How is OCD different from generalized anxiety?
Let’s do a quick overview about what obsessive compulsive disorder (OCD) actually is. It’s one of those terms that we use in an off-hand way like, “Ugh, I’m so OCD, I just have to have everything super clean.” Or, “Wait a second, I have to straighten that crooked picture because I’m super OCD.”
That’s not actually OCD.
OCD is fueled first by obsessive, intrusive thoughts. We all have these — every person on the planet has intrusive thoughts — but in OCD these thoughts get stuck.
For example, you likely have had the experience of driving when all of a sudden the thought, “What if I spun the wheel and drove off the road” shows up in your brain. These thoughts are unwanted and show up uninvited. They are often contrary to what we really want or are upsetting. Like, “What if I got out of bed and when I put my feet down someone under the bed grabbed me.”
If we don’t have OCD those thoughts can be annoying or give us a little shiver or surprise us. They may even embarrass us but they pass quickly. We think, “Huh, that’s weird” and we move on.
If we have OCD we give those thoughts meaning. We think, “Oh my gosh, do I have a death wish? What’s wrong with me?” Or we think, “Maybe I had that thought about someone under my bed because it’s a premonition.”
Then we have to do something to address the thought and that’s the compulsion.
Perhaps we have to pull over and take deep breaths until we’re sure we’re not going to drive off the road. Or we need to check under the bed before we can go to sleep. As you can see, there’s a lot of magical thinking present in OCD.
Again, that may happen with someone who doesn’t have OCD, too. If you’ve ever had to go back and make sure you locked your front door behind you then you know about compulsions, too.
We have a thought, “What if I left the door unlocked?” And then it nags at us until we go check.
The difference with OCD is that we get trapped in those obsessions (the uninvited, upsetting, intrusive thoughts) and stuck in the compulsions. Eventually going back and checking once doesn’t help. We have to go twice. We have to go back and try the door, them check if the keys are in our pocket, take two steps and turn around and check again.
Now as you’re thinking about this, about how OCD works, you may recognize signs of it in yourself or your child but again, I want to reiterate that we all have intrusive thoughts and we all occasionally get stuck in them a little bit.
Kids especially go through developmental stages when we would expect some OCD-like behaviors. Preschoolers who are hung up on things being just right don’t necessarily have OCD. I think we can all relate to standing over a sobbing child who wants the other shoes or needs them retied so they are the same tightness on each side or who won’t wear that shirt but will only wear a “soft shirt” or can only drink out of a green cup. Right? Right. That’s developmentally appropriate. Annoying but not a mental health issue.
So how do you tell the difference?
The picky preschooler should grow out of their demands. These things are preferences and may upend the day but the child eventually learns to be more flexible. The child with OCD will remain well and truly stuck and their rituals may become more elaborate.
The child with developmentally appropriate preferences can learn to be flexible with support. They will eventually run out of steam and move on. The child with OCD becomes increasingly upset. They may want to move on but are unable to.
The other thing is that in OCD the compulsions may seem more bizarre or disconnected from what’s happening. Like that example of checking the door, it may need to happen in a particular pattern. Check the door by turning the knob twice, step away, turn back, turn it twice again. This is because in OCD the person is chasing that “just right” feeling and it gets harder to reach the longer they stay trapped in the compulsion.
Children who have OCD need their parents assistance in some of their compulsions and parents may not realize this. This often comes in the form of reassurances, which are also common in general anxiety, but may also show up in needing the parent to do things in a certain order. Such as say good night in a particular way. The child will meltdown if the parent says, “Good night, sleep tight. Sweet dreams.” Instead of, “Sweet dreams, good night sleep tight.” The child will demand that the parent does it over and over until it’s exactly the way the child needs to hear it. The parent may not realize that the obsessive thought has to do with, “What if a robber breaks in” and needs the parent to say good night exactly right to neutralize that obsessive, intrusive thought.
Other common ways that OCD shows up is washing hands and concerns about contamination. A child may not be able to eat off a particular fork or needs to rinse already clean dishes. Checking is common, checking for homework or checking that no one’s hiding in the closet. Children may need to enact particular rituals like repeating words to themselves or doing things in a particular order.
Children may also need to confess their intrusive thoughts. Those thoughts are upsetting and remember they’re assigning meaning to them. A child might think about going on a forbidden web site and then need to come and tell you that they thought about it. Or they may have an intrusive thought about hitting the dog and will need to confess it to you. Again, we all have intrusive thoughts. We might board the bus and randomly think, “What if I kissed the bus driver” and we forget about it almost as soon as we think it. The child with OCD will worry it means they want to kiss the bus driver. That might make them feel ashamed and they’ll need to tell you about it or say hello to the bus driver in a particular way or squeeze their eyes shut repeatedly to try to neutralize that upsetting thought.
This is another way that OCD gets diagnosed, is when a child has to blink or sniff or click their tongue or do some other repetitive motion that adults notice. These kinds of tics are not uncommon in childhood even for children who don’t have OCD, but they tend to disappear after a few months. This is super common in younger children, like kids who get that chapped rash around their mouth because they can’t stop licking their lips. Parents should consider getting their child evaluated for OCD if those tics continue for more than six months or start getting more complex like if A child who shrugs their shoulders after every question starts shrugging their shoulders then blinking or yawning, for example.
In the latest version of the DSM, which is the DSM-5, OCD got moved out of anxiety disorders and into its own categorization. This is because the current theory is that OCD in itself isn’t fueled by anxiety but that the obsessions CAUSE anxiety. Also it allowed them to move other disorders like hoarding and body-focused repetitive behaviors such as skin picking or hair pulling into the OCD category since this seems to be a more accurate way to case conceptualize. These, too, are marked by an intrusive thought or feeling of not-quite-rightness. Hoarding is about a worry of losing something important and everything might be important and body-focused repetitive behaviors are driven by an intrusive need to pull hair or skin pick, that feeling that things won’t feel right until they do.
Treatment for OCD is about helping the child to tolerate that uncomfortable feeling brought on by the intrusive thought and preventing them from doing the exposure. This is called Exposure Response Prevention and is an arm of CBT or cognitive behavioral therapy. Some children may also benefit from medication to help them calm their anxiety enough to work on the CBT piece. Because parents are usually part of a child’s compulsions and because parents are such an important support, they should be part of the treatment. In fact most of the research around anxiety and parent involvement has focused on parents of children with OCD and it’s clear that they are central to treatment success. In other words, the child won’t get better if parents don’t do their own work to support their child. My program, Child Anxiety Support, addresses the kinds of things that parents can do to support a child with OCD.