Some Compulsions Are More Difficult to Recognize than Others
By Shannon Metzler, PhD, LCSW
Compulsions are purposeful behaviors or mental acts that are experienced as an urge or drive to relieve anxiety-related discomfort. Compulsions are associated with obsessive-compulsive disorder (OCD), where the compulsion is preceded by what is typically a recurring disturbing thought, and the compulsion serves as a strategy to remove the discomfort activated by the thought. Most people are aware of their disturbing thoughts because of the discomfort they cause. Awareness around when and how the discomfort is being removed can be less obvious. Some compulsions can become so normalized and invisible that they become a normal part of everyday life.
The term intrusive thought is sometimes helpful for describing obsessions as unwanted thoughts that intrude into our awareness, tend to recur, and feel “stuck” when they do not subside. Everyone is familiar with the experience of an unwanted thought intruding into their intentional stream of consciousness. Many are odd, off-putting, repugnant, or even funny, but for most people, the thought passes quickly and is not revisited. For someone who struggles with intrusive thoughts, certain thoughts, images, and even sensations are experienced differently because of the discomfort that is triggered by them. Commonly described as anxiety or panic, this discomfort is often experienced in the body as a “woosh” or an amplified bodily sensation when the thought disrupts the intended stream of thought.
Anxiety is described as unease or a feeling of worry, which people naturally experience at different points in life. While anxiety is often viewed as a bad thing, it is also associated with beneficial qualities, such as increased focus, enhanced problem-solving, and a motivator for taking action to prevent undesirable outcomes. Anxiety becomes more of a concern when the episodes of worry and unease become excessive and unmanageable. When the thoughts begin to feel like they are controlling you more than you can control them.
Obsessive thoughts generally fall into four categories: Contamination, Harm, Symmetry/Ordering, and Taboo thoughts.
Example: If I am constantly worried about contamination, I likely experience frequent intrusive thoughts and anxiety about potential exposure.
Hypervigilance is a state of chronic, heightened alertness. It is a key feature of many anxiety-related mental health struggles because it is a sign that the neurological system is “stuck” in a fight-or-flight response, which feels uncomfortable and unmanageable. Being in a hyper-alert state takes a cumulative toll on the body; the longer it continues, the more it contributes to fatigue and burnout.
Example: If I am anxious about coming into contact with a contaminant, I’m likely to be hypervigilant about potential exposure and experience discomfort whenever a threat arises, such as when shaking someone’s hand. Eventually, I might even start to feel discomfort and a woosh as soon as I anticipate having to shake someone’s hand, and panic and struggle to regulate my thoughts and emotions after contact because my fight-or-flight response has been activated.
Unwanted intrusive thoughts can cover a range of topics, including personal failure, moral and religious transgressions, past traumatic memories, loss, harm, disgust, revenge, illness, health, pain, big issues, problem-solving, and finances, to name only a few. The more an intrusive thought, image, or sensation is associated with discomfort, the more likely a response will develop to reduce it. When the strategy is repeatedly used to neutralize the trigger that causes discomfort, or the discomfort itself, the more likely it becomes a compulsion.
Compulsions include behaviors such as checking, ordering, arranging, cleaning, counting, washing, mental acts, and seeking reassurance. All of these examples can be normal, everyday behaviors. Most of us have checked to make sure a stove or oven is off and probably used cleaning to help ease our discomfort with a dirty house. The difference lies in the intensity of one’s reactivity to the trigger or source of discomfort, the resulting level of discomfort or distress, and the urgency to perform the compulsion to relieve the distress, which intensifies over time with repeated use, making the urge increasingly harder to resist.
Example: One way to reduce my discomfort after shaking someone’s hand is to excuse myself “to use the restroom” so I can quickly wash my hands and remove the contaminant. The first time this strategy was used, I successfully reduced the discomfort by washing my hands before returning to the group. As I continued to use this strategy, there came a time when one wash was not enough, and the intrusive thoughts and distress returned, so I went back to the restroom to wash them a second time to stop the intrusive thoughts and relieve the distress. Eventually, it might take a third or fourth time to stop the discomfort.
Covert compulsions are more difficult to recognize because they typically do not involve an obvious action, such as repeated handwashing or flipping a light switch a specific number of times. Reassurance, avoidance, and distraction are the most common types of covert compulsions. Often referred to as “safety-seeking behaviors,” they are mental strategies used to secure a sense of safety by neutralizing discomfort.
Example: To reduce my uncertainty around potential discomfort from having to shake someone’s hand, I decide to stay home from a gathering and avoid the threat altogether. Deciding to stay home for this reason is an example of a safety-seeking behavior. It feels less threatening (safer) because I eliminated the threat by removing myself from the equation. I might even make an excuse for why I am unable to attend that has nothing to do with my fear of contamination, which is also likely a form of avoidance. I offer a deceptive explanation to avoid the discomfort of being honest about the actual reason I am not attending.
We have all experienced times when we decided to stay home from a gathering or meeting to avoid something. Perhaps we were tired from a long day of work, which could be a healthy limitation to recognize and set for ourselves. This example describes a specific type of strategy being deployed to neutralize a threat, exposure to contamination. It is the discomfort that is driving the covert strategy. Doing this once or even on a rare occasion doesn’t make it a compulsion. It becomes a covert compulsion when the strategy becomes a pattern, and the urge to perform it grows more difficult to control. Severe patterns can evolve into an involuntary mental act that automatically neutralizes discomfort. Perhaps like always being busy or having a prepared reason why you can’t attend an event.
The heightened state of feeling the need to fight or flee is often called the fight-or-flight response and results from activation of the nervous system. It is part of the body’s natural alarm response, which is automatically activated at the first sign of a threat. But other threat responses include freeze and fawn, in which disconnection is part of the freeze response, and appeasement is part of the fawn response. In general, to deal with a threat, we run from it, fight it, disconnect from it, or appease it. Covert compulsions can use all of these strategies, but rarely, if ever, involve openly/visibly confronting a threat.
Common covert compulsive strategies include:
Avoidance
Examples: Using a hypercritical internal dialogue to avoid potential embarrassment or a sense of failure. Using appeasement, often described as people-pleasing, to avoid others being disappointed or angry at us, which can also be associated with trauma, and understood as a “fawn” response. Compulsive people-pleasing relies on suppressing personal boundaries and authenticity to control how others react. Fawning often stems from past experiences (often in childhood) in which the individual learns that compliance, inauthenticity, silence, and self-sacrifice are necessary to maintain personal safety or secure love. The primary goal of avoidance is immediate relief from distress, fear, or anxiety by evading a trigger.
Reassurance
Examples: Repeatedly checking in on people to reduce uncertainty about whether anything bad has happened. Ongoing patterns of asking others specific questions or mentally reviewing past conversations to reassure oneself that nothing they did was wrong or embarrassing. Excessively seeking confirmation from romantic partner(s) that they still want to be in the relationship to reduce discomfort associated with abandonment. The general aim of reassurance-seeking is to alleviate discomfort by reducing uncertainty around a trigger or potential trigger.
Another form of reassurance-seeking involves discomfort with trusting oneself to perceive things correctly, including in decision-making. This can result in a pattern of excessively asking others questions intended to reassure oneself that their perceptions and decision-making are correct or acceptable. This compulsion is also potentially connected to past trauma or complex post traumatic stress disorder (C-PTSD) and stems from experiences (often in childhood) in which the individual’s sense of reality, emotional responses, decisions, and identity are consistently undermined and manipulated to make the individual doubt themselves and become more dependent on the abuser for validation, direction, and prioritizing the abuser’s views, values, wants, demands, and needs. When this type of abuse is experienced in childhood, it often disrupts healthy development paths and leads to struggles with knowing oneself, identity development, and self-trust and trusting others. The impact of this abuse pattern typically has a deleterious effect on the ability to form and maintain healthy relationships throughout one’s life.
Distraction
Examples: Engaging in active thought suppression to intentionally push a disturbing thought out of one's mind. Staying constantly busy to distract from discomfort and avoid triggering thoughts. Social media, cellphones, and screens in general have become widespread tools for distraction, making it more difficult to recognize distraction-seeking patterns because such behaviors are widely adopted and socially normalized. Distraction can include using alcohol or substances to distract from discomfort through numbing and sedation. Distraction-seeking strategies involve disconnection and being less present with the discomfort.
What makes most covert strategies harder to recognize is that they can look fairly normal or even be socially reinforced. Working all the time can be used to distract from discomfort and be seen as dedication to one’s job rather than a way to distract from anxiety-related discomfort. It might even result in secondary gains, such as being seen as a good worker or getting a promotion. Asking people questions that serve to secure reassurance can look like a typical friendly conversation or showing concern rather than a way to remove uncertainty and avoid discomfort. Other people are less likely to recognize a self-critical inner dialogue and may only see a well-organized person who optimizes their productivity and time.
We have all likely used one or more of these strategies at some point in our lives. The point at which a strategy moves from helpful coping to OCD largely depends on the nature of the threat, the desired outcome, the impact on daily life, and the intensity of the cycle. Threats are typically unrealistic or feel bigger than they should. The goal of the compulsion is typically complete certainty rather than comfort. The impact on daily life becomes more debilitating over time due to the temporary nature of relief, which often requires increasing amounts of time, attention, and energy as the pattern progresses and takes more control over one’s life. OCD patterns typically strengthen over time, intensifying the need for control rather than reducing it.
While shaking someone’s hand may involve coming into contact with a contaminant, the actual risk of harm from exposure is probably low. Moreover, there are reasonably effective ways to reduce the risk without resorting to more extreme measures, such as isolating or skipping gatherings altogether. Staying home is an example of demanding complete certainty rather than comfort, but it is important to realize that there is also a likelihood of eventually facing new struggles with contamination as the need for control intensifies.
Over time, just thinking about shaking someone’s hand, known as “thought-action fusion,” could trigger similar discomfort and require another round of handwashing, despite never leaving the house. It may become increasingly difficult to invite people to visit or to leave the home as the fear of contamination intensifies, and the motivation to leave or invite people to visit is increasingly overtaken by the need for safety. In this example, depression may become an obvious symptom and even be attributed to the isolation, which could be true, and result in greater focus on the depression symptoms, while the covert OCD goes unaddressed. Moreover, the pattern of using avoidant strategies might even reinforce a desire to focus more on the depression symptoms rather than address the safety-seeking behaviors, as they can be viewed as a source of comfort. For this reason, working with a professional who is trained to recognize covert OCD patterns can be important.
Exposure response and prevention therapy (ERP) are a specialized, evidence-based treatment approach are considered the gold standard for treating OCD and has proven effective in treating many other anxiety-related conditions. ERP has two primary areas of focus for treatment: exposure and response prevention. The first area of focus is gradual exposure to triggers (thoughts, images, sensations), starting with those that elicit a lower anxiety response and gradually progressing to those that elicit a higher one, at a pace that helps people stay within their window of tolerance. Gradual exposure is essential to successful response prevention, as it allows for practice with less-threatening triggers before attempting the more challenging ones. Response prevention strategies are tailored to the specific safety-seeking behavior pattern and are used to disrupt existing patterns and increase the ability to choose and use a counterresponse while learning to regulate the distress (distress tolerance) during activation. Over time, this allows the brain to recalibrate, lowering the threat response and reducing distress and the need or urge to use compulsions for safety/control.
As mentioned, OCD is sometimes intertwined with past trauma, which can make it especially difficult to regulate emotions during “activation” (after a thought or event triggers the alarm response). Eye movement desensitization and reprocessing (EMDR) is another specialized, evidence-based treatment for trauma and PTSD. EMDR can be an effective method for processing traumatic experiences and reducing the brain’s threat response by systematically working with triggers that activate the alarm response and using bilateral stimulation to help process trauma and recalibrate the body’s threat response. If you recognize the patterns discussed in this article or believe you have OCD or PTSD, it is important to seek help from a qualified licensed mental health professional who specializes in treating OCD and complex trauma.
Disclaimer: The information provided in this article is for educational and informational purposes only and does not constitute professional psychological, psychiatric, or medical advice, diagnosis, or treatment. Reading this article does not establish a therapist-client relationship. If you are experiencing symptoms of OCD or any other mental health condition, please seek the advice of a licensed mental health professional or other qualified healthcare provider immediately.