the Difference: OCD vs. Delusional Disorder in Mental Health

Could you please tell me if this is obsessive-compulsive disorder or delusional disorder?

My younger brother started having some bizarre thoughts in high school, and his academic performance plummeted.
He was later diagnosed with Obsessive-Compulsive Disorder (OCD) and has been on medication for four years without improvement.
However, I am puzzled as to why he does not have Schizophrenia or Delusional Disorder.
Here are some of his symptoms:
Symptoms:
1.
Unrealistic thoughts that he constantly ruminates on.
Here are some examples of thoughts he has had since the onset of his condition:
(1) Solipsism: He believes that everyone else is fake and that he is the only real human being, which drives him to the brink of insanity (this thought occurred during high school but has since faded).
(2) He believes that when a female classmate changed her Instagram profile picture to black, it was because he hurt her by not answering her call four years ago (he thinks she had a crush on him, but I feel this is an exaggerated imagination).
(3) He feels that after having a certain thought a few months ago, he completely transformed into a high school classmate he envies (referred to as Classmate B).
He believes this thought and worries that anything he does now is not his own, as he is now Classmate B and not his original self (he thinks that if one can conceive a method, anything is possible.
Since he thought of a way to become Classmate B, he believes he is now Classmate B).
This leads to significant anxiety and distress, and he has even had fleeting suicidal thoughts (this is his current belief, and he says he cannot comprehend it but still believes it).
(4) He sees attractive unfamiliar girls on the street and wants to ask them for casual sex (he thinks it's acceptable to confess feelings but questions why asking for casual sex is not permissible.
I believe his moral judgment is quite low) (this is also a current thought).
2.
Commonalities among the above thoughts: He ruminates on these thoughts all day after waking up, leading to depression, anxiety, and a bit of mental exhaustion.
3.
Anxiety and depression.
4.
Insomnia (he has gone two days without sleep).
5.
Self-centeredness.
6.
Poor social skills and communication (no friends, dislikes work).
7.
Frequently lost in thought with poor attention.
I asked my brother's doctor, who insists that he has OCD, and my brother chooses to trust the doctor and does not wish to seek other opinions.
However, after four years on medication, there has been no improvement (he was recently troubled enough to have suicidal thoughts), and I believe his thoughts have become detached from reality and are very difficult to understand, resembling Delusional Disorder.

I would like to ask the doctor:
1.
Is it possible that my brother does not have Schizophrenia or Delusional Disorder? If not, why has he not improved after four years on medication?
2.
Is it true that the doctor says psychological therapy is ineffective for my brother (because he does not listen)? Shouldn't therapy be beneficial when combined with medication?
I apologize for taking up so much of your valuable time, but I hope you can find a moment to respond.
Thank you.

A-Hong, 20~29 year old female. Ask Date: 2023/11/03

Dr. Qiu Junda reply Psychiatry

Hello.
1.
The diagnosis of my brother should still respect the physician's judgment and assessment (Obsessive-Compulsive Disorder).
Whether there is a delusional disorder or other possibilities cannot be predicted by anyone.
2.
The treatment for Obsessive-Compulsive Disorder can indeed be challenging.
However, my brother's choice to continue follow-up visits should indicate at least some improvement and is not entirely ineffective.
As for whether to pursue psychotherapy, it may be necessary to wait until the medication treatment reaches a certain level of effectiveness before asking the physician to evaluate whether it can be combined for better therapeutic outcomes.
Thank you.

Reply Date: 2023/11/03

More Info

Understanding the distinction between Obsessive-Compulsive Disorder (OCD) and Delusional Disorder is crucial for effective treatment and management of mental health issues. Your brother's symptoms raise important questions about his diagnosis and the effectiveness of his current treatment plan.

1. Differentiating OCD from Delusional Disorder:
- OCD is characterized by intrusive thoughts (obsessions) that lead to repetitive behaviors or mental acts (compulsions) aimed at reducing anxiety. Individuals with OCD often recognize that their obsessions are irrational, but they feel compelled to perform certain actions to alleviate their distress. For example, a person might obsessively check if the door is locked, even though they know it was locked.

- Delusional Disorder, on the other hand, involves the presence of one or more delusions that persist for at least one month. These delusions are fixed beliefs that are not based in reality and are resistant to reasoning or contrary evidence. For instance, a person might believe they are being persecuted or that they have a special relationship with a celebrity, despite clear evidence to the contrary.

In your brother's case, some of his thoughts, such as believing that everyone else is fake or that he has become another person, suggest a departure from reality that aligns more closely with delusional thinking. The fact that he experiences significant distress and impairment in functioning, including suicidal ideation, further complicates his situation.

2. Treatment Considerations:
- The lack of improvement after four years of medication raises concerns about the appropriateness of the current treatment. It is essential to evaluate whether the prescribed medication is suitable for his specific symptoms. Sometimes, individuals may require a different class of medication or a combination of therapies to see improvement.

- Psychological therapy, particularly Cognitive Behavioral Therapy (CBT), is often recommended for both OCD and delusional disorders. However, if your brother is not receptive to therapy or does not believe in its efficacy, it may be challenging to engage him in treatment. This is a common issue in delusional disorders, where the individual may not recognize their beliefs as problematic.

3. Next Steps:
- It may be beneficial to seek a second opinion from another mental health professional who specializes in psychotic disorders. A comprehensive evaluation could help clarify the diagnosis and lead to a more effective treatment plan.

- Encourage your brother to consider therapy, even if he is skeptical. Sometimes, building rapport with a therapist can help him feel more comfortable and open to the process.

- If he is experiencing suicidal thoughts, it is crucial to seek immediate help from a mental health professional or crisis intervention services. Safety should always be the priority.

In conclusion, while your brother's symptoms may initially appear to fit within the framework of OCD, the nature of his thoughts and the distress they cause suggest a more complex issue that may warrant further investigation. A thorough reassessment by a qualified mental health professional could provide clarity and lead to a more effective treatment approach. It is essential to remain supportive and encourage him to explore all available options for his mental health.

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