Did you know that the average person makes around 35,000 decisions each day—from choosing an outfit in the morning to deciding what time to go to bed. You might make many of them without giving your choices a second thought. But for millions of people with obsessive-compulsive disorder (OCD), making any choice can feel like a daunting, sometimes impossible task.
The constant need for perfection that OCD can bring, as well as a fear of making the wrong choice can lead to endless cycles of overthinking. It can feel like having a committee of anxious voices in your head, each one weighing in on every decision.
In this article, we’ll discuss how OCD can make it difficult to make decisions—and perhaps most importantly, we’ll detail a treatment option for OCD that can ease your symptoms. (Wear the green shirt, for sure! And turn in by 10 pm.)
OCD and decision making
OCD is characterized by obsessive thoughts that are intrusive and often irrational. These thoughts can make it hard to make decisions, because you may feel overwhelmed by the distress and anxiety they cause.
“Distress intolerance” is a term that refers to the difficulty people with OCD have dealing with anxiety and uncertainty. It can make decisions hard, and the fear of making the wrong choice may feel overwhelming.
“It all comes down to wanting to make the good decision, the right decision,” explains NOCD Clinical Trainer April Kilduff, MA, LCPC, LMHC. “In the case of religious or scrupulosity OCD, for example, it could mean making the best value decision or the decision that will make God happy.”
OCD often demands 100% certainty that the decision you’re making is the right one, and inflates the risk posed by making the wrong decision. Of course, no one wants to make the wrong choice, but for people with OCD, the need for an impossible degree of certainty can short-circuit the ability to make a choice at all, resulting in something known as decision paralysis.
Kilduff adds that a range of compulsions caused by the distress and anxiety about making a choice can further exacerbate the problem and make it even harder to make a decision.
Compulsions related to decision making
Let’s take a moment to look at some of the specific compulsions that people with OCD use to cope with the distress and uncertainty associated with making decisions.
Avoidance: This is a very common compulsion where you avoid making a decision to prevent anxiety that’s caused by the uncertainty of the outcome. Kilduff explains that someone with OCD may avoid making a decision altogether or avoid it until a circumstance forces them to make a decision, meaning that the person can feel free from responsibility for it.
Reassurance seeking: Another compulsion is reassurance seeking from others, which involves trying to alleviate your anxiety and uncertainty about your decisions. This can involve repeatedly asking others for their opinions or needing validation for their decision-making process. People can also seek reassurance through research—like reading every review of a product that you can find before making a purchase.
“I once worked with a NOCD member who wanted a gray couch,” says Kilduff. “She probably spent two solid weeks looking at every gray couch on the internet, poring over reviews and putting all this information into a spreadsheet before finally choosing one.” There’s nothing wrong with doing thorough research, especially about a big purchase like a couch. However, if it takes up an excessive amount of your time and energy to the point that it detracts from other things in your life, it can be a problem.
Rumination: Rumination is compulsion where you persistently, repeatedly think about a decision you have made or are about to make, trying to analyze all possible outcomes and their consequences. This can lead to excessive worry and indecisiveness, and make you feel stuck in a cycle of overthinking.
“OCD’s core message is that uncertainty is bad, and bad things will happen if you are uncertain. For someone with OCD, uncertainty is, therefore, unacceptable,” explains NOCD’s Chief Clinical Officer Patrick McGrath, PhD. “For example, I can’t be sure that the cable suspending the elevator won’t snap when I get inside it. So does that mean that I should take the stairs? But if I take the stairs, I don’t have any guarantee that I won’t slip, fall, and break my neck. So should I have somebody carry me? I could, but where’s the proof that this person won’t drop me or slip themselves? If I’m looking for absolute certainty, I will fail every time because it simply doesn’t exist.”
Checking and reviewing: Other compulsions include checking and reviewing. This is when someone repeatedly goes over their decisions, seeking certainty and reassurance that they’ve made the right choice. This can involve checking and rechecking information, or seeking second opinions, leading to a delay in decision making and increased anxiety.
While these compulsions may temporarily relieve the anxiety associated with decision making, they reinforce the underlying OCD cycle and contribute to increased distress and impairment in daily functioning in the long run.
Types of decisions affected by OCD
Daily decisions like what to wear or eat can be a source of anxiety for someone with OCD, but important life choices, such as picking a career or a place to live, can lead to especially intense distress. The fear of making the wrong decision can create indecisiveness and avoidance, significantly affecting your life, especially if you persistently put off important opportunities. It can also affect your relationships and cause stress and tension.
An example: Steve is a 32-year-old man who has been struggling with OCD for several years. He’s in the market for a new car, but his OCD has made the process almost unbearable.
Steve’s distress intolerance has created a situation where he’s constantly worried about making the wrong choice, and then being unable to return or exchange the vehicle. As a result, Steve experiences decision paralysis. He’s unable to pick a car even after researching and comparing various makes and models.
Steve’s OCD also leads him to engage in compulsive behaviors in an attempt to find relief from his obsessions. He spends hours reading reviews and watching videos about cars, seeking reassurance from friends and family that he is making the right decision. He also repeatedly checks and rechecks the features and prices of various cars, hoping to find some sense of certainty in his decision making. Despite his efforts, Steve’s OCD impairs his ability to decide, and causes him significant distress.
Fortunately, with the help of a therapist trained in ERP, Steve learns to manage his symptoms and make decisions like buying a car with greater confidence and ease.
ERP: The gold standard treatment for OCD
The most successful treatment for OCD is a form of behavioral therapy called exposure and response prevention (ERP). Unlike traditional talk therapy, which can backfire and make OCD worse, ERP—which was developed specifically to treat OCD—is clinically proven to be highly effective in the majority of people.
Here’s how it works: A trained therapist who specializes in OCD will take the time to understand your symptoms and create a custom ERP therapy plan specifically for you. Then, you’ll work together to rank your fears or triggers based on how stressful they seem. To begin with, your therapist will typically prompt you to face a fear that brings on only a mild amount of distress. For example, your therapist might simply show you a photo of a room where things aren’t lined up perfectly. The fear thoughts—like the idea that something terrible will happen when things in your environment aren’t perfectly symmetrical—will likely come up, but instead of responding with a compulsion, you’ll learn to tolerate the discomfort. By making this conscious choice and seeing that nothing bad occurs, or realizing that you handled the discomfort better than you thought you could, your brain gets the message that there was nothing to fear in the first place.
As your therapy progresses, you’ll tackle triggers that elicit a bit more distress, to conquer bigger fears. With an ERP therapist guiding you, you’ll practice confronting your fears in your everyday life, too, instead of just the controlled setting of therapy.
Most of the time something amazing happens as a result of this therapy: You won’t be riddled with distress from intrusive thoughts, images, or urges. Your need to engage in compulsions goes away. And the things that matter the most to you won’t be at risk of slipping away. For instance, when you spend time with a loved one, you’ll be able to focus on the connection between the two of you—rather than on whether the salt and pepper shaker on the table are in a perfectly straight line. In essence, you’ll get to live a life that’s free from the grip of OCD.
Working with an OCD specialist to address the thoughts and situations that cause you distress is more accessible than ever thanks to virtual ERP therapy. In fact, peer reviewed research shows live teletherapy sessions of ERP can be more effective, delivering results in less time than traditional outpatient ERP therapy, often in as little as 12 weeks.
Want to begin your ERP therapist search? We encourage you to browse the NOCD Therapist Directory. Every NOCD therapist is not only specialized in ERP but trained to deliver treatment online. Choose your therapist and we do the rest, including helping with scheduling and payment. Of course, if NOCD Therapists aren’t the right fit, you can also explore the International OCD Foundation Therapist Directory.
ERP’s role in helping people learn to accept uncertainty
One of the main goals of ERP therapy is to help people with OCD learn to tolerate doubt and uncertainty. This is especially relevant when it comes to making decisions, as the fear of choosing the wrong thing is linked to doubt and uncertainty about the outcome. By exposing yourself to the possibility of making a mistake or being uncertain about the outcome, ERP helps you learn that you can handle the discomfort and anxiety that comes with uncertain decisions.
“Doubt is not a four-letter word,” explains Dr. McGrath. “Doubt is something that we live with on a daily basis. It doesn’t have to stifle us and stop us from living our lives. ERP’s role is to help prove that to you.”
We want to make the decision to get help for OCD easy, so you can regain control of your life. If you think you might have the condition or are interested in learning how it’s treated with ERP, I encourage you to learn more about NOCD’s evidence-based, accessible approach to treatment.
All of our therapists specialize in OCD and receive ERP-specific training. You can also get 24/7 access to personalized self-management tools built by people who have been through OCD and successfully recovered.