From choosing what to wear in the morning to picking what to eat for dinner, decision-making is a part of everyone’s daily routine. 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 and the 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 for people with the condition to make decisions. We’ll explore how OCD affects decision-making, the kinds of compulsions making decisions can provoke, and the types of decisions that tend to be affected.
We’ll round things out by detailing a treatment intervention that’s highly effective in treating OCD and is now more accessible than ever.
OCD and decision-making
OCD is characterized by obsessive thoughts that are intrusive and often irrational. These thoughts can make it hard for people to make decisions, as they may feel overwhelmed by the distress and anxiety they cause.
“Distress intolerance” refers to the difficulty people with OCD have in tolerating anxiety and uncertainty, and it’s a key feature of OCD. This distress intolerance can make it hard to make decisions, as the fear of making the wrong choice can 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, 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. Let’s explore what these compulsions might look like, and why they make decision making harder.
Compulsions related to decision making
Let’s take a moment to familiarize ourselves with some specific compulsions people with OCD use to cope with the distress and uncertainty associated with making decisions.
Avoidance: A very common compulsion is avoidance. This is when someone avoids making a decision to prevent the anxiety caused by the uncertainty of the outcome. Kilduff adds 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, where a person seeks to alleviate their anxiety and uncertainty about their decisions. This can involve repeatedly asking others for their opinions or seeking validation for their decision-making process. People can also seek reassurance via research. A common example is people with OCD reading an excessive number of reviews before they feel comfortable making a purchase.
“I worked with a member who needed 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 in a spreadsheet before finally choosing one.”
Rumination: Rumination is compulsion where a person persistently, repeatedly thinks about a decision they 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 the person may 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, Dr. Patrick McGrath. “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 checks and reviews 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 such as what to wear or eat can become a source of distress and anxiety for someone with OCD. They may worry about the potential consequences of their decisions and feel overwhelmed by the sheer number of choices they have to make.
Important life decisions, such as choosing a career or a place to live, can also be affected by OCD, and often lead to especially intense anxiety and distress. The fear of making the wrong decision can lead to indecisiveness and avoidance, significantly affecting a person’s life, especially if they persistently avoid taking important opportunities. It can also affect their relationships and cause stress and tension.
An example: Steve
Meet Steve, a 32-year-old man struggling with obsessive-compulsive disorder (OCD) for several years. Recently, Steve has been in the market for a new car, but his OCD has made the decision-making process almost unbearable.
Steve’s distress intolerance has made it difficult for him to tolerate the uncertainty and anxiety that comes with making a major purchase. He’s constantly worried about making the wrong choice and being unable to return or exchange the vehicle. As a result, Steve is experiencing decision paralysis. He’s unable to make a choice even after researching and comparing various car models for hours on end.
Steve’s OCD is also leading him to engage in compulsive behaviors in an attempt to find relief. 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 is impairing his ability to decide and causing him significant distress.
Fortunately, with the help of a trained therapist using Exposure and Response Prevention (ERP) therapy, Steve can learn to manage his symptoms and make decisions with greater confidence and ease.
ERP: The gold standard treatment for OCD
Exposure and Response Prevention (ERP) is a type of cognitive-behavioral therapy considered the gold standard treatment for OCD. ERP aims to help people confront their feared thoughts or situations in a safe and controlled environment while learning to resist the urge to perform compulsive behaviors or mental rituals.
By being exposed to triggers and preventing the usual compulsive responses, the brain eventually learns to tolerate uncertainty and make informed decisions with confidence. The anxiety and distress associated with the obsessions then decrease over time.
Research shows that ERP is highly effective in treating OCD, with response rates ranging from 65-80% across multiple studies.
Moreover, studies have shown that ERP effectively treats various OCD symptoms, including contamination, checking, symmetry and ordering, and sexual and religious obsessions. ERP has also been found to be effective in reducing comorbid symptoms such as depression, anxiety, and social impairment.
This and other evidence strongly supports the effectiveness of ERP in treating OCD symptoms, making it the first choice for people seeking relief from the disorder and hoping to regain control of their lives.
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 decision-making, as the fear of making the wrong decision is linked to doubt and uncertainty about the outcome. By exposing the person to the possibility of making a mistake or being uncertain about the outcome, ERP helps them learn that they can handle the discomfort and anxiety that comes with uncertain decisions.
“Doubt isn’t bad; doubt is not a four-letter word,” explains Dr. McGrath. “Doubt is something that we live with on a daily basis. Doubt does not have to stifle us and stop us from living our lives. ERP’s role is to demonstrate that.”
Getting help
We want to make the decision to get help for OCD and regain control of your life easier. If you think you might have the condition or are interested in learning how it’s treated with ERP, schedule a free 15-minute call with the NOCD clinical team to learn how it can help you.
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.
