This is another in a series of articles on psychiatric diagnosis. This one will focus on the interface between OCD and psychosis. Keep in mind that there is a now a dx called “OCD with psychotic features.” Here are five cases of OCD with psychotic features. As you can see, these people believe in some really strange stuff! They are also very, very ill. Case 1
Z suddenly developed rituals at age 17. While watching television he looked up and saw a man’s face at the glass kitchen door and heard a voice say: “Do the habits and things will go right”. He came to believe in a ‘power’ that could bring him luck if he could retain it within his possession through ritualising.
He bought an electric guitar which he felt contained the ‘power’ and would turn the controls ritualistically. He often saw a ‘black dot’ the size of a fist leave his body and enter some object around him. When experiencing the loss of the ‘black dot’ he felt compelled to ritualise to regain the ‘power’ that he believed was contained in it.
At age 19 he began to believe that a workman possessed a second ‘power’ for evil and began a second set of rituals to ward off this evil power while striving to retain the good one. He believed absolutely in the ‘power’ and feared disastrous consequences for himself and his family should he fail to retain the good and repel the evil power.
Before his admission to hospital, obsessions and compulsions affected every area of his life. Before performing any action he felt compelled to imagine the letter ‘L’ and the phrase ‘X away, power back’ for up to 20 minutes. He felt unable to sit on chairs or walk on grass or leaves, and slept with his feet uncovered for fear of the ‘power’ being transferred to some object from which he might be unable to retrieve it. On leaving home he constantly retraced his steps to place his foot on a crack in the pavement or a leaf that he felt he had trodden on and so lost some of the ‘power’. If he saw the black dot leave his body (about 20 times a day) he had to touch the object it had entered and superimpose the letter ‘L’ and the phrase ‘X away, power back’ in his mind until he saw the black dot return. From age 18, Z also had recurrent depression, hopelessness and suicidal urges, with deliberate self-harm (overdoses and wrist-slashing) when he was in a depressed mood. He said he harmed himself to appease the power or as a wish to die “when everything was perfect” after a day of ritualizing.
Y developed beliefs about a ‘power’ at age 13. He felt that everyone had a certain ‘quality’ or ‘goodness’ which was stored in the brain as a ‘power’. He believed that other people drained the power from him and replaced it with their own rubbish (feces and urine). The exchange of power was triggered by an image in his mind of a face or object. When it happened he felt distressed, ‘dirty’ and ‘horrible’. He could only regain the power by doing complex rituals. He imagined the person’s face and that he had detached their head from their body and sucked the power from the major vessels of their neck or from their eyes. He then transferred the power back into himself by banging his palm on a particular spot on his forehead, and breathing out repeatedly. This made him feel relieved and ‘good’, but as the events recurred up to several times a minute the relief was short-lived. He felt ‘compelled’ at times to get revenge on people who stole his power by drawing with his finger on a wall a deformed and ugly representation. If he touched anything he left a ‘power’ trace behind and so had to touch it repeatedly to get the ‘power’ back. Y’s belief in the experience was absolute. He knew it might seem strange to others but believed that if they experienced it, they would understand. From age 17 he also had recurrent depression, hopelessness and suicidal urges requiring hospital admission.
At the age of 8, X had transient counting rituals associated with fear of harm coming to others. When she was 15, after a relative died, she feared that harm would befall her family and friends unless she completed specific tasks. She thought a supernatural ‘power’ inserted unpleasant thoughts into her mind, e.g. “if you read that book a relative will die”. She believed unshakably that the power was supernatural, but could not explain it. To appease the ‘power’ and the thoughts, she developed complex counting rituals pervading her daily activities. She also did ritualistic hand-washing and checking. She avoided specific numbers, colours and clothes and counted from 0 to 8 on her fingers and toes throughout the day. She repeated rhymes, avoided multiple numbers she associated with death or harm, and brushed her hair hundreds of times a day. She felt unable to resist the rituals, as her belief in negative consequences was absolute. Before she was admitted to hospital, rituals took all of her time until she fell asleep. X had two episodes of moderate depression at age 25 and 34, both associated with worsening of her OCD. She had never harmed herself.
At the age of 7, W developed fear of harm coming to relatives. He engaged in hand-washing and touching rituals to prevent this. Gradually he began to believe that ‘spirits’ or an outside force ‘reminded’ him to carry out his rituals lest harm should result. He associated the numbers 13 and 66 with harm and, if he saw them, believed they were placed by an external force to remind him to carry out his rituals. He defended his belief absolutely but said he could not be 100 Prior to admission he was homeless and had thrown away all his ‘contaminated’ possessions, carrying all he owned in two carrier bags.
For 20 years V had had a fear of being transported into another world. At age 17 he worried that reflections in mirrors represented another world, and had complex checking rituals involving mirrors. This gradually spread to all reflective surfaces. He believed that turning on electrical switches, using the television remote control or hearing car engines turned on could cause him to be ‘transported’ and constantly checked to make sure this had not happened. He believed that if he ate while in another world, he would be forced to stay there, and so either avoided eating, or ate with complex rituals, or induced vomiting. Other rituals involved switching electrical switches on and off and wearing particular clothes. The ‘other’ world was tangibly the same as the real one, but ‘felt’ different – he felt that friends and family, although appearing the same, were ‘different’ and might have been replaced by ‘doubles’. The symptoms gradually worsened, occupying all of his time prior to admission to hospital. When he was 27 he suffered severe depression requiring in-patient care, and again at age 30. He had no history of self-harm.