by Molly Schiffer, LGPC

When I meet clients for the first time they often arrive at my office with some mixture of trepidation and despair, their suffering quite evident. They may have varying degrees of knowledge about OCD, but what they all share is this overwhelming feeling or urge to do something about their unwanted thoughts and eradicate or alleviate doubt and uncertainty. While often times the content of their obsessions falls into a subcategory such as harm, relationship, contamination, sexual orientation, pedophilia fears, or “just right” obsessions, this is not always the case. These subcategories are not all-encompassing nor are they always distinct from each other. However, what they do all share in common is the oh-too-familiar process of a thought arriving with an emotional jolt followed by the desperate attempt to get rid of the anxiety, and then always followed by an increase in the obsessive thought.

Compartmentalizing OCD

Identifying subcategories of OCD can be an effective way for clinicians to organize and describe specific manifestations of OCD. For individuals with OCD, having a label for their OCD is a way for them to join with others and feel a part of a group with fellow sufferers. When I attended my first International OCD Foundation conference I remember thinking how interesting it was when you would meet someone new and they would ask for your “brand” or “flavor” or “theme” of OCD. This is similar to the culture of Alcoholics Anonymous where people talk at meetings about being “daily” drinkers versus “binge drinkers”. What had once been a source of shame can serve as a way to end the isolation and loneliness many people with OCD experience.

That being said, I have also noticed a tendency of some of my clients to want to “perfectly” compartmentalize their OCD, or cleanly separate and label what is OCD versus another kind of anxiety. But OCD does not discriminate in regard to subject matter and one can have obsessions and compulsions about nearly anything. OCD sufferers can get duped when the content shifts away from some “obvious” OCD theme and into something masquerading as a potential “real issue”. “That’s not my OCD because it’s about something real,” they say. But trying to separate OCD from what they view as “regular” anxiety is part of the OCD trickery.

Is Or Isn’t My OCD?

This perceived need or urge to label and categorize different types of anxiety is actually a compulsion. By trying to be certain of what is or isn’t OCD you are also trying to feel more certain that you are getting the exact “right” treatment specific for the exact right anxiety. When OCD presents in a typical or obvious form, identifying it as such becomes a thing of comfort. “I don’t have to do compulsions because this is obviously my ‘Harm’ OCD.” But this focus on the content of the thoughts can sometimes make it more difficult to catch the more subtle forms OCD can disguise itself in. Here are some examples of OCD hiding in potential “real issues”:

Mary is 27 and was raised in a Christian home, but turned away from the church during her teen years. After the birth of her first child Mary began going to church again, and had been enjoying it despite the fact she wasn’t sure she agreed with all of the teachings, particularly the creation story. Mary began to wonder what she really believed in regard to creation versus evolution. Over the course of a session it became evident that Mary was stuck in the OCD loop of “I need to know exactly what I believe.” Mary stated this was a real issue because she wondered if she could be a Christian if she didn’t believe in the creation story. The OCD had her focused on her religious ambivalence instead of on “I need to know exactly…”

John is 29 and has been sober for a year. John was working the steps of a 12 step program. John was doing a daily inventory which was part of his step work. The purpose of the inventory was to look out for places where he had been dishonest or selfish so that he didn’t slip back into old behavior and pick up drinking again. As John continues to practice writing his daily inventory John became unclear about his motives in situations and whether he had been selfish or dishonest. John began to spend excessive amounts of time writing and re-writing his inventory as he wanted to be thorough. John felt that his concerns were real issues because his sobriety might be on the line. OCD had him focusing on the content (his very real sobriety) and not on the obsessive drive for certainty about his motives and the compulsive re-writing.

Sara is 36 and recently gave birth to her second child. Sara loved being a mother, but found her second child to be more challenging to care for than her first. Soon Sara began dreading those moments when her baby would cry and Sara would become frustrated. Sara had a great experience with her first child who slept through the night and seemed content most the time. Sara became concerned about her feelings and whether she loved her children the same. Sara wanted to be sure she cared for her children equally and felt that she might need to explore the issue further to make sure she was being a good mother. This resulted in hours of ruminating on whether she was certain she loved her child the right way. OCD had her focusing on her frustration with a more challenging child and not on the compulsive mental review and attempts to be certain she is having the “right” feelings.

These examples highlight three subtle manifestations of OCD focusing on belief systems, motives for behavior and feelings. These sufferers may find themselves continuing to engage in compulsions without insight because of the assumption that the content of their concern doesn’t clearly fit an OCD theme. OCD loves to poke OCD sufferers on content that is inherently riddled uncertainty. The idea that one needs to pin down beliefs, motives or feelings is black and white thinking, a cognitive distortion that often propels OCD sufferers to look for a singular truth when often people have multiple conflicting beliefs, motives and feelings.

Unanswerable Questions

What I find helpful when working with clients who get sidetracked by content that is disguised as a potential “real issue” is to revisit the idea that OCD is not identified by the subject matter but by the process of how the thoughts arrive with a feeling of import and urgency, almost like receiving a message of warning. A telltale sign that you have entered OCD territory is when you are asking a question of yourself that can’t actually be answered. Some examples of unanswerable questions:

  • How do I know exactly what I believe?
  • How do I know this is my OCD and not a real issue?
  • What does this mean about me?
  • How do I know with 100% certainty that I am getting the right treatment?
  • What if I am not relaying the content of my obsession sufficiently and get the wrong type of treatment?
  • How do I know that this time it’s not true?

It is important to recognize these subtle yet familiar processes and not be fooled by the lack of creativity in the content. In other words, the way in which you think is a better measure of OCD than the details of what your thoughts and how bizarre or “normal” they appear.

“OK, so what should I tell myself then?”

When I respond to clients with, “don’t tell yourself anything,” they often look completely dumbfounded. The idea of not saying anything at all seems ludicrous, maybe even impossible. “But I have to tell myself something!” they reply. However, that behavior is driven by a secret (or not so secret) hope all OCD sufferers have, which is to get rid of these thoughts and feelings, and that means the behavior is compulsive. The hope is that with saying the “right” thing to yourself or applying the “right” strategy you will get rid of the unwanted thought for good. This is when applying a “strategy” itself becomes a compulsion. No matter what strategy you use or what you say to yourself, if your goal is to make thoughts go away, it will fail due to the paradoxical nature of anxiety. Trying to get rid of it teaches the brain that it is important, dangerous, and must be the focus of attention.

Thoughts actually don’t require us to do or say anything at all. They are not intrinsic messages or mandates to act. The fact that the content of the thoughts has shifted to something that feels more like a “real life” issue, does not make them operate any differently from any other OCD process. When I see clients stuck in “Well, that thought was obviously OCD, but what do I do about this thought?” I usually recommend that they put away their books on anxiety and OCD and start doing the hard work of putting less effort into their recovery.

The Paradox of Doing Less to Achieve More

Doing less means letting go of the whack-a-mole approach to OCD, of jumping from one scary thought, concluding it must be OCD nonsense, and then jumping to the next scary thought until that one has been neutralized. Instead what is needed is a shift in attitude and mindset; a move from “I have to get rid of these thoughts” towards a stance of “I can get better at accepting mental chatter as it comes and goes.” Sufferers can strive to recognize that the volume (or loudness) of the subject matter or content is not an indicator of its importance. We all walk around with a degree of mental chatter or “the committee,” a term used by members of Alcoholics Anonymous to describe their awareness of the mental activity going on. What sets apart the OCD sufferer from those without the condition is the OCD sufferer’s acute awareness of the chatter and the predisposition to judge or attribute meaning to the chatter.

Sometimes I like to ask my clients to stop and consider who is asking these questions and who are they responding to? The response I usually get is, “I don’t know.” There is only one person involved here and it’s you. The mental gymnastics that takes place in trying to prove what is OCD and what isn’t may seem like real problem solving and self-searching but it is in fact just OCD in disguise.

I find it helpful to think of my mind as having radio channels that are pre-set. Some of these channels play desirable thoughts and other times they play undesirable thoughts. Chances are that at any point I can tune in to a channel and find these unwanted thoughts no different than walking into the mall and hearing the Chumbawamba song…”I get knocked down but I get up again…(sorry, can’t stand writing it either) for the gazillionth time. The point being that my level of misery will directly correlate with how much I am tuning in to the channels and how much effort I put into trying to change the channel or get rid of my awareness of it.

Bumper-to-Bumper or Smooth Sailing

The message I hope to impart is that one can make room for all types of thoughts. Imagine you are driving home in rush hour after a long day at work. In rush hour you’d likely see a multitude of vehicles of different shapes, sizes and colors all keeping you from arriving home. Sure, you could beep your horn and scream in frustration or you could accept that there are a lot of cars on the highway making movement difficult. Similarly, one can learn to accept that they are human and humans have a lot of different kinds of thoughts that don’t require any special attention or specific response.

Don’t let OCD trick you into taking the bait by seeking certainty about the content of your thoughts and debating about whether the content is OCD or a “real” issue. Instead, look to how you are thinking, and look at the the way in which the thought arrives with that feeling of import.  These are your best clues that OCD is involved. I often tell my clients that if you are asking whether OCD is involved or whether there’s a “real” issue, go ahead and treat it like OCD because chances are the question itself is the OCD. Don’t wait to be sure it fits into a category, don’t try to be certain, but beat the OCD at its own game by taking the risk and letting all vehicles in traffic flow.

Molly Schiffer, LGPC is a psychotherapist specializing in OCD and related disorders at The OCD and Anxiety Center of Greater Baltimore.