Obsessive compulsive disorder is still considered primarily an anxiety disorder, though historically there has always been a question of whether obsessive-compulsive symptoms may be more properly considered psychotic in nature, the so-called schizo-obsessive disorder or subtype. A case is presented here of a middle-aged man with debilitating obsessive-compulsive symptoms of sudden onset in his late teens. Given the nature of onset and symptomatology, and the failure of prior therapies, the case was approached as a primary psychotic disorder. The neuroleptic-naive patient had remarkable response to low-dose antipsychotic medication, as well as to psychodynamic psychotherapy modeled along the lines of neuroplasticity. The case illustrates the blurred distinctions among anxiety, mood, and psychotic disorders and the improved outcomes when the proper underlying disorder is addressed.