Anxiety disorders are some of the most prevalent psychiatric conditions, with over 40 million US adults diagnosed with at least one type of anxiety disorder in the past year.
Many assume that obsessive-compulsive disorder (OCD) is classified as an anxiety disorder, because people with OCD often feel very anxious when their obsessions are triggered, leading them to seek relief by performing compulsions. This assumption, however, turns out to be misleading. We spoke with Dr. Patrick McGrath, Chief Clinical Officer at NOCD, to better understand OCD and anxiety disorders, how they are related, anxiety’s role in OCD, and more.
What Are Anxiety Disorders?
Everyone experiences anxiety, fear, and worry from time to time. For some individuals, though, anxious thoughts and feelings are consistently excessive, meaning they do not correspond with the actual threat posed by what they are scared of or worrying about. Anxiety disorders occur when one experiences these excessive feelings of fear, anxiety, or worry for a prolonged period of time—around six months—and when their ability to function is impaired.
What Is OCD?
OCD is characterized by two primary symptoms: obsessions and compulsions. Obsessions are intrusive thoughts, images, feelings, or urges that are experienced as involuntary and cause significant stress. Compulsions are mental or physical actions performed in response to obsessions that are done to alleviate distress or prevent a negative outcome from occurring. For example, an individual with OCD may have distressing intrusive thoughts regarding contamination and wash their hands repeatedly to reduce their anxiety and prevent themselves and others from getting sick.
Is OCD an Anxiety Disorder?
Given that people with OCD can experience a great deal of anxiety, it’s natural to think that OCD may be a type of anxiety disorder.
For several decades experts felt the same way, as the Diagnostic and Statistical Manual of Mental Disorders (DSM) classified OCD as an anxiety disorder. However, this changed in the DSM’s fifth and most recent edition. Instead of being grouped with other anxiety disorders, OCD is now categorized with conditions such as hoarding, body dysmorphic disorder, and trichotillomania (hair pulling) under the general classification of obsessive-compulsive and related disorders.
Differences Between Anxiety Disorders and OCD
Why separate OCD from anxiety disorders if those with the condition so often experience strong anxiety and fear? Researchers have cited several distinguishing factors.
Anxiety Isn’t Always a Prominent Feature of OCD
One primary consideration is that OCD doesn’t have to involve anxiety. Obsessions and compulsions can give rise to and be driven by “other uncomfortable feelings, like shame, disgust, and guilt,” shares Dr. McGrath. Each of these emotions can result from intrusive thoughts, images, and urges and compel people with OCD to perform compulsions. This means that for some, anxiety may not be the primary feeling that keeps the obsessive-compulsive cycle going. Since it’s possible to have OCD without anxiety as the primary or core symptom, experts argue that it is most accurately classified in another category.
Obsessions Are Not the Same as Worries
One reason why you might think OCD is an anxiety disorder is that obsessions, on the surface, seem similar to worries. Given that persistent and excessive worry is the main symptom of a generalized anxiety disorder (GAD), shouldn’t OCD be counted as an anxiety disorder too?
It comes down to specifics distinguishing factors between worries and obsessions. Though the boundary between obsessions and worries can be fuzzy, there are some general differences.
- Worrying is about problem-solving: While worrying, one often tries to figure out how to prevent some bad outcome. Individuals with GAD are thought to have an inflated sense of the value of worry with regard to problem-solving. One reason that those with GAD worry so much is that they believe doing so will help them avoid the problems they are concerned about. For example, they may ruminate about an upcoming interview because they believe that by doing so, they will be better prepared for all possible interview questions. Those with OCD, on the other hand, most likely don’t hold the same beliefs about the benefits of obsessions.
- Obsessions are less voluntary: Though worries and obsessions can be challenging to control, obsessions are more likely to feel as if they are occurring entirely against one’s will. Worrying tends to be a more active and deliberate process.
- Obsessions involve thought-action-fusion: A common element of obsessions is what experts call “thought-action fusion.” This involves either the belief that thinking about an outcome makes it more likely to occur, or that thinking about performing an action is just as morally wrong as doing it. Researchers have found that they can successfully distinguish between worries and obsessions based on whether they involve thought-action fusion.
- Obsessions are “ego-dystonic”: Experts often note that obsessions are “ego-dystonic.” This means they are inconsistent with the individual’s genuine values and beliefs. For example, obsessions might involve thoughts about harm coming to a loved one, even though the person has no desire to harm anybody.
- Obsessions are less realistic: “Worry is typically going to be about topics in day-to-day life, like whether one will lose their job or have enough money to support their families.” shares Dr. McGrath. Studies have found that obsessions tend to be harder to believe and involve less practical concerns from an outsider’s perspective.
It’s worth noting that some of these features exist on a spectrum. For example, an obsession or worry can be more or less realistic. In many cases, the difference between obsessions and worries is more difficult to distinguish than in others.
Anxiety Disorders Don’t Involve Compulsions
Dr. McGrath explains that “with anxiety disorders, there are no associated compulsions. However, there are safety behaviors that people often do that may look like compulsions.”
What is the difference between a safety behavior and a compulsion? Compulsions are safety behaviors in people with OCD—they are designed to relieve distress or prevent an outcome associated with an obsession. McGrath notes that people with panic disorders may seek reassurance from loved ones that they aren’t having a heart attack, or someone with social anxiety may avoid parties after work so they do not have to socialize. Others, like people with phobias, may seek safety in distraction or substances.
“In other words,” he explains, “individuals with anxiety disorders don’t tend to perform ritualized behaviors to alleviate their anxiety. Instead, they use broad safety behaviors to get through anxiety-provoking experiences, while obsessive-compulsive and related disorders involve some type of ritualized, repetitive behavior.”
With that said, Dr. McGrath notes that the need for reassurance or the elimination of doubt is shared among people with anxiety disorders and those with OCD. In both cases, reassurance-seeking doesn’t provide the lasting relief from the doubt that it promises. However, when seeking safety or reassurance only leads to more and more doubt and reinforces a cycle, the need to find certainty is much closer to a compulsion.
When it comes to the brain, anxiety disorders share things in common with each other, but not with OCD. For example, several studies have found over-activity in a part of the brain called the orbitofrontal–basal ganglia pathway in people with OCD, but not in those with anxiety disorders.
This is reflected in the fact that some medications that alleviate the symptoms of anxiety disorders aren’t as effective with OCD. For example, benzodiazepines, such as lorazepam and alprazolam, can be very effective in the short term for phobias, panic disorder, and social anxiety disorders, but studies suggest that they don’t do as much to stop obsessions and compulsions, and are only helpful when OCD occurs along with anxiety.
The Role of Anxiety In OCD
Though anxiety isn’t always a primary feature of OCD, feelings of fear and anxiety are common experiences among individuals with the condition. When they do occur, they are often a driving force behind obsessions and compulsions. Because obsessions are often about scary possibilities, they can trigger a lot of anxiety. For example, experiencing an urge to jump from a high surface can make one feel incredibly anxious. Thought-action fusion can make this even worse—since obsessions can involve the belief that thinking or imagining a bad possibility makes it more likely to occur, those with OCD often feel anxious when experiencing scary intrusive thoughts.
As Dr. McGrath notes, all of this can “trigger the brain’s fight, flight, or freeze response and get people to do things for immediate relief. So OCD, through the occurrence of the obsession, creates immediate discomfort and promises immediate relief through the completion of a compulsion.” It can do this in several ways. Some compulsions may be done to extinguish an obsession completely and relieve the anxiety stemming from it. Additionally, people may believe that their compulsions can prevent a bad event associated with their obsessions from occurring, so engaging in them can provide temporary reassurance or a sense of confidence that the bad outcome will be avoided. “Of course, the problem is that the compulsion only works for a few moments,” says Dr. McGrath. “Then you have to do it again and again and again, and you don’t actually get the relief.”
The urge to complete compulsions can also make one feel out of control. As a result, completing compulsions can make one feel anxious about their ability to control their actions. This increase in anxiety can lead to more obsessions, which cause further compulsions, and so on.
Frightening experiences can give rise to and shape the focus of one’s obsessions and compulsions. For example, suppose one experiences a serious illness; following this highly stressful period, they may develop obsessions about the possibility of contracting something similar in the future and engage in compulsions to prevent this from happening at all costs. Evidence actually suggests that stressful life events can make those without OCD more disposed to develop it in the future. For example, one study found that compared to control groups, individuals with OCD were much more likely to report a stressful life event in the six months prior to the onset of their OCD.
What Anxiety Disorders Are There?
The most common type of anxiety disorder is generalized anxiety disorder (GAD), which is characterized by excessive and persistent worry about a variety of issues that lasts for at least six months and is accompanied by other negative experiences such as muscle tension, irritability, and sleep disturbances. Other types of anxiety disorders include:
- Separation anxiety disorder: Characterized by an inappropriate or excessive fear regarding separation from attachment figures, such as a parent or significant other.
- Specific phobia disorder: Occurs when one experiences intense and unwarranted fear regarding a particular object, circumstance, or situation
- Panic disorder: Panic disorders involve recurring panic attacks, which are abrupt surges in fear, typically peaking within a few minutes. Often, they are unexpected and have no apparent cause.
- Social anxiety disorder: Occurs when an individual is anxious about and avoids social situations due to fears of judgment and scrutiny.
- Agoraphobia: Characterized by an irrational fear of being in crowded public spaces or leaving one’s home.
While all of these conditions involve excessive or inappropriate fear, anxiety, or worry, they differ with respect to the nature of their fears and worries and the types of safety-seeking behavior they trigger. For example, while individuals with agoraphobia are nervous about public spaces and may avoid leaving their homes, those with social anxiety disorder worry about being judged in social settings and avoid situations where this is possible.