Obsessive-compulsive disorder (OCD) is an anxiety disorder that is categorized by an individual experiencing unwanted and intrusive thoughts (obsessions) and behavioral rituals (compulsions).
These obsessions are usually recurring and can be intrusive thoughts, images, or urges (uncomfortable bodily sensations). Because of these obsessions, they can drive an individual to perform certain actions, often repetitively, to alleviate the anxiety that the obsessions have caused (compulsions).
According to Jon Hershfield, MFT, author of The Mindfulness Workbook for OCD:
“People describe for me that they are sort of reading this spam junk mail that’s coming into their feed marked as urgent and they don’t know, are they supposed to ignore it, or are they supposed to open it and reply to it, which then teaches the algorithm to send you more of that stuff.”
OCD, for many people, could center around certain themes, such as fear of contamination, so they may excessively clean, and hand wash.
A lot of people may experience obsessive and intrusive thoughts; however, for OCD, these thoughts are persistent, and the behaviors displayed are rigid.
If the obsessive thoughts are ignored, or the behaviors cannot be performed, anxiety and distress can increase.
Therefore, OCD can significantly interfere with daily activities, typical functioning, and social interactions if left untreated. Often, the person with OCD may recognize that their obsessive thoughts aren’t true but will still have trouble disengaging from these thoughts or stopping the compulsive behaviors.
OCD is thought to affect approximately 2-3% of the general population (Rasmussen & Eisen, 1994) and appears to be more common in women than men. The average age of the onset of OCD is 19 years old, with 25% of the cases being recognized by the age of 14.
What are Obsessions?
Obsessive thoughts in OCD often involve a feared outcome.
It is thought there are four features that are essential to OCD obsessions (Abramowitz & McKay, 2009):
- Recurrent and persistent thoughts, impulses, or images that are intrusive and cause great anxiety
- These thoughts are not simply excessive worries about real-life issues
- The individual attempts to ignore, suppress, or neutralize these obsessions with some other thought or action
- The individual is able to recognize that these thoughts are a product of their own mind
Depending on the type of obsession experienced will depend on the feared outcome. For instance, someone may fear losing something important, fear upsetting someone, or fear for their loved one’s safety.
These obsessions may become so overwhelming that it drives them to perform compulsive actions.
These obsessions are often time-consuming and distressing to the individual, unwanted, and outside of the individual’s control.
Although many with OCD understand their thoughts are unrealistic, they cannot be resolved by logic or reasoning. People may try to ease their distress by ignoring or suppressing their obsessions or distracting themselves, but this can often cause more unease and distress.
What are Compulsions?
Compulsions in OCD are the result of obsessive thoughts. These can be repetitive behaviors or mental acts that individuals feel driven to perform in response to an obsession.
These compulsions are used to prevent or reduce the distress associated with the obsession. The compulsions could be the constant repetition of an action, disrupting the normal routine, or being used to prevent something bad from happening, according to the person with OCD.
These actions could be unrelated to the obsessions, and someone could repeat the compulsion so often that they find themselves ‘stuck’ in the compulsion.
The individuals may make up their own rules to stick to or rituals they must perform. Compulsions often do not bring pleasure, only temporary relief from anxiety.
Some examples of compulsions include:
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Washing and cleaning – e.g., excessive hand washing and cleaning of an object.
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Checking – e.g., repeatedly checking the oven is switched off, doors are locked, and switches are all turned off.
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Orderliness – e.g., arranging items to face a certain way or wanting items to be placed in the same spot every time.
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Counting – e.g., this could be counting in patterns or to a certain number, counting how many steps are taken, or tapping an item to a certain number.
The aim of carrying out compulsions is to prevent or reduce distress, or prevent a dreaded event. However, they are excessive or not realistically connected to what they are intended to prevent (Abramowitz & McKay, 2009)
Types of OCD
Below are some types of OCD. Note that this is not an exhaustive list.
It’s important to note that obsessions and compulsions in OCD can vary widely and may not fit neatly into specific categories. Many individuals with OCD may experience a combination of different types of obsessions, and the severity and impact of obsessions can vary from person to person.
Contamination OCD
Those with contamination obsessions will usually have an excessive fear of germs, dirt, and disease. They may fear being contaminated by other people or by the environment.
They might have obsessive thoughts surrounding the fear of touching items others have touched or excessively worry about catching infections from others and the environment.
Compulsions may include excessive cleaning, hand washing, or avoiding certain places or objects perceived as contaminated.
Perfectionism OCD
Those with obsessions about perfectionism may be excessively concerned with exactness and symmetry.
They may worry about items that are not organized in a specific way or will perform compulsions for things to feel ‘just right.’
The person may feel a strong need to arrange things in a specific way or perform repetitive rituals to achieve a sense of symmetry or order. This could also involve touching or tapping objects until a touch feels right to them.
Orderliness And Symmetry OCD
Symmetry OCD, sometimes called Order OCD, is characterized by ongoing intrusive thoughts and compulsive behaviors surrounding sameness, orderliness, balance, and symmetry.
Those with Symmetry OCD will experience frequent obsessions around things not feeling symmetrical or ordered. They will become fixated on the position or arrangement of certain objects and will feel uncomfortable and distressed when items are not aligned correctly or appear in disarray.
Checking OCD
Checking OCD is a subtype of OCD characterized by obsessive thoughts and compulsive behaviors related to checking.
People with this type of OCD may feel compelled to repeatedly check things due to persistent fears or doubts about potential harm or negative consequences.
Obsessive thoughts may revolve around fear of harm or negative consequences, such as worrying about leaving the door unlocked and someone breaking in. Compulsions typically involve repetitive checking behaviors, such as checking locks, appliances, or personal belongings multiple times to alleviate the anxiety caused by the obsessive thoughts.
Harm OCD
Individuals who experience this type of OCD may have obsessive thoughts about harming themselves or others. They may have intrusive and violent thoughts, impulses, or urges about causing harm, which can prove distressing.
Someone with this type of OCD may avoid certain objects or situations, seek reassurance, or engage in mental or behavioral rituals to prevent harm. They may also repeatedly check a situation to make sure they have not caused someone harm.
Superstitious OCD
This type of OCD involves excessive reliance on superstitious beliefs or engaging in repetitive rituals or behaviors to prevent perceived negative outcomes or to bring about desired outcomes.
Individuals with superstitious OCD may have irrational and exaggerated beliefs about the power of certain actions or objects to influence events and may engage in compulsive behaviors or mental rituals to alleviate their anxiety or prevent perceived harm.
For example, an individual may go to lengths to perform an action a certain number of times to their lucky number, e.g., switching on and off a light switch seven times before leaving a room. Completing this compulsion may mean that they avoid bad luck or harm coming to themselves or others.
Counting OCD
Counting OCD, also known as arithmomania, is a common subtype of Obsessive-Compulsive Disorder (OCD) characterized by an obsession with numbers and counting.
Specifically, individuals experiencing this disorder have a strong urge to engage in repetitive and ritualistic counting behaviors.
Counting OCD can manifest in a number of different ways, but some common symptoms include mental counting, item counting, measuring, or waiting for a particular time to perform a specific task.
Religous or moral OCD
This type of OCD involves obsessions related to religion, morality, or ethics. These obsessions may involve fear of committing sins, blasphemy, or violating moral or ethical codes.
Those with religious obsessions may have obsessive thoughts, worries, or concerns surrounding moral judgment. They may have excessive worries about offending religious entities.
Compulsions may include repetitive prayers, rituals, or avoidance of certain thoughts or situations.
Real Event OCD
People who experience Real Event OCD will experience unwanted, obsessive thoughts and fears around an actual event that occurred in the past.
Individuals with Real Life OCD become fixated on actual events or past experiences that make them question their character or morality or made them believe that they are not good or ethical people.
Sexual orientation OCD
This type of OCD involves obsessions related to one’s sexual orientation or identity. This was known as homosexual OCD, but this is misleading as it can happen to anyone, regardless of gender or sexual orientation.
These obsessions may involve persistent doubts or fears about one’s sexual orientation, and compulsions may include seeking reassurance, avoiding certain situations, or engaging in mental or behavioral rituals related to sexual orientation.
Relationship OCD (ROCD)
Many of us occasionally experience varying levels of relationship anxiety.
However, for those with ROCD, these obsessions are all-consuming and uncontrollable and often get in the way of establishing and maintaining romantic relationships.
Individuals with ROCD may experience intrusive and repetitive thoughts about their relationship, their partner’s qualities or flaws, and may engage in compulsive behaviors such as seeking reassurance, constantly checking their feelings, or engaging in mental rituals related to their relationship.
ROCD can cause significant distress and uncertainty in romantic relationships, and may lead to difficulties with trust, intimacy, and relationship satisfaction.
Magical Thinking OCD
Magical Thinking OCD is a form of OCD in which people believe their thoughts, words, or actions can have real-life consequences.
People with Magical Thinking OCD believe that they will be responsible for something awful happening to themselves or a loved one if they do not perform specific compulsive behaviors that their OCD demands.
No matter how unreasonable and irrational, they believe that their thoughts or actions have the ability to alter the course of events in the physical world.
Embracing Uncertainty with OCD
Uncertainty is an inherent part of life. Yet, for those with OCD, uncertainty can become an obsession in and of itself. Intrusive thoughts may latch onto a specific fear or doubt, analyzing the endless possibilities of an uncertain situation or future. This only fuels anxiety and dysfunction.
The good news is there are effective approaches to better cope with uncertainty when you have OCD:
Acknowledge Nothing is Truly Certain
It can be helpful to take a step back and acknowledge the deeper truth – very little in life is actually 100% knowable or certain.
The obsession around a specific intrusive thought or fear is usually not about the content itself, but rather the fact that the outcome is uncertain.
Reframe Thoughts Around the Fear of Uncertainty
Rather than analyzing the specific “what if” content, recognize the underlying fear is likely tied to uncertainty in that moment.
For example, an intrusive thought like “what if I lose control?” is not so much about the specifics of losing control, but rather the uncertainty over knowing if that could happen.
Reframing intrusive thoughts to focus more on the fear of uncertainty can help reduce rumination.
Share Your Thoughts and Realize You’re Not Alone
Writing down intrusive thoughts and seeing examples of how common various themes are can provide immense relief. Online groups even allow for anonymity.
Realizing others have very similar thoughts and fears around uncertainty helps reinforce that these thoughts are symptomatic of OCD – not a reflection of oneself or reality. There is power in exposing thoughts to the light and seeing we don’t suffer alone.
While certainty may remain elusive, there are healthy, compassionate ways for those with OCD to better cope with uncertainty.
Reframing fearful thoughts and finding community can help transform uncertainty from an enemy into simply a part of living.
What Causes OCD?
A direct cause for the onset of OCD has not been found, and the condition’s causes are not fully understood. There are some theories for possible causes and risk factors that could make someone more likely to develop OCD.
Genetics
Genetic factors could be a potential cause of OCD. OCD appears to run in families; therefore, those with parents with this condition are more at risk of developing OCD themselves compared to parents who do not have the disorder (Hettama et al., 2001).
Comorbid conditions
OCD could also be caused as a result of other mental health conditions experienced by the individual. Commonly, other conditions with comorbidity of OCD are other anxiety disorders (e.g., generalized anxiety disorder, social anxiety) and mood disorders such as major depressive disorder, bipolar disorder (Ruscio et al., 2010).
Some of the symptoms of these disorders, among others, may contribute toward the development of OCD.
Brain injury
Another possible cause of OCD is a traumatic brain injury. Some cases have reported an acute onset of OCD within a day to a few months following traumatic brain injury (Berthier et al., 2001). Symptoms of OCD have also been associated with stroke lesions, brain tumors, and Parkinson’s Disease (Kurlan et al., 2004).
Serotonin levels
Individuals with OCD appear to respond well to medication that affects the neurotransmitter serotonin (specifically selective serotonin reuptake inhibitors, SSRIs). Because of this, it has been suggested that serotonin levels and how the brain processes this chemical are associated with OCD (Sinopoli et al., 2017).
However, considering a lot of people with OCD also have other conditions alongside this, such as anxiety and mood disorders, it could be that the medication targeting serotonin is improving symptoms of those other conditions rather than OCD directly.
Environmental factors
Environmental factors, such as trauma, stress, and childhood adversity, may increase the risk of developing OCD (Boileau, 2022). For example, a history of childhood abuse, neglect, or other traumatic events may contribute to the development of OCD symptoms later in life.
Emerging studies suggest that individuals with a predisposition for feeling shame may be at a higher risk for developing OCD.
Childhood experiences that induce intense feelings of shame, such as bullying or critical parenting, may lay the groundwork for obsessive-compulsive tendencies later in life (Anderson & Clark, 2022).
Cognitive factors
Cognitive factors, such as dysfunctional beliefs and thought patterns, may contribute to the development and maintenance of OCD.
For example, having a heightened sense of responsibility, a need for certainty, or a tendency to catastrophize may contribute to obsessive thoughts and compulsive behaviors.
Learned behaviors
Behavioral factors, such as learned behaviors and conditioning, may play a role in OCD. For example, engaging in compulsive behaviors as a way to reduce anxiety or distress may reinforce the cycle of obsessions and compulsions.
Likewise, if someone has observed their parent complete compulsions, a child may learn that this is typical behavior and may be more likely to carry these behaviors themselves.
Treatment Options
Treatments for the symptoms of OCD depend upon the symptoms experienced and the extent that they affect the individual’s life and overall functioning.
It’s important to note that treatment for OCD is highly individualized, and what works for one person may not work for another. It’s best to consult with a qualified mental health professional to determine the most appropriate treatment plan for your specific needs.
Cognitive behavioral therapy (CBT)
Psychotherapy, such as cognitive behavioral therapy (CBT), is a possible treatment for OCD. Specifically for OCD, a type of CBT called exposure and response prevention (ERP) alongside cognitive therapy may be appropriate for the treatment of CBT.
ERP involves initially exposing the individual with OCD to situations or objects that trigger their fear and anxiety. They are then instructed to avoid performing their compulsions.
This will usually lead to increased levels of anxiety to begin with. By staying in a situation with heightened fear and without anything bad happening (which is the obsessive fear of the individual), the individual will learn that their fearful thoughts are just thoughts rather than reality.
The aim is that over time and repeated exposure in later sessions, anxiety will decrease or even disappear.
Findings have consistently found that ERP procedures are highly effective in treating OCD (Foa, 2022).
The cognitive therapy part of CBT helps the person with the way they think, feel, and behave. It encourages individuals to identify and re-evaluate their beliefs about the consequences of engaging or disengaging in compulsive behaviors.
A technique involves working with the therapist to examine the evidence that supports or does not support their obsessions. This can encourage the individual to view the situation more realistically and question whether their thoughts are real.
Through CBT, people can learn to cope with their obsessions without relying on ritualistic and repetitive behaviors. Many people may be reluctant to begin participating in CBT due to the initial anxiety it evokes at the start, although over time, this anxiety should significantly decrease in many people.
Mindfulness
Mindfulness for OCD involves bringing open, present moment attention to whatever arises, including difficult thoughts, feelings, and sensations that may come up during ERP treatment.
It involves allowing and inviting in these experiences non-judgmentally as part of being human, rather than resisting or trying to get rid of them.
The tendency is often to categorize feelings as either “good” or “bad,” usually with things like anxiety, fear, and disgust falling into the “bad” category. We’re culturally conditioned to view them as negative emotions that we need to get rid of.
So when those types of feelings arise, our automatic judgment is often that “this feeling is bad, I need to make it go away.” There can be a lot of meanings we assign – “If I feel anxiety, something must be wrong, it means I can’t handle this,” etc.
Mindfulness involves catching ourselves when we default into judgmental thinking, labeling emotions as bad or problematic.
With mindfulness, the aim is to step back from assigning meaning and instead view feelings more objectively – simply as sensations arising in the present moment, without perhaps all the cultural baggage and connotations attached.
Stepping into an observer role creates some distance from the feeling, so we can see it without immediately judging it to be bad or latching onto stories about what it means about us or the situation.
We recognize it simply as one part of the range of human experience, allow it to be there without making things worse by piling on judgments, and then we can choose how to respond.
Medication
Medication can also be an effective treatment for OCD. Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, fluvoxamine, sertraline, and paroxetine, are commonly prescribed medications for OCD and are well-established treatments for this disorder (Walsh & McDougle, 2011).
These medications work by increasing the levels of serotonin, a neurotransmitter, in the brain, which can help reduce the symptoms of OCD. Other types of antidepressants, such as clomipramine, which is a tricyclic antidepressant, may also be prescribed for OCD.
Typically, an improvement in symptoms relating to OCD can be seen after several weeks of taking the medication. It is usually recommended that those with more severe OCD symptoms receive a combination of CBT and medication to aid with their condition.
Psychodynamic therapy
Psychodynamic therapy, also known as psychoanalysis, is a type of therapy that focuses on exploring the unconscious thoughts and feelings that may underlie OCD symptoms. This type of therapy may help individuals gain insight into the underlying causes of their OCD and develop coping strategies to manage their symptoms.
Many researchers question psychodynamic therapy and psychoanalysis for the treatment of OCD. Expert guidelines claim there is little evidence-based to justify it’s use in mental health services for OCD (NICE, 2006).
Lifestyle changes
Certain lifestyle changes can also be beneficial in managing OCD symptoms on one’s own. Here are some examples:
- Improved sleep hygiene: Establishing a consistent sleep routine and creating a relaxing bedtime routine can promote better sleep, which may help manage OCD symptoms.
- Stress management: Learning effective stress management techniques, such as deep breathing or mindfulness, can help cope with stress and reduce OCD symptoms.
- Regular exercise: Engaging in regular exercise can help regulate mood and provide a healthy outlet for managing OCD symptoms.
- Healthy diet: Eating a balanced and nutritious diet can support overall mental health and help manage OCD symptoms.
- Time management: Effective time management, such as creating a schedule or to-do list, can reduce stress and contribute to better OCD symptom management.
- Avoidance of substance abuse: Avoiding or minimizing substance abuse can be important in managing OCD symptoms effectively.
It’s important to note that lifestyle changes alone may not be sufficient to manage OCD, but they can complement other treatment approaches and contribute to an overall healthy lifestyle that supports mental well-being.
Frequently Asked Questions
What can happen if OCD is left untreated?
If left untreated, OCD can result in a decline in mental health, including increased anxiety, depression, and reduced quality of life.
It may interfere with daily functioning, such as work, school, and relationships, due to the time-consuming nature of compulsions.
Untreated OCD can also increase the risk of developing other mental health disorders and may lead to harmful behaviors or rituals that can result in physical injuries or legal issues.
How does OCD affect daily life?
The obsessions and compulsions of OCD can interfere in daily functioning.
Obsessions may cause intense anxiety, fear, or distress, leading to preoccupation and interference with regular activities.
Compulsions can use up a lot of time and energy, disrupting daily routines and responsibilities.
OCD may also result in avoidance of certain situations or places, strained relationships, and reduced enjoyment of hobbies or interests.
Overall, OCD can impair an individual’s ability to function effectively in various areas of life, including work, school, social interactions, and personal well-being.
What can make OCD worse?
There are many factors that can worsen the symptoms of OCD.
Stress, anxiety, and emotional distress can worsen OCD symptoms as the increased tension may trigger or intensify obsessions and compulsions. Lack of sleep or poor sleep quality can also contribute to increased OCD severity.
Avoidance of triggering situations or engaging in safety-seeking behaviors, which provide temporary relief from anxiety, can reinforce the vicious cycle of OCD and make it worse in the long term.
Additionally, using substances like drugs or alcohol as a coping mechanism may exacerbate OCD symptoms.
Is OCD always linked to anxiety?
Anxiety is commonly associated with OCD, but it’s not always a defining feature.
While anxiety often arises from the distress caused by obsessive thoughts, compulsions may also be driven by a need to reduce discomfort, uncertainty, or distress, rather than anxiety specifically.
Additionally, some individuals with OCD may experience more feelings of guilt, shame, or disgust rather than anxiety. However, anxiety is a common emotion that many people with OCD experience due to the distressing nature of intrusive thoughts and the urge to engage in compulsive behaviors to manage the anxiety.
Nevertheless, it’s important to note that not all individuals with OCD experience anxiety as their primary emotional response, and the symptoms and experiences of OCD can vary greatly from person to person.
Is OCD Neurodivergent?
Yes, OCD is considered a form of neurodivergence. Neurodivergence refers to variations in the human brain regarding sociability, learning, attention, and mood. OCD, characterized by intrusive thoughts and compulsive behaviors, falls under this umbrella as a distinct neurological variation.
Do you need mental health support?
USA
If you or a loved one are struggling with symptoms of an anxiety disorder, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline for information on support and treatment facilities in your area.
1-800-662-4357
UK
Contact the Samaritans for support and assistance from a trained counselor: https://www.samaritans.org/; email jo@samaritans.org .
Available 24 hours a day, 365 days a year (this number is FREE to call):
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Rethink Mental Illness: rethink.org
0300 5000 927
References
Abramowitz, J. S., Taylor, S., & McKay, D. (2009). Obsessive-compulsive disorder. The Lancet, 374(9688), 491-499.
American Psychiatric Association. (2020, December). What Is Obsessive-Compulsive Disorder? https://www.psychiatry.org/patients-families/ocd/what-is-obsessive-compulsive-disorder
Anderson, L., & Clark, M. (2022). Childhood Shame and OCD Onset: A Longitudinal Analysis. Journal of Child Psychology, 41(6), 758-769.
Berthier, M. L., Kulisevsky, J., Gironell, A., & López, O. L. (2001). Obsessive-compulsive disorder and traumatic brain injury: behavioral, cognitive, and neuroimaging findings. Cognitive and Behavioral Neurology, 14(1), 23-31.
Boileau, B. (2022). A review of obsessive-compulsive disorder in children and adolescents. Dialogues in clinical neuroscience.
Foa, E. B. (2022). Cognitive behavioral therapy of obsessive-compulsive disorder. Dialogues in clinical neuroscience.
Hershfield, J., & Corboy, T. (2020). The mindfulness workbook for OCD: A guide to overcoming obsessions and compulsions using mindfulness and cognitive behavioral therapy. New Harbinger Publications.
Hettema, J. M., Neale, M. C., & Kendler, K. S. (2001). A review and meta-analysis of the genetic epidemiology of anxiety disorders. American Journal of Psychiatry, 158(10), 1568-1578.
Kurlan, R. (2004). Disabling repetitive behaviors in Parkinson’s disease. Movement disorders: official journal of the Movement Disorder Society, 19(4), 433-437.
Leckman, J. F., Denys, D., Simpson, H. B., Mataix‐Cols, D., Hollander, E., Saxena, S., Miguel, E. C., Rauch, S. L., Goodman, W. K., Phillips, K. A. & Stein, D. J. (2010). Obsessive–compulsive disorder: a review of the diagnostic criteria and possible subtypes and dimensional specifiers for DSM‐V. Depression and anxiety, 27(6), 507-527.
Murphy, D. L., Timpano, K. R., Wheaton, M. G., Greenberg, B. D., & Miguel, E. C. (2010). Obsessive-compulsive disorder and its related disorders: a reappraisal of obsessive-compulsive spectrum concepts. Dialogues in clinical neuroscience, 12(2), 131.
National Institute for Health and Clinical Excellence (NICE). Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. The British Psychological Society & The Royal College of Psychiatrists. 2006. Available at: www.nice.org.uk
Rasmussen, S. A., & Eisen, J. L. (1994). The epidemiology and differential diagnosis of obsessive compulsive disorder. The Journal of clinical psychiatry, 55, 5-10.
Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Molecular psychiatry, 15(1), 53-63.
Sinopoli, V. M., Burton, C. L., Kronenberg, S., & Arnold, P. D. (2017). A review of the role of serotonin system genes in obsessive-compulsive disorder. Neuroscience & Biobehavioral Reviews, 80, 372-381.
Walsh, K. H., & McDougle, C. J. (2011). Psychotherapy and medication management strategies for obsessive-compulsive disorder. Neuropsychiatric disease and treatment, 485-494.
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