Psychosis, OCD, and Questions of Reality

"What does that mean?"

"It means you are disconnected from reality."

I still remember looking up at the psychologist who had shared her impressions with me of my psychosis. At just 13 years old, the term "disconnected from reality" mystified me. As an adult and therapist specializing in psychosis, it still does.

Reality in Psychosis

An objective reality is nearly impossible to define. There is consensus on a few topics. For example, most would agree that we share this interaction on Earth. Yet, even in these consensus pieces, the variations in experience are wild. Most people have at least one belief that could be called unusual.

Many clinicians find the concept of fixation more accurate in defining psychosis and especially delusion. A delusion is difficult to challenge; it doesn't typically bow to reason.

Reality in Obsessive-Compulsive Disorder

On the opposing side, we have conditions of doubt. Most notably, obsessive-compulsive disorder (OCD). In OCD, one's belief in oneself as a reliable narrator is often shaky, so much as to spark rituals of checking, reassurance seeking, counting, and washing to verify.

OCD is stereotyped as a condition of organization and psychosis one of disorganization. One would think there would be little overlap, but this is not the case.

Differentiation and Treatment

Differential diagnosis between OCD and psychosis is sometimes tricky. For example, intrusive thoughts can sometimes be voice-like, so loud that a person shudders. Similarly, voices in psychosis have been noted to sometimes give commands including ones at times that appear like OCD rituals.

Both individuals with OCD and psychosis might report fear of losing touch. In a sense, both are conditions of how we relate to reality.

To make matters even more confusing, comorbidity between OCD and psychotic disorders like schizophrenia is high. Research suggests that between 12 and 24 percent of individuals with a schizophrenia spectrum disorder may also have OCD (Pardossi et al., 2024).

Accurate diagnosis is key here as treatment of OCD and schizophrenia spectrum disorders is quite different both in psychotherapy and with medication. While individuals who have experienced psychosis may be encouraged to reality check in cognitive behavioral therapy to test the integrity of their perceptions, tolerating uncertainty is a common objective in psychotherapy for OCD.

A Philosophical Question

Still, the overlap in these conditions and their comorbidity furnish questions regarding doubt, belief, and the nature of reality. In a world where some may estimate we live in a simulation, and, by contrast, others turn to faiths of all kinds to explain reality, and still others hold rigidly to what is readily observable by our fragile senses, it can be asked, is anyone connected to reality?