Obsessive-Compulsive Disorder, OCD, is a mental health condition that consists of obsessions, compulsions, or both, which adversely interfere with your quality of life.
What is Obsessive-Compulsive Disorder (OCD)?
Obsessive-Compulsive Disorder (OCD) is a chronic mental health condition characterised by persistent, intrusive thoughts (obsessions) and repetitive behaviours (compulsions). These obsessions and compulsions significantly interfere with daily life, causing considerable distress and impairing an individual’s ability to function normally. OCD occurs in roughly 2 per cent of the general population worldwide (Sasson et al. 1997)1. However, this figure could be much higher as many people do not come forward for help and remain undiagnosed. The World Health Organisation, estimates that OCD affects approximately 1 in 40 people globally, making it a prevalent mental health disorder. Despite the availability of effective treatments, OCD remains widely misunderstood and underdiagnosed.
Most people have heard of OCD or watched programs about it on television. People often think of it as hand washing or repeatedly having to perform some ritual where handwashing is a compulsion that follows a thought that something is dirty or contaminated. However, OCD has more categories or subtypes than contamination.
OCD can be divided into several categories. Intrusive thoughts fall under what Abramowitz et al (2010) called taboo categories.
- contamination
- symmetry/incompleteness
- responsibility for harm
- intrusive taboo thoughts
Many misconceptions surround OCD, leading to a significant misunderstanding of the disorder. One common myth is that OCD is solely about cleanliness or being overly meticulous. This stereotype undermines the severity and complexity of the condition. In reality, OCD is a legitimate and debilitating mental health disorder that affects various aspects of a person’s life. Another misconception is that individuals with OCD can simply “snap out of it” or that their behaviours are a sign of weakness. This misunderstanding contributes to the stigma associated with OCD and can prevent individuals from seeking the help they need. Addressing these myths is crucial for fostering a better understanding of OCD and encouraging those affected to seek appropriate treatment.
Symptoms of OCD
Touching something and scrubbing your hands is the typical presentation of OCD shown in the media, but this represents only a sub-type of the condition.
If you suspect you might have OCD, you will have both obsessions and compulsions, a thought and then feeling compelled to do something.
At its simplest, OCD is a thought which creates anxiety, followed by a ritual or compulsion which gives you temporary relief from the tension. The idea on its own will not lead to compulsion. The feeling of anxiety, shame, disgust, or guilt compels you to ritualise, which is a crucial point in treating OCD and the backbone of ERP. If you can manage the uncomfortable feeling without carrying out the compulsion, you are well on your way to breaking the cycle of OCD.
Obsessions
People with OCD can go to great lengths to either avoid these thoughts or
carry out elaborate or repetitive compulsions to cleanse the idea, reduce the emotion and prevent the thought from coming true.
Obsessions in OCD are recurrent, persistent thoughts, urges, or images that are intrusive and unwanted, causing significant anxiety or distress. These thoughts often conflict with an individual’s values and beliefs, leading to intense feelings of shame, guilt, or disgust. Unlike typical worries, obsessions are relentless and cannot be easily dismissed or controlled, making them particularly distressing and disruptive to everyday life.
Important. Having the thought does not mean that it is true. This is thought-action fusion.
Common Themes
Another prevalent theme is the fear of harm, involving persistent concerns about causing harm to oneself or others, even when no real danger exists. Intrusive thoughts, another form of obsession, involve unwanted thoughts about sex, religion, or violence, which are often distressing and contradictory to the person’s moral beliefs. The need for symmetry and order is also a common theme, where individuals feel compelled to arrange objects in a specific manner to achieve a sense of balance and perfection. Lastly, doubts and uncertainty are pervasive, causing individuals to question their actions or decisions constantly, leading to a cycle of reassurance-seeking and second-guessing.
Intrusive Thoughts vs. Obsessions
Regardless of the type of obsession, compulsions are carried out to prevent something bad from happening.
While everyone experiences intrusive thoughts occasionally, those with OCD find these thoughts to be persistent and distressing. The difference lies in the frequency, intensity, and the distress they cause, leading to compulsive behaviours to alleviate the anxiety. Intrusive thoughts are common and typically fleeting, but in OCD, these thoughts become overwhelming, persistent, and cause significant distress, disrupting daily life and functioning.
Compulsions
Compulsions develop to reduce the anxiety associated with obsessive thoughts and images.
Compulsions are, for example, feeling compelled to go back to the house and check the curling irons are turned off, and unplugged and that you can see the plug is far away from the socket.
We all have compulsions or rituals to a certain degree.
For example, think about superstitions, throwing salt over the shoulder, not putting an umbrella indoors, not walking under ladders or splitting a post or pole with a friend.
Do you think throwing salt over the shoulder will stop something from happening? Or you may lose a long-term friendship because while out walking, you both walked either side of a post. Maybe not, but many of us do not risk it or “tempt fate” all the same.
However, it becomes problematic when compulsions or rituals interfere with daily life.
Overt Compulsions (Visible)
Overt compulsions are observable actions that individuals perform to alleviate anxiety. One common overt compulsion is washing and cleaning, where individuals excessively wash their hands or clean surfaces to eliminate perceived contamination. Checking is another frequent compulsion, involving repeated checking of locks, appliances, or personal belongings to ensure safety or prevent harm. Ordering and arranging are compulsions where individuals feel compelled to rearrange objects to achieve a specific order or symmetry. Repetitive actions, such as tapping or touching objects in a particular sequence, are also common overt compulsions aimed at preventing perceived harm or achieving a sense of completeness.
Covert Compulsions (Hidden)
Covert compulsions are mental rituals or hidden actions performed in response to obsessions. These compulsions are not easily observable by others but are equally distressing and disruptive. Mental rituals may include counting, repeating specific phrases, or seeking reassurance mentally to neutralise the anxiety caused by obsessions. Avoidance is another form of covert compulsion, where individuals go to great lengths to avoid situations or objects that trigger their obsessions, significantly impacting their daily activities and interactions.
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.
Case example
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.
How obsessions and compulsions become OCD
When you start having obsessions, your brain is quick to learn that compulsions can ease your anxiety, even for a little while, and the urge to repeat the compulsions is strong, as you want to feel better, but this attempt to feel better, unfortunately, is the path to obsessive-compulsive disorder, where you have an uncomfortable thought, which makes you anxious, and you carry out compulsions, which makes you feel better for a short time until the obsession starts again.
To explain this better, I shall give some examples below of how obsessions and compulsions can work together to become obsessive-compulsive disorder.
Checking
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.
| Obsession | Fear | Compulsion |
|---|---|---|
| Did I lock the door? | Someone will break in | Rechecking door locks and latches |
| Did I turn everything off? | A fire might start | Rechecking everything turned off |
| Did I leave my email account open? | Someone is reading my stuff | Rechecking computer and mobile devices |
Contamination
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.
| Obsession | Fear | Compulsion |
|---|---|---|
| Is this clean? | I could make someone ill | Washing |
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.
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.
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.
The OCD Cycle
The OCD cycle begins with an obsession, which triggers significant anxiety or distress. In an attempt to alleviate this anxiety, the individual engages in a compulsion, which provides temporary relief. However, this relief is short-lived, and the obsession soon returns, restarting the cycle. This cycle of obsession, anxiety, compulsion, and temporary relief reinforces the OCD patterns, making it increasingly difficult to break free from the compulsive behaviours.
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.
Types of OCD
OCD can manifest in various ways, and while subtypes are not formal clinical diagnoses, they help categorise OCD based on common themes. Understanding these subtypes can aid individuals in relating to their experiences and guide treatment approaches. Recognising the different subtypes of OCD can provide clarity and direction for both individuals affected by the disorder and the professionals treating them.
Individuals may experience multiple subtypes simultaneously, and their subtypes can change over time. Recognising these subtypes is crucial for tailored treatment and support.
Checking OCD
Harm OCD
Harm OCD is marked by intrusive thoughts about causing harm to oneself or others. Despite having no intention or desire to act on these thoughts, individuals with Harm OCD are consumed by fear and guilt. They may engage in checking or avoidance behaviours to prevent perceived harm, further entrenching their anxiety and distress.
ROCD
Religious OCD
HOCD
POCD
Pedophilia OCD involves intrusive thoughts about pedophilia, despite having no desire to harm children. Individuals with this subtype are deeply distressed by these thoughts and may engage in avoidance behaviours or seek reassurance to alleviate their anxiety and guilt. The fear of being perceived as a pedophile can lead to significant social and emotional isolation.
Post partum OCD
Existential OCD
Hit and Run OCD
Sensorimotor OCD
Sensorimotor OCD is marked by heightened awareness of bodily sensations and an urge to control them. Individuals with this subtype may focus intensely on their breathing, blinking, or other bodily functions, leading to compulsive behaviours aimed at controlling or normalising these sensations.
Pure O
Intrusive Thoughts
Causes of OCD
Possible Contributing Factors
Genetics
Brain Structure
Environment
Learned Behaviours
Diagnosis of OCD
Diagnosing OCD involves a comprehensive evaluation by a mental health professional, as there is no single test for the disorder. The diagnostic process requires a thorough understanding of the individual’s symptoms, history, and overall functioning.
Assessment Process
Clinical Interview A clinical interview is a crucial component of the OCD assessment process. During the interview, a mental health professional will discuss the individual’s symptoms, their severity, and how they impact daily life. The clinician will ask about the onset and duration of the symptoms, any family history of OCD or other mental health conditions, and the individual’s overall mental health and medical history. This information helps the clinician understand the context and nature of the symptoms.
Questionnaires Standardised questionnaires are often used to assess OCD symptoms. These tools help quantify the severity and frequency of obsessions and compulsions, providing a structured way to evaluate the disorder. Commonly used questionnaires include the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which assesses the severity of OCD symptoms and their impact on daily functioning.
Differential Diagnosis Differential diagnosis is essential to rule out other conditions that may present with similar symptoms. Conditions such as Generalised Anxiety Disorder (GAD), Body Dysmorphic Disorder (BDD), Hoarding Disorder, and other anxiety or mood disorders may have overlapping features with OCD. A thorough evaluation ensures that the diagnosis is accurate and that the individual receives appropriate treatment.
Diagnostic Criteria (DSM-5)
Mental health professionals use a diagnostic handbook: The Diagnostic and Statistical Manual for Mental Disorder, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013)
Until the new edition of The Diagnostic and Statistical Manual for Mental Disorder DSM in 2013, OCD fell under anxiety disorders, including other conditions such as panic disorder, social phobia, simple phobia, GAD, and post-traumatic stress disorder. The defining diagnostic criteria for OCD was anxiety when classified as an anxiety disorder.
OCD was given a separate category in 2013 by The Diagnostic and Statistical Manual for Mental Disorder DSM-5, known as obsessive-compulsive and related disorders. This change was significant as the defining diagnostic criteria for OCD are now obsessions and compulsions.
Obsessions and compulsions, though, are not sufficient for diagnosing OCD. To be given a diagnosis, the mental health professional will be interested in how much the obsessions and compulsions impact your life, how much distress they cause you, and how much of your time they affect.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), provides specific criteria for diagnosing OCD. These criteria include:
- The presence of obsessions, compulsions, or both. Obsessions are defined as recurrent, persistent thoughts, urges, or images that are intrusive and cause significant anxiety or distress. Compulsions are repetitive behaviours or mental acts that an individual feels driven to perform in response to an obsession.
- The obsessions or compulsions consume significant time, typically more than an hour per day.
- The obsessions or compulsions cause significant distress or impairment in social, occupational, or other important areas of functioning.
- The symptoms are not attributable to the physiological effects of a substance (e.g., drug abuse or medication) or another medical condition.
- The disturbance is not better explained by the symptoms of another mental disorder.
Treatment and Management of OCD
The cornerstone of therapy is to help you reduce and eliminate your compulsions and stop having distressing thoughts and images. To achieve this, we work with your thought processes and help you reduce your overall anxiety levels.
When you feel calmer, you are in an excellent position to start working towards reducing and finally eliminating your compulsions.
What to expect if you meet with a mental health professional?
People often start with a visit to their doctor, who will refer them to a psychologist or psychiatrist. I’m a psychologist and will briefly outline what will happen if you attend a psychologist.
Assessment
Your first and maybe second appointments are used to undertake an assessment.
In the assessment, you will be asked questions about the following;
your obsessions (the unwanted thoughts and images) to identify the type of obsession (if any), how often they happen, and whether or not they interfere with your quality of life.
The psychologist will ask about what you do to help cope with the obsessions. The things that you do to manage are known as compulsions. Again, the psychologist will record the type of compulsion, how often you do this, how much it bothers you, and how much it interferes with your quality of life.
The psychologist will score your answers, and depending on your score, you will be told you do not have OCD or have mild, moderate or severe OCD.
OCD is highly treatable, and with proper treatment, individuals can experience significant improvement. The primary treatment approaches include therapy, medication, and other complementary methods. A combination of these treatments is often the most effective way to manage OCD symptoms and improve quality of life.
Therapy
Cognitive Behavioural Therapy (CBT)
Cognitive Behavioural Therapy (CBT) is a well-established and effective treatment for OCD. CBT focuses on identifying and changing negative thought patterns and behaviours. It helps individuals understand the connection between their thoughts, feelings, and behaviours and develop healthier ways to respond to obsessive thoughts.
Exposure and Response Prevention (ERP)
A specialised form of CBT, Exposure and Response Prevention (ERP), is considered the gold standard for OCD treatment. ERP involves gradually exposing individuals to feared situations or thoughts while preventing the associated compulsive behaviours. This exposure helps reduce anxiety over time and breaks the cycle of obsession and compulsion. For example, a person with contamination fears might be gradually exposed to touching commonly perceived “dirty” objects without washing their hands afterward.
Acceptance and Commitment Therapy (ACT)
Acceptance and Commitment Therapy (ACT) is another therapeutic approach that can be effective for OCD. ACT focuses on accepting intrusive thoughts without trying to change or eliminate them and committing to valued actions despite the presence of anxiety. This approach helps individuals develop a more flexible and accepting relationship with their thoughts and feelings, reducing the impact of OCD on their lives.
Medication
Selective Serotonin Reuptake Inhibitors (SSRIs) SSRIs are a class of antidepressants commonly used to treat OCD. These medications help regulate serotonin levels in the brain, which can reduce the severity of OCD symptoms. Common SSRIs prescribed for OCD include fluoxetine, sertraline, and fluvoxamine. It may take several weeks for the full benefits of SSRIs to become apparent, and some individuals may require a combination of medication and therapy for optimal results.
Other Therapies
Mindfulness-Based Therapies Mindfulness-based therapies, such as Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR), can be beneficial for individuals with OCD. These therapies focus on developing mindfulness skills to observe thoughts and feelings without judgment, reducing the impact of obsessions and compulsions on daily life.
Support Groups Support groups provide a valuable resource for individuals with OCD and their families. These groups offer a safe space to share experiences, receive support, and learn from others who are going through similar challenges. Participating in support groups can help reduce feelings of isolation and provide practical strategies for managing OCD symptoms.
Alternative and Complementary Treatments
Relaxation Techniques Relaxation techniques, such as meditation, yoga, and deep breathing exercises, can help reduce overall stress and anxiety levels. Incorporating these practices into daily routines can provide additional support in managing OCD symptoms.
Lifestyle Changes Making lifestyle changes, such as prioritising sleep, regular exercise, and maintaining a balanced diet, can positively impact mental health. These changes can help improve overall well-being and support the effectiveness of other treatments.
Note on Brain Surgery Brain surgery is a rare and experimental treatment for severe, treatment-resistant OCD. Procedures such as deep brain stimulation (DBS) may be considered for individuals who have not responded to other treatments. DBS involves implanting electrodes in specific brain regions to regulate abnormal activity. While this treatment shows promise, it is typically reserved for extreme cases and requires thorough evaluation and consideration.
Living with OCD
Long-Term Management
While OCD is often a lifelong condition, ongoing management can help individuals live full and meaningful lives. Consistent treatment and coping strategies are essential for maintaining progress and preventing relapse.
Tips for Coping
Adherence to Treatment Consistency in following treatment plans is crucial, even when symptoms improve. Adhering to therapy sessions, medication regimens, and recommended practices can help sustain progress and prevent symptom recurrence.
Trigger Management Identifying and developing strategies to handle triggers is essential for managing OCD. Triggers are situations, objects, or thoughts that provoke obsessions and compulsions. Developing a plan to cope with these triggers can help individuals maintain control and reduce anxiety.
Self-Care Prioritising self-care is vital for overall well-being. Ensuring adequate sleep, healthy eating, regular exercise, and effective stress management can support mental health and improve the ability to cope with OCD symptoms.
Support System Connecting with a supportive network of loved ones, friends, or support groups can provide emotional support and practical assistance. Having people who understand and validate the challenges of living with OCD can make a significant difference in managing the condition.
Education Continuing to learn about OCD and coping strategies is important for both individuals with OCD and their support networks. Staying informed about new treatments, therapies, and self-help techniques can empower individuals to manage their condition effectively.
Realistic Expectations Understanding that recovery is a journey with ups and downs is crucial. Progress may be gradual, and setbacks are a normal part of the process. Maintaining realistic expectations and being patient with oneself can help sustain motivation and resilience.
Supporting Loved Ones
Education Encouraging family and friends to learn about OCD is essential for providing informed support. Understanding the nature of the disorder, its symptoms, and effective treatment approaches can help loved ones offer meaningful assistance and reduce misunderstandings.
Avoid Enabling Resisting the urge to accommodate compulsions is important, as enabling these behaviours can reinforce the OCD cycle. Loved ones can support treatment efforts by gently encouraging the individual to use coping strategies and seek professional help when needed.
Communication Openly discussing OCD with empathy and understanding can help build trust and provide a safe space for individuals to share their experiences and challenges. Effective communication can strengthen relationships and foster a supportive environment.
Support Groups Exploring support groups for families and friends of individuals with OCD can provide additional resources and coping strategies. These groups offer a platform to share experiences, seek advice, and learn from others who are supporting loved ones with OCD.
Conclusion
OCD is a treatable condition, and with the right support and treatment, individuals can regain control of their lives. Recovery is possible, and it is essential to seek help and support from mental health professionals. By increasing awareness and understanding of OCD, we can reduce stigma and provide better support for those affected by this challenging condition.
If you or someone you know is struggling with OCD, do not hesitate to reach out to a mental health professional for guidance and support. Early intervention and appropriate treatment can make a significant difference in managing the disorder and improving quality of life. Encouraging open conversations about mental health and advocating for accessible resources can help those affected by OCD lead fulfilling and meaningful lives.