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by Patricia Thornton, PhD
OCD

Often patients, in the course of their treatment for OCD, will question whether they actually have OCD or not. This doubt feels different to them than the doubt arising from the intrusive thoughts that initially brought them into treatment. But this doubt about having OCD is OCD! OCD demands certainty and convinces the sufferer that bad things will happen if they’re not certain. The content of the intrusive thoughts is always irrelevant, but the content can distract patients (and sometimes clinicians) from dealing with uncertainty and risk.  

In the initial stages of treatment for OCD, when I’m evaluating a new patient and setting up a treatment protocol, I tell the patient that I believe they have OCD, explain my reasoning, and describe how Exposure and Response Prevention (ERP) works (if that’s my determination after a thorough evaluation). I will also alert my patients that in the course of treatment they may question their OCD diagnosis because of the very fact that they have OCD.  We discuss how obsessions can be about anything, including OCD.  

After the initial evaluation, doubt about whether they have OCD or not usually emerges after patients have successfully used ERP and their symptoms are abating. They are not as fearful of their intrusive thoughts and they can usually let those intrusive thoughts hang out in their minds without attaching much significance to them. They have also reduced the amount of mental or behavioral rituals they engage in and are less avoidant of situations that trigger their obsessions. But there is still some doubt and this new way of thinking about intrusive thoughts has not been yet been fully ingrained. A patient might say something like this: “I’m not as bothered by my intrusive thoughts about harming my daughter, but what if I don’t have OCD?  Then the thoughts mean I’m a deviant, especially because I’m not bothered by them as much.”

I tell my patient, “Getting better has triggered another OCD thought which is: ‘What if I don’t have OCD?’ OCD will try to instill doubt that your decrease in symptoms is evidence that you may be a deviant after all, because you’re less bothered by the thoughts. It’s circular thinking that can never be satisfied. The only way to get out of questioning yourself is to say, ‘I don’t know and I don’t need to know. Maybe I have OCD, maybe I don’t. I might be a deviant. Maybe I’ll harm my daughter, maybe I won’t. One can never know for sure, so I’m not going to search for the answer.’”

At this point in treatment, I try not to reassure my patients that they have OCD, if that is what their obsession is focused on. Reassurance will be only momentarily satisfying to them and is likely to perpetuate the obsession that they must be absolutely sure they have OCD. I reiterate that the content of their obsessions is irrelevant and point out how OCD has tricked them by instilling doubt about their diagnosis. 

I encourage my patients to proceed with embracing the uncertainty that they may or may not have OCD and to refrain from rituals such as, seeking reassurance, looking up symptoms of disorders, and/or checking their thoughts. I emphasize that OCD is tricky. It morphs and changes over time and folks with OCD can get caught up with seeking certainty before they realize it’s OCD rearing its ugly head again – because it’s instilled doubt about something new. They will get stuck on the content of the obsession and their need to be safe and sure, rather than seeing OCD’s process, which is always the same. I remind them that whenever they have an intrusive thought that demands attention and certainty, they can deal with that thought by saying, “I don’t know. Life is about risk and uncertainty. I’m choosing to be uncertain, so I can live a freer life.”  

I ask my patients to continue the therapy work they’ve been engaged in while being unsure that they actually have OCD. ERP will now include dealing with the intrusive thoughts and doubt that they have OCD. Eventually, most patients realize that all of these intrusive thoughts, whatever the content, are just like spam email. The spam is in their brains, but those messages (thoughts) don’t need to be opened, examined, or answered. They don’t need any response at all.  


About the Author

patricia_thornton_picture_0.pngPatricia Thornton, PhD specializes in the treatment of anxiety disorders and OCD. She practices in New York City.

I just wanted to take some time out to thank you for writing this. I have OCD and fit the patient description you give in the article pretty well. I've gone through a good few months of CBT now and a lot has gotten better, but every day there's still some measure of doubt lingering about. Since I can't seem to get rid of it, I get depressed. I start to question whether I actually have OCD. Maybe I don't. Maybe that's why CBT isn't working. Now I realize those thoughts is OCD talking.

I am uncertain what is meant by the use of the term 'deviant' in this article?

OCD is known as disturbing/upsetting thoughts

I have some enjoyable and pleasurable repetitive thoughts that are out of control
but still enjoyable and pleasurable

Is that also considered OCD ?

If not; What it is called or diagnosed ?

N.B: I do NOT have any complusions
JUST thoughts

I wonder this too. I have repetitive thoughts that aren't pleasurable but I think i know it's a bad thought but I don't care that i have that bad thought ill just keep getting rid of it cause I should, not cause I want to. These are bad thoughts about words or phrases which are morally wrong e.g.involving children. I think am I okay with being a paedophile and I just get rid of it cause I feel I should. I can't see myself ever harming a child or wanting to actually do anything in real life. I feel like the only way to make me feel guilt is to tell someone. I don't get much opportunity usually but I am seeing doctors psychiatrists lately. I just get rid of
these thoughts automatically with no feeling attached to it just like a 'stop it'. Also I've started to notice there is no point me doing some of the things I doin terms of repeated actionz i just do them because I think oh better had, I usually do that. There is a small feeling of I should do that but it's not very strong. I could probably ignore it entirely but I haven't tried. I don't know how i feel about all this. I think I dont like the fact that I am not doing some of the things I used to do. So I don't dread walking back from station as taking a taxi became no longer an option. I don't have same groinal feelings when hanging out washing because I place less importance on getting it right cause I have told myself it doesn't matter its going into my own storage facility or I can put it in there and rewash it at a later date. I think I am finally getting round to writing an honest synopsis if you will of what I actually do for example in the bath (which is one of the few ocd symptoms I have left to question) to see if its ocd or not and part of me is thinking I am not going to be good enough and I won't like it for a split second after hearing it. After that I can't think what I'll feel I will probably be okay with it??? So what's the big deal about not being OCD.. Another thought I have is go away from this and maybe you'll come back with real OCD one day. It's like I want to be ill, in fact I do want to have OCD at times, but I know that when I used to not like doing certain things I'd want it to go away so what does that mean? I too Google OCD symptoms or depression or if procrastination means I am either of things. I google questions, I look up self harm and questions centred around if people have to feel a certain way to self harm or if its normal to do it for no reason and is this an underlying sign of a problem but if this does all point to OCD I mean it doesn't affect my life. I go to work and function. So do I need the medication I have been prescribed. This then leads to the feeling of having to have an answer for that. Maybe it just puts me in this unnecessary victim mentality. Maybe it's stopping me on a subconscious level moving forward - I can be lazy I have a mental health problem I will do stuff when better? I feel like people won't take me seriously if I say I want to have a mental health problem. Part of me thinks it's because well what else do I have to do with my life. Having a mental health problem is something I can put all my energy into and fill my day. A part of me is thinking have I simply moved my obsessions on from the old ones as I am thinking about self harm more than I used to. I think I do contemplate overdosing more seriously than I used to because I don't want to die I just want to end up in a specific hospital that I think about every so often. My self harming thoughts have increased since going to hospital (I actually did go recently for a healthy reason, having some teeth out which prompted me to miss the place in the first place) as I told myself well that's what I did the night before I went to hospital so I have to keep that up as a sort of... I don't know now, just a remembrance thing to keep myself in that moment of time????? Now I do it to keep it up so I can say I self harm every day (not to anyone in my life apart from health professionals). I do get a bit of a kick out of looking at my self harm marks in the mirror at work and thinking don't get caught by anyone. I don't want anyone to see them but there is a thrill in the risk. I don't Think I care about scarring my body I want them to be deeper to look impressive to me. The pain i dislike a little but I occasionally get a rush like when I used a knife for the first time but then after I'm like I will never be a proper self harmer I am too scared to really cut with the knife properly. It hurts. I think I am going off on a tangent I think i just want someone to tell me I have ocd. When i hear that a symptom of ocd can be doubting if you have ocd then I feel Comforted. Anyway hope someone replies.

I am currently going through a very difficult moment with my OCD. I had it under control for 7 years but in the last year it has crept up on me, without me even realising, and now I am in a very dark place. I don't have a particular point, but just wanted to say that reading this article gave me some comfort - it reminded me of the attitude I have to adopt to overcome this and what gave me the freedom to live 7 wonderful years OCD free.

Elizabeth, I hope you are doing better - I have battled this for 30 years and have had many years of dormancy, and have had a recent flare up and have gone on meds and therapy to try to snap me out of it. A little traumatic event triggered my contamination OCD, dang it... don’t give up hope. I have studied this extensively, you would think I could help myself more. Don’t be afraid to ask for help.

I am really doubtful about having ocd because everyone says they do. I experience compulsions where I need to do things at least three times, or things need to be lined up perfectly or it makes me really uncomfortable. Also another thing that triggers my so called ocd is when someone hits my hand, leg, etc. I have to hit the opposite one and the original one and its really frustrating. I dont really know how to deal with it either

actually same. if i tap two finger together on my left hand then i have to do the same to the right. been having over a lot lately but been working on it. stuffs hard

Thank you so much for this I finally feel more free and I can do more things that I used to enjoy or do without making sure I haven’t hurt anyone in the past but now I question if I have OCD or not. After reading this I feel a lot better and I understand that is OCD doing what it does best. Create doubt. Thank you so much!!!

Actually, enjoying your repetitive thoughts is a rule-out for OCD. If you enjoy your repetitive thoughts, OCD is literally ruled out.

Actually an obsession is an exaggerated preoccupation .
It's something that you think or worry about a lot .
It doesn't matter whether it is pleasant / enjoyable or not .

Whenever I do something it has to be an even amount of times. I also am always washing my hands. I also have to recheck things to make sure they are done right. I have go through all of my homework twice or I feel like I will fail. I feel like everything has to be even, and has to be in its right place. I also constantly think about failing tests, and bad things happening to my family, and I hate thinking about it. I also always feel like things are my fault. Should I go and see a doctor to see if I have OCD?

I just need someone to help me out. Am from India, and forget about people understanding these, the psychologist also never understand. I have this for 11 yes, my whole teenage n work life fucked up.
I sometime manage to gather strength to go and visit a doctor, but believe me as if they never read any informative article about treating OCD.
Sometime, they won't agree that I have OCD. Sometime, they will say it's just normal overthinking. And I know, there is nothing in name, but it's like all my struggle are due to a silly reason and that means I am just kinda weak.
I think I have OCD, and I desperately need help. I don't know what options I have left. I don't wanna quit, but everyday makes me feel like am letting more people down and am never gonna be okay.

Just wanted to share. Cz most people will be like you are overthinking, don't think

I started experiencing new thoughts about racism in Aug 2018. At first, I knew it was OCD and I was extremely depressed. I would cry all the time. Then in November 2018, in my mind and body I felt like I started to believe the thoughts. At first,I could tell myself I’m not racist for several different reasons. Especially dating mostly minorities in my life and my family dynamics. My son is half Hispanic. I’m a Caucasian American but my grandad is Arab. Now I can’t even except in my mind the reasons why I couldn’t be racist and don’t question it anymore. I just repeat in my head that I’m racist and I can’t date or hang out with friends, etc bc im racist. I Also got thoughts that I’m a discriminatory person. I feel like I believe that too. I feel like the thoughts aren’t intrusive and they are coming from me when before I would so no I’m not racist. I don’t know what to do anymore or what this could be.

I've started believing my thoughts too. They started appearing after I got off medication and depression sharply worsened. At first they were doubts and I talked to my girlfriend, she reassured me that I'm not wrong like I think I am and she's not a person to lie. Then I experienced a trigger and they started getting more intense. Appearing in my dreams, making me unable to live normally, do anything. Her reassuring me gave me a temporary relief but after a short while it started again.

Everything I say and think is wrong, even if I'm educated on a subject, people who say the opposite without any knowledge and not caring must be right, because I absolutely must be wrong. My girlfriend who is even more educated on the subject my thoughts are about tells me that I have no reason to doubt that I am right, it's as if I have a lot of proof that I'm right but I can NEVER believe it no matter what. It's as if I can't "prove" it therefore it's wrong.

The subject is a bit personal, but to compare it to something, it's about how many people believe schizophrenia is having multiple personalities - but my experience would say different, my girlfriend doing research would say different, the professionals would say different - but I can't believe it... I must be wrong, because I'm always wrong, and those people who I know have very little knowledge about the subject must be right. I try to convince myself with lots of proof I have, but I can never become convinced, and it's destroying my life, I have thoughts of ending it because I can't even have a minute of freedom, as it's even appearing in my dreams.

I've started antidepressants yesterday - you should think about medication or therapy too. No matter how much proof you will have you won't be able to stop believing you're racist - as I can't stop believing I'm wrong, because everything I think is wrong and I'm dumb compared to everyone else - even if they don't even care about the subject and never studied on it and the people who did tell me my thoughts are false.

I haven’t been diagnozed yet, but I think i suffer from the exact contrary of this article. I obsess that maybe I have OCD. This has been going on for over than 6 days and I’m not feeling that well

Wow. I just got diagnosed recently, and I finally feel like I make sense for once in my life by reading this article. I try to catch myself in that loop thinking- and it’s so hard to get out of it. You have described what I go through to a T. I’ve never read anything that was so accurate about OCD before. Thank you