A question about delusions versus obsessions

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When I developed severe mental illness at age 14 in June 1998, I was on 60 mg/day of Prozac and 10 mg/day of Zyprexa. I developed major preoccupations: that I was Sephiroth, was super-powerful, was destined to take over the world, and had to train to prepare for Y2K. I would be hospitalized for this about a month to a month-and-a-half later, when I acted on these preoccupations and engaged in bizarre and dangerous behavior. In the hospital, the Prozac was dropped and I was moved up to at least 20 mg/day of Zyprexa. Pretty soon, these preoccupations ended. My challenging behaviors also ended, and I was noted to be cheerful during my recovery, while staying on at least a 20 mg/day dose of Zyprexa.

My current psychiatrist says he wasn't there, so he doesn't know if the preoccupations were mere obsessions or were full-on delusions, but I'd say if dropping the high-dose Prozac and hiking up the Zyprexa fixed the problem, then they were delusions and I was psychotic. I told him this, but he continued to say he didn't know what that was when I was 14 and reassured me Prozac won't make me psychotic.

Still I wonder about the Prozac I'm taking presently, if it could expose a psychotic vulnerability. My psychiatrist has dismissed this wondering as obsessiveness.

I did take my first dose today. I haven't noticed anything strange yet.

Those pre-occupations sound like delusions just because they involved false beliefs.

It doesn't even matter whether they led to abnormal or self-destructive behaviour because obsessions can do that to an extent too. It just matters if there's a false belief involved. Obsessions can also be ego-syntonic without being delusions. You can agree with your obsessions 100%.

My obsessions can and have led to self-destructive behaviour (in other people's eyes) and often if I'm in the midst of them I don't want help medicating them away because I don't see them as bad. Why would I want the obsessions to go away? I just want to act on them. Usually they don't cause me distress unless I can't act on them so acting on them is the solution. Medication/treatment isn't. That's how I see things in the midst of the obsession anyway.

People might say that OCD doesn't make you want to pull 3-6 all-nighters in a row or overload on stimulants in the hopes of experiencing psychotic-like symptoms but my obsessions make me want to do that. Clomipramine reduces the intensity of it which makes me think of it as OCD related. I had the urge and I started sleep deprivation recently but came to my senses and stopped. I don't think I would've done that without the Clomipramine. I would've kept going.

It still didn't involve a false belief that most people would consider absurd. The pre-occupations were absurd and my actions in response to them were unreasonable but there was no absurd belief. The only difference I can think of between an obsession and a delusion is the presence of a false belief that most people would consider outrageous.

Interesting distinction, but my psychiatrist even has a response to that, with obsessions with poor insight, that a person can be so obsessed with catching germs that he believes he would die if he touches a door knob with his bare hand, and that would still be an obsession with poor insight, rather than a delusion.

Though, seeing it written down, I wonder if my psychiatrist was overstating the case. Believing you will die if you touch a door knob seems to come closer to delusion for me, now that I see it written out.

If one day you find yourself turned on to doorknobs, start collecting doorknobs (no longer on doors), buying coffee table books on the history and evolution of doorknobs, and start to bore your friends at parties by talking to them endlessly about doorknobs, then that means that your are "obsessed with doorknobs".

But if you have a false belief that you will contract ebola from doorknobs in your house (which is thousands of miles away from west Africa) then you are "delusional" about doorknobs.

Some people have such severe OCD that their obsessions take on a delusional form. A key criterion of typical OCD is that the individual recognizes the obsessions are nonsensical and bizarre, even though they still fear them. Also, people with typical OCD know that the obsessions are a product of their own mind, even though their content is ego-dystonic. But somebody who has "OCD with poor insight" can be delusional, believing that the obsessions are being placed in their mind (i.e., a Schneiderian first-rank symptom) or having 100% belief in the obsession's nonsensical nature. To use the Ebola example above, somebody with regular OCD knows deep-down that they can't catch Ebola from a doorknob, but somebody with delusional OCD truly believes that they can catch Ebola from a doorknob.

Honestly, schizophrenia and OCD (pure obsessional OCD, in particular, which is what I have) are more alike than they are different. There is a category of schizophrenics called "schizo-obsessives" who have both schizophrenia and OCD, and with these individuals it's sometimes hard to know which delusions are a product of the schizophrenia and which are a product of the OCD. Many studies have also shown that people with OCD often have significantly higher schizotypal traits than those in the general population. This is because "magical thinking" and superstition are part and parcel of OCD.