What are obsessions and compulsions?
As suggested in the name, the defining aspect of Obsessive-Compulsive Disorder is having both obsessions and compulsions.
Obsessions are the repetitive thoughts, images or urges that are unwelcome and cause distress, repulsion, shame, guilt or disgust.
Compulsions are all the things you feel compelled to do to ease the suffering caused by the obsessions. You undertake repetitive actions to prevent your obsession from happening and thus avoid a feared consequence.
You can see a few examples of obsessions and compulsions below.
People whose obsessions are clustered around checking fear of making a mistake or forgetting to do something that could cause harm to themselves or others, and it would be their fault.
- Did I lock the door?
- Did I turn everything off?
- Did I leave my email account open?
- Someone will break in
- A fire might start
- Someone is reading my stuff
- Rechecking door locks and latches
- Rechecking everything turned off
- Rechecking computer and mobile devices
For most people with OCD, the compulsions are much more elaborate than in the example I gave above. They can start relatively small, double-checking that everything is locked, but over time this quick check is not enough to ease the doubt created by the obsessions and quite elaborate, disabling rituals can occur.
Structured self-help course for Intrusive Thoughts from the privacy of your home
Dr Ryan: Psychologist and Founder of MoodSmith
You might have a specific number of times you check in addition to how you check. You might say the word ‘off’ out loud several times. You may take a picture of the locks to ease your doubt while away from home.
People whose obsessions are clustered around contamination are afraid that, ultimately, they might be responsible for making themselves or someone they care about ill or worse.
- Is that clean?
- I might make someone ill
Compulsions surrounding contamination can be very complex. It is not as simple as not wanting to touch something another person may have touched.
A complex chain of events may mentally torture a person whose OCD centres around contamination.
They may not want to touch, for example, the door handle. Not just because someone touched it before them, but they are concerned about what person one may have touched before the door handle, person two who touched it before them, and so forth.
Regardless of the type of obsession, compulsions are carried out to prevent something bad from happening.
Compulsions can be obvious to see. We call these overt compulsions. But someone can also suffer from hidden compulsions. These are not visible to another person as they occur in the person’s mind. They are mental compulsions, and we call these covert compulsions.
I have found people can miss getting the diagnosis they need if they have covert compulsions hidden from view.
Someone attending therapy is not an expert in mental health. In the assessment sessions, they will not announce that they suffer from hidden compulsions, helping the clinician make a diagnosis.
Even though the person wants to be as honest as possible to get the help they need, they probably do not recognise their mental rituals as compulsions.
An example is when the person has intrusive thoughts and no visible compulsions. You might recognise this if I give it the label Pure OCD.
In my experience as a psychologist for 20 years, even those individuals who think they have Pure O always have hidden compulsions such as cognitive testing or reassurance seeking. 1
It is important to note that compulsions start as voluntary, as they are something you consciously do. However, over time, they become habitual and no longer ease your anxiety, and the compulsions become the thing that interferes with your quality of life.
How do compulsions start?
Compulsions always have a function; they serve a purpose. Most clinicians working with OCD are familiar with the function of compulsions concerning, for example, avoiding harm.
The person might repeatedly check that they have turned things off and unplugged electrical appliances. However, it would help if you also considered the less visible function of compulsions related to the person’s emotional experience. In this instance, the driving force of the compulsions is that something is ‘just not right.’
For a compulsion to start, you need to have a recurring, persistent thought that is upsetting to you; an obsessive thought. If you did not have the uncomfortable idea, you would never have felt the need to neutralise it. Or reassure yourself or prevent something wrong from happening to you or the people you love.
I shall use an example from my practice to help explain this to you.
The following is an example of how obsessions and compulsions work together using a case study from a client I worked with several years ago. I have changed names and details to ensure anonymity.
I chose this case as an example, as OCD is rarely as simple as something dirty. I need to wash my hands.
Her General Practitioner referred Mary, a 39-year-old separated woman, to the service for reporting Obsessive-Compulsive Disorder (OCD) symptoms. Specifically, Mary was having difficulty with a fear of contamination from faeces. This was the main reason for her referral. Mary recalls being concerned about waste paper bins as she stated that ‘these contain nappies’.
Mary’s symptoms started after finding out her husband had been having an affair. Mary recalls being concerned about waste paper bins as she stated that ‘these contain nappies’.
Mary and her husband have been separated for 11 years. While they were living together as husband and wife, Mary described telephoning her husband often to reassure herself that he had arrived at work safely.
Note. Those diagnosed with OCD may recognise Mary calling to make sure someone arrived at their destination as a compulsion. It follows an obsession that something terrible could happen to someone you care about, which was one of Mary’s obsessions.
She stated she was concerned that something might happen to him, causing her to worry about coping alone.
For most of her adult life, Mary was afraid that she would be abandoned. She was scared she could not cope alone. This fear manifested itself in her repeatedly telephoning her husband to reassure herself that nothing had happened to him.
Mary’s thoughts exacerbated this need for reassurance that she could not cope alone if anything happened to him. For those interested in Schema Therapy, we also discovered an abandonment schema based on dependence 2 (Young and Klosko, 2019).
The OCD, in terms of her fear of contamination, which was why she was referred to me by her doctor, was a visible compulsion. At the beginning of this article, I explained people might not get the help they need if less visible compulsions are missed. We discovered that the compulsions Mary found most challenging were her hidden mental compulsions that stemmed from her fear of being left alone.
As you can see from the above example, obsessions and compulsions can be complex. Still, there is always a reason you perform rituals.
Williams, M. T., Farris, S. G., Turkheimer, E., Pinto, A., Ozanick, K., Franklin, M. E., Liebowitz, M., Simpson, H. B., & Foa, E. B. (2011). Myth of the pure obsessional type in obsessive-compulsive disorder. Depression and anxiety, 28(6), 495–500.
- Young and Klosko 2019 Reinventing Your Life