When my son Dan’s obsessive-compulsive disorder (OCD) became severe, he was in college, fifteen hundred miles away from home. My husband and I arranged for him to see a psychiatrist near his school, who telephoned us (with our son’s permission) after he met with Dan. The doctor certainly didn’t sugarcoat anything. “Your son is suffering from severe OCD, and he is borderline psychotic.”
I knew very little about OCD at that time, but I knew what psychotic meant: out of touch with reality. I was terrified. Psychosis made me think of schizophrenia, though that illness was never mentioned. In fact, after I united with Dan and we met with the psychiatrist together, there was no more reference to psychosis.
So what was going on? What my son was experiencing was OCD with poor insight. In many instances, OCD sufferers are aware that their obsessions and compulsions are irrational or illogical. They know, for example, that tapping the wall a certain number of times will not prevent bad things from happening. And they know their compulsive tapping is interfering with their lives. But they can’t control their compulsions, and so they tap away.
Those who have OCD with poor insight do not clearly believe their thoughts and behaviors are unreasonable, and might see their obsessions and compulsions as normal behavior; a way to stay safe. It is interesting to note that the recently published DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) specifies that OCD may be seen with: good or fair insight, poor insight, or absent insight/delusional beliefs.
In all previous editions of the DSM, the criteria for the diagnosis of obsessive-compulsive disorder included the sufferer’s realization that their obsessions and compulsions are irrational or illogical. Now, absent insight/delusional beliefs can be part of an OCD diagnosis. In addition, the statement, “At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable,” has been removed.
Another important aspect of the disorder to be aware of is the fact that OCD sufferers’ levels of insight can fluctuate, depending on the circumstances. When Dan was initially diagnosed with OCD, he did indeed have good insight. He knew his obsessions and compulsions made no sense. But by the time he met with the psychiatrist mentioned earlier, his OCD had gotten so severe that he had poor, or possibly even absent, insight. This is when the doctor used the term “borderline psychosis.”
In some cases, OCD sufferers’ levels of insight can change quickly. For example, while calmly discussing a particular obsession and compulsion, those with OCD might acknowledge their thoughts and behaviors are unreasonable. But an hour later, when they are panic-stricken and in the middle of what they perceive as imminent danger, they might totally believe what they had previously described as nonsensical. This is the nature of obsessive-compulsive disorder.
It is crucial to differentiate between OCD and a psychotic disorder, because drugs that are prescribed for psychosis (antipsychotics) have been known to induce or exacerbate symptoms of OCD. In addition, research has shown that these antipsychotics often do not help those with severe OCD. In Dan’s case, the antipsychotics he was prescribed did indeed exacerbate his OCD, in addition to causing a host of serious side effects, both physical and mental.
OCD sufferers and their caregivers need to be aware that things are not always what they seem. A misdiagnosis of psychosis in those with OCD is just one example. A comorbid diagnosis of depression or ADHD are others. Because the DSM-5 categorizes certain behaviors as belonging to specific illnesses, we really need to be careful not to jump to conclusions in reference to diagnoses and subsequent treatments.
In the case of obsessive-compulsive disorder, maybe the best way to proceed is by treating the OCD first, and then reassessing the situation. Once OCD has been reined in, we might be surprised to find that symptoms typically associated with other disorders have fallen by the wayside as well.