When Obsessions Meet Psychosis: Recognizing the Schizo-Obsessive Spectrum Through a Case of Autism, Obsessive-Compulsive Disorder, and Schizophrenia

Abstract

The schizo-obsessive spectrum encompasses a range of phenotypes positioned between obsessive-compulsive disorder (OCD) and schizophrenia (SCZ), characterized by the co-occurrence of obsessive-compulsive symptoms within a psychotic illness. While the high prevalence of obsessive-compulsive symptoms in schizophrenia — affecting up to 64% of patients — has generated substantial interest in whether schizo-obsessive disorder constitutes a distinct diagnostic entity, clinical recognition remains limited and diagnostic criteria continue to be debated. Differentiating obsessions from delusions, and compulsions from stereotypies, presents a formidable clinical challenge, particularly in the context of co-occurring autism spectrum disorder (ASD), where overlapping phenomenology can obscure diagnosis across all three conditions. We present the case of an adolescent male with ASD whose clinical course evolved from social anxiety to OCD to schizophrenia over several years, with symptoms that never fully conformed to any single diagnostic category. His presentation — intrusive thoughts without frank compulsions, positive psychotic symptoms without negative symptoms, and preserved insight despite active hallucinations — exemplifies the diagnostic ambiguity inherent to the schizo-obsessive spectrum. This case underscores the clinical utility of conceptualizing schizo-obsessive presentations as a spectrum that has direct implications for treatment selection, prognosis, and the avoidance of diagnostic errors that may delay effective care.