It can be hard to untangle the web of our brains and put it into words. You might have a hard time differentiating between obsessions and compulsions—even if you’ve been diagnosed with obsessive-compulsive disorder (OCD)—especially if your compulsions are primarily mental, rather than physical actions.
It’s natural for it all to feel jumbled together. Obsessions and compulsions do, after all, share a close relationship with one another. That being said, learning to identify and distinguish these symptoms is a crucial part of the OCD recovery process. It’s extremely important to recognize the compulsive behaviors—again, mental or physical—that are keeping you stuck in the loop of OCD.
While seeking help from a licensed mental health professional is the best way to do that, it can also be extremely helpful to learn about your own experience as you take steps to start treatment.
Because “obsessions” and “compulsions” are words that are specific to OCD, this article will focus primarily on this condition. However, since there are other conditions that share similarities with OCD, I’ll give a short overview of those, too. And to conclude, we’ll talk about how OCD and related conditions are best treated.
What is an obsession?
Of course, the word “obsession” has use outside of a diagnostic or mental health context, so it can be hard to grasp its meaning within a mental health context. When used in conversation, it might even have a positive connotation: “I’m so obsessed with that TV show” or “I’m obsessed with your outfit.”
When talking about obsessions characteristic of OCD, though, they are not positive or enjoyable. In OCD, an obsession is a repetitive, unwanted intrusive thought, image, urge, feeling, or sensation.
Dr. Patrick McGrath, clinical psychologist and Chief Clinical Officer at NOCD, says they can be “inappropriate or uncomfortable” in nature. Obsessions cause great distress, including potential feelings of anxiety, guilt, shame, fear, and disgust.
While everyone has similar intrusive thoughts, images, urges, sensations or feelings, they turn into obsessions when you feel unable to move past them, finding them important or even dangerous. Someone without OCD, for example, can think What if I swerved my car off the bridge? then recognize the thought as untrue to reality and what they want to do, and simply move on.
On the other hand, someone with harm OCD, a theme of the disorder that focuses on harming oneself or others, might interpret that thought as something to be taken extremely seriously. They will have an urgent need to “get to the bottom” of whether that thought really meant something.
Intrusive thoughts can latch onto anything, and they typically attack what we value most, making OCD a particularly idiosyncratic and difficult disorder. There are common themes, including:
- Contamination (What if I contract a deadly illness from this public restroom? What if I contract germs at the concert and then bring them home to my family?)
- Relationships (Is this person really ‘“the one”? Am I attracted “enough” to them?)
- Harm (What if I grabbed a knife from the kitchen and stabbed my partner? What if I pushed this stranger in front of the train?)
- Sexual orientation (What if I’m lying to my partner, and I’m actually straight? What if I’ve been repressing my sexuality my whole life, and I’m actually queer?)
- Pedophilia (What if I am attracted to this child? What if I want to molest children?)
- Scrupulosity/Religion (Am I actually a bad person? What if I’m going against my religion?)
- Existential (What if I never know the purpose of my life, and I waste it? How do I know I’m not really dead or in a simulation?)
- Sensorimotor (What if I am not blinking correctly? What if I can never stop paying attention to my breathing?)
Again, these are some of the most common themes, but OCD truly knows no limits. It can latch onto anything. The good news is that when treating OCD, the content of obsessions doesn’t matter—they’re all treated the same. We’ll talk about how in the final section of this article.
What is a compulsion?
A compulsion is a behavior or mental action done to relieve the uncomfortable feelings brought on by obsession. It’s often performed to find certainty, prevent a “bad” thing from happening, or to “neutralize the thought,” Dr. McGrath says.
If your compulsions are mostly done in your head, they can be especially tricky to recognize. Here are some of the most common mental compulsions:
- Reassurance-seeking from yourself. For example, repeatedly thinking I am a good person or My life has purpose.
- Rumination, or over-analyzing a perceived problem. It looks like turning something over and over in your mind. It comes from feelings of “needing to get to the bottom” of your intrusive thoughts, and the desire to “think your way out” of the uncomfortable feelings brought on by them.
- Thought replacement. This happens when you attempt to replace a “bad” thought with a “good” one. For example, after thinking What if I pushed that person in front of the train? you might intentionally think that person looks really kind.
- Mental review. This is when you go through prior experiences and situations to look for proof that your intrusive thoughts are true. For example, if you have pedophilia OCD, you might look back on memories you have with children and ask yourself, Was that creepy? How about that? Was it wrong that I hugged them? Could I have done something when I was changing their diaper?
- Distraction. This happens when you try to keep your mind occupied in order to not leave room for intrusive thoughts. For example, maybe you watch a lot of TV because you get so focused on the show’s storyline that you don’t have intrusive thoughts.
Physical, visible compulsions are naturally more difficult to hide from those around you. You may find yourself doing them in secret out of embarrassment or so you’re not interrupted. Some of the most common physical compulsions include:
- Washing/cleaning. Those with contamination OCD typically find themselves trying to rid their body, objects and/or environment of any potential contaminants. They might engage in excessive hand washing, showering, or disinfecting of surfaces.
- Checking. For example, checking to make sure the stove is off, or the door is locked, or you didn’t accidentally run over someone with your car.
- Tapping/touching. With this compulsion, there is often no logical connection between the intrusive thought and the action; one just feels like they need to do it in order to neutralize the thought and relieve distress. For example, you may need to pick up and put down your coffee mug or tap your arm a certain number of times in order to feel “just right.”
- Redoing. Similarly to the above compulsion, this may not have a logical connection to the content of intrusive thoughts. It can look like repeating words or sentences until they sound “just right” or rewriting one’s class notes over and over until they’re “perfect.”
- Reassurance-seeking from others. Asking a loved one, “Do you think I’m going to be okay?” or “Did I hit that person on the bike back there?”
- Avoidance. This involves refusing to go to places, be in situations, or take in stimuli that may trigger your intrusive thoughts. For example, if you have relationship OCD, you may avoid going to restaurants where you could see other couples to compare your relationship to.
Compulsions tend to bring temporary relief, but they ultimately feed the OCD cycle. These behaviors end up reinforcing the idea that intrusive triggers and obsessions are serious threats, that compulsions are keeping you safe, and that you cannot tolerate the uncertainty and discomfort that OCD causes.
Do conditions besides OCD have obsessions or compulsions?
OCD is commonly misunderstood and misdiagnosed. Part of this is because it shares some symptoms with other disorders. However, it is distinct in more ways than not. The act of performing compulsions in order to relieve distress brought on by intrusive triggers is unique to OCD.
There are other conditions that experience either excessive fixation or compulsive behavior, but not in the same way that they’re experienced in the context of OCD. I’ll go over conditions that share similarities with OCD, including the conditions that are included in the diagnostic category of “obsessive-compulsive and related disorders.”
Other conditions that entail excessive fixation or compulsive behavior
Body dysmorphic disorder (BDD). People with BDD fixate on their appearance. They spend an excessive amount of time thinking about specific perceived flaws and looking in a mirror—or, conversely, avoiding mirrors. They may engage in compulsive “checking” or reassurance-seeking (“Do I look okay? Are you sure?”), which are also common with OCD.
Body-focused repetitive behaviors (BFRB). A BFRB is a repetitive behavior focused on the body, such as skin picking and hair pulling. Unlike OCD, these behaviors tend to bring pleasure or satisfaction (even if it causes impairment later on). The behavior can be described as compulsive, but not as a compulsion, because it’s not typically done in order to relieve distress from intrusive triggers.
Eating disorders, including anorexia, bulimia, orthorexia, and binge eating, are characterized by a fixation on bodily weight/shape and/or on food. They also often involve compulsive behavior surrounding food and the body.
However, the nature of that fixation differs from the nature of OCD’s intrusive triggers; they are not ego-dystonic, meaning that even though they’re destructive, they’re not necessarily against the sufferer’s desires or values. The focus of fixation is not taboo, inappropriate, or uncomfortable, and compulsive behavior is done to uphold an ideal or goal, not to relieve distress or discomfort.
Anxiety disorders, such as generalized anxiety, social anxiety, specific phobias, and panic disorder, are a common misdiagnosis for those with OCD. People with OCD do commonly experience anxiety, but people who meet diagnostic criteria for anxiety do not experience obsessions and compulsions.
In the case of specific phobias, one could experience intrusive fears, but typically only when presented with the subject of their phobia. OCD, on the other hand, tends to remain with its sufferer no matter where they are.
Moreover, beyond avoiding their triggers (often at all costs), those with phobias don’t generally perform compulsions. They feel an intense fear, but it’s not taboo, inappropriate, or uncomfortable in nature, and typically doesn’t go against the individual’s values.
For more information about these conditions that share some similarities to OCD, check out this helpful comparison page from the International OCD Foundation.
How can you get help for obsessions and compulsions?
Like I said earlier, all themes of OCD are treated the same: with exposure and response prevention therapy (ERP). You may have heard the term “exposure therapy” before, but the response prevention part is
perhaps even more crucial.
ERP begins with you and your therapist working together to identify all your intrusive triggers, obsessive thought patterns, and compulsive responses. From there, you collaboratively plan a hierarchy of therapy exercises for you to confront your triggers in a gradual manner.
You will start with exposures that bring minimal discomfort and work your way up to those that bring the most distress. All the while, your therapist will teach you tools to resist compulsions before, during, and after the exposures.
Over time, the effect of this is that you learn to tolerate discomfort, accept uncertainty, and ultimately, the distress you feel in response to triggers is greatly reduced.
One major reason why differentiating between diagnoses is so important is that it changes what the best course of treatment is. With the exception of specific phobias and other anxiety disorders, other forms of treatment are typically used for the other conditions we mentioned.
Body dysmorphic disorder and eating disorders are often best treated with cognitive-behavioral therapy (CBT). CBT teaches the client about the relationship between their thoughts, feelings, and behaviors. It helps one to recognize their symptoms, alter harmful thought patterns, develop healthier coping skills, and ultimately change their behavior.
Note that ERP is a specific type of CBT, but typical CBT is not an evidence-based treatment for OCD. If a therapist says they use CBT to treat OCD, you should be sure to ask them if they use ERP specifically.
BFRBs are treated with habit reversal training (HRT) or the comprehensive behavioral treatment model (ComB). These treatments help the client develop awareness around their behavior and strategies to interrupt and alter the behavior. Both of these treatments are proven to be highly effective—ComB is an approach that’s more specifically tailored to individual experience.
Where you can find help for obsessions and compulsions
No matter what your obsessions and compulsions are, there are trained specialists who know how to help you. OCD symptoms don’t have to rule your life, and you can begin the rewarding journey to long-term recovery.
If this article has helped you identify the impact that obsessions and compulsions are making in your life, I encourage you to learn about NOCD’s evidence-based, holistic approach to OCD treatment. We provide effective, accessible ERP therapy that’s covered by insurance—relief from your symptoms is closer than you may think.