Distinguishing Visual Hallucinations, OCD Imagery, and Anxiety

Gain valuable insights into the distinction between obsessive-compulsive disorder (OCD) imagery and visual hallucinations and also between OCD and anxiety. Join John Grant, MD, as he delves into previously unanswered audience questions from his live Psych Congress 2023 session, "When a Childhood Habit Is Something More: Exploring the Management of Pediatric Obsessive Compulsive Disorder."

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Read the transcript:

John Grant, MD: Hello, I'm John Grant. I'm a professor of psychiatry at the University of Chicago. I spoke at the Psych Congress 2023 on the topic of children and adolescents with OCD.

Audience question: How do you differentiate between visual hallucinations and OCD imagery?

Dr Grant: The DSM-5 criteria made the obsessions not just about thoughts that come to people's heads, but recurrent images that the person may get images of them doing something inappropriate or violent, et cetera. The question often arises, [whether] this is the same as a visual hallucination, and it's not.

It may be along some type of continuum, though. To be fair, we all have images, however, that come in our mind's eye. I can remember something and I can see myself on a vacation, very quickly in my mind. The obsessive images that people get are very similar to that; that's what we all get. They'll just have them repetitively to the point that they're quite intrusive and disturbing.

However, if I am talking, about a visual hallucination, that's generally something outside of my own mind's eye, right? So, if I struggle with a psychotic disorder, I may see something crawling on the walls, or I may see figures as I'm walking down the street that are nefarious, dangerous characters that are trying to kill me or something. But those are not in my mind, those are outside of my own head and I'm seeing in the external world. I think that separates out visual hallucinations versus just visual images. We do always have this specifier in OCD that it refers to insight. So some people can have images so much in their mind's eye that they will actually start believing that they're somewhat true. That would be labeled as poor insight or no insight in the most extreme cases. That would be less common in OCD, but it may look a little bit more delusional and that's why sometimes we can see these along a spectrum, from one very extreme end to the visual hallucinations and visual images that we all get.

Audience Question: What are your tips for differentiating between OCD and anxiety? Do they sometimes present together?

On the extremes, the examples can be quite clear that OCD tends to be about more irrational topics that people will recognize the irrationality. So, "can I get AIDS by touching a doorknob Well, no, I'm not gonna get AIDS, but I can't stop getting bothered by this irrational thought. I know it's irrational, but I constantly think about it, and it's creating anxiety. So when I present to a my doctor, I may describe it as bad anxiety, but it's really obsessional and a symptom of OCD given that irrational aspect." Now, we can sort of see on the opposite end, a more typical anxiety thought in the case of adolescence is  "I'm worried that I need to do well on this exam, otherwise I'm going to fail the class. Well, maybe it's a little bit irrational. My grades are actually been quite good, but I'll get worried about school."

But, school is a real worry for children, right? And adolescents, they often do worry about how well they do, and they could technically fail something if they failed an exam. It has much more of a real-world grounding, if you will. Then their concern about it is excessive, and that may be why they might be diagnosed with something like generally generalized anxiety disorder because of real-life worries that are extreme. Having said that, OCD and anxiety often co-occur, and I can worry about germs one minute and failing an exam the next. So I may, even though I may as a, a 15-year-old adolescent, for example, present to a doctor saying, it's all anxiety, it's all anxiety.

It may be very important, however, for the clinician to separate out what is anxiety symptoms versus OCD symptoms. As mentioned the OCD symptoms have a specific course of treatment, particularly pharmacologically, that can work for the anxiety, but there are others for anxiety that may not work for OCD. So the gray zone gets quite a bit more complicated, which is why for many decades older clinicians were aware that OCD was kind of considered just one of those anxiety disorders. We know it's quite qualitatively different from an anxiety problem, but given that comorbidity and that overlap, it can often clinically feel like they both have their tentacles in each other.

Closing:

I can't thank people enough for being interested in this topic. Thank you for joining me today. I'm hopeful that we'll have more treatments down the road and more understanding for many of your questions. It sounded as if we still have a lot yet unanswered, but people are working on it, so stay tuned!

John E. Grant, MD, is a Professor of psychiatry and behavioral neuroscience at the University of Chicago. He directs a clinic and research lab on addictive, compulsive, and impulsive disorders. Dr. Grant is the author of over 400 peer-reviewed scientific articles and 15 books.