Schizophrenia OCD

What is schizophrenia OCD?

In schizophrenia OCD, obsessions centre on the fear of developing schizophrenia or psychosis, or of losing touch with reality. A thought, a sound or a brief sense of unreality may prompt the question: Is this an early sign?

In an attempt to find an answer, the person examines the form of their thoughts, scrutinises background sounds for voices and checks their speech for signs of incoherence. The checking rarely produces an answer that lasts. Instead, new details appear that must also be assessed.

Fear of losing touch with reality

The fear may begin after hearing about someone who developed psychosis or after a period of stress and poor sleep. An otherwise unremarkable experience may suddenly be examined as a possible beginning of illness.

Some fear a gradual development in which the earliest signs are so subtle that they can only be detected through constant vigilance. Others imagine an abrupt loss of control in which, without warning, they begin to believe something untrue, hear voices or act in a way they can no longer control.

Attention may then centre on stress, sleep deprivation, cannabis use or genetic predisposition. The information is compared with the person’s own life in an attempt to rule out the risk entirely. Each answer, however, points to another possible course of illness that must also be investigated.

What is examined?

Thoughts are examined for their form, content and degree of conviction. A spontaneous thought such as perhaps they are looking at me is tested: Does part of me believe it? Does the thought feel more true because I keep thinking about it?

Sensory experiences are checked for possible hallucinations. Background noise, a tune playing in their head or a sound from a neighbour may be mentally replayed. The person listens for words and tries to determine whether the sound came from inside or outside their head.

Speech and language become a test of whether thoughts are coherent. After a conversation, the sentences are reviewed for pauses and unusual word choices. Some read aloud or ask others to assess whether they spoke normally.

Feelings and behaviour are compared with descriptions of illness. A lack of pleasure may be interpreted as a symptom, while an intense interest in a subject prompts fear of fixation or grandiose thoughts.

The experience of reality is tested directly. The person asks whether the surroundings feel real, whether other people seem unfamiliar or whether a moment of dizziness was the beginning of derealisation. When the experience is repeatedly checked, it may lose its ordinary sense of familiarity and feel even more unfamiliar.

Typical doubts

Doubt may include:

• What if that strange thought was the beginning of a delusion?
• Did I believe the thought for a moment, or was I only afraid of believing it?
• Was it the neighbour I heard, or could it have been a voice?
• What if I already have symptoms but lack insight into them?
• Could my fear of psychosis itself be an early sign of psychosis?
• Why do my thoughts feel unfamiliar if nothing is wrong?
• Was my speech incoherent, or am I overinterpreting a pause?
• If I stop checking, will I detect the illness too late?

The checking also serves as a form of vigilance intended to detect illness in time. It may therefore feel risky to stop, even when monitoring occupies most of the day.

Typical compulsions and strategies

Mental checking is often central. The person repeats a thought and checks whether it feels true. Arguments for and against it are reviewed, and the person searches their memory for earlier signs. The same experience may be reconstructed many times because small differences in memory change the interpretation.

In a listening check, the person may turn off music, hold their breath or return to a room to determine where a sound came from. Some record the sound on their phone. If it is absent from the recording, a new question arises: Did the microphone miss it, or would a hallucination be impossible to record?

Research may include descriptions of early symptoms, patient accounts and diagnostic criteria. Age, sleep, family history and minor changes in behaviour are compared with what the person has read. A single patient account may carry great weight because it shows that an unlikely course is possible.

Some seek reassurance from family, friends or professionals. They repeatedly ask variations of Do I seem different? or Does this make sense? A reassuring answer lasts only until doubt returns: perhaps the others are trying to spare them, or perhaps they do not know the early signs well enough.

Avoidance may become as prominent as active checking. Some avoid films and articles about psychosis or situations that may prompt new questions. Others avoid being alone because no one would be there to notice a change. Their own thoughts may also feel dangerous, so the person tries to keep their thinking simple and harmless.

Three examples

Why can thoughts feel more unfamiliar?

Thoughts normally arise without us examining their form. When attention is directed towards the thinking process itself, familiar thoughts may begin to seem different. A sentence may suddenly sound mechanical, and a spontaneous association may seem surprising.

Feelings and sensory experiences also change character when they must constantly be assessed. If someone repeatedly asks whether the world feels real, the experience may lose its taken-for-granted quality. The unfamiliar sensation is easily interpreted as evidence that what the person fears is true.

Attempts to avoid strange thoughts have a similar effect. To keep a thought away, one must first monitor whether it is on its way. The thought therefore remains close to awareness, and this may in turn be interpreted as a loss of control.

The difference between OCD fear and psychotic symptoms

The typical checking question is whether a thought or experience is a sign of psychosis. This leads to investigations, comparisons and reassurance seeking. The fear is often that the person will one day come to believe something that is not real.

Psychosis may involve hallucinations, delusions, disorganised speech or behaviour, and marked changes in functioning. Insight alone does not provide a reliable dividing line. A professional assessment considers, among other things, the nature of the experience, how firmly the belief is held and how the condition develops over time.

Actual experiences of hearing voices, fixed beliefs, marked disorganisation or a clear loss of reality testing should be assessed professionally. The same applies to rapid and substantial changes in behaviour or level of functioning.

Overlap with other OCD types

Schizophrenia OCD may resemble illness OCD because the person looks for signs of illness. The theme may also overlap with Harm OCD if fear of psychosis is linked to losing control and harming someone. Mental illness then becomes the explanation for how the feared action could occur.

In self-monitoring OCD, one’s speech, facial expressions, behaviour and thought process are monitored. In sensorimotor OCD, attention may centre on inner speech, visual impressions or other sensory processes. In schizophrenia OCD, the same monitoring is used to determine whether the experiences are signs of psychosis.

How are daily life and relatives affected?

Mental monitoring may take place almost continuously. Reading becomes a test of concentration, a conversation a test of language, and silence a test of hearing. When ordinary activities are used to check whether the mind is functioning normally, it becomes difficult to have a break.

Relatives may be given the role of reality check. They are asked to assess whether the person seems changed, whether a sound was real or whether a thought sounded normal. Some are also asked to promise that they will say something if they notice signs of psychosis. It thereby becomes their task to provide certainty that OCD can still cast doubt on.

Shame may make the theme difficult to discuss. Some fear that others will regard them as psychotic if they mention the thoughts. They may therefore speak only about sleep problems or feeling unsettled and conceal the extensive analysis behind them.