OCD And Schizophrenia: Is There A Connection?

Schizophrenia and obsessive-compulsive disorder (OCD) are classified under different categories in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), but they do have a few commonalities. For example, both are considered chronic disorders—meaning they are persistent and long-lasting, and there is no cure for either. Their symptoms can be severe, causing significant challenges in daily life and affecting one’s mental and emotional well-being. 

Understanding obsessive-compulsive disorder (OCD) 

Types

While there’s a potentially infinite number of OCD manifestations, there are a few common subtypes grouped according to their primary symptoms, including the following. 

• Ruminations and intrusive thoughts: This type of OCD involves excessive, persistent, repetitive thinking about a theme or topic. These thoughts are unwanted and may range from preoccupation with cleanliness to spending an inordinate amount of time reliving memories of past events to disturbing thoughts of harming someone. People with ruminating, intrusive thoughts may display related compulsions such as repetitively checking to verify they haven’t harmed anyone or avoiding certain people or places.
• Checking: Checking involves repetitive rituals and compulsions to eliminate the chances of unwanted consequences. For example, someone might repetitively check and recheck that all the lights and appliances are off before leaving home or rush home from work to ensure the house is locked throughout the day. Some people may redo a task or assignment many times to ensure they haven’t made any mistakes. There are also checking behaviors associated with sickness where an individual may take their temperature repetitively or examine their body to ensure they aren’t sick. 
• Contamination: This type of OCD involves the extreme fear of being contaminated or contaminating others by contact with an object or another person. Mental contamination is another subset in which an individual experiences a sense of dirtiness in the absence of an inciting stimulus.  
• Symmetry and ordering: This type of OCD can cause a compulsive need to ensure objects are symmetrically ordered. One may also experience sensation or body symmetry OCD, in which the individual is obsessed with ensuring their bodily positions or movements are symmetrical. 

While hoarding is classified under the obsessive-compulsive and related disorders category in the DSM-5, researchers present evidence that it might have a deeper connection to major depressive, generalized anxiety, and social phobia disorders.  

Symptoms

OCD symptoms often involve thoughts, fears, and doubts that make up obsessions and compulsions, which are behaviors used to cope. The themes each person experiences with OCD can vary, but obsessions might look like the following:

• Unpleasant, repetitive thoughts of sex or violence
• Intrusive, repetitive thoughts about partaking in socially unacceptable or illegal actions in public
• An intense fear of germs or contamination
• Severe anxiety associated with disorganized objects
• A fear that one has made a mistake they can’t remember 

Compulsion examples might include the following: 

• Repeating a word or phrase silently or aloud
• Checking and rechecking the stove to make sure it’s off
• Hand washing until the skin is raw and chafing
• Counting and recounting objects or counting in patterns

In some cases, individuals may display facial or bodily tics as a symptom of OCD.

Diagnostic criteria

According to the DSM-5, an individual must experience obsessions, compulsions, or both to receive an OCD diagnosis. 

Obsessions must emerge as recurrent, persistent thoughts, images, or urges to fit the criteria. These obsessions are unwanted and intrusive and often cause anxiety and distress. The individual may attempt to suppress or ignore the obsessions or perform a compulsion to neutralize them. 

Compulsions are characterized as repetitive mental acts or behaviors that the individual believes they must perform to follow strict rules, neutralize a compulsion, prevent and avoid distress, or prevent and avoid a disturbing event or situation. 

The obsessions or compulsions must take up more than one hour per day of the individual’s time or cause significant problems in the individual’s daily functioning. These disturbances must not be better explained as a symptom of another mental disorder or medical illness. 

Understanding schizophrenia 

Schizophrenia is a serious, lifelong brain disorder that inhibits an individual’s ability to interpret reality, often severely impacting how a person thinks, feels, and behaves. Schizophrenia typically emerges in three phases:

• Prodromal: Symptoms during this phase emerge before psychotic episodes and may be mistaken for another disorder like anxiety or depression. They may include apathy, flat affect, and social withdrawal. It may sometimes be challenging to know when an individual with schizophrenia is in the prodromal stage of an episode.
• Active: Symptoms of psychosis occur in active episodes, including hallucinations, delusions, and disordered speech and behaviors. 
• Residual: Though not officially recognized in the DSM-5, the residual phase may occur for individuals with schizophrenia. These symptoms may be similar to those in the prodromal stage.

Positive symptoms

Positive symptoms of schizophrenia refer to those that emerge as observable changes in thoughts and behaviors. They include the following: 

• Hallucinations: Hallucinations are false sensory experiences like hearing voices or seeing stimuli that aren’t actually present. Other somatic sensations like feeling, tasting, or smelling may also occur but are not as common.
• Delusions: Delusions are firmly held false beliefs that are difficult to sway. They are often characterized as implausible or odd, such as thinking that one is being controlled by outside forces or has special powers. 
• Disorganized thinking and speech: Disorganized thinking often presents as dysfunctional speech patterns. For example, an individual may have difficulty expressing their thoughts, or their words may become incoherent or disorganized (sometimes called “word salad”).
• Abnormal or disorganized motor behavior: Behaviors may include repetitive movements, unpredictable agitation, or other unusual mannerisms. In rare cases, some individuals display catatonia, a lack of movement or response to external stimuli.

Negative symptoms

Negative symptoms are associated with affect and emotion, representing a diminishment of participation in daily life, including the following: 

• Alogia: A reduced quantity and quality of speech and vocabulary
• Avolition: A lack of motivation to engage in daily activities, achieve goals, and complete tasks
• Anhedonia: Reduced ability to experience pleasure or joy
• Asociality: Avoiding social interaction, isolating, and withdrawing from others
• Blunted affect: Difficulty expressing emotion outwardly through physical cues, facial expressions, or tone of voice.

Cognitive symptoms

Cognitive symptoms are associated with cognitive abilities, including memory, problem-solving, and information retention. People with schizophrenia may have difficulty organizing their thoughts or concentrating. Remembering information and making decisions may be challenging for some. 

Diagnostic criteria

According to DSM-5 criteria, individuals must exhibit at least two of the above symptoms frequently over one month, and at least one must be a positive symptom. The symptoms must create significant difficulties in daily functioning in key areas of daily living, such as the workplace, school, social settings, and self-care. Symptoms cannot result from another mental health condition, such as depressive disorder, schizoaffective disorder, or bipolar disorder, or from the physiological effects of a medical condition, substance use, or medications. 

If you are struggling with substance use, contact the SAMHSA National Helpline at (800) 662-4357 to receive support and resources.

The connection between OCD and schizophrenia

A growing body of research indicates there may be a link between conditions on the obsessive-compulsive spectrum and schizophrenia spectrum disorders. Though schizophrenia is a relatively uncommon disorder, the World Health Organization (WHO) estimated that it affected 0.32% of the worldwide population in 2022. Research indicates that obsessive-compulsive symptoms manifest in roughly 25% of people with schizophrenia, with 12% having full OCD comorbidity. In some cases, OCD-like symptoms present in the prodromal phase, and a precise diagnosis of schizophrenia isn’t made until psychotic symptoms emerge. 

Symptom similarities and differences

Symptoms of schizophrenia and OCD can vary between people and are often influenced by factors like an individual’s unique experiences, age, and environmental conditions. However, OCD and schizophrenia do have some symptoms, including the following: 

• Intrusive thoughts, emotional dysregulation, and unusual or irrational behaviors (compulsions in OCD and sometimes delusions or hallucinations in schizophrenia)
• Emergence that typically occurs between adolescence and early adulthood 
• Challenges in daily life, including in interpersonal relationships 
• Comorbidities like depression and substance use disorders

There are some differences between the two disorders. For example, individuals with OCD don’t often experience delusions and hallucinations. Negative symptoms of schizophrenia, such as anhedonia, avolition, and flat affect, aren’t always present in people with OCD. 

Though both disorders typically feature disordered, intrusive thoughts, there are differences in how they are internalized. Typically, people with schizophrenia experience delusions that they believe are real, and they aren’t compelled to challenge them (these are referred to as ego-syntonic thoughts). Conversely, individuals with OCD are often aware that their obsessive thoughts don’t serve their needs or self-image (ego-dystonic thoughts). 

Etiology

Researchers have yet to find a primary cause for developing schizophrenia or OCD, but it may be due to a combination of factors, including the following: 

• Neurological functioning: There may be some of the same neurobiological factors involved in OCD and schizophrenia. Research suggests that abnormalities in certain brain regions, such as the basal ganglia and frontal cortex, are implicated in both OCD and schizophrenia.
• Genetics: There is evidence to suggest a genetic predisposition for both OCD and schizophrenia. Certain genetic variations have been linked to an increased risk for both disorders, indicating a potential genetic overlap.
• Environment: Family studies have revealed that individuals with OCD and schizophrenia are more likely to have a relative(s) with a mental illness. Research also suggests there may be a connection between OCD, schizophrenia, and childhood trauma.  

Schizo-obsessive spectrum disorders 

While not listed in the DSM-5 as an official psychiatric disorder, some experts have suggested that schizo-obsessive disorder should be recognized as a new subtype of schizophrenia due to the prevalence of clinical correlates. To qualify for a schizo-obsessive disorder diagnosis, individuals would need to meet the following:  

• Present symptoms that meet the criteria for OCD and schizophrenia. 
• The subject of the patient’s obsessions and compulsive behaviors must be connected to their delusions or hallucinations. For example, compulsive checking would be prompted by commanding auditory hallucinations.
• The individual’s OCD obsessions and compulsions must be recognized by them as such. 
• The patient’s OCD symptoms must create significant dysfunction or emotional distress unrelated to those caused by schizophrenia symptoms. 
• Symptoms cannot emerge due to drug use, antipsychotic medications, or other medical conditions. 
• OCD symptoms may not present exclusively as a delusion without co-occurring behaviors.

Schizophrenia and OCD may have certain symptoms in common

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Treatments

Despite their similarities, treatment approaches to OCD and schizophrenia can differ significantly. Treating OCD often involves a combination of therapy (such as cognitive-behavioral therapy) and medication (such as selective serotonin reuptake inhibitors), while schizophrenia often requires antipsychotic medications and may involve additional psychosocial support services.

Both conditions can benefit from intervention in the form of talk therapy. While it may not be suitable in every case, some individuals may find online talk therapy through a platform like BetterHelp, which can be a beneficial alternative to in-office counseling. These platforms often offer more affordable options than in-person treatment without insurance. Some people appreciate the scheduling compatibility and convenience of at-home therapy. 

Additionally, some people report that online therapy enables them to commect with more therapists with diverse backgrounds and experiences, making finding a therapist they connect with more feasible. Studies show online therapy may be helpful for psychotic disorders. More studies are needed to understand these treatments' benefits fully. However, in limited studies, online counseling has been shown to benefit people with schizophrenia and their family members.