What’s the difference between Obsessive-Compulsive Disorder (OCD) and psychosis? OCD is characterized by the experience of recurring and often unwanted thoughts (obsessions) and/or repetitive behaviors or mental acts that are difficult to resist (compulsions). Psychosis is a clinical state that occurs when individuals have difficulty distinguishing between what is real and what is imaginary, which usually takes the form of hallucinations (feeling, seeing, hearing things that are not there) or delusions (odd or strange beliefs that are not true). These two mental health conditions look very different on paper, but sometimes it is difficult to distinguish the two in real life.
Sometimes, mental health professionals initially struggle to determine if a patient is experiencing OCD or psychosis because of their level of insight. In the context of mental health, insight refers to the degree to which a patient understands that the experiences they’re having are due to mental illness. In OCD, we often talk about insight as it relates to obsession and compulsions. If a patient is aware that their obsessive-compulsive beliefs are not true, they are thought to have “good or fair insight.” However, if a patient completely believes that the obsessive-compulsive beliefs are true, they are said to have “absent insight/delusional beliefs.” If or when a patient displays “absent insight/delusional beliefs” in regards to obsessive or intrusive thoughts, how then do we tell the difference?
One way that mental health professionals can make this determination is to look at the patient’s presentation holistically. If the patient is displaying delusional belief in regards to potential obsessive-compulsive beliefs, what other symptoms are they exhibiting? If other symptoms of psychotic disorders are absent, like hallucinations, this could point to a diagnosis of OCD. If, however, patients display either obsessions or compulsions, delusional belief regarding the obsessions or compulsions, and hallucinations, a diagnosis of a psychotic disorder or comorbid psychosis and OCD might be considered.
Another way that mental health professionals may try to distinguish between OCD with absent insight and psychosis is by examining the content of the delusional thinking. Obsessions or compulsions observed in OCD are often “ego-dystonic,” meaning the content is contrary to a person’s core values and beliefs. For example, someone who strongly values family may experience highly distressing obsessional thinking about harming their family members, also called harm OCD. On the other hand, the content of delusions or hallucinations in psychosis can be about anything and are often unrelated to an individual’s beliefs, values, or identity. For example, someone who does not value religion and may not identify with any type of religion could become convinced that they are a deity, an angel, or some kind of omnipotent being.
Finally, a third way to distinguish between OCD with absent insight and psychosis is to examine the underlying thinking pattern. Individuals with OCD engage in repetitive or ritualistic behaviors (compulsions) in order to reduce anxiety, fear, distress caused by the obsessional or intrusive thinking. Consider the example of harm OCD mentioned above – an individual who obsessively thinks that they may hurt their family members may repeatedly check that knives, sharp objects or weapons are locked up when they are around their family members because this helps relieve their anxiety that they will harm their family. People diagnosed with OCD report relying on compulsive behaviors or rituals because they believe this will prevent a negative event from happening. On the other hand, an individual who believes they are a deity or angel may quit their job and begin trying to “save” others, not because they are distressed by their delusional belief that they are a deity or angel or want to prevent a negative outcome, but because that is what a deity or angel should do.
Sometimes, the difference between OCD and psychosis is unclear, and it may require time for an individual to be properly diagnosed. Unfortunately, a lot of misinformation about psychosis and OCD exists. If you have questions about OCD or psychosis, speak to your mental health provider or visit some of the websites below for more information: