Tricky presentations: OCD, medical stuff, psychosis?
Last week, a colleague asked me for my thoughts on how to differentially diagnose OCD and psychosis, especially when perceived physical symptoms are part of the client’s suffering. They gave me a case example and I was struggling with how to address this colleague’s core questions without divulging potentially identifiable aspects of the case (I actually don’t know if the client was hypothetical or real. We tend not to ask these things in consultation because the less we know, the better. This is how we protect confidentiality! #funtherapyfacts). Then late last week, my chronic migraines returned and I realized that nearly all core aspects of this colleague’s OCD case matched my personal experience at some point over my migraine journey over the last 20 years. Problem solved! I’m the client. Some details are/were true in my real life and some I’m adopting from the case and smooshing them into my story.
Katie: Adult white female with past medical history of classic migraine and inner ear issues, in remission and recently returned. She reported experiences of derealization, detachment, visual changes, and head and heck pain at unpredictable intervals. She’s afraid of potential worsening of these symptoms and “losing everything” as a result. Doctors have assured her that migraine explains these experiences but she’s concerned they’re missing something. She endorses substantial anxiety, secondary to sensory changes and worried thoughts about the future. During an attack, Katie notices herself monitoring her body and senses and completing motor and cognitive tasks in an attempt to confirm/disconfirm that symptoms are occurring. She sees reassurance from friends, family, and doctors. She finds herself avoiding “difficult tasks” during the day, especially relationally complex tasks when symptoms occur. Her therapist has thus far conceptualized this as Illness Anxiety Disorder (a form of OCD), layered on top of neurological symptoms but is concerned about missing true psychosis.
What do the experts say about differentiating OCD/IAD and psychosis??
Below, you’ll find a much more comprehensive discussion of the definition of psychosis and I encourage you to read it if you don’t know it “in your bones.” I’ve been trained to see psychosis as a process in which the sufferer experiences information from their five senses in a way that is very out of line with reality as most people perceive it AND without insight into that difference. Many folks WITHOUT psychosis can perceive vague physical symptoms which are not objectively observable but the sufferer often has a sliver of doubt about what’s causing the symptoms. This article by experts agrees:
-Arciniegas D. B. (2015). Psychosis. Continuum (Minneapolis, Minn.), 21(3 Behavioral Neurology and Neuropsychiatry), 715–736. https://doi.org/10.1212/01.CON.0000466662.89908.e7
My method of differentiating psychosis from IAD is through unstructured or semi-structured clinical interviews targeted at determining whether or not the client has insight into the possibility that the symptoms are influenced by anxiety. I don’t tend to use a lot of measures in my practice as I find them minimally helpful in developing a conceptualization of the individual. I screen for age of onset of symptoms and family history of psychosis, as both of those factors increase my suspicion of psychotic processes. The other question I ask myself is “Can OCD explain these symptoms? Can I map these symptoms into a typical OCD cycle in a way that makes sense?” OCD also occurs much more commonly than psychosis and common things being common, is a more likely explanation regardless.
What does that OCD cycle look like?
Components of the IAD/OCD cycle:
OCD and related disorders are made up of a few predictable pieces that create and maintain the OCD process:
Intrusions/obsessions which are uncontrollable intrusive experiences: Thoughts, images, sensations, phrases, worries, etc. Sensations are key in IAD.
Compulsions which are reactions to the obsessions, with the aim of reducing associated anxiety. It’s anything the OCD says you have to think or do to feel better. Compulsions in IAD usually include reassurance-seeking through doctors, friends, internet “research,” and monitoring one’s own body for signs of “danger.”
Commentary/narrative is my personal addition but it’s about the words and stories (LANGUAGE) the OCD sufferer’s brain says as it experiences obsessions and compulsions. This is the Acceptance and Commitment Therapy part of my training coming through and I believe if we understand the commentary and use some interventions to shape it, our Exposure and Response Prevention efforts will be augmented.
Mapping the client’s experiences onto the cycle.
Let’s map my historical migraine experiences onto the OCD cycle. Let’s review a narrative report of my symptoms (ahem… I mean our “client’s” symptoms): First, I sense that something is a little “off” with my vision. It’s vague. I can’t read quite as well. Things are a bit blurry. I get anxious thinking “Oh no… here we go again…” I then get visual changes that look like twinkle lights in same spot, in both eyes. If it’s in one eye, it’s an eye thing. If it’s in both eyes, it’s a brain thing. By this point, my thoughts go “oh shit… I’d better get somewhere to ride this out..” My aura or “twinkle lights” usually show up in the shape of the letter c. The “c” of twinkle lights starts at the center of my visual field and slowly moves from the center of my visual field to the periphery (over 30-60 minutes) and that’s the point where I start to sense a headache. When I first got migraines, I had horrible headaches with vomiting but today, it’s usually quite mild. By the time my head starts hurting, the visual changes are over and while I’m a bit “out of it” for 24 hours, I’m usually functional. I have not always been this chill about the experience.
While I’ve always had occasional migraines, after I weaned my first child, I had them HORRIBLY - many times a week with a ton of pain. I had never had migraines that frequently or intensely before and so back then, I had a much more amplified reaction to the experience. Let’s analyze my migraine presentation from 10 years ago onto our known OCD/IAD cycle. Here’s what it looked like 10 years ago:
Intrusions/triggers/obsessions: Visual changes, a sense of depersonalization, severe anxiety, dread, fear, etc. All of the sensations! Intrusive thoughts about catastrophic outcomes - am I having a stroke? Do I have a brain tumor? Should I go to the doctor? What do I need to do next?
Compulsions: Leaving what I’m doing to go lie down, asking for reassurance that someone can take me to the hospital if I need to go, looking up articles on migraines, taking medicines that might work but weren’t actually indicated by my doctor.
Commentary: What if I’m like this for the rest of my life? What am I doing wrong to cause this? Why can’t I make this better? This must be solvable if only I can find the right solution.
You might be thinking, “Katie, does everybody with chronic pain have IAD/OCD?” No they don’t. What makes my previous coping fit the pattern of IAD/OCD is the fact that I was using strategies, in an effort to reduce my anxiety, that perpetuated both my own distress and the headaches themselves. I was using costly, non-functional strategies. See criteria three on this link: “…there is a verifiable medical condition present…the patient’s anxiety or concern is out of proportion to the objective reality.”
I hate this phrase “objective reality.” According to who? As mental health clinicians, we need to drop the idea of “objective reality” and replace it with “what is useful for maintaining or increasing the client’s quality of life.” It does not matter whether a client’s “symptoms” area objectively varifiable, vague and difficult to pinpoint, or entirely based in anxiety and depression. Even patients with verified cancer diagnoses need to make decisions on how much they’re going to invest in treatment and what boundaries they want to put in place to maintain quality of life.
One can have IAD/OCD due to the fact that they’re ineffectively coping with their cancer diagnosis and engaging in OCD behaviors around their health. In my case, having IAD/OCD did not mean that my headaches weren’t real but that the way I was coping with them was not useful for maintaining my quality of life. Mental health clinicians need to stop being the arbiters of “reality” when it comes to symptoms and instead, help clients find flexibility to cope with their experiences in a more effective, value-based way. The neurologist’s job is to figure out what’s causing the headaches and we can help them understand our clients’ symptoms better by working with them to identify patterns including if relaxation and different coping reduce frequency or severity of the condition. It does not mean that anxiety CAUSED the headache or other medical condition.
The original question: OCD/IAD or psychosis?
So to answer the core question about the client my colleague presented to me who sounded a lot like me of 10 years ago: It sounds like this client’s distress can me mapped neatly onto an OCD cycle. I think you have enough information to treat them as if they have OCD/IAD, using the conceptualization that does not require you be the arbiter of what’s “real” vs. “somatized.” It sounds like their engagement is ineffective and not helping them better navigate some unpleasant (neurological?) experiences. Check in on their personal value system - what if these unpleasant depersonalization experiences are not fixable? How can they know they’re being “responsible” about their healthcare while also not allowing a potentially chronic condition keep them from living their best life? If you know they’ve had adequate medical care, how can you help them get back to living, knowing that they may be going through a period of very unpleasant and weird body stuff that might not be fixable?
Of course, if you treat them as though they have OCD and they don’t respond to well-targeted ERP (your clinical judgment is always paramount as this blog is not a substitute for medical advice or personal consultation), you may have a different question on your hands which will be further complicated by the fact that I see a lot of folks with clear OCD who are also on antipsychotics for their anxiety. But that might be a discussion for next time :)