Obsessive Compulsive Disorder Is Often Misunderstood

The term obsessive obsessive-compulsive disorder is not well understood and is sometimes thrown around casually. Someone who likes cleanliness and order may say, “I am so OCD about how I organize my closet.” Others may refer to these people as being “a little OCD.” And because anxiety is a component of OCD, people including therapists may sometimes assume that we approach OCD treatment and management in the same way we treat anxiety. OCD has distinct and unique characteristics in how it manifests and operates for the individual grappling with it. Failing to recognize its unique traits can lead to its unsuccessful treatment, and at worst, worsen its symptoms.

What are the differences between obsessive-compulsive disorder and anxiety? And what are the goals of successful OCD treatment?

There is a predictable cycle and pattern with OCD that serves to reinforce and strengthen the anxiety and OCD behaviors each time it is repeated.

It begins with an intrusive thought or sensation, followed by a feeling of anxiety or distress. In response to the anxiety, you engage in rituals or behaviors to calm the anxiety or neutralize the distress. Common compulsive behaviors are:

1. Researching
2. Reassurance seeking
3. Cleaning and handwashing
4. Checking
5. Ordering and rearranging
6. Mental rumination—thinking about the problem over and over again, searching for certainty or reassurance in your mind—certainty that cannot be achieved.
7. Rituals that must be completed, and in a particular way or order.

Next comes one of the most important characteristics of OCD. When you engage in the compulsion, it may bring momentary relief, but the anxiety will quickly re-emerge. This time, it will be accompanied by a doubting thought to explain why your attempts to reduce the anxiety were unsuccessful. This serves to strengthen the anxiety, leading to re-engaging the compulsive behavior. The pattern continues, with no obvious way out, reinforcing the anxiety with each cycle.

Typical anxiety and OCD share “what if” worries and behavior patterns designed to reduce anxiety. It differs in the inability of OCD fears to be reassured by any fact, opinion, or action.

To illustrate this pattern and how it differs from typical anxiety, use the example of contamination fear. In response to the thought or sensation, “I feel like my hands are dirty,” you wash your hands. For someone with typical anxiety, the act of washing your hands would likely eliminate contamination or cleanliness fears. You may then focus on something else to worry about but are not likely to continue to worry about the cleanliness of your hands. If you have OCD, after washing your hands, you may feel momentary relief, but the anxiety will return and your mind will create a question or thought to create doubt in yourself. For example, you might think, “But what if I didn’t use enough soap?” You then engage in washing your hands again, only to have the anxious feeling resume and another doubting thought emerge, “But what if I didn’t wash them for long enough?" You then wash your hands again, and the cycle repeats and repeats.

There is no amount of reassurance – in the form of verbal challenge, information gathering, fact-finding, opinion seeking, or behavior that will quell the obsessive thought and ensuing anxiety. Instead, it keeps you trapped in a state of pervasive doubt; doubt that is ultimately about your ability to trust yourself. This is why OCD is so challenging.

Another characteristic of OCD that makes it differ from other forms of anxiety is that the thoughts and impulses are ego-dystonic, they are inconsistent with who you are and your values. This, combined with the self-doubting nature of OCD creates a painful dynamic. You have thoughts that are inconsistent with your values or what you want, and you are simultaneously filled with self-doubt.

Due to these unique characteristics of OCD, applying strategies that can help manage other forms of anxiety will be at best unhelpful for OCD, and at worst will worsen its symptoms.

OCD patterns are sneaky and persistent. It will be easy for you, and a therapist, to get caught up in reasoning with or seeking to reassure them. As a therapist, I have gotten caught in the OCD trap plenty of times.

Strategies that are helpful for anxiety but unhelpful for OCD:

1. Challenging your anxious thoughts. This can be useful when applied to anxiety. However, when used with OCD, will only encourage more self-doubt to emerge, strengthening the anxiety and inability to trust oneself.
2. Welcoming the anxious thought with curiosity about what it wants you to know. This is a powerful strategy for typical anxiety that is contraindicated for OCD. This strategy will encourage the self-doubt component of OCD to fixate on the ego-dystonic messages of OCD and seek to convince you they are valid.
3. Exploring the underlying meaning or origin of the anxious thought. For typical anxiety, tracing the underlying root or meaning of the anxious thought to past experiences can help you relate to the anxious thought in a new way and disempower it. This would be an unhelpful approach to take if you are actively experiencing OCD symptoms because OCD thoughts are ego-dystonic and the nature of OCD makes you question what you know to be true about yourself. This approach would only feed into these characteristics of OCD.
4. Any approach that can be construed as reassurance seeking. Other forms of anxiety can potentially be relieved with reassurance or reality testing. OCD thoughts cannot. And, because reassurance seeking is a compulsive behavior when engaged, it only serves to reinforce the anxiety.

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With the abundance of information available at your fingertips to address anxiety, it is important to understand how OCD differs from anxiety, which approaches for managing anxiety are counterproductive for OCD, so that in your efforts to relieve the anxiety that is a component of OCD, you don’t unintentionally reinforce it.