The criteria used to diagnose OCD give rise to a lot of confusion among sufferers and clinicians.
Resistance: Resistance is certainly the hallmark of OCD. Obsessions often provoke the most ferocious resistance. However, not all OCD’ers resist their thoughts. Some just hate them and want them to go away. Also, when the illness gets bad, resistance is often gone and the thoughts just take over and resistance is impossible. Others choose not to resist.
I talked to a female OCD’er with Harm OCD who said she didn’t want to fight off the thoughts because that would be “going against who I really am.” This is a case where the obsessions have taken over so badly that the person is starting to believe them. Unfortunately, this is quite common in the illness, and the sufferer often feels that the obsessions are completely real, because that is how they feel. Nevertheless, resistance is still an excellent marker for OCD. My feeling is, “If you try to stop it, it’s an obsession.” And that’s pretty much true.
Resistance can turn into a cause of endless doubting and ruminations. I have talked to people who spend a good part of their time resisting and fighting off and trying to stop obsessions. Nevertheless, one of their worries was, “Am I really trying to stop the thoughts?”
Anxiety: Certainly, anxiety is prominent in OCD. However, as OCD goes on, the anxiety often attenuates and the person does not feel so much anxiety anymore about the obsessions. For instance the Gay OCD’er feels that the gay thoughts do not cause anxiety anymore, so this means that they are gay. The pedophile OCD’er does not feel much anxiety about the pedo thoughts anymore, so that means they must be a pedophile. The Harm OCD’er finds that the violent thoughts do not cause much anxiety anymore, so they must be a murderer or a psychopath. It is uncertain why the anxiety goes down in OCD. Some think that the body simply tires of being anxious all the time and simply becomes attenuated to the anxiety.
Feelings of numbness and lack of feelings: This is very common in OCD. Why this happens is not certain, but it may be because the anxiety has gone down.At any rate, numbness is very common. This often causes a lot of worry, particularly in Harm OCD, when the person feels that that they have lost their feelings and are turning into a psychopath.
Lack of desire to carry out the actions: It is often said that the difference between someone with OCD and someone without it is the lack of desire to carry out the actions associated with the obsessions. “The person with OCD does not really want to do these things,” is how it is often phrased. However, this causes a lot of confusion because in many cases, the OCD will make the person feel that they want to carry out the acts.
A person with Gay OCD will feel gay and feel like he wants to have gay sex, a person with pedophile OCD will feel like he wants to have sex with children, and a person with Harm OCD will feel like they want to attack or kill people. So this isn’t a very good barometer. However, in general, they do not want to have these feelings, and they fight them very hard. So you look at such things as unwantedness and resistance instead. Whether the person with OCD really wants to do these things is more of a philosophical question. They probably don’t, but OCD can make them feel like they do.
Obsessions as repugnant: While it is probably true that the OCD’er finds their obsessions repugnant on a deep level, hence all the discomfort, anxiety and resistance, this can cause problems because when the illness is bad, the OCD will try to convince the person that they like the thoughts and don’t want to get rid of them. I have spoken to many OCD’ers who were panicked because they felt they were starting to enjoy the pedophile, gay or violent thoughts. This is just OCD trying to convince you that you like something that you really don’t. But the repugnant criteria can result in endless ruminations along the lines of, “Do I really find them repugnant?…Maybe I don’t…Maybe I like them…”
Sometimes this leads to endless compulsions where the person tests themselves over and over again with the images to see if they are disgusted or not. A Gay OCD’er may look at gay images on the Net to see if they generate the proper amount of disgust. A pedo OCD’er may conjure up images of sex with children to see if they are properly disgusted by them. A Harm OCD’er conjures up images of crime scenes, homicides, or themselves committing a violent act over and over to see if they feel the proper amount of disgust and horror.
I talked to one OCD’er who had an image of himself slitting his father’s throat in his head. He had to conjure up the image over and over until he “got it right” and had the proper feeling towards it. This compulsion could take some time and was accompanied by some interesting physical maneuvers in conjunction with it.
“Am I really disgusted by the thoughts? Am I really horrified by them? Do they really bother me?…” These are the sorts of endless ruminations that one encounters.
“I am going to do X…”: It is actually fairly common for an OCD’er to think that they are going to carry out the unwanted act. For instance, a someone with pedophile OCD may think, “I am going to have sex with this child,” and someone with Harm OCD may think, “I am going to kill this person,” or, “I am going to shake the baby right now.” Often these more dramatic forms cause a lot of anxiety because the person worries that the thinking is too extreme to be OCD. However, this thinking is quite common in OCD.
Confusion of voices with thoughts: The person with OCD often describes the thoughts as “voices,” but what they are describing is their inner voice only, not external hallucinations. Also the inner voice in the person with OCD often goes through a lot of changes in tone, etc. to where it seems there are different internal voices going on. Sometimes the obsessions seem to be in a voice other than one’s own, and this is very frightening.
An internal voice is just a thought. Thoughts are internal voices. You hear them in your head, as the phrase “inner voice” implies. You can have one internal voice or many. It’s probably better to have as few as possible since otherwise you might find yourself confused. A hallucination is something you hear with your ears. It is external to the environment.
Confusion of “fake hallucinations” with real hallucinations: In the form of OCD called Schiz OCD, the person worries that they are developing schizophrenia. They often worry that they are starting to hallucinate. They listen intently for all sorts of noises in the environment and start to either mistake them for voices or wonder if they are really voices. A person with true hallucinations will be quite clear that they are hallucinating. Usually careful questioning can ferret out the fake hallucinations from the real hallucinations.
“Lack of empathy” in Harm OCD: In OCD, the obsessions often feel very real. So a person with Gay OCD feels 100% gay. A person with pedophile OCD feels that they are a pedophile. A person with Harm OCD feels like a killer. I have had many Harm OCD’ers tell me such things as, “I feel evil…I feel like the devil…I feel like I could kill!…I feel like a serial killer…I feel like a murderer…I feel like a psychopath.” The OCD simply creates a situation where the person feels that they have become the theme of their obsession.
In Harm OCD, many times persons report a “lack of empathy.” Many Harm OCD’ers have told me this. “I feel like I don’t care anymore…I feel like I don’t love people anymore…I have lost the feeling of love…I feel like I don’t care about others’ lives or value them…I feel like I could take a life and not even care…” One told me, “You know, when my grandfather died, everyone around me was sad, but I felt like I didn’t even care. I felt like I wanted to laugh.” He was terrified as he told me this.
On the surface, this looks like the lack of empathy associated with psychopathy and I have had OCD’ers tell me that their therapists told them that this sort of thing was not associated with OCD and was instead associated with psychopathy. This just caused them even more worry as they were already afraid they were psychopaths.
Typically, this person had felt decent empathy for others before the onset of the Harm OCD. They are generally alarmed that they “seem to be losing their empathy” and see this as a sign that they “are turning into psychopaths.” They make desperate efforts to regain their empathy and feelings of love, but it often doesn’t work very well. This often turns into a form of a compulsion where the person can spend hours a day “practicing feeling love or empathy for others.”
Presumably, a person with psychopathy or a true lack of empathy would not feel bad about it.
The “lack of empathy” is probably a “false feeling” created by the OCD.
Confusing obsessions with delusions: Unfortunately, many OCD’ers are still diagnosed with psychosis. I have had many of them come to me with a diagnosis of psychosis. In all cases, I felt the diagnosis was wrong. However, at times, obsessions take a very strange form in which the content looks like a delusion. In these cases, you look at how much the person believes in the thought, whether they are resisting it, etc.
Confusion of checking with interest: I have talked to some pedophile OCD’ers who had looked at child porn or had masturbated to pedophilic imagery as a form of checking to see if they were interested in it or not. They were now terrified that they did not have OCD and instead they had pedophilia. They were not doing this because they were pedophiles. Instead they were they were checking to see if they were pedophiles or not.
Concerns about escalation: It is quite common for OCD’ers to accept a diagnosis of OCD but to then feel it is “turning into something worse.” In other words, at first they had Harm OCD or Pedophile OCD, but now it is getting worse, and they are turning into pedophiles or psychopaths. Escalation is a strong worry in the form of OCD called Schiz OCD where the person worries that they have schizophrenia. Invariably these persons feel that they are developing schizophrenia. Realistically almost none of them are. I do not regard this as much of a worry. My feeling is, “Once it’s OCD, it’s always OCD.”
“Is it really OCD?” This is not so much a matter of diagnostic confusion as it is a hallmark of the disorder. I cannot tell you how many OCD’ers I have talked to who ask me, “Is it really OCD?…I am worried it is not OCD…What if it isn’t OCD?” It is called the doubting disease after all. My feeling is that if you are asking yourself over and over, “Is it really OCD?” then in all probability it may well be OCD. Sometimes a person without OCD will wonder if they have it, but they are not usually so obsessive about it.
The criteria used to diagnose OCD give rise to a lot of confusion among sufferers and clinicians.