OCD - A Master of Disguise
- Hannah Muller, ATR-BC, LPC
- 2 days ago
- 4 min read
Updated: 1 day ago
By: Hannah Muller, ATR - BC, LPC At Perez Therapy, LLC.
Did you know that up to 50% of people with OCD (Obsessive-Compulsive Disorder) are initially misdiagnosed with another mental health condition? Some mistaken or comorbid diagnoses include ADHD, major depressive disorder, personality disorders, autism, and more. Very commonly, in addition to the disorders listed above, one of the most frequent incorrect diagnoses is GAD (generalized anxiety disorder), in part because OCD is an anxiety disorder. OCD and anxiety are both mental health conditions that involve fear, worry, and stress, but they’re not the same thing. People often confuse them because they can look similar on the surface, but how they work and how they make a person feel are significantly different.
OCD involves having unwanted, upsetting thoughts, called obsessions, that keep coming back. These obsessions are typically ego-dystonic, which means the thoughts are bothersome to the person. To try to get rid of these thoughts or calm down the anxiety they cause, the person might feel the need to do certain actions or routines, which are called compulsions. For example, someone might constantly worry that their hands are dirty and feel like they must wash them again, even when they know they’re clean. It’s not just about wanting things neat or tidy, it’s about feeling like something bad will happen if they don’t do the behavior. Washing hands repeatedly is a sign of physical compulsions, but there are also mental compulsions, which usually don’t get the time and attention they deserve. Mental compulsions can take the form of constantly seeking reassurance, mental reviewing, –such as replaying a conversation in your head dozens of times to ensure you did not say anything “wrong”, mental avoidance of certain topics or thoughts, neutralizing thoughts, and so much more.
Anxiety, on the other hand, is a more generalized feeling of worry, nervousness, or fear. People with anxiety might feel constantly on edge, have racing thoughts, or find it hard to relax. Sometimes anxiety can be more specific, like experiencing social anxiety. Anxiety can also manifest as a phobia, like an intense fear of heights, known as acrophobia. Anxiety can manifest both physically and mentally, causing people to experience a wide variety of symptoms, such as shortness of breath, trouble sleeping, rapid heart rate, sweating, mental rumination, restlessness, irritability, and so much more. However, unlike OCD, they usually don’t feel driven to do specific actions (mental OR physical) repeatedly to relieve the fear.
Because both conditions involve worry and stress, they can be easy to mix up. For example, someone with anxiety might double-check something because they’re nervous, and someone with OCD might check something too. However, the reasons driving these actions are very different. With OCD, it’s part of a cycle of obsessive thoughts and compulsive behaviors that feel very hard to control. With anxiety, the checking might be more occasional and based on general nervousness or concern.
One of the most ego-dystonic ways in which OCD symptoms can manifest are through intrusive thoughts. For both clients and clinicians, it is extremely important NOT to stigmatize these thoughts, as this can prevent individuals from sharing and working through these. Intrusive thoughts can be about anything, but often latch onto themes surrounding harm, violence, religion, and sexual acts, causing people shame when looking to discuss them in counseling spaces. Sometimes, these thoughts are accompanied by unwanted images. When disclosing OCD-related intrusive thoughts, it is so important to be self-compassionate and remind yourself that these thoughts are a result of your OCD and not of you, as a person. As a clinician, when a client is discussing their intrusive thoughts, it is of utmost importance to distinguish between suicidal and homicidal ideation and unwanted, intrusive thoughts that are fueled by one’s OCD. These thoughts are usually extremely distressing to a person, contradict one's values and morals, and continue to return despite reasoning a way out of them.
The good news is that OCD and anxiety are highly treatable conditions! There are now a variety of treatment options for OCD specifically, including Exposure and Response Prevention therapy (ERP), Inference-based cognitive behavioral therapy (I-CBT), cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based therapies.
ERP is a type of therapy where you plan controlled exposures to your fears without performing compulsions. Typically, triggers are identified, and you create an exposure hierarchy, consisting of easier to harder challenges in relation to those triggers. This way, a person can gradually expose themselves to their fears while learning to tolerate and accept the anxiety that arises.
One example of an ACT-based coping strategy is called cognitive defusion. This is when we place distance between ourselves and our thoughts, labeling them for what they are and taking their power away. This might look like stating “I notice that I am having an OCD thought” when interacting with an intrusive thought. This way you are not in the thought, but rather, you are observing it.
The key to healing is knowing the difference so the right kind of tailored support can be given, not just addressing one condition while ignoring others. The healing journey might be complex and time consuming, but that doesn’t mean we can’t be successful in working through it.
Resources for OCD are listed below:
