How to Tell Others You Have OCD: Exploring vs. Confessing

Part 2 of a 6-Part Article Series on Revealing Your Diagnosis

This is the 2nd article of a 6-part series. While this article can be read and understood on its own, I recommend first reading the previous part for full context:

• Part 1: The Power of Social Support

Interplay between OCD and imagination

Obsessions are intrusive and distressing thoughts, feelings, images, urges, and body sensations that are typically egodystonic [1]. “Egodystonic” means “thoughts, values, actions, and beliefs that one does not align with”. For example, if you love dogs and you have an obsession about harming dogs, that obsession is egodystonic. For many people with OCD, obsessive themes can revolve around deeply taboo topics, like harming oneself or others in specific ways. Everyone experiences intrusive, egodystonic thoughts sometimes [2,3], and people with OCD are no more likely to act on such thoughts than people without OCD [4].

However, people with OCD experience a greater frequency, duration, and intensity of intrusive thoughts compared to the average person [2,3]. Authors Aardema and Wu write in a 2011 study, “[Individuals with OCD have an] overreliance on imagination during reasoning[, which] gives rise to experiences that are inconsistent with reality [5].” In other words, people with OCD assign excessive meaning to what happens in their imagination, which leads to confusion in perceiving reality.

Despite experiencing intrusive thoughts, images, and urges at a greater frequency, duration, and intensity than the average person, people with OCD do not act on such thoughts because:

• They are, by definition, intrusive (meaning they are involuntary and unwanted).

• They are egodystonic (meaning they are the opposite of what one actually believes or wants).

• The person with OCD experiences intense anxiety and self-repulsion at the thought of acting out a taboo obsession.

• A central part of what makes OCD a disorder is the OCD sufferer’s compulsive attempts to stop, avoid, or counteract the perceived negative outcomes associated with intrusive thoughts.

Illustration of an egodystonic obsession

Here is an example that ties together all the concepts I described in the above bullet points: A mother with OCD is relaxing next to a pool while her 6-year-old son is swimming. She is enjoying watching her son play in the water when she suddenly experiences an involuntary and highly uncomfortable multisensory imagination (sights, sounds, feelings) of herself intentionally drowning her own son (this is the intrusive thought). The mother’s biggest priority in life is to protect her child (the intrusive thought is egodystonic).

The mother is immediately horrified at the intrusive imagination she experienced. The vividness of the involuntarily imagined sights, sounds, and feelings of drowning her own child makes her feel almost as if she committed the act, so she becomes awash with guilt and shame. She begins to question her own morals and goodness (she experiences intense anxiety and self-repulsion in response to the intrusive thought). The mother then entirely avoids being out by the pool when her son is swimming because she is so afraid she might suddenly drown him. She asks her partner to do all the pool time supervision for their son (this is the compulsive attempt to stop, avoid, or counteract the perceived negative outcomes associated with the intrusive thought).

People with OCD do not act out their obsessions

Consider this quotation from a 2009 article by Veale et al. regarding the risk of an individual with OCD acting on their obsessions:

At its simplest, this need never be a concern: there are no recorded cases of a person with OCD carrying out their obsession. By definition, such intrusions are unacceptable and ego-dystonic, and the person is no more likely to act on their intrusions than a person with height phobia is to jump off a tall building. The obsession represents a type of fear or worry that the patient does not want to happen; like all fears or worries, it concerns ideas that the patient wishes to avert at all costs [4].

The brain of someone with OCD functions differently

People with OCD have significantly increased activity in the amygdala [6], which is the threat-detection center of the brain. Someone with a chronically overactive amygdala will experience an amplification of miniscule risks and can even perceive threats that don’t exist. If you’ve ever walked alone in the woods at night, you likely know what a highly active amygdala feels like. You walk along, feeling vulnerable and on edge, highly sensitive to anything happening in the environment. You hear what sounds to be loud rustling and heavy movement through the forest underbrush. A bear?! A mountain lion?! No, it turns out to be just a chipmunk.

Living with OCD is like having that level of hypervigilance most of the time. Miniscule or nonexistent threats in mundane parts of life are perceived as highly dangerous. Then throw in other neurobiological complexities of OCD, and not only will you perceive miniscule/nonexistent threats in your environment, you may even begin to perceive yourself as a threat.

People with OCD are not responsible for having OCD

If you have OCD, you aren’t responsible for the genetic and environmental factors that led to the onset of the disorder and you’re certainly not responsible for any taboo obsessive themes that run through your mind, as such obsessions are involuntary manifestations of dysfunctional brain activity. You’re no more responsible for your nervous system function than people with other conditions that alter one’s perception of reality, like color blindness.

Therefore, telling someone about your diagnosis and symptoms should not be looked at as a confessional. Instead, I encourage you to frame your conversations around OCD as a nonjudgmental exploration of your experience and ways others can support you. If you experience taboo/violent obsessions, it can be helpful to provide others with context around the egodystonic nature of OCD (like I’ve described in this article) so they can understand that people with OCD are not dangerous. Some researchers assert that those with OCD may actually be less dangerous than the average person [4].

While adults with OCD aren’t responsible for their condition, they are responsible for exploring effective strategies for recovery once they are aware of their condition, which involves getting people on your support team by having potentially difficult (but by no means shameful) conversations. For children with OCD, it’s imperative their caretakers take the lead in exploring strategies for recovery because children typically have less insight about their condition [7] and are unable to effectively advocate for themselves due to a lack of competency and agency regarding healthcare system utilization.

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References

1. Vaghi, M. M., Cardinal, R. N., Apergis-Schoute, A. M., Fineberg, N. A., Sule, A., & Robbins, T. W. (2019). Action-outcome knowledge dissociates from behavior in obsessive-compulsive disorder following contingency degradation. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 4(2), 200-209.

2. Berry, L. M., & Laskey, B. (2012). A review of obsessive intrusive thoughts in the general population. Journal of Obsessive-Compulsive and Related Disorders, 1(2), 125-132.

3. Julien, D., O'Connor, K. P., & Aardema, F. (2007). Intrusive thoughts, obsessions, and appraisals in obsessive–compulsive disorder: A critical review. Clinical Psychology Review, 27(3), 366-383.

4. Veale, D., Freeston, M., Krebs, G., Heyman, I., & Salkovskis, P. (2009). Risk assessment and management in obsessive–compulsive disorder. Advances in Psychiatric Treatment, 15(5), 332-343.

5. Aardema, F., & Wu, K. D. (2011). Imaginative, dissociative, and schizotypal processes in obsessive‐compulsive symptoms. Journal of Clinical Psychology, 67(1), 74-81.

6. Simon, D., Adler, N., Kaufmann, C., & Kathmann, N. (2014). Amygdala hyperactivation during symptom provocation in obsessive–compulsive disorder and its modulation by distraction. NeuroImage: Clinical, 4, 549-557.

7. Lewin, A. B., Bergman, R. L., Peris, T. S., Chang, S., McCracken, J. T., & Piacentini, J. (2010). Correlates of insight among youth with obsessive‐compulsive disorder. Journal of Child Psychology and Psychiatry, 51(5), 603-611.