Why OCD Gets Missed: Common Therapist Confusions

Karen Cassiday

3 October, 2023

According to the International OCD Foundation, it currently takes 14 to 17 years for someone with Obsessive Compulsive Disorder to receive effective treatment. As we mark OCD Awareness Week 2023, clinical psychologist and anxiety specialist Karen Cassiday outlines the complexities around OCD diagnosis, shares ways to distinguish it from other, sometimes overlapping conditions, and explains why it is so important that clients with OCD are helped to find the right treatment path.

People 3131802 1280

 

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.

Karen Cassiday
Dr. Karen Cassiday is a sought-after speaker, trainer and commentator on television, radio and popular national and international media. She is a past president of the Anxiety and Depression Association of America, a clinical assistant professor at the Rosalind Franklin University of Medicine and Sciences, and the founder of the Anxiety Treatment Center of Greater Chicago. She is the author of The No Worries Guide to Helping Your Anxious ChildFreedom From Health Anxiety, How to Help Children and Teens with Difficult to Treat OCD and numerous scientific and many popular media articles. Her scientific publications are in the area of information processing in anxiety disorders, theoretical psychopathology of anxiety disorders, and treatment of anxiety disorders. Dr Cassiday approaches her own life and work with a sense of adventure and good humour. She has five children and a not so sharp dog whom she credits with helping her hone her sense of humor during crisis. 

Get exclusive email offers!

Join our email list and be the first to hear about special offers, exciting new programmes, and events.

You May Also Be Interested In These Related Blog Posts
Overthink 7619403 1280
“How Do I Know Who I Am?” Identifying Existential OCD
It may be mistaken for dissociative experiences, dysmorphia, even psychosis. But clients who are plagued by existential doubts and ‘what ifs?’ may actually be experiencing a lesser-known form of Ob...
It may be mistaken for dissociative experiences...
Read More
22 June, 2023
Unhappy G90b944a9c 1920
Helping Clients Switch off the Worry Channel
Worrying has its benefits. But clients with high anxiety tend to experience more of the painful costs. International neuroscience and anxiety specialist Catherine Pittman shares her approach for he...
Worrying has its benefits. But clients with hig...
Read More
23 November, 2022
Megan Te Boekhorst 3Sn9mulx2ze Unsplash
Helping Anxious Clients Sleep
What is the role of the amygdala in maintaining wakefulness? How can we help clients to get their cortex off the ‘Worry Channel’ at bedtime? Ahead of a two-part live webcast training (1-2 October),...
What is the role of the amygdala in maintaining...
Read More
22 September, 2020
Russian 1090697 1920
Caring Through Crises: How Therapist Anxiety Might be Manifesting
Panicky exchanges about preferred online platforms have been common among therapists this week. Worrying over details may be a distraction from our primal anxiety in the face of the Covid-19 pandem...
Panicky exchanges about preferred online platfo...
Read More
24 March, 2020