What do you think when you hear the word “compulsion?” As therapists, we often immediately think of OCD. Whether we hear the term from a client, another provider, or our own classification of someone’s symptoms, “compulsions” tend carry with them some level of assumption – that this might just be OCD. This is especially true for a trainee, someone less well-versed in the nuances of mental health diagnoses, and the general public; and I’ll admit, it is a good place to start! However, the mere presence of compulsions does not necessarily indicate OCD. Compulsions are not always what they seem.
What is a compulsion? The dictionary defines it as an irresistible urge to engage in a particular behavior, usually against one’s own desire. While we can certainly see the role of compulsions in OCD, it is worth noting that compulsions are actually present in a wide range of disorders, from other OCD spectrum disorders and anxiety disorders to far-ranging psychiatric diagnoses and even non-clinical symptom presentations. But when our minds are primed to look for OCD at the first mention of compulsive behavior, how are we to distinguish what they’re truly a part of? And, just as importantly, how do we teach others (from supervisees to our clients or general public) to consider the same?
Let’s start with OCD-related disorders. We know in these disorders, compulsive behaviors are immensely difficult to resist. The compulsions themselves cause marked impairment in one’s life, and resisting the compulsion tends to come with extremely intense anxiety and/or discomfort. At my practice, we tend to observe clients going to a “10/10” on our SUDs scale when discussing the resistance of a compulsion that falls in the OCD-spectrum. In this class of disorders, we can see that the severity of a compulsion and the high investment in engaging in it puts it in the OCD-spectrum category. But when is it truly OCD? Here is where the content of the compulsion (and related obsession) becomes critical for differential diagnosis. If the compulsion and/or obsession is specific to one area (eg: hair pulling, skin picking, body dysmorphia, hoarding behaviors), then those diagnoses may be more appropriate for this specific scenario. If the compulsions and obsessions follow more classic OCD themes, or do not seem specific to another OCD-spectrum category, then we may be seeing true OCD.
Things may get murkier when we begin to see compulsive behavior in other diagnostic categories. Compulsions are quite common in generalized anxiety disorder, social phobia, panic disorder, agoraphobia, addiction-related disorders, eating disorders, sleep disorders, behavior disorders (eg: ODD or conduct disorder), and even conversion disorders. In fact, it seems that some level of “compulsion” is present in many diagnoses we see in the DSM. The critical piece here is to understand the function of the compulsion. In other words, why is someone engaging in this behavior? What is the purpose for this person? People engage in behaviors for good reasons that make sense in the context of their current situation and worldview. So what are their reasons? The justification tends to sounds quite different in an OCD case than it does when the behavior points to another diagnosis. In social anxiety, for example, we typically see that compulsive behaviors are better described as “safety behaviors,” or things that increase a person’s sense of safety/decrease anxiety in the moment. When we assess the reason behind the behavior, clients will often point to the need to avoid a social interaction which may be uncomfortable or anxiety-provoking. This, in turn, may make us turn our head toward a social phobia diagnosis. Further, when asked to resist the behavior as an experiment, clients are more likely able to resist the behavior with less distress than we would see in someone with OCD.
Lastly, it is worth mentioning that not every compulsion is diagnostic at all. Have you ever stopped to pick something up off the floor that was not yours, but you felt compelled to do so? What about putting something in your Amazon cart that maybe wasn’t 100% necessary, but you bought it anyway because you felt like you needed it? We’ve all been there, and these behaviors also, by definition, may qualify as compulsions. With that we can see that the mere presence of compulsions does not actually indicate much on its own. What matters most is the level of distress associated with resisting the compulsion, and the general theme of the compulsion.
Where have you seen compulsions crop up in situations where it probably is not OCD? What diagnostic considerations lead you toward or away from OCD when compulsions are present? Leave a comment with your experience of compulsions that aren’t what they seem!
This post is presented in collaboration with ADAA’s OCD and Related Disorders SIG. Learn more about the SIG.
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