October is obsessive-compulsive disorder (OCD) Awareness Month, and there are a lot of people out there – right now – who don’t even know they have it. One reason? They think they have anxiety instead.
It’s not surprising; the two mental health conditions do overlap. For example, part of having OCD is experiencing feelings of anxiety, Simone Leavell-Bruce, PsyD, a psychotherapist who specialises in OCD, previously told Women’s Health. As she puts it: ‘OCD is like anxiety on steroids.’
Meet the experts: Simone Leavell-Bruce, PsyD, is a North Carolina-based psychotherapist who specialises in OCD. Levi Riven, PhD, is a clinical psychologist and founder of Riven Psychology.
There is one major difference: OCD requires a different treatment approach from anxiety, and traditional therapy for anxiety can actually make OCD worse. So it’s definitely worth knowing the difference between the two.
Around 2.2% of adults in England have OCD, according to the latest NHS Adult Psychiatric Morbidity Survey, rising to 5.7% among 16- to 24-year-olds. Unlike some other common mental health conditions, OCD appears to affect men and women at similar rates.
Here are the core signs therapists look for when diagnosing OCD, and how they tell it apart from anxiety.
The key differences between OCD and anxietyYour worries seem unusual to others
While generalised anxiety disorder tends to focus on everyday fears, OCD worries – or obsessions – are often more out of the ordinary, especially to those who don’t have the condition.
Take this example: the night before a big presentation at work, someone with anxiety might be kept awake by racing thoughts about all the ways it could go wrong the next day. What if I fail? Did I practise enough? I hope I can pull it off.
For someone with OCD, the worries may be less rooted in everyday reality. Instead of worrying about preparedness or whether people will like their presentation, they might have intrusive thoughts about impulsively swearing or saying a racist slur while presenting. What if I offend people? Have I done anything like this before? Am I a bad person?
Obsessions can also be outlandish, surprising or taboo. Some common OCD themes revolve around worrying that you’re secretly a paedophile, getting intrusive thoughts that you’ve harmed others – or have the capability to – or experiencing confusing, all-consuming doubts around your sexuality.
That brings us to a core component of OCD: obsessions are usually ego-dystonic, meaning they contradict your value system, morals and sense of self, Levi Riven, PhD, a psychologist based in Ottawa, says. In other words, the person who is worried they’re a paedophile is not one. The things people with OCD are worrying about – such as harming someone – are often the things they would least want to do.
‘That’s what makes OCD so scary: it hits you with something you just don’t recognise in yourself,’ says Leavell-Bruce.
Common obsessions include:
Contamination, or the extreme worry of encountering germs, diseases or dirt that might infect youFear that you might harm someone, or already have but don’t know or remember doing itExcessive worry about your health, such as having an undiagnosed condition or worrying that you’ll develop oneIntrusive thoughts, fears and doubts about your sexuality and genderOverwhelming concern about things being even, ordered or feeling ‘just right’You follow each obsession with a compulsion
Every case of OCD will include compulsions, says Leavell-Bruce; they may just not be what you think. When most people think about OCD, they probably think about compulsive hand-washing, cleaning or other physical rituals – but many compulsions can happen entirely inside your own head.
Instead of physical checking or seeking external reassurance, many people with OCD go through an internal checking or rumination process to make themselves feel better, Riven says. That can look a lot like what someone does when they’re anxious.
Common compulsions include:
Avoidance of a stressful stimulus or thoughtConstantly asking others for reassuranceChecking that you have or have not done somethingExcessively cleaning a space or yourselfExcessively ruminating about an obsessionMaking sure things are ‘just right’CountingOrdering or arranging
A recent study published in Psychological Assessment that surveyed 641 OCD patients found 62 unique compulsion rituals among patients. Across this wide spectrum of physical and mental rituals, avoidance, reassurance, checking and cleaning or hand-washing were the most common.
Among those, avoidance, asking for reassurance and checking can all look as though a person is simply anxious about something, rather than performing a compulsion.
Compulsions are also central to OCD treatment. But essentially, performing – or not performing – these rituals can be the difference between reducing OCD symptoms and making them worse.
Your rumination looks different
Because rumination can also happen in generalised anxiety disorder, it can be difficult to identify it as an OCD compulsion. Rumination is when someone thinks deeply about one particular worry for a long time in the hope of better understanding it.
Someone with generalised anxiety disorder may use rumination as a way to ‘anticipate possible catastrophes and find ways to prevent them,’ says Riven. They might weigh future choices against each other – such as how much to prepare for a presentation – and stress about making the wrong decision.
Meanwhile, someone with OCD rumination compulsions can become trapped in cycles where they review and analyse memories of past actions, check their own interests and desires, or try to cancel out ‘bad thoughts’ with ‘good thoughts’.
While classic anxiety rumination focuses on catastrophising events and possibilities about the future, OCD rumination often focuses on catastrophes of the self: reassuring yourself that something did or didn’t happen, or checking your memories and emotions to make sure certain intrusive thoughts aren’t true.
Let’s say someone with rumination OCD is worried they’ll say a slur during their work presentation. The night before, they might lie awake examining their emotions around slurs to be sure they don’t actually want to use them, and reviewing their memories to collect ‘evidence’ that this behaviour has never happened before.
OCD rumination is all about finding proof that something did or didn’t happen, or that something about you is true or untrue.
Traditional therapy doesn’t help you feel better
In typical cognitive behavioural therapy (CBT), a therapist will unpack a patient’s anxiety to help them understand where it comes from and reframe the threats, says Riven. CBT talk therapy is widely considered to be the best therapy for generalised anxiety disorder treatment, according to the National Institute of Mental Health.
But for someone with OCD, trying to understand a nonsensical obsession can make things worse. If someone has an intrusive thought that they might hurt someone, for example, there is little benefit in trying to understand where in their personal history that thought comes from, since it is not based in much of anything at all. Again, OCD thoughts tend to go against what a person actually believes or wants.
‘If it’s not clear that a person has OCD and they’re just expressing anxiety, a supportive and well-meaning therapist might focus on providing a lot of reassurance, which actually maintains the cycle of doubt,’ says Riven.
Think about it like this: performing a compulsion, such as seeking and receiving reassurance, is almost like rewarding a dog with a treat every time it barks, says Leavell-Bruce. It reinforces the idea that whatever obsession you have is a real threat and deserving of attention, which can make it stronger.
Getting specialist support from a therapist trained in OCD care – who won’t provide that reassurance – can make all the difference.
What to do if you think you might have OCD
If you recognise yourself in any of the above, you don’t have to work it out alone. Speak to your GP, who can talk you through treatment options and refer you for support. In England, you can also self-refer directly to an NHS talking therapies service.
For specialist information and support, charities including OCD Action and OCD-UK offer resources for people affected by OCD, as well as their families and carers. OCD Action also runs a helpline and email support service.
If you need urgent help or feel at risk, call NHS 111 and select the mental health option, contact your local NHS urgent mental health helpline, call Samaritans free on 116 123, go to A&E or call 999 in an emergency.
Another thing OCD and anxiety have in common? They’re highly treatable. The most important step is asking for help – and getting the right kind of support
Halle Newman is a freelance journalist and copywriter based in New York City. When she’s not writing, she’s probably strolling through Central Park with a matcha or trying out a new dance class.