Obsessive-Compulsive Disorder with Psychotic Episodes

The most severe cases of OCD can develop psychotic symptoms.

Everyone has at some time had some obsessive thought, some thought, fear or doubt that we cannot get out of our heads even if we want to. Also most of us have had at some time thoughts that do not embarrass or displease us, such as wishing someone else not to get what we want for ourselves or the temptation to yell at the uncaring person who is talking on the phone in the movie theater. Most people don't give them much thought.

However, for those affected by an Obsessive-Compulsive Disorder these ideas generate great anxiety about their possible implications and their possible consequences, so they they try to perform different ritual actions to control their thoughts and regain control. and regain control.

Most people with OCD consider and recognize that deep down these thoughts and fears have no basis in reality that should really concern them and have no real effect on the world. Others do not. Among the latter we can find cases in which the obsessive ideas become delusions and may even have hallucinations. Although it is something very unusual, there are cases of Obsessive-Compulsive Disorder with psychotic episodes.. Of this we will speak in this article.

The Obsessive-Compulsive Disorder

It is denominated Obsessive-Compulsive Disorder or TOC to the ailment characterized by the presence continued throughout the time of obsessions, mental contents or ideas that appear in an intrusive way. in the mind of the subject without this one can control them but that are recognized as own and that in the majority of cases are generators of a high level of anxiety. Frequently, together with these ideations, a set of acts or rituals called compulsions appear, which are carried out in order to reduce the anxiety generated by the ideas or to avoid the possibility of the obsessive thoughts occurring or having consequences in real life.

It is one of the mental disorders that causes the greatest suffering to those who suffer from it, since in most cases the subject is aware that he/she cannot control the appearance of his/her thoughts and that the acts performed as rituals have no real effect beyond a temporary and brief tranquilization, which in fact reinforces the future appearance of new thoughts. In fact, a vicious circle is set up between obsession and compulsion that increasingly aggravates the anxiety that the subject suffers, feeding back the symptoms of the disorder.

The feeling is one of lack of control over their own thoughts, or even of confinement within a dynamic from which they cannot escape. A large part of the problem is in fact the excessive attempt to control thinking and actively avoiding the appearance of the thought that generates anxiety, which indirectly reinforces its appearance. Thus we are faced with a disorder of egodystonic character.

It is common for there to be a certain level of magical thinking and thought-action fusion, unconsciously considering that it is possible that one's thoughts can have an effect in real life despite consciously recognizing that this is not the case.

This disorder has serious repercussions on the daily lives of those who suffer from it, since the repeated presence of obsessions and compulsions can require long hours and limit their personal, work and academic lives. Personal relationships may deteriorateThe subject also tends to isolate him/herself to avoid social rejection, and his/her work and academic performance may be greatly diminished by devoting much of his/her attention and cognitive resources to the avoidance of the 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 are not based on a real basis, and may even consider them as stupidity without being able to control them. This fact generates an even higher level of discomfort and suffering.

However, there are cases in which the obsessive ideas are considered true and in which the subject is completely convinced of their veracity, not questioning them and turning them into explanations of reality. In these cases the ideas can be considered delusional, acquiring the OCD psychotic characteristics..

In these cases, considered and also called atypical obsessive or schizo-obsessive, it is observed that the insight necessary to detect that their behaviors do not have a real effect on what they intend to avoid is not present. Also in these cases the compulsions may not be experienced as something annoying or egodistonic but simply as something to be done, without seeming intrusive or forced. Another option is that the continued suffering of an obsessive idea may end up reactively triggering hallucinations or delusions as a way of trying to explain the functioning of the world or the situation experienced.

Three main possibilities

The comorbid presence of obsessive and psychotic symptomatology is not particularly common, although in recent years there seems to have been a certain increase in this joint pattern. Studies suggest that there are three main possibilities:

Obsessive disorder with psychotic symptoms 2.

This is the most prototypical case of obsessive-compulsive disorder with psychotic episodes. In this clinical presentation people suffering from OCD may present transitory psychotic episodes derived from the transformation and elaboration of their ideas, in an understandable way according to the persistence of the obsessive ideation. These would be episodes that will occur reactively to the mental exhaustion generated by the anxiety..

2. OCD with lack of insight

Another possibility of an obsessive disorder with psychotic symptoms derives from, as mentioned above, the absence of 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 overvaluation of their influence and responsibility. Generally, they tend to present a family history of severe psychopathology, and it is not unusual for them to show 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 context where obsessive-compulsive disorder does not actually exist. These would be those patients with schizophrenia who during or even before the presence of psychotic symptomatology obsessive characteristics, with repetitive ideas that they cannot control, and a certain and a certain compulsiveness in their actions. It is also possible that some 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 features and those without, are largely unknown. However, there are different hypotheses in this regard, considering that OCD is not due to a single cause but has a multifactorial origin.

On a medical and neurological levelIn addition, neuroimaging has shown the presence of hyperactivation of the frontal lobe and the limbic system, as well as an involvement of the serotonergic (which is why pharmacological treatment is usually based on antidepressants in those patients who need them) and dopaminergic systems. The involvement of the basal ganglia in this disorder has also been observed. Regarding those modalities of Obsessive-Compulsive Disorder with psychotic episodes, it has been observed that at a neuroimaging level they tend to have a smaller left hippocampus.

At a psychosocial level, OCD is more frequent in people with a sensitive nature who have received an excessively rigid or very permissive education, which has generated in them the need to have control of their own thoughts and behavior. They tend to be hyper-responsible for what happens around them and to have a high level of doubt and/or guilt. It is also not uncommon to suffer from bullying or some type of abuse that has induced them to need, initially in an adaptive way for them, to control their thoughts. The association with psychotic symptoms may also be due to the suffering of traumas or experiences that have generated traumas or experiences that have generated a rupture with reality, together with a predisposition toThe association with psychotic symptoms may also be due to traumas or experiences that have generated a break with reality, together with a predisposition to this type of symptomatology.

An existing hypothesis with respect to the functioning of OCD is the bifactorial theory of Mowrerwhich proposes that the cycle of obsessions and compulsions is maintained by a double conditioning. First of all, classical conditioning occurs in which the thought is associated with the anxious response, which in turn generates the need to flee from it, in order to subsequently, through operant conditioning, maintain the avoidance or escape behavior by means of compulsion. Thus the compulsion is associated with the reduction of immediate discomfort, but has no effect on the real aversive stimulus (the content of the thought). Thus it does not prevent but in fact facilitates the occurrence of future obsessive thoughts.

Bibliographical references

• American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders. Fifth edition. DSM-5. Masson, Barcelona.
• Rincón, D.A. and Salazar, L.F. (2006). Obsessive-compulsive disorder and psychosis: a schizo-obsessive disorder? Revista Colombiana de Psiquiatría, 35 (4).
• Toro, E. (1999). Psychotic forms of OCD. Vertex, Revista Argentina e Psiquiatría; 37:179-186.
• Yaryura-Tobias, J.A. & Neziroglu, F- (1997). Obsessive-Compulsive Disorders Spectrum. Washington DC, American Psychiatry Press.