Question. I was diagnosed with OCD a couple of months ago, even though I have had symptoms since the age of seven. I mentioned to my therapist that during difficult situations, I think people are watching me and that they can sense what is wrong with me. She said that I was suffering from paranoia, which she said is common in people with OCD and she recommended that I get medication for it. What exactly does this mean? Can I expect my paranoia to go away without medication? Is paranoia part of the disease or is it something else entirely?
Answer. The terms paranoia and paranoid are widely overused and rarely understood. We often hear our friends or coworkers saying, “I’m getting really paranoid about losing my job!” or “He’s paranoid about being too fat,” etc. In the strict sense, paranoia should apply only to delusional beliefs, characterized by fears that one is being watched, stalked, plotted against, invaded by outside forces, etc. And by delusional, I mean that (a) the individual has a fixed, false belief that is not explained by his/her culture or religion; and (b) the individual has lost all, or nearly all, his or her ability to distinguish reality from fantasy-what clinicians call reality testing.
If the belief is not false, or the person has not lost reality testing, then the person is not delusional, and hence, not paranoid. Imagine, for example, that you are at a fancy party and have just spilled some punch on your white shirt or blouse. Many people might feel self-conscious and worry that people were looking at them, but this is not necessarily delusional or paranoid–it could actually be the case! Similarly, if you have obsessive-compulsive disorder and perform visible rituals or gestures (such as avoiding stepping on cracks in the sidewalk, wiping off chairs before you sit on them, etc.), it is not impossible that some people observe this and correctly infer that you have OCD. Thus, your feeling that people are watching you and can sense what is wrong could be correct.
On the other hand, if you show absolutely no outward abnormal behaviors that anyone could observe, and you believe that people can somehow read your thoughts, that is a different story. That might, indeed, qualify as paranoia. Similarly, if you showed no outward signs at all of obsessive-compulsive disorder, yet were absolutely convinced that people could somehow sense that you have OCD; and if you inflexibly maintained this belief despite all the evidence to the contrary, you might be described as delusional. I would disagree that true paranoia (as I have defined it) is common in obsessive-compulsive disorder. It is often true that people with OCD have some symptoms of social phobia – undue anxiety related to fears of being judged, scrutinized, watched, or evaluated by others, in public situations. These people, however, have not lost reality testing; i.e., they can say, “I guess it is possible that I’m overreacting, and that people may not really be making comments about me.”
There is, on the other hand, a very small minority of people who meet the criteria for both obsessive-compulsive disorderand a delusional disorder of some kind, but these individuals are very rare. Antipsychotic medication would be appropriate only if the individual was truly delusional or paranoid, not merely anxious about being watched. Other medications – such as Prozac, Zoloft and Paxil – are appropriate for OCD. If, after all this, you are still in doubt, I would encourage you to see a psychiatrist with a good background in obsessive-compulsive disorder, for an opinion.