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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8 thoughts on “Borderlands: Obsession, Delusion and Their Differential Diagnosis”

  1. Robert, there is another distinction I never see made, wich is the different element that exisf, the ontology, in the human mental realm :
    – you have the inner speech,
    – the imagery wich can be visual, aural (the distinction with inner speech is that it can be any sound, and when it’s the same voice as inner speech, it is heard and not produced), haptic, kinestetic etc. Every sens can be reproduced by the mind .
    – you have the abstract unsymbolic thinking : you can use it for thinking or reading without subvocalization
    Very few persons have it all, so some of those capacities sounds like magic power to many people, when they understand it !

    1. My experience is that a lot of very high IQ persons (>3sd) fall into two weird and narrow categories :
      – either they only have and use inner speech with no other imagery nor abstract thinking
      – either they combine strong imagery with abstract thinking .

      1. Inner speech exist lato sensu meaning internal thought. But some people can’t subvocalized. So they can read at loud. They can read abstractly. But they can produce the sound in their mind.
        What’s even more bizarre is that some of those people have auditive imagery. So they are able – for some of them – to hear the sound of a voice – maybe their own voice – in the reading process or in the thinking. Then the distinction among the two is very subtle : inner speech is like recording your own voice in a recording machine (its active ). Imaged sound is like playing it. Some people can have an internal conversation among their inner speech and one or several imaged sounds . But the inner speech is only one voice and it’s always the same . We don’t know yet how this ontology is implemented by the brain.
        My ontology is extremely poor because I have only inner speech. I never get a sound or an image or an unvocalized thought in my mind. It’s very poor. I would say it is the Nirvana some oriental are looking for because their is no memories and no mind travelling … I don’t know if this state of mind is desirable. Because I lose a big part of the human being experience.

  2. 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.

    1. I mean, psychotic symptoms without being an actual psychotic person because all those symptoms are caused by the ongoing anxiety process?

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