Checking Boxes: Continued

When it comes to the assessment and treatment of obsession and compulsion, what is realistic?

Psychologists and psychotherapists can have a tendency to tinker with psychological models, and not necessarily always in a way that is backed up by research. We can often start putting our own stamp on things. At times, this is necessary, tailoring standardised treatment to individual needs. Other times, more our own personal worldview.¹

As someone with rigid internal rules around doing things "correctly" for most of my life, and despite manualised therapy being my least preferred method of working, I've generally been a stickler for it, mostly due to the research base. Yet, I've rarely seen the outcomes produced by the randomised controlled trials mapping onto the nuance of clinical practice.

Many people require ongoing work, either through periodic episodes of therapy or broader support addressing emotional and cognitive patterns.

Often, I am the third, fourth, or fifth therapist someone has seen, which comes with pros and cons. On the one hand, there can be a lot of pressure to be a magician, the therapist who can unearth what others have failed to find before. Obviously, this is unrealistic; there are no perfect therapists, and the models of therapy I lean into are generally no different from those used by previous therapists.

The main advantage is the opportunity to explore what has already been tried. Less is the case that I am a brilliant or magical therapist. More the case that I have hindsight based on the prior legwork from the client and the therapists before me. And, from my own personal therapy experiences, I have the confidence to ask realistic, often very frank, direct questions from the outset.

A frequent barrier to treatment is misdiagnosis, the most common being generalised anxiety (GAD), especially when the symptoms are less overt or involve taboo content. Studies show that about half of OCD cases are misdiagnosed, with errors more likely when symptoms centre on sexual or violent thoughts.²

Over the last few years there has also been a significant increase in public awareness of mental health and other conditions—which is a good thing. I've been increasingly asked whether certain obsessive and compulsive symptoms might be better explained by autism or ADHD. The question tends to come up a lot in psychological assessments. And it's not an unreasonable question. On the surface, the behavioural aspects of both OCD and OCPD can look similar: repetitive actions, intolerance of uncertainty, difficulties with attention or flexibility.³

But the reasons behind what is driving them are often quite different.

From my own lived experience of obsession and compulsion, neither my early developmental history, thinking patterns, nor how I experience the external world would indicate either autism or ADHD. However, for many people, they can coexist.⁴ There is often a lot of overlap, and they can look very similar, even to a trained eye. But there are important differences.

OCD is classified as a mental health condition. It tends to develop during adolescence or early adulthood, although symptoms can appear earlier. Autism and ADHD are neurodevelopmental conditions. That means they're present from early life, even if they're not recognised at the time, and they affect how the brain processes information across a wide range of domains, not just in response to anxiety-inducing thoughts or rule-bound behaviour.⁵

Autism typically involves a range of differences in social communication, sensory processing, and cognitive flexibility. Many autistic people experience what's often called masking (copying others to blend in socially), which can be absolutely exhausting. There's often a strong need for routine, intense interests, and a struggle with unstructured or unpredictable situations. Repetitive behaviours, often termed stimming, typically serve a self-regulatory purpose, helping to calm or manage sensory overload.⁶

However, where this may relate to symmetry-based compulsions, there can be considerable overlap.

Regarding ADHD, the features tend to be more about attention regulation and impulse control. Traits typically show up by the age of twelve, often earlier, and they're experienced across multiple settings. For example, home, school, and social situations. People with ADHD may struggle with focus, organisation, memory, and time management. Hyperactivity might look like constant movement, excessive talking, or mental gymnastics, like being powered by batteries that don't switch off until they're entirely drained.⁷ Parents often describe their children as "on the go all the time," with problems retaining information and difficulty following instructions.

Living with chronic disorganisation or underperformance due to problems with executive function, especially in structured environments like school, can wear away at self-esteem. It's not uncommon to see low mood or worry as secondary issues.⁸

All of this makes diagnosis more complicated than it looks on paper. I've had patients who technically met the criteria for all three: OCD, autism, and ADHD. Each of them had nuanced and individual experiences. The implications matter, though, at least in terms of how best to help the person.

Obsessive and compulsive problems are usually treated with psychotherapy and sometimes medication. Autistic people may need environmental adjustments, family education, and advocacy around school or employment.⁹ For people living with ADHD, this might involve practical structure, school adaptations, and, in some cases, prescribed stimulant medication, which can involve long-term physical health monitoring.¹⁰

All human traits exist on a spectrum, and people are more complex than checkboxes in a manual. Still, understanding which ballpark you are working with can significantly increase the likelihood of the person getting what they need.

So, how do you become a compulsive-obsessive person?

That would really depend on who you ask.

There are many theories, from faulty thinking, overexcited brain regions, and entrenched belief systems to emotional regulation and psychological conflicts.

From a cognitive-behavioural perspective, the cycle begins when we attach exaggerated meaning to our thoughts. We try to neutralise or keep them at bay through repeated actions.

Schema models take a broader developmental view. This is the idea that our early experiences shape deep-seated rules and beliefs about how the world works. If you grew up in chaos, you might learn that being highly controlled with clear rules brings more emotional safety. If love was conditional, being "perfect" might reduce the potential of rejection.

Neuroscience tends to lean into brain function. OCD has been linked to hyperactivity in certain regions involved in error detection, decision-making, and habit formation.¹¹ Neurotransmitters like serotonin and glutamate appear to play a role, as do certain genetic factors.¹² The brain registers threat, and the alarm senses scorched toast. Over time, this forms a feedback loop.

More traditional therapists, using psychodynamic theory, sometimes come from a different angle. Compulsions are seen as symbolic "defences" or strategies we unconsciously develop to manage impulses, feelings, or emotional discomfort that we can't fully process. It's less about the thought itself and more about what it represents. In this frame, the rigidity and control of OCPD might be ways to defend against vulnerability or emotional intimacy, especially if this felt dangerous or unpredictable in early life.

Each model brings something to the table, and from both my personal and clinical experience, there's a degree of truth to each of them. Yet, none of them explains everything. And if you live with OCD or perfectionistic traits, chances are you'll recognise bits of yourself in all of them.

Of course, as humans, we are a meaning-making species. We like to understand things and have clear answers. But when it comes to why we do what we do, there is rarely anything neat and tidy about it.

To understand this in the context of real human life, we need to go back to the very beginning.

The initial relationship between self and others serves as a blueprint for all future relationships

— John Bowlby

Tell me about your childhood.

Words that typically send my own patients into a spiral during their first appointment. Undoubtedly, the field of psychology and psychiatry often has a caricatured image of attributing our adult life problems to our parents or early guardians. However, personality formation and our perception of the social world are complex. There are key development stages from birth to adulthood that significantly shape our worldview. Hence, it's crucial to consider our historical timeline when we explore current psychological issues.

But we need to tread carefully. There is no general benchmark or specific ideal that we are aiming to achieve with our clients. Recollection of early life is often sketchy to some degree. Human memory isn't entirely reliable, and we will each hold our own perspectives and interpretations of the same events.

What we can recall and how we recall it are shaped by many variables. Even memory that feels crystal clear or photographic may still be incomplete or subject to distortion.

Essentially, the human brain does not record and save information like a smartphone camera does; it reconstructs information, reassembles impressions and fragments, and pieces them together. Our current mood and emotional state can also affect how memories are recalled.¹³

Clinical depression is associated with memory recollection that holds a negative bias and a tendency to interpret ambiguous events with pessimism.¹⁴ Repetition, or constantly going over events, can also lead to memory becoming more intense and emotionally charged, regardless of the original intensity when it was first recalled.¹⁵

Even our recollection of significant events can become distorted. A well-known example comes from the psychologist William Hirst, who conducted a long-term study on flashbulb memories.¹⁶ This is a term he uses to describe vivid, emotionally charged recollections formed during traumatic experiences.

Many people remember watching the first plane, American Airlines Flight 11, crash into the North Tower of the World Trade Centre live on television at 8:46 am on the morning of September 11, 2001. But that footage was never aired live. There were no news cameras filming the towers at that time. It was the second plane, United Airlines Flight 175, striking the South Tower 17 minutes later, that was filmed live on air.

Footage of the first crash was captured by Jules Naudet, a documentary filmmaker who happened to be filming firefighters in Manhattan that morning. His footage wasn't released by the media until several hours later.

Now, imagine if footage of the first plane had never surfaced. Our memory of that first impact would be shaped entirely by secondary information: images of the burning tower and news commentary recorded after the fact. So, we might turn to eyewitness accounts to fill in the gaps. Some of the eyewitnesses described seeing a small aircraft flying toward the towers. Yet, Flight 11 was a large commercial airliner. Eventually, we'd be left to piece together what happened using flight path data, specialist engineers, and forensic analysis of the site.

Essentially, human memory is subjective and not always made up of the full facts. Many of us also struggle to recall memories from our very early lives in great detail.

As psychologists and therapists, we're generally pretty good at objectively finding problems you didn't know were problems until you walked into the room. Obviously, any decent therapist isn't trying to help you invent your history or dictate it to you. Nevertheless, most people are somewhat apprehensive about exploring their early relationships, especially where this may involve confronting sensitive topics that they have limited recollection of and may not fit, despite sounding plausible.

I've been there. It's not an easy process, regardless of which chair you are sitting in. What I can safely say is that if you consider your early life to have been "completely perfect," void of any mistakes or flaws; maybe striving to be a perfect parent yourself—you may want to sit down.

I have bad news.

Perfect parents don't exist.

Like all humans, everyone has flaws, and we all make mistakes. Children can drive their parents crazy at times, scream all night, and fight with their siblings. Naturally, parents can both love and hate their children simultaneously. It's part of everyday life.

Working as a therapist, I've learned firsthand that regardless of how much showboating parents may do at the school gates, no matter how much they manufacture an Instagram life, rarely are things so gold-plated behind the scenes. For most of us, we do our best. Our parents or guardians raised us with what they had available to them at the time. And if we are very honest with ourselves, most of us would likely do things differently in our daily lives, with foresight. For that, we would need a crystal ball.

Sadly, some children experience terror at the hands of their caregivers. Some are severely neglected by them or are not kept safe by them. This is not uncommon to hear as a trauma therapist. In cases involving significant abuse, violence, or life-threatening situations, these are the types of events that the brain can sometimes struggle to process and can lead to complex emotional problems, difficulty creating and maintaining relationships, and mental health problems.

Of course, some people with OCD will have experienced these kinds of events or struggle with additional concerns, such as post-traumatic stress (PTSD). In my experience working across primary, secondary and specialist NHS services, as well as the private sector, it's more common to find that obsessive-compulsive tendencies, including perfectionism, are typically fuelled by clusters of memories commonly referred to as "small-t" traumas, feeding the narrative in the background.

Small-t traumas are adverse life events that vary in quality, severity, and impact. They can be single experiences we've witnessed or difficulties we've personally experienced: emotional neglect, bullying, humiliation, illness, or loss. These events can occur during our formative years when we establish our primary attachments or later in life, such as during school or early adulthood. They may not be as explicit as significant abuse or violence. However, they can still influence our emotional well-being and relationships for some time to come.

So, am I implying here that obsessive-compulsive problems are a trauma response?

No. At least this isn't the case for everyone.

It doesn't necessarily mean that negative or bad experiences directly lead to mental health issues. We all experience life in our own ways, and our brains will appraise information differently from our unique reference points.

Still, these can stem from even the most ordinary life experiences.

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