is aware and recognizes that his obsessive thoughts and compulsions he exercises are not based on a real basis, and may even consider them stupid without being able to control them. This fact generates an even higher level of discomfort and suffering.
However, there are cases when obsessive ideas are considered to be true and the subject is completely convinced of their veracity, does not question them and turns them into explanations of reality. In these cases, the ideas can be considered delusional, acquiring OCD psychotic characteristics.
In these cases, considered and also called atypical obsessive or schizo-obsessive, we observe that the insight necessary to detect that their behaviors have no real effect on what they seek to avoid is not present. Also in these cases compulsions may not feel like something boring or selfish but simply as something to do, without appearing intrusive or coerced. Another option is for the continued suffering of an obsessive idea to end up reactively triggering hallucinations or delusions as a way of trying to explain how the world works or the situation being experienced.
Three great possibilities
The concomitant presence of obsessive and psychotic symptoms is not particularly common, although in recent years there appears to have been some increase in this joint pattern. Studies show that there are three main possibilities:
1. Obsessive-compulsive disorder with psychotic symptoms
This is the most typical case of obsessive-compulsive disorder with psychotic episodes. In this clinical presentation, people with OCD may exhibit transient psychotic episodes resulting from transformation and elaboration of their ideas, understandably depending on the persistence of obsessive ideation. These would be episodes that they will react reactively to the mental wear and tear generated by anxiety.
2. OCD with lack of insight
Another possibility of obsessive-compulsive disorder with psychotic symptoms arises, as we said above, the absence of the capacity to perceive the non-correspondence of the obsession with reality. These subjects would have ceased to see their ideas as abnormal and would consider that their ideas do not contain an overestimation of their influence and their responsibility. They generally tend to have a family history of severe psychopathology, and it is not uncommon for them to express anxiety only about the consequences of not performing compulsions and not about the obsession itself.
3. Schizophrenia with obsessive symptoms
A third possible comorbid presentation of psychotic and obsessive symptoms occurs in a setting where obsessive-compulsive disorder does not really exist. These would be schizophrenic patients who during the suffering or before the presence of psychotic symptoms they exhibit obsessive traits, with repetitive ideas that they cannot control and a certain compulsiveness in his action. It is also possible that certain obsessive symptoms appear induced by the consumption of antipsychotics.
What causes this disorder?
The causes of any type of obsessive-compulsive disorder, both those with psychotic characteristics and those without, are largely unknown. However, there are different hypotheses in this regard, considering that OCD is not the cause of a single cause but that it has a multifactorial origin.
Medically and neurologically, Thanks to neuroimaging, it was possible to observe the presence of an hyperactivation of the frontal lobe and the limbic system, as well as an affectation of the serotonergic systems (reason why the pharmacological treatment is generally based on antidepressants in patients patients they need it) and dopaminergic. An implication in this disorder of the basal ganglia has also been observed. Regarding these OCD modalities with psychotic episodes, it has been observed that neuroimaging levels tend to have a smaller left hippocampus.
At the psychosocial level, OCD is more common in people of a sensitive nature who have been educated either too rigid or very permissive, which has generated in them the need to control their own thoughts and behaviors. They tend to be hyper-responsible for what is going on around them and have a high level of doubt and / or guilt. It is also not uncommon to experience bullying or some form of abuse that has caused them to need, initially in an adaptive way for them, to control their thoughts. The association with psychotic symptoms may also be due to suffering from trauma o experiences that have generated a break with reality, In conjunction with a predisposition to this type of symptomatology.
An existing hypothesis regarding the functioning of TOC is Mowrer’s bifactor theory, Who proposes that the cycle of obsessions and compulsions be maintained by a double conditioning. In the first place, there occurs a classical conditioning in which the thought is associated with the anxious response which also generates the need to flee it, later by means of an operant conditioning to maintain the avoidance or flight behavior by means of of constraint. Thus, the compulsion is associated with the reduction of immediate discomfort, but has no effect on the actual aversive stimulus (the content of thought). In this way, it does not prevent but actually facilitates the emergence of future obsessive thoughts.
- American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth edition. DSM-5. Masson, Barcelona.
- Racó, DA and Salazar, LF (2006). Obsessive-compulsive disorder and psychosis: a schizophrenic obsessive-compulsive disorder? Catalan Society of Psychiatry, 35 (4).
- Toro, I. (1999). Psychotic forms of OCD. Vertex, Revista Argentina i Psiquiatria; 37: 179-186.
- Yaryura-Tobias, JA and Neziroglu, F- (1997). Spectrum of obsessive-compulsive disorder. Washington DC, American Psychiatry Press.