Not all fears are the same: OCD

I’ve told you before that emotions, both primary ones (fear, disgust, sadness, joy, anger and surprise) and secondary ones (shame, guilt, jealousy, envy, pleasure, pride…), always serve a purpose. Whether we think of them as positive or negative, they all exist for a reason. Today I want to focus on fear. Fear has a very specific job: to protect our survival. So when I perceive a threat, that signal goes straight from the thalamus to the amygdala and from there to the hypothalamus, which sends signals to the rest of my body to put it into survival mode. Fear puts us on alert in situations that might be dangerous and helps us act accordingly. However, rational fear helps us (the kind triggered by a real threat), whereas irrational fear can harm us to the point of making our lives miserable. And that’s where anxiety disorders and OCD come in (in case you didn’t know, since the DSM-5 OCD is no longer classified as an anxiety disorder).

This week, in the middle of a Skype session with a patient with OCD, he told me he considered himself a coward because he couldn’t overcome his disorder, and yet he had managed to beat his fear of COVID over the months. I stopped, because I thought it was important to clarify a few things about what he’d said and explain how unfair that comparison was. I started by asking him whether his fear back in March (when hospitals were overwhelmed, little was known about the virus and we were all in lockdown) was the same as now, in October. He said no. Then I asked him why, and he said that now there was room in the hospitals and we all knew much more about it and how to act. “So the situation is different, less threatening, and your fear has gone down in proportion to the situation. It hasn’t disappeared, because the virus is still around, but it has gone down noticeably since March,” I replied.

In this patient’s case, the fear of COVID was a rational fear: it goes up or down according to how threatening the circumstances or context are. It’s a natural, functional and useful fear.

Then I turned to his OCD area (“What if there’s mercury in object X, I touch it or swallow it and something happens to me or my family?”) and reminded him how many times he must have checked the same objects for mercury and how many times, day after day, the answer was the same: there isn’t any. In other words, the circumstances, his context, keep giving him the same information over and over: there’s no threat. So I asked him whether the fear had gone down after checking that the situation wasn’t threatening. His answer was obvious: no. “Exactly, because fear in OCD is an irrational fear that doesn’t respond to context, whereas your fear of COVID is rational. That’s why you and I are treating mercury contamination OCD and not COVID infection OCD. So comparing them and punishing yourself for not getting the same results is unfair to you and a waste of time,” I replied.

Fear in contamination OCD is irrational and therefore dysfunctional.

I took the opportunity to link this little explanation to the Inference-Based Cognitive Behavioral Therapy (I-CBT) we’re working on together. Here’s a quick reminder: I-CBT holds that obsessional doubts in OCD always arise in inappropriate contexts, that is, they aren’t justified by the person’s here and now. The context I perceive through my senses doesn’t justify me raising the obsessional doubt.

• Example: I’m about to sit down at the table with my family, I see my wife pour water into my glass and the thought pops into my head: “What if there’s mercury in the water in the bottle?” (compulsion: not drinking and not letting anyone else drink).
• Example: I’m playing football with my son and the thought comes: “What if there are traces of mercury on the ball?” (compulsion: stop playing, throw the ball in the bin and intense handwashing for both father and son).

In OCD the person pays more attention to their imagination than to what their senses tell them (the facts they perceive); they give priority to what could happen / could be / could be there over what is happening / is / is there. So no matter how little the circumstances justify the obsession, the person’s fear won’t go down, because it doesn’t come from the context (from outside) but is born and fed in their imagination. That’s why fear in OCD, besides being irrational, is different in nature and needs to be handled differently from other fears.

As you can imagine, patients know from the outset that fear in OCD is irrational, but sometimes they lose sight of it and make comparisons like this one, which only end up demotivating them and bringing them down. So it’s often worth stopping for a while and taking time to remember the nature of fear in OCD. And as I told this patient (and have had to remind many others before him): having difficulty overcoming a disorder has nothing to do with cowardice; the very fact of trying says a lot about a person’s courage. Let’s finally get it into our heads that mental disorders are not a choice. Just as nobody chooses to go through cancer, nobody chooses to develop a mental health problem. And just as the first shouldn’t punish themselves for not being able to make their illness go away, neither should the second.