OCD vs. Phobia: How to tell the difference

What is OCD?

According to the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Obsessive Compulsive Disorder (OCD) is characterized first by the presence of obsessions and compulsions.

Obsessions are defined as “recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals caused marked anxiety or distress.” Some examples of obsessions may be:

• Sexually explicit images/disturbing content involving children that pop into one’s head unprompted
• Thoughts are harming someone: “I could just grab that butcher knife and slide it into my husband’s neck.”
• Fear that something may be contaminated: “I need to smell this meat to be sure it hasn’t spoiled.”
• Fear of illness/sickness: “I might be having a heart attack” or “this sensation in my head must mean I have a brain tumor.”
• Fears about feelings “just right”: “If I don’t pass through this archway at the right time, something bad might happen” or “My socks need to hit my calves at exactly the same spot or I’ll feel off all day.”

The list could go on for pages—everyone’s obsessions are different. Any thought, urge, or image that causes distress and is unwanted could be an obsession in OCD.

Compulsions are “repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.” Compulsions are done in an attempt to relieve the anxiety that comes from obsessions or to prevent a feared outcome. Consider some examples:

• Repetitive hand washing to rid oneself of contamination after touching anything that hasn’t been sanitized.
• Repeating words in one’s head in order to drive out an unwanted thought or feel reassured about one’s doubts: “I don’t want to hurt children. I don’t want to hurt children.”
• Asking someone else for reassurance in search of absolute certainty about fears or doubts: “Are sure I never acted inappropriately with you when you were a child?” “Are you sure you will be safe driving to work this morning?”
• Repetitively revisiting places or objects to ensure that nothing is wrong.
• Hiding all the knives in a house, so there is no opportunity to hurt a loved one.

In addition to the presence of obsessions, compulsions, or both, a person with OCD engages in these behaviors for a significant amount of time. Usually this constitutes at least an hour per day, but often time spent in OCD behaviors is much higher. These behaviors will also cause a significant amount of distress and will cause impairment in areas of life such as: relationships, work, home life, social life, and general quality of life. The symptoms of OCD must not be attributed to the use of a substance like drugs, alcohol, or prescription medication side effects. These symptoms of OCD will not be better explained by another mental health diagnosis like Generalized Anxiety Disorder, Panic Disorder, or a Specific Phobia.

What is a phobia?

People often mistakenly believe that phobias are a form of OCD, but this is not the case; Specific Phobia is an entirely distinct diagnosis. According to the DSM-5, a Specific Phobia is a “marked fear or anxiety about a specific object or situation” (e.g., flying, heights, animals, receiving and injection, seeing blood). There are different phobic categories for diagnosis: Animals, Natural environment, Blood-injection-injury, Situational (flying, elevators, enclosed spaces) and other (such as situations that could lead to choking or vomiting).

As with OCD, a person’s life will be affected by their fear, which is usually not proportional to any actual threat. Someone with a Specific Phobia will take steps to avoid their phobic stimulus, such as never going to a zoo because they have a fear of snakes, or traveling by boat to a destination that others would reach by airplane. Similar to OCD, people with a phobia may seek reassurance about their fears. Both OCD and Specific Phobias can start in childhood or adulthood, and may or may not be triggered by a traumatic event. 

There are important points that distinguish the two disorders, however. OCD involves intrusive thoughts, images, or feelings, known as obsessions—these are what lead to fear and compulsive behavior. For example, someone who has Contamination OCD may fear needles because of intrusive fears that they will contract a pathogen from a dirty needle, feeling that the slightest uncertainty about sanitation cannot be tolerated. A person with a Specific Phobia that has a fear of needles may not have intrusive thoughts at all, but know that seeing a needle will cause them to panic or faint. The needle is the phobic stimulus, whereas in OCD the needle may be a trigger for obsessions about getting a transmitted disease. It’s not really the needle that the person with OCD fears, but what may result from an injection and the array of uncertainties and doubts associated with it. 

Another difference between the two disorders is that OCD symptoms often wax and wane from their onset. A person may spend only several months consumed by obsessions and compulsions related to contamination resulting from needles, after which their intrusive thoughts and compulsive behavior focus on another theme. In a Specific Phobia, one’s fears and behaviors usually remain consistent in the absence of treatment. 

How can I tell if I have OCD or a phobia?

Sometimes OCD may be misdiagnosed as a Specific Phobia, and some people may be taught that they have a “multi-phobic personality.” However, if a therapist is properly trained in diagnostic techniques, chances of misdiagnosis are lower, as clear distinctions exist between the two conditions. While these two diagnoses can present some similarities, OCD can be much more fluid in its presentation, and involves cycles of obsessions and compulsions. 

Is it worse to have one or the other?

Both OCD and Specific Phobia can be debilitating and cause problems for one’s quality of life. One might feel that removing the phobic stimulus in a Specific Phobia may be easier to accomplish, while triggers in OCD are less predictable. However, with both disorders, avoidance does nothing to ease one’s suffering and the impact the condition can make, and pursuing treatment is recommended for both.

Can people have OCD and a phobia at the same time? 

It is possible to have both OCD and a Specific Phobia at the same time. It is also possible for a Specific Phobia (or multiple phobias) to develop into obsessive and compulsive cycles as a person’s behaviors change and interact with their thoughts and fears. 

Are OCD and phobias treated differently?

OCD and Specific Phobias can both be treated with a particular form of therapy called exposure and response prevention (ERP) therapy. (Exposure and Response Prevention). This evidence-based treatment has shown to be highly effective in resolution of symptoms for both disorders. 

By doing ERP therapy with a trained therapist, individuals can find relief from the cycle of OCD as well as relief for their Specific Phobia(s). ERP is the gold standard of treatment for OCD and Specific Phobia(s), and is backed by decades of clinical research. Most individuals who do ERP with a trained therapist experience a decrease in symptoms, reduced anxiety and distress, and increased confidence in their ability to face their fears. 

People who struggle with OCD or a Specific Phobia can work with their therapist to build an exposure hierarchy and begin working on one trigger at a time. Usually an ERP therapist will start with an exposure that is predicted to bring about a low level of fear and anxiety and work up to the harder exposures as confidence is built. When doing exposures, the goal is always response prevention: your therapist will guide you in resisting the urge to respond to fear and anxiety by doing compulsions or avoiding triggers. Over time, this allows you to tolerate anxiety without relying on compulsions or avoidance to feel better.