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Fears about psychosis

7 min read
Josh Hamrick, LPCC-S

Possibly related to:

Sometimes fears related to “going insane” or becoming psychotic and doing something terrible can be a form of Responsibility OCD. This might include fears about having a psychotic break and harming someone, or doing a terrible act that you would have no memory of or desire to do. Individuals may have overwhelming intrusive thoughts related to psychosis, hallucinations, or acting outside of their control. 

These intrusive and unwanted thoughts are called “obsessions.” They can involve intrusive thoughts, images, or urges, and can be extremely unpleasant, provoking anxiety or other distress. Obsessions often go against one’s core values, identity, and beliefs, which contributes to the distress one feels. These individuals care deeply about the people around them, doing the right thing, and being in control of their actions and behaviors. Someone experiencing obsessions revolving around psychosis or becoming psychotic may be afraid of harming people they care about while in a psychotic state or having a fear of “going insane” and doing something that they would never do otherwise. 

Often, these thoughts will be overwhelming to the point where a person will do anything to no longer have these thoughts or to feel less stressed about them. In order to find relief or avoid their fears, they perform physical or mental behaviors called “compulsions.” Compulsions are done in response to the distress experienced when intrusive thoughts, images, or urges occur. They can include asking for reassurance from others, thought replacement (thinking a “good” thought in response to a “bad” one), physical rituals that make someone feel safe, and avoidance of situations, objects, or people.

Fear of psychosis in OCD – Common obsessions

  • Am I going crazy or psychotic? When will I go crazy?
  • What if I already did something terrible during a psychotic experience?
  • What if I hurt or kill people I care about?
  • What if I end up in a psychiatric hospital?
  • What if I’m responsible for a shooting, arson, or other violent acts?
  • What if I do something embarrassing?
  • What if my friends or family will no longer love me?
  • What does psychosis feel like? Am I experiencing it right now?

Common triggers

People with a fear of psychosis in OCD may be triggered by experiencing psychological distress, being around others experiencing psychological distress, hearing about psychosis or schizophrenia, or even hearing stories of people having a psychotic break. This can include news stories, movies, or TV shows depicting mental health or substances. They may find themselves overthinking social situations or ruminating at length on past experiences. 

Sometimes these obsessions can lead to intense feelings of distress and danger, which can cause symptoms of lightheadedness, rapid heart rate, shallow breathing, headache, and difficulty concentrating. In turn, these sensations may be interpreted as signs of psychosis, making fears even more intense.

Common triggers for people with a fear of psychosis in OCD include:

  • Hearing about stories of individuals who had a psychotic break or psychosis 
  • Movies or TV shows about mental illness
  • Not remembering a time and place or event
  • Feeling headaches, dizziness, or lightheaded
  • Coincidences
  • Feeling as if people recognize you or watching you
  • Learning about people who were responsible for harming others
  • High stress or anxiety

How can I tell if I’m experiencing psychosis themes in OCD, and not anxiety, stress, or real signs of psychosis?

If you find yourself being overwhelmed by these thoughts, it is important to know that you are not alone. Intrusive thoughts of any nature are nearly universal, and it can be difficult for someone dealing with these intrusive thoughts to know the difference between real signs of psychosis and anxiety resulting from these thoughts, especially because they can both cause physical sensations such as headaches, lightheadedness, and difficulty concentrating.

In psychosis-themed OCD, you may find that your thoughts are increasing in distress and frequency, no matter how many times you try to stop them. Your compulsions may also be increasing in frequency and occupying more and more of your time. Another indicator of OCD is an inability to disengage from these thoughts, no matter what you do when they pop into your head. 

It is best to be assessed by a mental health professional who has experience with OCD and is trained in exposure and response prevention (ERP) therapy who can help you understand your experiences and determine the best way to help you get better. 

Common compulsions

When people with a fear of psychosis in OCD experience intrusive thoughts, images, feelings, or urges that cause distress, they may engage in repetitive behaviors called compulsions to feel better. Especially as anxiety related to their thoughts worsens, the distrust of their own experiences increases, leading to even more anxiety and fear. This creates a vicious cycle of intrusive thoughts and increasing anxiety, leading to more symptoms associated with what one interprets as signs of psychosis, and feeding anxiety even more.

These compulsions can take various forms, such as asking for reassurance from others: “Do I seem like myself? Do you think I am going to have a psychotic break? Have you noticed anything different about me?” In addition, they may try to neutralize or rationalize their thoughts; they may stop a thought from completing, use a rubber band to slap their wrist when having a “bad thought,” say “no” repeatedly, or think a positive thought when an intrusive thought occurs. 

In addition, one may avoid situations, people, and places that are associated with intrusive thoughts. For example, an individual may have a thought occur while driving and avoid driving in an attempt to stop intrusive thoughts from returning, or because they are afraid that they will become psychotic while driving. 

Compulsions performed mentally or physically by people with fears of psychosis in OCD include:

  • Researching symptoms of psychosis or schizophrenia
  • Asking for reassurance from others 
  • Ruminating on details or timestamps of where they may have been
  • Seeking reassurance from medical professionals
  • Avoiding stressful situations, people, or reminders
  • Reviewing and replaying social interactions

How to treat fear of psychosis

Psychosis-themed OCD can be debilitating for people who struggle with it, but it is highly treatable. By doing exposure and response prevention (ERP) therapy with a therapist trained in ERP, you can learn how to handle and live with intrusive thoughts, without feeling intense distress or resorting to compulsions.

Treatment begins with an assessment of your symptoms. You and your therapist will then create an inventory of your obsessions, how often they occur, and what situations, places, or things trigger these obsessions. An assessment of subjective units of distress (SUDs) will be used to identify your most feared situations in order to help gain understanding and build a hierarchy for ERP. 

Progressing through ERP with a therapist will require discomfort, but it is effective in teaching you how to manage OCD long-term. Exposures can result in a reduction in anxiety when experiencing intrusive thoughts, teaching you that you can tolerate more anxiety or distress than you may have believed. In addition, this can help improve your overall tolerance of uncertainty and challenge your belief that when thoughts occur, they are likely to come true.

Examples of possible exposures done to treat psychosis themes of OCD include: 

  • Writing an imaginal script of becoming psychotic and doing a feared action
  • Reading stories about people who had psychotic breaks
  • Purposefully inducing mild physical sensations such as lightheaded, dizziness, and heavy breathing
  • Reading about symptoms of schizophrenia

With these exposures it is critical that they are done with response prevention. If one does these exposures but then engages in compulsions, it will only continue the cycle of OCD. One way to avoid engaging in mental compulsions includes intentionally accepting uncertainty. For example, saying to oneself: “I may or may not have a psychotic break” or “maybe I am, and maybe I am not.” By creating a new way of dealing with intrusive thoughts, your anxiety may decrease over time as you learn that you can tolerate uncertainty.

If you’re struggling with OCD, you can schedule a free 15-minute call today with the NOCD care team to learn how a licensed therapist can help. At NOCD, all therapists specialize in OCD and receive ERP-specific training. ERP is most effective when the therapist conducting the treatment has experience with OCD and training in ERP.

We look forward to working with you.

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