People struggling with Obsessive Compulsive Disorder (OCD) are often misdiagnosed as having other psychological conditions. One of the most common misdiagnoses for this population is Generalized Anxiety Disorder (GAD). This diagnostic problem arises for two reasons. First, the distinction between OCD and GAD is somewhat vague. And second, many treatment providers have only a limited understanding of the varying ways in which OCD can manifest. While this issue may seem like an esoteric concern to some, making a proper diagnosis is important for those struggling with either condition, as the primary treatment for OCD is different than the treatment for GAD.

The Difference Between OCD Thoughts and GAD Thoughts

There are two essential differences between GAD and OCD. First is the nature of the thoughts involved. While unwanted thoughts are central to the diagnosis of both GAD and OCD, the unwanted thoughts experienced by those with GAD tend to focus on common, real-life concerns such as work, school, family, relationships, health, and financial issues. These are issues that most people worry about to some degree, but people with GAD worry about to such an extent as to significantly interfere with their daily functioning.

While GAD thoughts are generally focused on reasonably plausible concerns (for example, losing money on investments, getting fired, or failing a class), people with OCD tend to obsess about less common issues that are often quite unrealistic. People in the OCD community have over the years developed a colloquial shorthand to describe some of the more common flavors of OCD:

• Contamination OCD – Obsessions about dirt and germs, and their impact on the sufferer or others (i.e., getting a disease from incidental contact with a suspected contaminant, etc.). When most people think of OCD, this is what they think of.

• Harm OCD – Obsessions about purposely or accidentally causing harm to others or one’s self.

• Hit and Run OCD – A variant of Harm OCD in which the sufferer obsesses about the fear of running people over with their car.

• Homosexual OCD (HOCD) – Also known as Sexual Orientation OCD, or SO-OCD. Obsessions in HOCD focus on the fear that your sexual orientation is not what you think it should be. For straight people, HOCD obsessions focus on the fear that they are secretly gay or bi. For gay people, SO-OCD obsessions focus on the possibility that they are secretly straight or bi.

• Trans OCD (TOCD) – Obsessions in TOCD focus on the fear that your gender identity is not what you think it should be. For cisgender people, TOCD focuses on unwanted thoughts of being transgender. Conversely, for transgender people, obsessions in TOCD focus on the fear of actually being cisgender.

• Pedophilia OCD (POCD) – Obsessions in POCD focus on the fear of possibly being a pedophile.

• Relationship OCD (ROCD) – Obsessions in ROCD focus on the fear of not actually loving one’s partner, or not actually being sexually attracted to their partner.

• Scrupulosity OCD –Religious Scrupulosity focuses on obsessions that one is not living in accordance with their spiritual beliefs. Moral Scrupulosity focuses less on religious obsessions, and more on the fear of not living in a manner that meets their personal moral standards.

Note that this is not an exhaustive list of the many variations of OCD, and is meant only to demonstrate some of the more prevalent variants of the condition. People with OCD can (and do) obsess about just about anything. That said, OCD obsessions are often about things that are highly improbable, and are frequently founded on the flimsiest of evidence. For example, a person with Harm OCD may think, “I enjoyed that horror film about a serial killer, so I must secretly be a serial killer myself”, while someone with POCD may think “I thought that child was cute – so I must be a pedophile!”

The line between OCD and GAD may at times be somewhat grey, and is to a certain extent arbitrary. The simplest way of conceptualizing the difference is to think of it as being a matter of both content and degree. GAD obsessions are generally focused on common, everyday concerns, while OCD obsessions tend to be significantly more unrealistic. Also, while someone with GAD (or anyone for that matter) may experience unwanted thoughts similar to those experienced by people with OCD, they are generally able to quickly write those thoughts off as being unrealistic. They are unlikely to become consumed by these thoughts, and will usually revert back to obsessing about more mundane concerns.

On the other hand, for people struggling with OCD, these atypical thoughts are not fleeting or incidental – they occur with great frequency, and are experienced as deeply intrusive and unwanted. Furthermore, these types of obsessions cause incredible amounts of distress in the sufferer, often because the thoughts directly conflict with how the individual sees him/her self. Someone with OCD may spend hours, or weeks, or even years tortured by the idea that these profoundly distressing thoughts may be a legitimate indicator of who they are as a person. For example, people with Religious Scrupulosity are often devoutly religious, and are devastated by the thought of acting or thinking in a manner that is contrary to their faith. Likewise, those struggling with POCD are universally horrified by the idea of sexually molesting a child.

Behavioral Differences Between OCD and GAD

The second primary difference between GAD and OCD is the sufferer’s behavioral response to their obsessional thoughts. In GAD, the primary (but not the only) behavioral response is to excessively worry about the issues that are causing them to feel anxious (more on this later). While people with GAD often spend great amounts of time ruminating about issues that concern them, they do not generally exhibit the classic compulsive symptoms seen in OCD, such as hand washing and door checking. Instead, in GAD, worrying is often both the obsession and the primary compulsion.

For example, someone with GAD may repeatedly have the thought “What if I don’t get that job and I end up going broke”. The initial appearance of this thought could be conceptualized as an obsession. Someone with GAD might then respond to this obsession by compulsively ruminating about the possibility of not getting the job they want, and then going broke, all in an attempt to resolve the anxiety that arose in response to the initial obsessive thought.

Conversely, those with OCD exhibit numerous compulsive behavioral responses to their unwanted thoughts. Some of these responses are fairly obvious and overt, such as repeated hand washing or lock checking. These behaviors are done in an attempt to reduce or eliminate anxiety related to their unwanted obsessions. Additionally, many people with OCD, especially those with variants of OCD that are frequently (and misleadingly) called “Pure O”, also exhibit numerous compulsive behaviors that are far less obvious to those unfamiliar with the subtleties of OCD. These more covert compulsions may include the following:

• Avoidant Compulsions – People with OCD often avoid doing mundane tasks that others do without hesitation, such as driving or shopping, or even touching certain items such as doorknobs or telephones. This avoidance behavior is done in an effort to prevent the onset of intrusive thoughts, and the unwanted feelings and sensations that come with them.

• Reassurance Seeking Compulsions – Many OCD sufferers compulsively seek reassurance that they have not said or done anything that they fear would confirm the legitimacy of their unwanted thoughts. Compulsive reassurance seeking is frequently done by repeatedly asking others questions related to one’s obsessional thoughts, and may also include compulsive internet searching about their intrusive thoughts.

• Mental Compulsions – Individuals struggling with OCD often have elaborate mental rituals that nobody can see, as they are occurring solely in the mind of the sufferer. These can include such things as compulsively praying or counting, or compulsively reviewing and countering their unwanted thoughts, all in an attempt to reduce the anxiety caused by their obsessions.

Unfortunately, most people don’t realize that these behaviors are compulsions, and that all compulsions actually make obsessions worse in the long run. For many people struggling with OCD, these types of less obvious behavioral compulsions are repeated over and over again, and are the most time-consuming feature of their struggle. Their OCD is essentially a nonstop battle that is hidden in plain sight. Even those closest to them often have no idea just how much of their life is consumed by these covert, never-ending compulsions.

While those with GAD do not generally exhibit the more obvious compulsive behaviors such as hand washing and door checking, it is not unusual for them to perform some covert compulsions. For example, someone with GAD may avoid certain situations, or seek reassurance in an effort to tame their anxiety about a particular real-life concern. Likewise, an individual struggling with GAD may do mental compulsions in order to cope with unwanted anxiety-provoking thoughts. For example, they might compulsively conduct contingency planning in their mind in order to feel less anxious about a feared potential health crisis or job loss. But while people with GAD may display some of these sorts of behaviors, the impact on their daily functioning is generally not as pronounced as it is for those with OCD.

Can you have both OCD and GAD?

While most people with GAD do not have OCD, it is fairly common for people with OCD to also have GAD. The simplest way to conceptualize this is that some people with OCD tend to over-think “real-life” issues just as they overthink the mostly implausible obsessions that cause them so much distress.

It is also worth noting that the symptoms of both OCD and GAD tend to spike during times of stress. It is not uncommon for people with OCD and/or GAD to experience a significant increase in their obsessionality when faced with normal life stressors such as taking tests, graduating from college, dealing with coworker conflicts, managing relationship issues, getting married, having children, etc.

Misdiagnosing OCD as GAD, and Vice-Versa

GAD is occasionally misdiagnosed as OCD, but OCD is frequently misdiagnosed as GAD, and one reason for this is fairly simple – most psychotherapists do not even remotely understand the various ways in which OCD is expressed in those suffering with the condition. Unfortunately, many mental health treatment providers conceptualize OCD as being solely about the more obvious outward manifestations of the disorder such as hand washing or door checking. But many people with OCD, especially those with the more obsessional “Pure O” variants, exhibit no externally observable compulsions whatsoever. When faced with a client reporting anxiety symptoms that they don’t understand, many psychotherapists simply use GAD as a sort of fallback diagnosis.

The real culprit here is that many graduate schools do a miserable job of teaching prospective psychotherapists about the complexities of OCD. Most graduate school psychotherapy programs provide nothing more than a cursory, extremely limited overview of the various psychological disorders, without providing an in-depth understanding of any specific condition, including OCD.

The only way that most psychotherapists can develop a more comprehensive understanding of OCD and its treatment is to consciously seek out specialized training beyond what they learn in graduate school. This can be done by taking post-graduate continuing education courses that are required to maintain one’s license. There are also advocacy organizations such as the International OCD Foundation that provide highly specialized training.

Unfortunately, most treatment providers never seek out this extra training because they don’t realize just how little they know about OCD – they don’t know what they don’t know. In lieu of having gained this sort of specialized training, the best thing that most therapists can do to ensure that their clients with unwanted thoughts are properly diagnosed is to refer them to a therapist who specializes in OCD. The bottom line is that an OCD specialist will be able to more accurately distinguish between GAD and OCD, while a more general therapist is unlikely to fully understand and identify certain OCD symptoms.

Treatment of OCD vs. Treatment of GAD

The most effective treatment for both OCD and GAD is Cognitive Behavioral Therapy (CBT). However, it is important to note here that CBT is not a singular technique, but rather a broad range of interventions. The specific CBT intervention that is usually best for GAD is substantively different than the CBT technique that is most effective for the treatment of OCD.

Because those with GAD generally do not have as significant of a behavioral reaction to their anxiety-producing thoughts, the primary treatment for GAD is usually a specific CBT technique called Cognitive Restructuring. Using this technique, the individual with GAD learns to more effectively identify their anxiety-producing thoughts, and to challenge their accuracy and importance. With Cognitive Restructuring, the individual develops their ability to not immediately buy into their irrational thinking, and to instead consider other more realistic possibilities.

While Cognitive Restructuring can also be helpful for some with OCD, it is crucial to realize that this technique has the potential to be problematic for this population. It is not unusual for those with OCD to use Cognitive Restructuring compulsively in an effort to reduce the anxiety they are experiencing in response to their obsessive thoughts. While this is both predictable and understandable, it is also entirely counterproductive. A compulsion is still a compulsion, even when done in the guise of treatment.

The most effective, evidence-based treatment for OCD is a specific form of Cognitive Behavioral Therapy called Exposure and Response Prevention, or ERP. This treatment focuses on gradually and repeatedly exposing OCD sufferers to the very thoughts and situations that they fear. This might include something as simple as having the person with OCD touch doorknobs over and over again without washing afterwards, or something more complex such as repeatedly driving on busy streets despite their fear that they will run someone over, or changing their child’s diapers on a regular basis, despite the fear that they are secretly a pedophile.

The reasoning behind ERP is that repeated exposure to uncomfortable thoughts and situations leads to habituation, and to learning a new ways to respond to your unwanted thoughts. Simply put, this just means that the more you face your fears, the less scary they become. If you struggle with OCD, Exposure and Response Prevention will assist you in learning four valuable lessons that help you better manage your obsessional anxiety:

1) If you face your anxiety instead of running from it, you discover that the feared outcome almost never occurs.

2) Even if the feared outcome does actually occur, it is unlikely to be anywhere close to catastrophic. Less than ideal perhaps, but not the end of the world.

3) If you don’t respond to anxiety by doing compulsions, your anxiety will usually decrease (or even disappear) anyway, just by virtue of letting yourself get used to its presence in your mind. In other words, you will learn that you don’t really need the compulsions.

4) Most importantly, you’ll learn that you are far more capable of tolerating your anxiety than you previously realized.

As noted earlier, the line between OCD and GAD may at times appear fuzzy or arbitrary. Some would even argue that GAD is essentially a variant of OCD in which the obsessions are simply more focused on “real life” concerns, or that GAD is “OCD Lite”. Further muddying the distinction between these two conditions is the fact that, while ERP is the treatment of choice for OCD, it sometimes has a place in the treatment of GAD as well.

Specifically, the more compulsive an individual’s GAD gets, the more it should be treated like OCD. If an individual with GAD exhibits any of the classic compulsive symptoms that are often seen in OCD (i.e., repetitive hand washing, door checking, etc.), it would be wise to treat those specific behaviors with the same ERP approach used for the treatment of OCD.

Likewise, if someone with GAD displays covert behavioral compulsions that are tangible, such as avoidance behaviors, reassurance seeking, and certain mental compulsions such as repetitive praying or counting, then ERP is appropriate. However, some mental compulsions may be extremely difficult to target with ERP. All of which brings us back to the lack of a perfect distinction between these two conditions, and between their respective treatments.

Finally, it is also worth noting that some more recently developed CBT techniques can be applied with equal value to both OCD and GAD. These newer techniques, such as Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT), are often described as Mindfulness Based CBT, or “third wave” CBT. These approaches are grounded on the premise that unpleasant thoughts and feelings are a normal part of the human experience, and that trying to control them actually makes them worse. This “third wave” approach focuses instead on accepting the presence of unwanted thoughts and feelings, without making an effort to reduce or eliminate them.

While we humans cannot control the thoughts that pop into our heads, the good news is that we don’t have to. Whether you struggle with OCD, GAD, or both, the various CBT techniques described above can provide you with a fuller, more realistic perspective towards any intrusive, distressing thoughts that you experience, while giving you the tools you need to more effectively respond to them.

•Tom Corboy, MFT, Lauren McMeikan, MFT, and Crystal Quater, MFT, are psychotherapists at the OCD Center of Los Angeles, a private, outpatient clinic specializing in Cognitive-Behavioral Therapy (CBT) for the treatment of OCD and related anxiety-based conditions. In addition to individual therapy, the center offers five weekly therapy groups, as well as online therapy, telephone therapy, home visits, and intensive outpatient treatment. To contact the OCD Center of Los Angeles, click here.