P came in to see me for an annual assessment last week. She was afraid that if she completed this paperwork with me she would never see her regular case manager again. P lives in fear each day. She is afraid of invaders, afraid that others are investigating her, afraid that her grown children will be attacked. As is often the case with my patients, P lives a reality that makes it difficult to tell if she experiences obsessive anxiety or psychotic delusions. Obsession grabs whatever is going on in real life and amplifies it. Psychosis distorts reality, it causes perceptual changes that lead people to misinterpret whatever is going on. P spent most of her life being violently attacked by both family and strangers. She is also poor because of her inability to work. So she really does live in an incredibly bad neighborhood. The kind of apartment complex she can afford will rent to anyone. She lives near drug dealers, child molesters and violent criminals. There's an old joke that it isn't paranoia if they really are out to get you. But of course most people with psychosis are very poor, and do live where predators lurk. So is she simply obsessively anxious about the reality she has lived, or suffering from paranoia when she just happens to have a background where people really were out to get her? Successful treatment relies on figuring out the difference. Different medications work to alleviate different symptoms. Different therapy approaches work best with obesession and paranoia. I learn things just by talking to P for an hour that make me favor anxiety over delusions. P is open about her fears, able to discuss them with the understanding that they are extreme. She does not try to provide evidence of the reality of her fears. She reports events that trigger her symptoms that are likely. Noisy neighbors at the crack house down the hall instead of hearing the radio reporter telling her personally that she is about to be robbed is a sign that her perceptions are correct. In my workplace only the doctors diagnose, but forming my own judgement helps me write an assessment that will help others ask the right questions and try the non-medicine treatment approaches that are likely to work. In the end though, I could be wrong either way - she could have both!