This is Crazy Talk: An advice column for honest, unapologetic conversations about mental health with advocate Sam Dylan Finch. While not a certified therapist, he has a lifetime of experience living with obsessive-compulsive disorder (OCD). Questions? Reach out and you might be featured: sfinch@healthline.com

Hi Sam, I’ve struggled with some form of anxiety for most of my life. At different points, I’ve been diagnosed with obsessive-compulsive disorder (OCD) and generalized anxiety disorder (GAD). However, I don’t really understand the difference. How are they different, and is it possible to have both?


This question is (as the youth say) “extremely my sh*t.”

As someone who was misdiagnosed multiple times before I could confidently say “I live with OCD,” I am all too familiar with trying to parse out the nuances of obsessive-compulsive disorder.

While they’re both anxiety disorders, generalized anxiety (GAD) and OCD are distinct in some pretty important ways. Namely, they diverge in these three areas:

  • the content of your anxiety
  • the “stickiness” of your thoughts
  • whether or not rituals and compulsions are involved

Let’s start with the main difference: Specifically what’s making you anxious

In OCD, our anxieties are largely irrational. Most anxiety is, but in OCD it’s definitely a little more “out there” in comparison.

We obsess about improbable, quite specific, and even bizarre things. Will I get a rare disease by touching this? What if this violent thought means I’ll kill someone? What if I fall in love with my psychiatrist?

I spoke with Tom Corboy, a licensed psychotherapist and executive director of the OCD Center of Los Angeles — so basically, the go-to expert on this topic — who emphasized that for someone with OCD, “these are not just random passing thoughts, but rather repeated thoughts that [are] causing great distress precisely because the thoughts are antithetical to the sufferer’s true self.”

And that’s a critical piece. With OCD, the anxieties are incongruent with how a person thinks of themselves.

Think of OCD as more of a conspiracy theorist: where the outcome or conclusion it offers is nearly impossible or quite outlandish. For example, as a mental health advocate, I’ve had obsessions about “making up” my mental illnesses, fearing that I’ve built my career on an elaborate lie I was unaware I was even telling.

I knew logically that this didn’t make any sense. But my brain still latched onto it, leaving me in a state of panic that interfered with my life.

OCD often latches onto some of our deepest fears. In my case, it was lying to people I care about (my readers) and manipulating them without meaning to.

This dissonance (caused by intrusive thoughts, which I discussed in a previous Crazy Talk column) is a big part of what makes this disorder so very painful. In many ways, it really is a waking nightmare.

Generalized anxiety, on the other hand, tends to be about real world concerns. Will I fail this test? Will I get this job? Is my friend angry at me?

GAD takes the stuff going on in your life and likes to remind you of the worst possible scenario of how it might play out, causing excessive and debilitating worrying.

It’s the original flavor of anxiety, hyped up aggressively.

Anecdotally, a lot of people note another difference between GAD and OCD is how “sticky” their anxiety is

People with GAD tend to jump from one anxiety to another throughout their day (or have a general sense of being overwhelmed), whereas someone with OCD is more likely to obsess on a particular anxiety (or a few of them) and devote excessive attention to it.

I wouldn’t get anxious about just anything — at least not in a dysfunctional way. But I may become fixated on a mental fidget spinner for hours, obsessing over it in a way that sounds arbitrary or ridiculous to everyone else.

In other words: GAD can feel more frantic, whereas OCD can feel like spiraling and getting sucked down the drain.

The big difference, though, comes down to whether or not compulsions are present

Compulsions can be visible or mental, but most importantly they’re present in OCD — not GAD.

There are as many compulsions as there are people with OCD — the main feature of them is that they’re behaviors that, while intended to self-soothe and alleviate doubt, actually fuel the cycle of obsessing further.

Examples of compulsions
  • Visible: knocking on wood, washing your hands, checking the stove, touching or not touching a particular thing
  • Mental: counting steps, replaying conversations in your head, repeating special words or phrases, even trying to “neutralize” bad thoughts with good thoughts
  • The list goes on! Check out the OCD Center of Los Angeles’ list of OCD tests for more.

This begs the question: If they’re both anxiety disorders at the end of the day, do these differences really matter?

As far as treatment goes, yes, they do. Because a treatment that helps someone with GAD may not be as effective for someone with OCD, and that makes getting a correct diagnosis very important.

As an example, imagine you have two people — one with GAD and one with OCD — who are both experiencing anxiety about their relationships and whether or not they’re a good partner.

Typically, people with GAD are told to focus on challenging anxiety-producing thoughts (Corboy refers to this as cognitive restructuring, a form of CBT). That means they would work on challenging their thoughts to hopefully realize the ways in which they’re a good partner, and to address how they can build on those strengths.

But if you used this approach on someone with OCD, they might compulsively begin asking for repeated confirmation that they’re a good partner. In this case, then, a client may compulsively focus on becoming less reactive to the idea that they might not be a good partner and learning to live with the doubt.

Instead, people with OCD need a different approach to help with their compulsions.

Corboy explains the most effective treatment for OCD is called exposure and response prevention (ERP). This is repeated exposure to fearful thoughts and situations in an effort to desensitize the client, with the ultimate outcome being reduced anxiety and frequency of the thoughts and compulsions (or put another way, getting “bored” of the obsession itself).

This is why the distinction becomes a critical part of getting better. These disorders might be similar, but healing requires a different approach.

Ultimately, only an experienced clinician can make the distinction between these disorders

Find one who preferably specializes in OCD to help.

In my experience, many clinicians only know about stereotypical manifestations of OCD, and as such, it’s misdiagnosed quite often. (Also worth mentioning, too, that some folks have BOTH disorders, or they have one but with some traits of the other! In this case, a clinician who knows the ins and outs of OCD may help bring more nuance to your treatment plan.)

In fact, for six years, I was misdiagnosed as having bipolar disorder, and even borderline personality disorder. The sad truth is, OCD is still widely misunderstood, even in the medical community.

This is also why I refer folks (for reading material and diagnosis help) to the OCD Center of Los Angeles so often. A disorder this tricky requires thoughtful resources that reflect the myriad ways people experience this condition. (Oh, and buy this book. Seriously. It’s the most definitive and comprehensive resource out there.)

To sum up, here’s my best advice: Do your homework and research as thoroughly as possible. And if it feels like OCD is a likely diagnosis, seek out a professional (if possible) that has a firm grasp on what this disorder is.

You’ve got this.

Sam


Sam Dylan Finch is a leading advocate in LGBTQ+ mental health, having gained international recognition for his blog, Let’s Queer Things Up!, which first went viral in 2014. As a journalist and media strategist, Sam has published extensively on topics like mental health, transgender identity, disability, politics and law, and much more. Bringing his combined expertise in public health and digital media, Sam currently works as social editor at Healthline.