People with obsessive-compulsive disorder (OCD) often fear that they may lose control, worrying that they could do something they don’t want to. Intrusive thoughts involving harm to others, for example, can cause people to fear the possibility, no matter how small, that they could act on these thoughts.
On the other hand, the strong urge people with OCD feel to engage in compulsions in response to their intrusive thoughts can feel impossible to resist, making them wonder just how capable they are of changing their behavior.
But what exactly is the relationship between these feelings and impulse control in people with OCD? Do their thoughts or compulsions mean anything about their ability to moderate and control their behavior, or do they mean something else entirely? To answer these questions and more, we spoke to Dr. Patrick McGrath, Chief Clinical Officer at NOCD.
What is OCD?
Obsessive-compulsive disorder is a mental health condition characterized by two primary symptoms: obsessions and compulsions. Obsessions are unwanted, intrusive thoughts, images, and urges that cause persistent distress. Compulsions are mental or physical actions performed to reduce this distress or prevent some bad outcome from occurring.
What does impulse control mean?
To understand impulse control, we first need a definition of what impulses are.
Dr. McGrath distinguishes impulses from other types of urges by noting that with impulses, “there’s a buildup of tension and excitement, and when you do them, you feel more than just relief, but almost a sense of joy.” In other words, impulses push us towards actions that are or are perceived to be pleasurable or rewarding.
Other urges, like those involved in OCD, don’t lead people to do things that they feel are rewarding on their own. Instead, they are done to neutralize distress or anxiety, and do not lead to the same sense of pleasure or satisfaction.
Impulse Control = Impulse Resistance
One way to think about impulse control is as the ability to resist strong urges. For example, someone with a gambling addiction may work to develop the strong impulse control needed to resist the overwhelming urge to go to the casino.
Are people with OCD likely to act on their obsessions?
Obsessions can cause individuals with OCD to perform all sorts of actions to neutralize anxiety. This is how the vicious OCD feedback cycle works. Compulsions reinforce the belief that obsessions pose real danger, and they do nothing to keep obsessions from coming back again and again. Over time, this leads to an even stronger urge to engage in compulsions when obsessions occur.
So while obsessions regularly lead people with OCD to engage in certain behaviors, many people with OCD may have different questions in mind: are intrusive thoughts the same thing as impulsive urges? Are people with OCD likely to act out their obsessions? People with OCD often fear that their obsessions could lead them to do something awful, and people without OCD who don’t fully understand it may have similar concerns.
The answer is unequivocally no: OCD does not make one disposed to act out their obsessions. This is because, as Dr. McGrath emphasizes, obsessions are ego-dystonic, which means they oppose a person’s genuine desires or values. In other words, they don’t represent what they really want. In fact, the fact that these intrusive thoughts, images, and urges are so intolerable to people’s actual desires and values is largely why people with OCD experience them in the first place. As a result, the actions that people engage with in response to obsessions are often done specifically to avoid even the slightest chance of acting out these thoughts.
Can weak impulse control make people act on obsessions?
Weak impulse control would not make someone with OCD more likely to act out their obsessions. Again, this is due to the ego dystonic nature of obsessions. Strong impulse control is required when there is a genuine or ego syntonic urge to do something. But that’s not what happens in OCD. For example, someone experiencing distressing intrusive thoughts about harming a friend has absolutely no genuine desire to do so, they do not need to utilize impulse control to avoid those actions.
Weak impulse control may, however, make people with OCD less capable of resisting compulsions in response to obsessions. If you have a hard time holding back against strong urges, resisting compulsions during OCD treatment may be especially difficult. This may be due to numerous reasons, such as how tired you are, time of day, hormonal irregularities, and so on. That being said, there is no clear evidence to suggest there are greater levels of impulsivity among people with OCD. This means that people with OCD are not weak-willed but are simply dealing with intensely strong urges to perform compulsions that any person would struggle to resist.
Are compulsions done impulsively?
There is no evidence that people with OCD in general have problems with impulse control, so describing compulsions as “impulsive” is not accurate. Generally, “impulsivity” describes enjoyable activities done without due consideration of potential harms or risks. In other words, it’s about acting for pleasure without thinking or caring about the potential negative consequences.
Under this model of impulsivity, compulsions aren’t done impulsively—if anything, they often come from an extreme, outsized concern for potential risks and negative consequences, rather than a disregard for them. Furthermore, studies have found that they are often carefully planned, timed, and executed. As Dr. McGrath notes, “Compulsions are usually done methodically, and according to very rigid rules.”
Interestingly, despite not showing signs of increased impulsivity, individuals with OCD often self-report higher levels of it, meaning they feel more impulsive even though they aren’t. This makes sense, given that people suffering from OCD can be hypersensitive to feeling “out of control” and experience strong fears about losing control.
Do you need strong impulse control to recover from OCD?
Exposure and response prevention (ERP) therapy is the gold standard treatment for OCD. In ERP, people with OCD confront their obsessions in a controlled environment and resist engaging in compulsions for temporary relief. Over time, this helps them learn to sit with uncertainty, reduces the frequency of obsessions, and makes them less distressing when they occur.
Given that ERP involves deliberately triggering obsessions, it might seem like strong impulse control is necessary in order to avoid performing compulsions and make progress in treatment. While strong impulse control can be helpful here, it is not essential for several reasons. Dr. McGrath suggests that rather than impulse control, “what one really needs to develop is the ability to tolerate uncertainty.” In other words, you need to be able to live with the feeling of not knowing what will happen if you don’t engage in compulsions, which is different from dealing with strong impulses.
With that said, tolerating uncertainty can be difficult, and these feelings can create strong urges to engage in compulsions to alleviate distress. So is strong compulsive urge control necessary?
The answer is still no. One reason why is that ERP is done gradually so that at any point it only causes manageable levels of distress, and treatment is tailored specifically to what therapy members are able to handle.
“It’s gradual,” says Dr. McGrath. “We’re not throwing you in the deep end of the pool and telling you to swim—we’re slowly building up to it.” More specifically, professionals trained in ERP for OCD will have therapy members provide a list of obsessions and rank how stressful each one is. From there, they’ll create a set of exposures that allow people to confront each one at the proper time. In this way, treatment can be adjusted precisely to work for a person’s own experiences, symptoms, and strengths.