Why OCD Gets Missed: Common Therapist Confusions

What is happening when 50 per cent of people with Obsessive Compulsive Disorder report their OCD went unrecognised when they first sought help? Clearly, there are some nuances to assessing and diagnosing OCD that confuse many therapists and even experts in anxiety disorders. Here is some helpful information so you can avoid misdiagnosis yourself, or help a client identify when they may have been misdiagnosed. 

Is it Generalised Anxiety Disorder or OCD? 

OCD occurs when someone has unwanted intrusive thoughts, sensations, or images that provoke anxiety. These are called obsessions. Obsessions provoke compulsions, which are thoughts, behaviours, or avoidance designed to reduce the anxiety.

The content of obsessions can be about anything and can even look identical to worries common in Generalised Anxiety Disorder (GAD). For example, a patient might have the obsession, “What if I hit someone while driving?” The person with OCD fears they might hit someone while driving because they feel a bump while driving. They repeatedly check the mirrors and drive back over their route to look for accident victims. They are aware that others do not act or think this way, but they get stuck in the imagined possibility of doing something awful even though they have never been a careless driver.   

A person with GAD, however, believes their worry and reassurance seeking adds value to their life because it expresses their responsibility, caring or thorough attention to detail. When they think, “What if I hit a pedestrian?” they feel they are being conscientious. They believe their reassurance seeking, such as checking the mirrors repeatedly and driving overly cautiously is the right thing to do. They do not see their reassurance seeking or avoidance of driving near pedestrians as disproportionate. They even get righteously upset that others do not worry and do the same!   

Multiple diagnoses  

Additionally, 70 per cent of patients who have OCD will also have a second or third anxiety disorder. The most common secondary diagnosis is GAD. Thus, many with OCD have both diagnoses at the same time. They may not realise they meet criteria for several diagnoses and push you to give them a single explanation for their symptoms.   

Specific phobia versus OCD 

Specific phobia can be mistaken for OCD when a patient has a dominant symptom, such as fear of vomiting. The onset of specific phobia will be spontaneous, between ages seven to nine, with no previous history of trauma. The person will dread the specific situation and feel disabling anxiety if they believe they will have contact with the feared object or situation. They will go to great lengths to avoid these situations and feel justified in avoiding them. Typically, they have no previous memory or experience with vomiting and what they fear is the act of vomiting.

Those with OCD, however, fear vomiting because it is the consequence of accidental contamination, poisoning or that it could lead to choking and death. In OCD, unlike specific phobia, the onset can range from early childhood through the young adult years. Any person with OCD will have multiple OCD subtypes and triggers that provoke rituals, avoidance and reassurance seeking, not just feeling nauseous.

People with both OCD and specific phobia will also recognise the quality of their anxiety response is different between the two disorders. They will be able to tell you their OCD symptoms have a more unreasonable quality than specific phobia.   

Why correctly identifying OCD matters

Treatment outcome research shows that OCD fails to respond to general interventions designed for other disorders or to medication alone. Treatments that fail to address the cycle of negative reinforcement or fail to address the inferential confusion that occurs when patients experience obsessive doubt might improve other areas of functioning unrelated to OCD but fail when applied to OCD.

OCD responds well to specific treatments that target these problems. These include exposure and response prevention (ERP) and inference-based cognitive behavior therapy (ICBT). Medications can take the edge off the OCD so that patients can successfully engage in ERP or ICBT. Transmagnetic cranial stimulation can also be very helpful when other treatments have failed. It too, is typically combined with medications and ERP and ICBT for the best outcome. If you are not skilled in these interventions or cannot get expert training and supervision for learning and providing these interventions, then it is best to refer your OCD patients to OCD specialty providers.