OCD or Psychosis? Yes: A Case Study of a Diagnostic Conundrum and the Caregiver Role

Abstract

Obsessive-compulsive disorder (OCD) and schizophrenia spectrum disorders, while distinct phenomena, have considerable overlap in their presentations which can present a challenge in their approach to diagnosis and treatment. The changes in the DSM-5 bring these challenges to light, in allowing OCD to be specified as having absent insight or delusional beliefs. This can be especially distressing for caregivers, who play a major role in treatment, especially among youth. We present a case of a 16-year-old male presenting to care in his first episode of psychosis with overlapping obsessive-compulsive features, later found to have OCD. We discuss diagnostic and treatment approaches for someone presenting with overlapping psychotic and obsessive-compulsive features and highlight the underrecognized, but indisputably important role of caregivers throughout the process.

Plain Language Summary

Obsessive-compulsive disorder (OCD) and schizophrenia spectrum disorders have many similarities, making them difficult to distinguish. Both present with abnormal, false beliefs that are not easily corrected when challenged. Distinguishing the two is important because these two disorders require different treatments and may have different outcomes. This can be especially difficult for the parents and caregivers of younger patients, who may feel confused and helpless about how to best care for their child. We present a case of a 16-year-old male who initially presents in a first-time psychotic episode who also has obsessive-compulsive symptoms, then later is diagnosed with OCD. We discuss how to approach diagnosis and treatment for similar cases like this, while also bringing attention to how to incorporate caregivers throughout this process.

Introduction

Obsessive-compulsive disorder (OCD) and schizophrenia spectrum disorders, while distinct phenomena, have considerable overlapping presentations which can present challenges in management. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) recognizes this overlap, explicitly stating that thought insertion and delusional preoccupations as seen in schizophrenia and other psychotic spectrum disorders must be discerned from obsessions as in OCD (American Psychiatric Association, 2022). Furthermore, schizophrenia and OCD can co-exist, with comorbid rates from 7% to 31% (Achim et al., 2011; Buckley et al., 2009). Understanding the interaction between these two phenomena has important clinical implications, such as in early intervention and treatment.

Diagnostic Challenges

The overlap between obsessive-compulsive symptoms (OCS) and schizophrenia spectrum disorders has a long history in research, having coined its own term, the “schizo-obsessive spectrum,” to encapsulate its array of presentations (Poyurovsky et al., 2012). Within this spectrum includes OCD with absent insight/delusional beliefs, OCD with schizotypal personality disorder (SPD), OCD with psychotic features, schizophrenia with OCS, and schizophrenia with OCD (Cavaco & Ribeiro, 2023; Eisen & Rasmussen, 1993). SPD in OCD is seen at rates as high as 50% (Poyurovsky & Koran, 2005), with poorer response to standard treatments (Hazari et al., 2016). Individuals with OCD with psychotic features are also found to have poorer insight, global functioning, and treatment course than those with OCD alone (Eisen & Rasmussen, 1993; Okamura et al., 2022). In schizophrenia, the rate of OCS ranges from 3% to 59% (Poyurovsky & Koran, 2005), with poorer outcomes compared to individuals with schizophrenia without OCS/OCD, including in suicidality, psychotic and depressive symptoms, and social functioning (Tezenas Du Montcel et al., 2019). Because of their distinct clinical and treatment outcomes, some have proposed separate diagnostic criteria for this subpopulation (Poyurovsky et al., 2012).

Insight was traditionally considered a hallmark trait distinguishing obsessions from delusions in schizophrenia spectrum disorders (Rasmussen & Parnas, 2022). However, the changes in the DSM-5 removed this criterion and added the specifier, “with absent insight/delusional beliefs,” blurring this distinction and facilitating a diagnosis of OCD in situations where a schizophrenia spectrum disorder may have otherwise been given (Moritz et al., 2025). Poor or absent insight is relatively common in OCD, with a prevalence of 9–36% (Cherian et al., 2012). Those with poor insight have greater severity of OCD and depressive symptoms, have higher rates of schizophrenia spectrum disorders among family members, and are less likely to achieve partial remission than those with good insight (Catapano et al., 2010; Hazari et al., 2016). Thus, identifying OCD with poor or absent insight separate from a schizophrenia spectrum disorder can significantly impact treatment and prognosis. As insight is deemphasized in diagnostic determinations, more reliance must be placed on other co-occurring features, such as presence of compulsions versus other psychotic symptoms, symptom onset and progression, and response to treatment (Bottas et al., 2005).

Experience of Caregivers

Especially among youth, the impact of OCS alone on caregivers, including parents, is substantial, resulting in poorer caregiver mental health, coping, and family impairment (Ramos-Cerqueira et al., 2008; Stewart et al., 2017). Challenges include coping with the impact of OCD, understanding how to respond to their child’s symptoms, and barriers to treatment (Sowden et al., 2023). Caregivers have described OCD as “ruling their lives” and expressed a need for understanding, connection with those with shared experiences, and respite. Involving parents is an important treatment component for children with OCD (Garcia et al., 2010; Lebowitz, 2013).

Distress among caregivers for patients with psychosis is also high (Addington et al., 2003). Caregiver support to their loved ones in activities of daily living, mental/emotional support, and functioning at work/school improves clinical outcomes, treatment adherence, and overall quality of life (National Institute for Health and Care Excellence, 2014). Understandably, the role is highly demanding. Caregivers are susceptible to trauma-like symptoms and worsened psychological well-being with greater illness impact (Addington et al., 2003; Barton & Jackson, 2008). Caregiver interventions, while efficacious (Jolley & Grice, 2024; Ma et al., 2018; Münchenberg et al., 2024), have run into significant implementation barriers (Jolley & Grice, 2024; Kuipers, 2010). Caregivers for patients with OCD and comorbid psychotic symptoms experience even greater demands, though even less is known of their experience and support needs.

We present a case of an adolescent male who presented to the inpatient psychiatric setting in a first episode of psychosis, later diagnosed with OCD. We highlight the diagnostic challenges when features of psychosis and OCD overlap and discuss the impact of his illness on the caregiving system. Written permission was obtained by the patient (adult by time of consent) and verbal permission from his parents for publication of this report.

Case

The patient is a 16-year-old male with no past psychiatric history from a Christian family in a rural town. After receiving salvation at 13 years old, he started regularly praying a few minutes per day. A year before presenting to care, he became increasingly isolative, sleeping three to 4 hours a night to have enough time to pray. He lost 60 pounds from fasting and stopped playing video games and watching TV, believing that the news represented “all the evil in the world.” He was dismissed from his school after a hostile debate with one of his teachers over evolution. His most extreme behaviors were toward his parents. Normally very loving toward them, he became physically and verbally aggressive, thinking they were “an evil, awful family” that was persecuting him and living in sin. He preached incessantly toward them, demanding them to repent. He denied auditory and visual hallucinations however believed he had a special connection with God.

Past Histories

The patient had no prior psychiatric diagnoses, hospitalizations, medication trials, or other treatment. His father had a history of scrupulous OCD. He denied any history of trauma. He denied any relevant past medical or substance use histories. His birth and development were unremarkable.

Hospitalization

At 16 years old, the patient was psychiatrically hospitalized after a behavioral outburst, destroying the family garden to bring his parents to repent of their “sinful ways.” While inpatient, he spent hours praying in his room and preached the gospel to all peers on the unit, stating he desired to teach the world about the Bible. He neglected showering and brushing his teeth as they were not biblical. While he exhibited no behavioral issues in the unit milieu, he was hostile toward his parents during visitation, calling them serpents and demanding them to repent. The best estimate diagnosis at the time was a first episode of psychosis, with concerns for OCS from scrupulous obsessions leading to compulsive praying and preaching. Diagnostic workup to rule out secondary causes of psychosis was unremarkable, including normal cell counts, electrolytes, ceruloplasmin level, thyroid level, and vitamins B9, B12, and D. He had a negative anti-nuclear antibody titer, low C-reactive protein, and urine drug screen. Magnetic resonance imaging of the brain without contrast was normal.

The treating provider met with the parents daily. They confirmed his behavior was out of the norm for their faith community and provided daily feedback on his interactions with them. The treatment team educated the parents on diagnoses and recommendations for managing the patient’s behaviors. Gradually, they shifted from challenging the patient’s delusions to acknowledging them and redirecting. Additionally, the provider noted significant caregiver burden and distress and provided emotional support and validation.

On hospital day 3, oral olanzapine 5 mg nightly was started, which the patient refused. Due to his lack of capacity to refuse medications and his declining condition, olanzapine was given via intramuscular injection if he refused oral administration, which was titrated to 7.5 mg. On hospital day 13, due to lack of clinical improvement, olanzapine was switched to haloperidol, titrated to 5 mg, administered intramuscularly if orally refused. He began to improve, eating meals, showering, and brushing his teeth more regularly. He was more easily redirectable and his affect brightened. By hospital day 22, when the patient was taking oral medications more consistently, haloperidol was transitioned to oral risperidone, titrated to 2 mg nightly. While he remained hyper-religious, his hostility toward his parents became more manageable and he was more cooperative in conversations around discharge and safety planning. He was discharged on hospital day 35 with outpatient medication management and therapy.

Post-Discharge

After discharge, the patient continued to see his parents as “impure Christians” and lack insight into his need for treatment, though remained complaint. Risperidone was transitioned to the long-acting injectable form of paliperidone 234 mg every 4 weeks. He continued in therapy and was active socially, spending time with his parents, attending church activities, and starting a job that he greatly enjoyed. After 6 months, he found himself enjoying activities he once considered too secular. His appetite and sleep had normalized. Shortly after, he endorsed a “cognitive breakthrough,” his thoughts of persecution toward his parents replaced by an overwhelming appreciation. He reflected on the last year as “all a different reality, but a very real reality” that he now recognized as irrational. He verbalized now struggling with intrusive, egodystonic thoughts around morality that lead him to excessively pray and repent. He was diagnosed with OCD and started on fluoxetine, titrated up to 60 mg daily. He was also started on prazosin, titrated to 2 mg nightly, for nightmares related to his school incident. He began seeing a Christian counselor and regularly practiced therapeutic exposures with his parents’ help. Over time, his symptoms became less distressing, and his relationship with his family and friends and his academic performance excelled.

His family expressed extreme gratitude for the inpatient experience, particularly the daily visitation. They valued the opportunity to have an explanation for his aberrant behaviors, receive counseling on “not arguing with a psychotic patient,” and see his progress over time. Meeting other parents in the waiting room helped them feel less alone, and positive experiences with the hospital staff helped them feel well-cared for. The patient reported that his memories of his parents’ unwavering involvement during his psychiatric crisis made a significant difference in challenging his delusions. He identifies his parents as a key motivating factor in his mental health recovery.

Discussion

This case highlights the challenges of a presentation of an adolescent experiencing his first psychotic episode with overlapping obsessive-compulsive features that, after treatment of his index episode, revealed an underlying diagnosis of scrupulous OCD. Caregiver intervention also became a crucial part of his care.

Diagnostic Considerations

From his initial presentation, the patient’s hyper-religious, grandiose, and persecutory beliefs reached delusional proportions, being out of the norm of his faith community and inflexible when challenged. Their intensity reached an obsessional quality and was accompanied by excessive praying and preaching. His agitation when these activities were disturbed suggested that they functioned to reduce distress from obsessive thoughts. When mixed obsessive-compulsive and psychotic features are present, Bottas et al. (2005) suggests further understanding symptoms’ themes, contexts, and response to treatment to improve diagnostic clarity. However, per Bottas, empiric treatment with an antipsychotic or serotonin reuptake inhibitor to first normalize the thought form may be necessary. Our patient’s description of an altered perception of reality (though more apparent in hindsight), symptom onset in adolescence, and insidious progression made his initial presentation more clearly consistent with a psychotic prodrome than OCD. His improvement with antipsychotic therapy helped confirm this. When his index psychosis lifted and insight improved, his scrupulous OCD became apparent.

Some literature supports a temporal relationship between obsessive-compulsive and psychotic symptoms, with OCS emerging as part of the psychotic prodrome (Niendam et al., 2009). One meta-analysis found a strong trend pointing to earlier onset of OCD compared with schizophrenia (Devulapalli et al., 2008). Similarly, our patient noticed obsessive-compulsive tendencies preceding his psychotic episode. Alternatively, psychosis could be considered a manifestation of severe OCD – our patient’s most severe symptoms occurred in his psychotic state. Treatment requires acknowledging both; our patient received medication for both psychosis and OCD, engaged in therapy, made efforts to return to normal social and occupational functioning, and received strong family support (Frawley et al., 2023).

Caregiver Considerations

The caregivers of our case played a crucial role from presentation to treatment. First, their perspectives were important in understanding their family’s cultural norms. Second, since the caregivers were the primary targets of the patient’s persecution, his interactions with them were an essential gauge of treatment response. Third, caregivers needed to learn how to respond to the patient’s delusions at home, to not only avoid worsening paranoia and prevent readmission, but also as a valuable therapeutic intervention. The caregivers identified this psychoeducation as one of the most helpful interactions. Lastly, providing emotional support to the family was an instrumental intervention. The caregivers needed to regulate their own emotions to prevent behavioral escalation and provide a healing environment (Butler et al., 2019).

The caregivers experienced several challenges. Struggling against their child’s resistance to school and neglect of self-care was exhausting. Emotionally, they were subject to his verbal and physical aggression. As the family’s first experience of psychosis, they may have felt traumatized, angry, ashamed, and helpless. Like other caregivers for a child with OCD, they may have felt powerless in responding to his obsessive delusional statements. For them to relate to matters of their faith could feel morally distressing. This stressful internal experience of caregivers is inevitably passed onto the family system, adversely impacting their child’s illness.

Research supports family interventions as an effective treatment modality for psychosis and for OCD. Strong evidence exists for family interventions, even over cognitive behavioral therapy, in reducing relapse and admission rates in psychosis (Bird et al., 2010; Lincoln & Pedersen, 2019). With childhood OCD, family interventions can be just as effective as, if not more effective than, individual exposure-based cognitive behavioral therapies (Lebowitz, 2013). However, these and other caregiver interventions (Ma et al., 2018; Münchenberg et al., 2024; Sowden et al., 2023) focus on outpatient settings, with little known on providing support while inpatient, when families are amidst their own crisis. Learning from the experience of this family, potential goals for inpatient intervention include empowering families to be included in the patient’s treatment, recognizing their place of expertise in the patient’s care, providing tailored psychoeducation on the illness, anticipating challenges in caregiver-patient interactions upon return home and addressing them early, providing emotional support, and facilitating transitions to lower levels of care. Providing a hospital culture of healing and recovery helps dispel stigma about psychiatric hospitals, especially among caregivers presenting for the first time. Motivating future research in this direction requires a shift in perspective from seeing not only the patient as the primary target for intervention, but also the family system as equally central to treatment in this important junction of the schizo-obsessive spectrum.

Conclusion

We present a case of an adolescent male who initially presented to care in a first-episode psychosis with obsessive-compulsive features, and upon improvement in psychosis, was diagnosed with OCD. We highlight the diagnostic challenges in the overlap that occurs between obsessive-compulsive features and delusions from a primary psychotic disorder. We also raise awareness of the importance of caregiver intervention in this distressing illness, which are important targets for future work.