Obsessive-Compulsive Disorder: The Doubting Disease

by Brittany Stahnke, DSW, LCSW, LMFT

     The second week of October is OCD Awareness Week. It is the time of year when sufferers reflect on all they’ve been through, all they’ve lost. It is the time when they think about how many more are out there, suffering in silence, unknowing to the true nature of their pain. We, as clinicians, can change this by first knowing how to identify the disorder when we see it in a client.

     Obsessive-compulsive disorder (OCD) affects two to three percent of the population and has been considered one of the most disabling disabilities in our world as a result of the loss of income and quality of life (Ocduk.org, 2020). Because of existing ignorance about its presentation and treatment, OCD sufferers usually go undiagnosed for 10 or more years.

     OCD is one of the most misdiagnosed and misunderstood disorders. One study that assessed clinicians’ abilities to correctly identify the presentation of obsessive-compulsive disorder found that 39% of clinicians, and as high as 44% depending on the specific OCD presentation, misdiagnosed cases of OCD (Glazier et al., 2013).

     Although some professionals will under-diagnose with anxiety or depression, causing lack of proper treatment and likely a progression of symptoms, others will over-diagnose, possibly causing a quicker and uglier progression of those symptoms. In such cases, practitioners have been known to misdiagnose those with OCD with psychotic disorders. In one case study, a man misdiagnosed with the lifelong, severe, psychotic schizoaffective disorder was medicated with anti-psychotics, which led to a worsening of as well as new obsessive-compulsive symptoms (Leung & Palmer, 2016). In another case, a 13-year-old boy was believed to be psychotic, rather than having OCD, because he acted on his sexual obsessions (Rohanachandra & Vipulanandan, 2019). When prescribed anti-psychotics, his symptoms became worse. After being properly diagnosed and medicated for OCD, the patient improved, and compulsions disappeared. Months later, the patient remained healthy.

     Psychotic disorders feature hallucinations and delusions as their hallmark symptoms. Unlike those with psychotic disorders, OCD patients’ hallmark symptoms are obsessions and compulsions. While those with severe OCD can feature psychotic features, these are caused by the obsessions rather than being stand-alone and primary symptoms.

     The diagnosis of obsessive-compulsive disorder (American Psychiatric Association, 2022) requires the presence of:

• Obsessions (recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress) that an individual attempts to ignore or suppress; and/or
• Compulsions (repetitive behaviors - e.g., hand washing, ordering, checking, or mental acts such as praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

     The obsessions and compulsions are time-consuming and take at least one hour per day, significantly impairing the functioning day-to-day life of the sufferer. Despite the DSM-V-TR listing OCD as requiring either obsessions or compulsions, OCD experts now know that OCD always has both. The compulsions of some individuals are simply invisible and are given the false misnomer of “Pure O OCD,” as they reside inside their minds.

     Intrusive thought OCD or “Pure O” is the most severe form of the disorder, both before and after treatment (McCarty et al., 2017). It is also the most misdiagnosed (Glazier et al., 2013). While most people with taboo intrusive thoughts do not act on those thoughts, some individuals who have no insight into the thoughts can believe those thoughts have meaning and respond to them as commands in order to rid themselves of the thoughts.

     Common compulsions to try to rid of such intrusive thoughts include counting, praying, talking back to thoughts, or “checking” if they are having a sexual urge. These unwanted thoughts can be violent or sexual, causing severe anxiety that the sufferer will act on the thought.

     Clinicians can mistake these individuals as violent, pedophilic, or a number of other damaging labels. Thus, the difference between someone with OCD and someone who is violent or sexual is important. The person with OCD is repulsed by the thoughts, and there is no real desire to act on them. Instead, there is fear that they will.

When Doubting Is Disorder

     People with OCD cannot tolerate doubt. A thought just like any other thought comes into our head. The thought is distasteful, negative, unpleasant. It may be a thought of putting a cat in a microwave. It may be a thought of touching a child’s genitals. Or having sex with a person of the sex that is not the true desire of that person. Or cheating. Shouting out inside of church.

     We all have these thoughts. All of us. In fact, a large study of 777 university students across 13 countries demonstrated this finding (Radomsky et al., 2014). But the differences between those who have OCD and those who do not is not the thought content. It is the reaction. OCD is very much a thought disorder—over time, these thoughts “stick” in a way that they do not in other brains, and we emotionally respond to these stuck thoughts. But more than a thought disorder, it is an emotional one.

     People with OCD begin to over-analyze and over-consider the thought that comes. What does it mean? Does this mean I am a pedophile? Or I am going to harm my child? Or my cat? Can I trust myself to not shout profanities in inappropriate situations? Am I gay/straight? Is this the right relationship? Did I leave the oven on? Am I possessed? Did I get HIV from that handshake?

     Obsessive-compulsive disorder is one of the few mental health diagnoses that has been found to be associated with brain abnormalities. There is difficulty in those with OCD recognizing “errors” in thinking and moving on from those errors without acting on them. In essence, the brain’s thoughts easily stick.

     PET scans of OCD brains reveal a brain that does not rest. Activity levels in certain parts of the brain, including the limbic system—the emotional center of the brain—are much higher than in comparison subjects. Further, fMRI scans show the same activity differences. On the other hand, in certain areas of the frontal cortex, responsible for our highest cognitive functioning, brains of people with OCD show less activity (Dieter et al., 1997).

     Similarly, in a study with 1,700 participants in Amsterdam, major differences in the structure of OCD brains were found (Boedhoe et al., 2018). In particular, they noted that the parietal lobe—a part of the brain thought to be involved in attention, planning, and response inhibition—was thinner in people with the disorder. These brain functions are often impaired in people with OCD, and such abnormalities might contribute to patients’ uncontrolled repetitive behaviors.

     Accurate diagnosis is crucial. Without educating ourselves to the OCD mind, we leave our clients vulnerable to those minds. Minds that will always be present, in every bad or good thing that happens to them. Minds that are looking for vulnerabilities, flaws, opportunities to doubt, and traumas to feed them.

To Do

     When people think of OCD, or joke that they are “so OCD,” they mean one of a few things. They are clean; they are picky; they want things a certain way. They are essentially perfectionistic.

     This is not OCD. Most of us with OCD are not super clean or super hygienic. OCD is not cleanliness. OCD is not arranging things, and it is certainly not perfectionism. Although some people with OCD have obsessions about cleanliness, health, and symmetry that would present with associated compulsions, this is only one presentation.

     OCD is not a disorder that anyone who knows its true nature would joke about. It is a disorder in which the obsessions of the mind take over to a degree that controls your thoughts, emotions, behaviors, and eventually, your life.

     Obsessive-compulsive disorder, like many other mental illnesses, takes lives, breaks families, and erases identities. For anyone who suffers a serious mental illness, it is isolating. But the most isolating factor is the misunderstanding from society, family, and friends, and even clinicians whose job it is to understand.

     These misperceptions and misdiagnoses can be minimized through an effort toward knowledge and away from stereotype—through education and ethical care. We cannot ever be confident enough to risk the health of a client. When someone isn’t improving, refer. When we do not know or only claim to know, refer. When we cannot truly understand the nature of an illness, refer. But otherwise, learn.

References

American Psychiatric Association. (2022). Obsessive-compulsive and related disorders. Diagnostic and statistical manual of mental disorders, 5-TR ed. 

Boedhoe, P. S. W., Schmaal, L., Abe, Y., Alonso, P., Ameis, S. H., Anticevic, A., Arnold, P.D., Batistuzzo, M. C., Benedetti, F., Beucke, J. C., Bollettini, I., Bose, A., Brem, S., Calvo, A., Calvo, R., Cheng, Y., Cho, K. I. K., Ciullo, V., Dallaspezia, S., …Kathmann, N. (2018). Cortical abnormalities associated with pediatric and adult obsessive-compulsive disorder: Findings from the ENIGMA obsessive-compulsive disorder working group. American Journal of Psychiatry, 175(5), 453-462. https://doi.org/10.1176/appi.ajp.2017.17050485

Dieter, E., Speck, O., König, A., Berger, M., Hennig, J., & Hohagen, F. (1997). 1H-magnetic resonance spectroscopy in obsessive-compulsive disorder: Evidence for neuronal loss in the cingulate gyrus and the right striatum. Psychiatry Research: Neuroimaging, 74(3), 173-176. https://doi.org/10.1016/S0925-4927(97)00016-4

Glazier, K., Calixte, R. M., & Rothschild, R. (2013). High rates of OCD symptom misidentification by mental health professionals. Annals of Clinical Psychiatry, 25(3), 201–209.

Leung, J. G., & Palmer, B. A. (2016). Psychosis or obsessions? Clozapine associated with worsening obsessive-compulsive symptoms. Case Reports Psychiatry, 1–5. https://doi.org/10.1155/2016/2180748.

McCarty, R. J., Guzick, A. G., Swan, L. K., & McNamara, J. P. H. (2017). Stigma and recognition of different types of symptoms in OCD. Journal of Obsessive-Compulsive and Related Disorders, 12, 64-70. https://doi.org/10.1016/j.jocrd.2016.12.006

Ocduk.org. (2020). World Health Organisation and OCD. https://www.ocduk.org/ocd/world-health-organisation/

Radomsky, A. S., Alcolado, G. M., Abramowitz, J. S., Alonso, P., Belloch, A., Bouvard, M., Clark, D. A., Coles, M. E., Doron, G., Fernández-Álvarez, H., Garcia-Soriano, G., Ghisi, M., Gomez, B., Inozu, M., Moulding, R., Shams, G., Sica, C., Simos, G., & Wong, W. (2014). Part 1—You can run but you can’t hide: Intrusive thoughts on six continents. Journal of Obsessive-Compulsive and Related Disorders, 3(3), 269-279. https://doi.org/10.1016/j.jocrd.2013.09.002

Rohanachandra, Y. M., Vipulanandan, S. (2019). A case of an unusual presentation of obsessive-compulsive disorder in an adolescent. Asian Journal of Psychiatry, 43, 34–36. https://doi.org/10.1016/j.ajp.2019.05.008

Brittany Stahnke, DSW, LCSW, LMFT, is an assistant professor at Newman University, where she teaches and conducts research on mental health, marriage, and suicide. She holds doctorate and master’s degrees in social work. Dr. Stahnke is the author of The Doubting Disease.