OCD vs. Generalized Anxiety Disorder: Understanding the Differences for Better Treatment
Obsessive-Compulsive Disorder (OCD) and Generalized Anxiety Disorder (GAD) are two mental health conditions that often overlap in symptoms but have distinct characteristics. Understanding these differences is crucial for accurate diagnosis and effective treatment. Both conditions can significantly impact daily life, causing distress and impairment in functioning. However, while they share some similarities, they have key differences in their core symptoms and treatment approaches. In this article, we will explore the symptoms, comorbidity, and treatment options for OCD and GAD, highlighting why recognizing these differences is essential for managing symptoms effectively.
OCD Symptoms and DSM-5-TR Criteria
Obsessive-Compulsive Disorder (OCD) is characterized by two main components: obsessions and compulsions. It’s coined the “Doubting Disorder” and its tagline is, “What if?” According to the DSM-5-TR, OCD is diagnosed based on the presence of obsessions and/or compulsions.
Hint: You can basically take the “or” out of there - if it’s OCD, there will be both obsessions and compulsions. There is a very common misunderstanding that if someone isn’t hand washing, checking and rechecking, or organizing, then compulsions aren’t present. If physical compulsions aren’t apparent, you may just have to check for mental compulsions. See more about this below.
Obsessions: These are intrusive and unwanted thoughts, urges, images, or doubts that can cause intense distress or anxiety. Obsessions can sometimes feel out of our control, and they can be triggered by things we see or encounter, or they can also just show up “randomly” and feel very uncomfortable. It’s important to remember that OCD obsessions are ego-dystonic, meaning they are not in line with one’s actual values, desires, or goals. (Don’t worry, OCD can make you doubt this too.) Obsessive urges can include the thought or feeling like you’re going to do something uncontrollable, shocking, or embarrassing. Doubts can show up as distrust for our memory, a need for certainty, and more.
Common obsessions include fears of contamination, harm, or symmetry, as well as unwanted thoughts involving sex, sexuality, religion, or harm. OCD will often come with more than one of these themes called “subtypes.” People with OCD often recognize these thoughts as irrational but feel compelled to engage in compulsions to prevent the feared outcome, distress, discomfort, or anxiety.
Compulsions: These are repetitive behaviors or mental acts performed in response to obsessions that are intended to reduce anxiety, distress, or discomfort.
Physical compulsions can include excessive handwashing, checking, physical avoidance, repeating actions repetitively until it feels just right, and more.
Mental compulsions are also actions, and involve rituals like mental review / rumination (replaying past events), mental checking (testing if an obsession is resolved or still around), scenario twisting (analyzing hypothetical situations), reverse ruminating (excessively preparing for future catastrophes), thought neutralization (using positive thoughts to counteract negative ones), and compulsive prayer (repeatedly praying to neutralize unwanted thoughts).
Additional DSM-5-TR Criteria
To meet the DSM-5-TR criteria for OCD, the following conditions must also be met:
Duration and Impact: The obsessions or compulsions must be time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Substance and Medical Conditions: The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
Differential Diagnosis: The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania).
Specifiers
The DSM-5-TR also includes specifiers for OCD, such as:
Insight Specifiers: These indicate the level of awareness the individual has about the irrationality of their OCD beliefs. Specifiers include "with good or fair insight," "with poor insight," and "with absent insight/delusional beliefs."
Tic-Related Specifier: This is used when an individual has a current or past history of a tic disorder.
GAD Symptoms
Generalized Anxiety Disorder (GAD) involves excessive worry about everyday things, such as work, finances, or health, which is difficult to control and persists more days than not for more than six months. The symptoms of GAD can be categorized into two main areas: excessive worry and associated symptoms.
Excessive Worry: This involves persistent and pervasive worry about various domains of life, such as work, finances, or health. Unlike OCD, GAD does not typically involve specific fears or intrusive thoughts but rather a generalized sense of anxiety. People with GAD may worry about things such as being late, completing household chores, finances, or the health and safety of loved ones. They may also worry about broader issues like community affairs, politics, or the environment.
Associated Symptoms: These are physiological and psychological symptoms that accompany excessive worry. According to the DSM-5-TR, at least three of the following symptoms must be present:
Restlessness or feeling on edge
Being easily fatigued
Difficulty concentrating or mind going blank
Irritability
Muscle tension
Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
Additional DSM-5-TR Criteria for GAD
Just like OCD, when diagnosing GAD, it's also essential to rule out other conditions that might explain the symptoms. This includes ensuring that the symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism), and that they are not better explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder, contamination or other obsessions in OCD, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in PTSD, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).
Similar Behaviors in OCD and GAD
While OCD and GAD have distinct symptoms, certain behaviors can appear similar. For example, rumination is a common feature in both conditions. In OCD, rumination involves persistently mentally engaging with intrusive thoughts, worries, or doubts in an effort to analyze them and decrease the distress, anxiety or fears caused by the obsessive thought. Similarly, individuals with GAD may engage in rumination by overthinking and analyzing their worries excessively. OCD rumination may feel more urgent, intense, or difficult to move on from. Both conditions can also involve excessive planning or preparing as a way to cope with anxiety. In GAD, this might manifest as repeatedly checking news or health information to prepare for potential threats, while in OCD, it could involve ritualistic behaviors to prevent a feared outcome, distress, or harm.
Comorbidity and Misdiagnosis
OCD often likes to bring its friends, and GAD is one of its favorites. Studies show that about 33.56% of individuals with OCD also have GAD. This comorbidity can lead to misdiagnosis, as both conditions share symptoms of anxiety and unwanted thoughts.
Fun Fact! OCD is no longer classified as an anxiety disorder in the DSM-5-TR; it is now categorized under "Obsessive-Compulsive and Related Disorders".
Misdiagnosis can significantly impact treatment effectiveness. Traditional Cognitive Behavioral Therapy (CBT) and talk therapy are not sufficient for OCD, and can even exacerbate symptoms. Exposure and Response Prevention (ERP) therapy, a specialized form of CBT, is a highly effective, evidence-based approach for OCD treatment. ERP involves gradually exposing individuals to their feared situations while preventing them from engaging in their compulsive behaviors, helping them learn that we can live with discomfort, choose our actions, and lead fulfilling lives.
My Personal Experience
I have firsthand experience with the challenges of misdiagnosis. In my early 20s I went through a very rough time with relationship OCD. Although I have known I had OCD since childhood, my understanding was my OCD was only related to my fears of contamination, germs, and things I find really gross. After feeling like I couldn’t deal with it on my own any longer, I sought out professional help. Initially I was diagnosed with GAD and treated with medication that, while helpful, did not address the underlying OCD symptoms. My therapist also didn’t catch my OCD, and we used traditional CBT approaches that were not helpful to reduce the torment of urgency I felt from the OCD. I do believe I had both OCD and GAD at the time, yet knowing the OCD was playing such a major role would have been extremely helpful to know how to best manage the symptoms and anxiety it caused.
It wasn't until much later when I was learning how to treat OCD using ERP, that I recognized my symptoms from all those years ago to be relationship OCD. I had been out of grad school for almost 10 years and had seen hundreds of clients by this time in my career. Sometimes I think about how many clients were dealing with OCD, and I diagnosed it as GAD because I had no idea about the complexities of OCD despite suffering from it myself since childhood. This also speaks to the continued need we have for better research and accurate dissemination of information about OCD. It’s not “just handwashing and cleaning.” There is so much more darkness to it (and not in a good way).
FAQs
Can you have OCD and generalized anxiety?
Yes, OCD and GAD can co-occur, which is common.Can OCD cause severe anxiety?
Yes, OCD can lead to significant anxiety due to intrusive thoughts and compulsions.How are OCD and anxiety treated?
OCD is typically treated with ERP, while GAD often involves CBT and lifestyle modifications.Is OCD a form of anxiety disorder?
No, OCD is no longer classified as an anxiety disorder in the DSM-5-TR.What does generalized anxiety disorder look like?
GAD involves excessive worry about everyday things, causing significant distress. It also involves associated symptoms that are physiological in nature.How to tell the difference between anxiety and OCD?
OCD involves specific obsessions and compulsions, whereas GAD is characterized by general worry and associated physiological symptoms.
One oversimplified way to think about it is this:GAD worries and “compulsions” such as rumination will feel more connected to reality or actual possibility.
GAD Example: I got a negative review at work, I could be fired. If I’m fired, I could need to find a new job, and that could affect my finances. If it affects my finances, it could impact my family. I now keep thinking about ways to improve on the job and/or find a new job. It’s also causing some physiological symptoms like muscle tension, fatigue, and irritability.
OCD worries and compulsions are going to be a little more “out there.”
OCD Example: I haven’t received any information that my job is on the line, but I read an article about people getting fired. Because I read the article, I fear that could mean I will get fired soon. I now feel the need to blink 3xs each time I think about getting fired, since 3 is a “good number” and will counteract me being responsible for reading an article and putting into motion my potential firing. I know that blinking really doesn’t do anything to impact me getting fired, but what if it does and I don’t do it then I end up getting fired because of it? If I get fired, I could become homeless, if I become homeless and lose everyone and everything that is important to me, including my mind, and then I may hurt myself even though I don’t want to. I should definitely make sure I blink “right” to prevent my fears from coming true.Can OCD be misdiagnosed as anxiety?
Yes, OCD can be misdiagnosed as GAD due to overlapping symptoms.
Key Takeaways
OCD and GAD are distinct conditions with different symptoms and treatment approaches.
Comorbidity is common, with many individuals experiencing both conditions.
ERP is crucial for OCD treatment, as traditional CBT may not be effective and can make symptoms worse.
Accurate diagnosis is essential for effective management of symptoms.
Call to Action
If you're interested in learning more about OCD, GAD, and how to differentiate them, consider joining my upcoming training "OCD, Generalized Anxiety Disorder (GAD), or Both?" offered three times a year. You can view the training and register here: https://ocd.xyz/ocd-gad-or-both.
Sources
National Institute of Mental Health. (n.d.). Generalized Anxiety Disorder: When Worry Gets Out of Control.
OCD UK. (n.d.). Clinical Classification of OCD: DSM and OCD.
OCD LA. (n.d.). Overview of Mental Rituals.
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).
Merck Manuals. (2023). Generalized Anxiety Disorder.
PsychDB. (2024). Generalized Anxiety Disorder (GAD) - DSM-5 Diagnostic Criteria.
