Obsessive-Compulsive Disorder (OCD)

Obsessions are recurrent or persistent thoughts, images, or urges that are intrusive in nature and cause marked distress usually with overwhelming feelings of anxiety, guilt, and/or disgust. Compulsive behaviors are maladaptive, repetitive behaviors completed for the purpose of reducing anxiety caused by obsessions. The behaviors are excessive and tend to require a substantial amount of time, resulting in impaired functioning at school, work, or social interactions and even the elimination of hobbies/leisure time. Symptoms of OCD, when left untreated, can become debilitating to the extent that those afflicted can no longer engage in work, school, or complete activities of daily living. Two common traits also associated with OCD are people-pleasing (very passive behaviors) and indecisiveness. These traits are also targeted in treatment.

OCD and related disorders affect many Americans. It is estimated that 1 in 100 adults suffer from OCD (IOCDF.org). According to the NIMH, anxiety disorders contribute to the second highest number of years of life lost due to a mental health disability. The emotional and financial burden of OCD and anxiety are substantial, and not just for those afflicted with the disorder. Family members and loved ones are commonly affected. Loved ones may struggle knowing how to approach the OCD or anxiety sufferer and can inadvertently escalate symptoms through accommodation. Functioning and relationships begin to suffer if the disorder goes untreated.

OCD is really a fear of uncertainty followed by pathological doubt. It has been nicknamed the “doubting disease” for a reason. Which uncertainty the OCD tends to choose to obsess about typically depends on the client’s environment or what the client is passionate about. OCD will attack whatever brings a client joy. If you have OCD and are reading this, you know exactly what we are talking about.

Additionally, clients who have OCD usually have an above average intelligence. OCD is a disorder where the client’s intellect is being used against them to problem solve something that has no resolution. Certainty does not exist. This is why you cannot utilize cognitive therapy when treating those with OCD. You cannot use logic or intellectualize yourself out of this one!

It is important to note that OCD symptoms lack any desire. OCD symptoms are ego-dystonic. The client does not desire any obsession and the symptoms are completely against their values.

Exposure response prevention (ERP) treatment is the gold standard treatment for OCD. ERP falls under the large umbrella of CBT treatment, but ERP is strictly behavioral. Cognitive therapy is harmful to someone struggling with OCD because cognitive therapy will provide the client with reassurance. It is incredibly important to receive treatment from someone who specializes in OCD. There are many nuances and manipulative tactics associated with OCD. The treatment is also counterintuitive. Loved ones should be involved in treatment at the client’s discretion.

To find out more about ERP, please click here.

Some obsessions include, but are not limited to:

Contamination

Contamination OCD encompasses so much. Most people are aware of contamination OCD where people are either disgusted or fear getting sick by what they touch. These fears are followed by washing rituals if the triggers can’t be avoided altogether. Those with ‘disgust OCD’ don’t always feel anxious by what they touch. Instead, they feel intense disgust combined with anger. Those with disgust OCD tend to initially be a bit more resistant to exposures compared to those who feel anxious.

Health-related OCD

Underneath the very large umbrella of contamination, OCD is health-related OCD. We feel that it deserves its own section because clients with these obsessions make up a significant part of our caseload at any given time. Clients can fear any kind of health concern such as cancer, any blood-borne pathogen, heart attack, ALS, brain-eating amoeba, rabies, and this list could go on and on. We learn about so many possible rare diseases and disorders from our clients! Almost 100% of clients with health-related obsessions experience psychosomatic symptoms. This means they can develop real symptoms that correlate with the feared illness, but those symptoms are a manifestation of anxiety and not the result of something physically wrong with them. For example, the person who fears having a heart attack could feel a pounding heart rate, dizziness, pain in their right arm, etc. The person who fears ALS may experience numbness, tingling, and muscle twitches. OCD is very predictable this way. Furthermore, almost 100 percent of clients with health-related OCD will also fear taking the medication usually necessary to help manage OCD because they fear potential side-effects. If they finally do take medication, they might experience psychosomatic symptoms at the beginning.

Mental Health-Related OCD

We believe that mental health-related OCD deserves its own section even though it’s still technically a health-related concern. These obsessions are often connected to harm OCD, which is another domain discussed below. A common obsession is for clients to fear becoming psychotic, depressed, or any mental health disorder that could lead them to harm someone else or harm themselves. Sometimes, there’s no harm that intrusive thoughts are involved, and the client just simply fears never feeling good. Sometimes, these obsessions can result in psychosomatic symptoms. For example, a client who fears they will always feel depressed will sometimes experience a ‘pseudo depression’ where they experience some symptoms consistent with depression and will even self-sabotage to prove to themselves that they have depression. Like those who struggle with health-related OCD, clients with a mental health obsession fear taking medication due to potential side effects that could result in some kind of harm. Have we mentioned how manipulative OCD can be yet?

Sexually Intrusive Thoughts

Sexually intrusive thoughts can include homosexual OCD, pedophilia OCD, incestuous OCD, and really anything sexual that goes against what the client desires. It is important to remember that the client does not desire these thoughts. The client who has homosexual OCD does not desire to engage in sexual behaviors with someone of the same sex. They are not confused about their orientation beyond just doubting what they’ve known since before puberty. The client is not denying their sexual orientation due to some kind of social consequence. The same goes for pedophilia OCD. The client does not desire to have any kind of sexual relationship with a child! Clients are most fearful to get help for pedophilia OCD because they fear being reported. This OCD domain keeps them from getting help because they feel extreme shame and fear of getting into legal trouble. We feel that sexually intrusive thoughts OCD is one of the easier domains of OCD to treat because the triggers are readily available, and it’s usually easy to do these exposures with some repetition. If you are a prospective client, it doesn’t matter what kind of sexually intrusive thought you fear disclosing, we’ve heard them all!

Scrupulosity

So this is a tricky one for several reasons, which will be explained. Before we get into that, know that there are two forms of scrupulosity. There’s a fear of going to hell or being blasphemous towards God. The other one is fear of being a bad person or immoral in some way. Even atheists can have scrupulosity. This domain of OCD is extra manipulative, and the client may lack insight. For example, a religious client who has scrupulosity cannot always determine the boundary between their faith and their OCD. The OCD has ingrained fear into their faith and sometimes the client will believe they are just being devout. When engaging in ERP, the client might feel they are going against God’s teachings. Please understand that the purpose of treatment is to bring peace back to a client’s relationship with God, not to create distance. Treatment will not impact someone’s beliefs. This can be a very distressing domain of OCD, too, because unlike health-related OCD and some contamination OCD where the client knows (but still doubts) that they are not sick, the client with scrupulosity will never completely know what will happen after they die. The client with moral scrupulosity is fearful of other people’s judgments and what they deem is a good person. Again, there’s never a definitive answer with scrupulosity obsessions.

Existential OCD

This is a fascinating domain and another indication of how OCD uses one’s intellect against them. Clients with existential OCD can have various fears. Sometimes a client fears that they are part of some simulation and aren’t actually real. Some obsess about whether we live in a state like that seen in the movie ‘The Matrix.’ Other clients might obsess about whether we as people truly have meaning or a purpose. These obsessions can be very confusing and abstract if they are layered with various philosophical and existential ideas.

Fear of Going to Jail or Being Wrongly Accused of a Crime

This fear is often connected to scrupulosity and the fear of doing or being accused of doing something immoral. We saw an uptick in this obsession during the “Me Too” movement. We were getting many more cases of clients fearing that they had raped someone in the past and questioned whether they had engaged in sexual acts with someone who might have been inebriated, even if the client themselves was inebriated. OCD doesn’t just attack someone’s future; it can make them doubt their past as well. A client might fear that they said or did something inappropriate in front of a device with a camera and those images or videos spreading over the internet. These clients frequently fear that the police will show up at their door. They may even check to see if there is a warrant out for their arrest in various states. The number of crimes we hear from clients that were never committed is sometimes a source of laughter in therapy sessions, especially as clients get better.

Harm

This is another common domain of OCD and we think this one is also fairly easy to treat given the availability of triggers. These clients might fear that they will stab someone, whether deliberately or lose control of their actions and stab someone. Hit and run OCD is when someone is driving and doubts whether they hit someone with their car. They might drive back to check that there is no body on the side of the road. Clients might fear being responsible for a burglary or a fire so they will check locks, windows, and heating appliances. Suicide OCD is when client fear they will end their lives even though they have no desire to do so.

Perfectionism

This domain is straightforward. Clients with this domain try to perfect their work or appearance. They may check their work tasks, emails, texts many times. They obsess about how they present themselves, whether it is how they dress, speak, and so on. They might avoid doing tasks or trying new things over time because they don’t want to start something they can’t perfect.

‘Just Right’ OCD

This domain of OCD doesn’t always involve a fear. A client could take a step, sit, go through a door threshold, pick something up, or any behavior and the client will repeat the behavior if they did not get the ‘just right’ feeling. Clients typically cannot articulate exactly how they are feeling when triggered. Therefore, they say that when they do something, it might not feel ‘just right.’ They repeat the behavior over and over until they get the ‘just right’ feeling. We’ve had clients who have struggled walking, driving, sitting, and much more with this obsession.

Symmetry or Exactness

These clients want items to be ordered or arranged in a certain way. They may become very angry towards others if their items are touched or moved.

Superstitious Fears

Some clients will fear that if they do a behavior or not do a behavior, then something bad will happen. Really anything can be a trigger depending on the superstition.

Some compulsions include, but are not limited to:

Compulsions are in the service of the client getting some kind of certainty about their obsession. Because certainty does not exist, the client suffers. The list of compulsions could be endless because a compulsion can be anything (physical behavior or mental thought) that the client’s OCD brain determines would neutralize their intrusive thought. Below are the most common compulsions.

Avoidance

This compulsion is why ‘Pure O’ OCD does not exist! Avoidance is the mother of all compulsions. Any person, place, thing, or situation that is avoided due to fear, anxiety, guilt, or disgust is a compulsion. The more a client avoids, the smaller their world becomes, ultimately reducing functioning over time. Clients will also find ways to get loved ones to avoid with them. Family accommodations of OCD is part of the illness. This is why we love having significant others, parents, or any support system to be a part of treatment at least for one session.

Reassurance Seeking

Clients will ask people if everything is ok.  They are trying to get certainty from someone else that their feared outcome will not happen. They might ask for reassurance in a question, however, sometimes they ask for reassurance in a statement form. For example, a client could say, “I feel dizzy. I sure hope I don’t have cancer.” What the client is really doing is gauging the other person’s body language and response. If the other person doesn’t take the client’s statement seriously, then they got reassurance that they are more than likely healthy. The reassurance seeking compulsion is often very irritating for loved ones and they don’t realize that the more reassurance they provide, the more the client will ask.

Information Seeking

This compulsion is when the client goes online to research whatever they are worried about, whether it is symptoms of an illness, signs that they are gay, statute of limitations related to a crime, and so on. This compulsion wastes so much time. Before the client knows it, they’ve spent hours online researching triggers in the hopes of getting a certainty that doesn’t exist.

Checking

There are physical checking and mental checking compulsions. A client might check locks and heating appliances to ensure they are locked and off. They will check their vitals if they are concerned about an illness. Checking to make sure no errors were done at work is another common practice. Mental checking can be when a client mentally checks to see how they are feeling especially if they fear a mental health illness. Clients might mentally check for signs of arousal if they have a sexually intrusive thought. The type of checking is dependent on the obsession.

Talking About the Obsessions (Often About Health)

In regard to health-related obsessions, clients will typically speak about their health ad nauseum.  They will find ways to talk about any kind of symptoms, even how well or terrible they slept the night before. The compulsion to talk about an obsession incessantly is the client’s way of ruminating out loud. It is important for loved ones to not listen to the client when this is happening. Those with scrupulosity and existential OCD can also talk about their obsessions, and those around them might think they are simply trying to have a theological or existential conversation. We can assure you that they are not.

Confessing

Almost 100% of clients with scrupulosity confess their thoughts or actions. Confessing in some religions is considered healthy and expected. However, when someone has scrupulosity, confessing is a compulsion and will make their mental health suffer even more.

Self-Assurance

Some clients will say to themselves, or even out loud, that everything is ok or say something else to neutralize their intrusive thoughts. This is a compulsion. Instead, the client must start saying, “Maybe, maybe not.” Maybe the feared outcome will happen, maybe not. OCD is a fear of uncertainty. The only way to treat it is for clients to be exposed to the feared uncertainty repeatedly until they reach habituation. More of this is discussed in the ‘treatment modalities’ section under ERP.

Washing Rituals

Clients might wash their hands repeatedly or do shower rituals. Some clients can shower up to several hours per day. Clients will also clean objects they feel are contaminated. OCD is very expensive in general, but especially when someone repeatedly washes their electronic devices to the extent of ruining them.

Praying

Most clients with religious scrupulosity pray as a compulsion. They might ask for forgiveness for their intrusive thoughts or repeat the same prayers until they feel that they have focused or said them perfectly. Sometimes, prayer is used like a superstitious compulsion even if the client is not struggling with religious scrupulosity. For example, a client can have contamination OCD and then fear that if they don’t pray, their contamination OCD will get worse. The clients who have religious scrupulosity are typically hesitant and sometimes defensive when it is suggested to stop praying when they are anxious. The OCD will convince them that the treatment is trying to distance them from their relationship with God. The more severe OCD symptoms are, the less insight the client will experience.

Repeating

Repeating compulsions can really be part of any domain of OCD. Those with ‘just right’ OCD will repeat the same behaviors until they get the ‘just right’ feeling. Those who pray as a compulsion might repeat the prayer if they feel that they did not focus perfectly on the prayer. Someone might repeat their words if they believe that they did not articulate themselves perfectly. There are endless examples of this type of compulsion.

Perfecting

When a client with perfection OCD redoes their hair, changes their clothes, edits their emails or text numerous times, they are perfecting and this is a compulsion.

Apologizing

OCD causes a tremendous amount of guilt and people-pleasing behaviors. These clients will often apologize or say disclaimers as a compulsion.

Mental Compulsions (Intellectualizing, Figuring it Out)

Mental compulsions are sometimes sneaky. Self-assurance can be a form of mental compulsion when the client is internally telling themselves that everything will be ok. Some clients will internally repeat mantras in their head as a compulsion. The mental compulsions we experience clients doing most are what we call ‘intellectualizing’ and ‘figuring out the why.’ The client will use their intellect during the session to justify their compulsions. They will try to debate their behaviors with the provider. Sometimes the client can become defensive if this is a prominent compulsion for them because refraining from intellectualizing or using logic to solve their OCD is an exposure. Some clients will spend time in session trying to find out why they have OCD or why they have a certain fear. The provider will explain how trying to “figure out the why” is a compulsion and the provider will redirect the client. If the client is doing the compulsion during the session, you can imagine how often they are ruminating about it when they are alone. Clients with these kinds of compulsions find themselves in a terrible mental loop. Medication helps tremendously with reducing mental compulsions.

For information on exposure response prevention (ERP) treatment for OCD, please click here.

For more information about OCD in general, you can also visit the IOCDF website here.