The Dangers of Avoidance in OCD
Avoidance, by definition, is the action of keeping away from a person or place or not engaging in a particular task or behavior. It’s something we all do, whether we realize it or not.
We may avoid cigarettes because of the health consequences of tobacco. We may avoid eye contact with a coworker so that we don’t have to hear about her cats. We may avoid a particular route on the highway because we know it’s always backed up during rush hour. We may avoid annoying housework by Facetiming friends instead. We may avoid that gut-wrenching Sarah McLachlan animal shelter commercial by changing the channel each time it comes on.
Sometimes, we avoid things because we want to avoid danger. Other times, we engage in avoidance as an attempt to avoid inconvenience or hassle. We even avoid things to our detriment (such as avoiding the gym because we’d rather sleep in on a snowy winter morning).
Avoidance is part of our lives because avoidance is part of the human experience.
But, sometimes, this means avoiding things that make us uncomfortable. We may avoid conflict with neighbors by keeping quiet when they let their grass grow two feet tall, we may avoid confronting our boss when he takes credit for our work, we may avoid talking about politics with our father-in-law.
While this type of avoidance is also human, it is different than avoiding exposure to toxins or avoiding a traffic jam. Avoiding discomfort, especially habitually, approaches the boundary between healthy avoidance and unhealthy avoidance.
Avoidance as a Coping Mechanism
Avoidance as a coping mechanism happens when someone alters their behavior in order to avoid certain thoughts or feelings. It is extremely prominent in Obsessive Compulsive Disorder but it exists in other disorders as well.
For example, people with eating disorders may avoid particular foods (such as those that are high in fat or high in calories) for fear that those foods will cause weight gain. People with social anxiety may avoid parties for fear that they’ll do something to embarrass themselves. People with a fear of heights may avoid ladders or roofs for fear that they’ll be scared of falling. People with panic disorder may avoid elevators for fear that the closed space will cause terror.
In the general public, avoidance is common as well as people may avoid all sorts of things that cause minor to major distress. For instance, an advertising exec with a demanding client may avoid calling that client, knowing the conversation won’t be pleasant. Someone who fears the dentist may avoid getting their teeth cleaned because drills or needles elicit anxiety. A teenager who has a nosy parent may avoid conversing with their parent in fear that they’ll pry to a discomforting degree.
As noted above, in moderation this appears pretty benign and isn’t something likely to affect wellbeing. But when it’s done as a matter of routine, attempting to avoid distress can actually make that distress worse.
In keeping with the previous examples, someone with eating disorders may avoid high-calorie or high-fat food, which reinforces the eating disorder and worsens their relationship with food. Someone with social anxiety may avoid parties, which reinforces that gatherings are linked to risk of personal embarrassment. Someone with a fear of heights may avoid ladders or roofs, which reinforces the idea that heights are dangerous. Someone with panic disorder may avoid elevators, which reinforces the idea that closed spaces are cause for emotional chaos.
In the general population, an advertising exec who avoids calling a demanding client reinforces the idea that confrontation is a bad thing. Someone who avoids getting their teeth cleaned reinforces the idea that dental visits are scary or painful. A teenager who avoids conversing with their parent reinforces the idea that their parent shouldn’t know anything about their life, making that relationship less comfortable in the process.
The takeaway is that avoiding anxiety (or the things that trigger it) reinforces the underlying fears that drive the anxiety to begin with. In short, avoidance validates the fears, only making the fears worse. In this way, it’s like a wolf in sheep’s clothing: It’s an anxiety enhancer disguised as a coping mechanism.
The Self-Fulfilling Prophecy
In addition to reinforcing the underlying fear, avoiding paves the way for a self-fulfilling prophecy, or the phenomenon where someone fears something bad happening and then engages in behaviors that assure their prediction becomes reality.
For instance, someone who fears their partner will leave them may want to stop this from happening. So, they’ll constantly ask their partner for reassurance, flood them with suspicions, demand to know where they are at all hours of the day, and get upset when their partner goes out with their friends. All of these behaviors can drive their partner to leave, resulting in a self-fulfilling prophecy.
Many mental disorders, such as social anxiety and obsessive compulsive disorder, serve as self-fulfilling prophecies in a less obvious manner, partly because of the avoidance involved. Someone with social anxiety may avoid group gatherings because they know those gatherings cause anxiety but this avoidance ultimately makes the anxiety worse. Someone with OCD may avoid driving because they know that driving causes anxiety but this avoidance makes them that much more afraid to drive.
How Avoidance Influences OCD
OCD sufferers engage in avoidance in the form of a one-two punch. First, they experience the “regular” avoidance of being human and then they experience the “OCD avoidance,” which tends to come with its own potent flavor.
Avoidance appears in OCD as a compulsion. Unlike most OCD compulsions, this compulsion is used proactively. For example, someone with Contamination OCD may touch a doorknob, experience an intrusive thought that the doorknob was contaminated with someone else’s body fluids, and then spend an hour washing their hands with soap and water. They engage in this compulsion after the triggering event.
Avoidance, on the other hand, is a compulsion that prevents the triggering event from happening. Instead of touching a doorknob and then washing their hands, the sufferer avoids the doorknob altogether. This essentially heads anxiety off at the pass and prevents it from taking root (or so the OCD sufferer thinks).
But even though it may look different than other compulsions, avoidance still behaves like one. In other words, it worsens OCD just the same. And it doesn’t lessen anxiety at all; it only builds upon it.
The Way OCD Manifests in Sufferers
OCD shows up in sufferers as a complicated dance between obsessions and compulsions (which is why the disorder is called “Obsessive Compulsive Disorder”). It’s a mental illness rooted in neurobiology that involves intrusive, unwanted, and terrifying thoughts (obsessions) that pop into the sufferer’s head frequently. Because these thoughts are egodystonic and go against the sufferer’s true desires, they cause extreme anxiety. This anxiety leads to rituals and routines (compulsions) that sufferers engage in as attempts to neutralize their distress.
The context of these thoughts are determined by the subset of OCD. Some sufferers have only one type of OCD (such as Sexual Orientation OCD or Self-Harm OCD) while others suffer from more than one subtype.
Oftentimes, the general public and pop culture assume that OCD is solely about organization, cleanliness, and germs but that’s only one subtype (Contamination OCD). In reality, OCD has several subtypes and it’s possible for a sufferer to have OCD that focuses on anything.
Overall, some of the most common types of OCD include:
- Contamination OCD
- Relationship OCD
- Scrupulosity OCD
- Harm OCD
- Self-Harm OCD
- Sexual Orientation OCD
- Existential OCD
- Health Anxiety OCD
- Pedophilia OCD
Someone with Harm OCD experiences thoughts that are different than someone with Contamination OCD. For example, a person with Harm OCD may experience the intrusive thought that they’ll push their child off a bridge while someone with Contamination OCD may experience a thought that walking into an old home exposed them to asbestos.
As a result of these different thoughts, the proactive and subsequent compulsions look different as well. Someone who is afraid that they’ll push their child off a bridge may avoid bridges or keep their distance from their child when up high. Someone who is afraid they’ve been exposed to asbestos may bathe compulsively (or they may altogether avoid going into any place where asbestos could be).
The goal of the compulsion is to reassure the OCD sufferer that their intrusive thought isn’t real (ironic, since engaging in a compulsion validates the thought). Sufferers engage in these rituals to assure themselves that the intrusive thought either hasn’t happened yet or won’t happen.
Some people engage in visible compulsions and physically act out a routine (such as handwashing). Others engage in mental compulsions and perform their compulsions in their head (such as thinking of a “good” word or a “lucky” number). Many sufferers may engage in both visible and invisible compulsions.
Intrusive Thoughts in Everyone
While intrusive thoughts are the foundation of OCD, they aren’t unique to the disorder; they appear in everyone. The potency and frequency are different, however, with the general population not experiencing intrusive thoughts as often or as powerfully as those with OCD. This deviation is due to the meaning applied to the thoughts.
People without OCD don’t give these thoughts meaning – they allow them to come and go without reacting to them. Simply, they recognize that the thoughts are nonsense.
People with OCD do the exact opposite, believing these thoughts say something about them – they react to the thoughts when the thoughts appear (assuring that they appear more frequently). Deep down, the sufferer may truly recognize that the thoughts are nonsense but they perform compulsions around them just to be safe (since OCD demands 100% certainty at all times). OCD is known as the “Doubting Disease” for this reason; its sufferers react to pathological doubt and they’re motivated by the idea of “What if?”
Examples of OCD Avoidance
Avoidance in OCD, like all compulsions, is dictated by OCD subtype; someone with Relationship OCD avoids different things than someone with Pedophilia OCD.
In general, some of the ways avoidance may manifest in various subtypes include:
- Avoiding specific places (someone with Harm OCD may avoid nursing homes or other places with vulnerable people, someone with Pedophilia OCD may avoid schools or playgrounds, and someone with Contamination OCD may avoid public restrooms)
- Avoiding certain behaviors (someone with Contamination OCD may avoid touching doorknobs, someone with Harm OCD may avoid handling knives, and someone with Relationship OCD may avoid eating fatty foods (believing that weight gain will cause their partner to leave)).
- Avoiding gatherings or parties
- Avoiding “unlucky” numbers or colors or “bad” words or songs
- Avoiding people or public altogether (in severe cases)
The entire point of avoidance is to avoid the anxiety-triggering situation. Some people with OCD erroneously believe that by avoiding the anxiety, they can sidestep OCD. But this is the furthest thing from the truth.
Why Avoidance Doesn’t Work
Avoidance doesn’t work because it’s a compulsion and compulsions never work. While they offer the sufferer a temporary reprieve from their anxiety, this is always short-lived and the compulsions only worsen the disorder in the long-run. They’re the cogs in the wheel that keep the OCD cycle turning.
The cycle works like this: The OCD sufferer experiences an intrusive thought that they’ll run over someone on the way to the grocery store (for example). As a result, they avoid driving, opting instead to ride their bike, take an Uber, or not travel to the store at all.
For a little while, this gives them the solace they seek: They didn’t drive to the store so it’s impossible that they would have run over anyone. But, ultimately, this avoidance only gives credence to the OCD, telling the sufferer that their intrusive thoughts are real. And this makes OCD that much more powerful.
Some people assume that they can out fox their OCD with avoidance. To expand on the example above, someone with Harm OCD who is afraid they’ll run over pedestrians while driving may assume they can cure their OCD by flipping it the bird, hanging up their car keys for good, and never driving again. Even if this were practical, it still wouldn’t work as OCD just finds something else to latch onto.
For instance, someone with Harm OCD who is no longer driving may begin to experience OCD thoughts that they’ll strangle their child or push a bystander in front of the subway. OCD is creative and persistent and it ups the ante when sufferers try to avoid it. The more they avoid it, the stronger it becomes.
It’s akin to everyday fears and phobias. Someone who is afraid of spiders will not get better by avoiding spiders – this avoidance merely doubles down on the idea that spiders are dangerous. Instead, the only way to lessen their spider phobia is to expose themselves to eight-legged creatures. OCD must be conquered the same way.
ERP and Avoidance
The goal of OCD therapy is to teach the OCD sufferer not to take their intrusive thoughts seriously. When those with OCD engage in avoidance, they’re listening to their intrusive thoughts and allowing those thoughts to dictate their behavior. In short, they’re doing exactly what they shouldn’t. This is where Exposure Response and Prevention exercises come in.
ERP is the gold standard of OCD treatment and the one most often used as it’s proven most effective. But ERPs elicit plenty of anxiety on the part of the sufferer, which makes them hard to complete successfully. This is why they may be combined with medication and, increasingly so, Acceptance and Commitment Therapy (ACT). Both medication and ACT can make ERPs easier, upping the odds that they’ll be completed successfully.
During ERPs, the OCD sufferer is instructed to expose themselves to their intrusive thought (or allow that thought to appear organically) and then refrain from engaging in their compulsions. In regard to avoidance specifically, the sufferer will be asked to avoid avoidance.
For example, someone who has an intrusive thought that using a public restroom will expose them to a communicable disease will be asked not to avoid using that restroom. Someone who has an intrusive thought that they’ll push people down the stairs in their office building will be asked not to avoid using the stairs. Someone who has an intrusive thought that stepping on cracks on the sidewalk will cause harm upon a family member will be asked not to avoid stepping on cracks.
This lack of avoidance ultimately generates a lot of anxiety in the sufferer but that’s kind of the point. The sufferer avoids their avoidance, they sit with their anxiety, they see that nothing bad happens, and the thought loses power.
It’s not a quick fix and many sufferers start ERPs only to give into their compulsions eventually. That’s okay, as long as they keep trying with the goal to practice them all the way through. Usually, sufferers begin on lower level ERPs (i.e., those that don’t elicit as much anxiety as their other obsessions) before diving into the heavier stuff. This allows sufferers to realize ERPs work, motivating them to practice more and more.
Avoidance, in those with OCD and everyone else, is a normal part of being human. Sometimes, this is benign and unlikely to impact life dramatically. But when done over and over again, or in the context of OCD, avoidance only perpetuates the underlying anxiety causing that avoidance in the first place.
The resulting moral: If you want to avoid OCD, avoidance is not the way to do it.