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So you’ve had anxiety off and on for years. (Relatable, tbh.) Maybe you’ve been diagnosed by a mental health specialist, maybe not. But you talked with your friend, a fellow anxious person, and they don’t constantly worry about germs to the point of washing their hands raw, or regularly ask their partner for reassurance that they’re not secretly a terrible person. Something doesn’t add up.
Guess what? That anxiety disorder you think you have could actually be obsessive-compulsive disorder (OCD). The conditions both involve high levels of anxiety, but the way they show up in someone’s mind and life is different.
Here’s how to tell them apart — and whether you should seek a diagnosis and get help.
How OCD is different from anxiety
While OCD is often used as a synonym for being a perfectionist, it is a real condition that is often misdiagnosed and misunderstood.
Originally classified as an anxiety disorder, OCD now has its own category in the Diagnostic and Statistical Manual of Mental Disorders, aka the DSM, which is the main diagnostic tool used by mental health professionals.
The distinction is important because OCD has some features that are unique compared to other anxiety disorders. (Plus, OCD has a genetic component and often runs in families.) Yet anxiety still plays a big role in OCD, so distinguishing between the two can be complicated — even for professionals. And, of course, it’s possible to have both anxiety and OCD.
According to one review of several studies, people with OCD wait on average a decade or more before receiving a correct diagnosis.
So, where is the overlap between anxiety and OCD, and what makes OCD distinct?
Both OCD and anxiety disorders can involve worrying obsessively about some feared outcome. But with something like generalized anxiety disorder (GAD), fears may change over time, whereas people with OCD often obsess over the same thing over and over. And in general, people with an anxiety disorder won’t have compulsions the way people with OCD do to relieve the anxious thought: An OCD compulsion, like repeating an action or saying phrase over and over, can take up hours of someone’s day and significantly affect their life.
What an OCD diagnosis means
There are two main things someone with OCD must have to be diagnosed:
- Obsessions, which are distressing thoughts that get stuck on repeat.
- Compulsions, which are actions or other thoughts someone uses to try to get rid of the obsessions or reassure themselves that their obsessions aren’t accurate.
“These thinking and behavior loops can feel compulsive, overwhelming to resist and very time-consuming,” says Ruth Varkovitzky, PhD, a licensed clinical psychologist and an assistant professor at the UW School of Medicine’s Department of Psychiatry and Behavioral Sciences. “A person with OCD often feels trapped in these loops, wishing they were different and wanting the thought and behavior loops to go away.”
OCD obsessions often revolve around themes such as:
- Contamination (fear of germs)
- Symmetry (needing things to be aligned or arranged just right)
- Perfectionism (fear of making mistakes)
- Responsibility (fear of harming oneself or others, intentionally or accidentally)
- Health (fear of contracting a severe or deadly illness)
For example, someone with OCD might convince themselves that they actually ran over that pedestrian they thought they stopped for, or that the intrusive thought they keep having about accidentally harming their spouse means they secretly want to.
Compulsions come in as an attempt to neutralize or reassure someone that the thing they’re obsessing over didn’t or won’t happen — a kind of temporary false reassurance of certainty. For someone with health anxiety, aka illness anxiety disorder, which some experts consider a type of OCD or OCD-adjacent, this may look like constantly monitoring heart rate or temperature, or not being able to stop paying attention to whether they’re breathing normally.
“Obsessions are thought loops that are hard to avoid, and compulsions are behavior loops that are difficult or impossible to resist,” Varkovitzky says.
Why treating OCD is different from treating anxiety
If you’ve seen a therapist for anxiety or are familiar with mental health treatment in any way, you may have heard that cognitive behavioral therapy (CBT) is considered the gold standard treatment for people with anxiety disorders.
CBT helps people understand when their thoughts are making them disproportionately fearful in certain situations and how to modify their behaviors so they can respond to stress with less anxiety.
However, there’s one part of CBT that can pose a problem for people with OCD: the concept that you can determine if a fear is rational or not, and thus reassure yourself that it’s not likely to come true.
Instead, when treating OCD, it’s important to encourage someone to accept the fact that they can’t rationalize away their fears and they will never be 100% certain of anything. It may sound harsh, but it’s a critical part of treatment being successful.
For treating OCD, exposure and response prevention (ERP) is the gold standard. ERP helps someone face their fears rather than avoiding or trying to neutralize them, and requires someone to completely stop doing their compulsions or rituals.
The idea is to teach your brain that it’s OK to not know the answer to everything you’re afraid of — and that you can learn to tolerate uncertainty.
“Part of the treatment requires a willingness to confront your worst fears,” says Rob Bailey, PhD, a licensed clinical psychologist at UW Medicine Primary Care at Northgate. “And yet, you’ll work with a therapist and take it step by step to work your way up the hierarchy of fears so you’re not completely overwhelmed at the start. Because you are confronting your anxiety instead of avoiding it, things might get worse before they get better, but you won’t need to tolerate the anxiety in perpetuity.”
ERP may not be easy, at least initially, but it is highly successful and can completely free people from OCD loops. And ERP can give people hours of their day back, since the time spent on compulsions tends to increase over time if OCD goes untreated.
Why OCD isn’t always obvious
Still not sure if you have OCD or anxiety? It’s important to talk with a mental health professional, even if you don’t ask for an official diagnosis. That way, you can make sure you pursue the type of treatment that will be most beneficial for you and your specific symptoms.
This is especially true if your symptoms aren’t textbook OCD and may be easily overlooked or misdiagnosed. For example, some people have mental compulsions, meaning their compulsions aren’t noticeable by others, and some people have more obsession-focused symptoms. Mental compulsions can be things like counting internally, replaying conversations over and over, or constantly reassuring yourself that something didn’t or won’t happen.
“Invisible compulsions can sometimes be missed or mistaken for obsessions, and it’s helpful to talk with a professional to parse these differences out,” says Varkovitzky.
Since there is so much overlap between OCD and anxiety, the most important thing is finding treatment that works for you — whether that’s ERP, medication or both — regardless of what you’re diagnosed with.
“If the person’s experience may not fit cleanly into one diagnostic category, but the core features of it align with OCD, there’s a good chance ERP will be a good starting point for care,” says Bailey.
Don’t hesitate to reach out for help
OCD can feel torturous when you’re stuck in a loop, and it can be a lifelong issue that someone deals with. However, it is treatable, and there are plenty of therapists out there who are familiar with OCD and using ERP.
“OCD is one of the mental health diagnoses where we have a very good, well-researched, evidence-based, targeted intervention,” Bailey says. “Treatment isn’t always easy, yet we’re lucky to have something so well developed that can be life-changing for people. You don’t have to suffer with OCD.”
