Demystifying OCD and "Pure O" [and what makes them different from anxiety]
Maybe I’m biased, but Obsessive Compulsive Disorder (OCD) seems to be one of the most poorly understood mental health disorders out there. Am I right? (Anybody? Bueler?) I mean, how many times have you heard someone spout off the crowd favorite explanation for why they like their desk clean or their bookshelf organized by color by saying “I’m so OCD.” Way too many times to even try to waste your time counting. And arguably way too many times for me to even have had to spell that out.
So let’s have a little chit chat about just what OCD actually can look like, and how it is different—sometimes only very subtly—from Generalized Anxiety Disorder, aka anxiety.
Let me paint some pictures for you real quick: it’s 3am, a 35-year-old mom lays in bed utterly certain that she just heard a voice in her head and is developing Schizophrenia. Her body is awash in panic—the same panic she’s had for the past 6 months every time her brain reminds her that she might be developing Schizophrenia. This time, it was probably her new kitten jumping out of the litter box, or maybe really a voice… was it a voice? This time it’s definitely real. It’s not like the other 30 times this week when she thought she heard a voice and the Schizophrenia did not, in fact, set in. This time something just feels slightly different. The flavor is just a tad off. One dash of salt tad. She starts to sharpen her hearing, catching every creak, and wind gust, and distant car sounds outside. She recalls her day to make sure she still has a coherent sense of her memory. She wakes her partner up to see if they have an odd response to her, like one they might have to someone who has just suddenly had an onset of psychosis. Her partner reassures her; no you don’t have Schizophrenia, and to go back to sleep. The reassurance allows the panic to settle just enough for her to fall back asleep before the cycle starts again in a few hours.
This is OCD.
Here’s another: it’s a Saturday night and a 30-year-old is out at a friend’s birthday party (pre-Covid, of course). Everything is going well, people are enjoying themselves, having some drinks, eating way too much sugar, pretty normal by all accounts. While in an engaging conversation about politics (not the move for a birthday party, by the way), his gaze quickly catches the knife used to cut the cake. All of a sudden he can’t think, his heart starts racing, his breathing shallows, and his legs get weak. What if I used that knife to hurt someone? It does not matter to these thoughts that these are his long-time best friends, that he is in a great mood, has been laughing all night, and has never hurt anyone nor wanted to. Images flash through his mind of him doing terrible things to the people in the room like a rolodex that a toddler got ahold of. He looks around the room trying to figure out how to get outside, away from the people he now fears that he might want to hurt. Once he slips away and gets alone in his car do the thoughts and the images start to dissipate.
This is OCD.
And just one more: a 22 year-old is hanging out with her roommates watching a movie. During the movie there is a birthday scene. Friends hanging out, balloons and cute decorations, nothing going wrong. All of a sudden she feels like the air has been sucked out of the room. Her focus falls completely away from the movie and to the inside of her mind. Birthdays, birthdays mean aging, aging means getting older, getting older means closer to death. She feels a deep sense of dread, of everything closing in. Lately, every time she listens to music that mentions love, sees an old black and white picture, or stands outside at night she has similar thought processes that always end with panic around death or nothingness. She starts to keep music off while in the car, gets herself out of earshot when her roommates have the tv on, and refuses to go outside at night.
This is OCD.
Now, let me just say for the record, these are three of MANY ways OCD can manifest. The well-known fear of germs/contamination depiction of OCD is absolutely one of those ways, it’s just not the only way.
These previous examples are examples of what we call “Pure O” or “Purely Obsessional” OCD. These forms of OCD have less obvious compulsions (such as hand washing, door checking, or compulsive organizing and rearranging) but often come with many cognitive compulsions (such as avoidance, mental tricks such as repetition of words/phrases, and reassurance seeking from others). Here are a few of the subtypes of Pure O:
Schiz Ocd (Example 1)
Harm OCD (Example 2)
Existential OCD (Example 3)
Sexual Orientation OCD
At its core, OCD is a fear of losing the things you hold most dear. Your sanity, your relationships, your life, your health, your control. And more than that, it’s the fear put on an endless loop in your mind. It’s like being stuck on a tilt-a-whirl of the things you fear the most for weeks, months, or even years. The only thing that pauses the tilt-a-whirl long enough to stop you feeling like you’re going to hurl are bits of reassurance that you are okay—that you do not have psychosis, that you are not secretly a sociopath, that the world isn’t going to end any second, and that you are, in that moment, safe. These bits of reassurance are the compulsive piece of Pure O. It may seem intuitive to ask close friends or family for their opinion on your well-being, but the problem is that in order to ask for reassurance you have to actually believe that the thoughts you’re having are valid. And when you get the reassurance, you are further reinforcing that the thoughts were indeed valid enough that getting someone else’s opinion about them would be a worthy endeavor. The reality is that the thoughts are not valid—at least not in the way you think they are. This is where OCD and anxiety treatment differ, big time. (And why having a therapist who has experience and specialty in working with OCD really matters).
Diagnostically, OCD and anxiety have a lot of similar traits. Of course, the felt sense of being anxious, worried, or having an impending sense of doom or that something bad is going to happen shows up in both. However, OCD and anxiety differ in their functioning. Generalized Anxiety Disorder tends to look more like excessive worrying about lots of different things. Maybe you worry about your work getting done, the weather, scheduling and time commitments, or whether or not others like you. Likely, with Generalized Anxiety Disorder you have all of these to some extent. I like to use to image of anxiety being like a little magnet dude with arms and legs who walks down the street and attracts any and everything with the slightest bit of metal in it. This is Generalized Anxiety. You might climb on and off tilt-a-whirls but you don’t live on one specific tilt-a-whirl.
OCD on the other hand, tends to have stronger pulls to one tilt-a-whirl or another and anything (even the most seemingly benign and unrelated) can plop you right back on that tilt-a-whirl at any time. You get deep into thought spirals around one (or a few) particular anxiety areas that never seem to reach a conclusion or solution that feels calming. There is no needle in the haystack but you cannot get yourself to stop looking. This is why thinking about your anxieties, challenging the validity of the thought by looking at the facts, considering alternative perspectives, or problem-solving the anxiety at hand (such as assuming that our friend who thought he might want to hurt his friends at the birthday party has problems with homicidal ideation and thus should get treatment for this homicidal ideation) do not work for OCD.
To me, OCD is about a lack of trust in the self to keep the self safe. It’s a not knowing where OCD starts and the self begins. And thus, treatment has to be about creating an internal sense of safety, groundedness, and trust, above any tricks and tips around changing thoughts. For those living with OCD, life is spent in the mind, often far away from the body. OCD recovery has to involve a shift from mind-living to embodied living. To learn and connect to what true, enduring safety feels like.
If you are struggling with anxiety or what you think might be OCD, reach out to a licensed mental health professional who is trained and knowledgeable in OCD treatment and diagnosis for an assessment. There are many out there who get it and can help you walk through the journey towards full embodied living.