We have all heard of Obsessive Compulsive Disorder (OCD). Most of us have at least a working knowledge of what people mean when they say they have OCD. We think of Adrian Monk counting toothbrush strokes or hear Leonardo DiCaprio as Howard Hughes in The Aviator, repeating the phrase “show me all the blueprints” over and over again as he descends into psychological crisis. But the complexities of the disorder are rarely communicated outside of the community of OCD sufferers and the niche world of mental health providers who specialize in treating OCD. The opacity surrounding OCD is such that many mental health professionals are unaware that traditional talk therapies can make OCD symptoms worse, and that many sufferers don’t know the cause of their suffering.

What is Obsessive Compulsive Disorder?

Obsessive Compulsive Disorder has been termed “the doubting disorder.” It is characterized by a tension-relief cycle based on uncertainty and reassurance. There are two main components to Obsessive Compulsive Disorder: obsessions (doubt) and compulsions (reassurance). The pattern of doubting and reassuring becomes disordered when the person afflicted is too consumed by their obsessions and compulsions to live life according to their values. Many people with OCD spend hours a day ruminating and ritualizing. It is even possible for an OCD sufferer to be consumed by mental compulsions, with nothing to indicate to the outside world that they are suffering. Because of this, OCD has been called “the silent sickness” and is sometimes left undiagnosed and untreated for decades.

What are Obsessions?

Any thought, feeling, urge, or sensation to cross a sufferer’s awareness has the potential to become an obsession. They only become obsessive if the sufferer keeps coming back to them—if they “stick” in the sufferer’s mind despite their efforts to move on. Typically, obsessions are rooted in something that is threatening to the sufferer’s sense of safety or sense of who they are. Some common themes for obsessions are:

• Causing harm. A harm OCD thought might be “what if I accidentally hit someone with my car?” or “what if I stab someone with a kitchen knife?”
• Contamination by a foreign/ dangerous substance. A contamination OCD thought might sound like “what if I caught a disease when I touched that doorknob?” or “what if I accidentally ingested some gasoline when I filled up my tank this morning?”
• Sexual Orientation. An SO OCD thought may sound like “I was attracted to that man back there—does this mean I’m not actually attracted to my girlfriend?” or “I was not repulsed by the idea of kissing that woman—does that mean I’m not really gay?”
• Relationships, especially romantic partnerships. A relationship OCD thought may sound like “how can I be sure this person is right for me?” or “I’m not feeling anything strong towards my partner right now… do I really love them?”
• Magical thinking. A magical thinking OCD thought may be “if I don’t line these books up perfectly, my mother will die” or “if I step on a crack in the sidewalk my partner will leave me.”
• Taboo sexual thoughts. Sexual obsessions can develop around any element of sexuality the sufferer deems unacceptable. Common examples are incest, bestiality, and pedophilia. Sufferers may develop sexual obsessions around themes that aren’t necessarily taboo, but are personally intolerable (being attracted to someone other than their partner, say). Sexual obsessions may sound like “am I in denial about being attracted to my family member?” or “how can I be sure I’m not attracted to that child?” or “what does it mean that I’m attracted to someone who isn’t my partner?”
• Religion and morality, called Scrupulosity. A thought in line with this theme might be “was I being sincere when I prayed just now? Maybe I should pray again…” or “if I don’t let everyone pass me in the grocery line, it means I’m a bad person.”

This is not an exhaustive list of OCD themes.  A theme can arise whenever the sufferer is confronted with a thought they perceive as threatening, scary, or uncomfortable. Everyone has these type of “fringe” thoughts, but non-sufferers can easily accept that thoughts are just thoughts, and don’t have any inherent meaning about their character or the objective safety of their environment.

What are compulsions?

Compulsions are what maintain the OCD cycle. They are physical or mental actions that offer temporary relief from the besieging obsessions, but ultimately reinforce the sufferer’s pattern. Reinforcement happens because the sufferer’s brain learns that since the compulsion works, even for a little bit, in easing the threat of the obsession, the obsession really was dangerous. This reinforces the perceived significance of the obsession.  Types of compulsions include:

• Checking. Checking can come in many forms. Checking the locks on the front door, checking the stove to make sure it’s turned all the way off, checking the internet to resolve uncertainty, checking your own body for signs of pain, strong emotion, illness or sexual arousal. As you can see, checking can be a physical action or a mental action.
• Reassurance seeking. This is similar to checking, but comes into play in relationships. A sufferer may frequently check with friends to see if they’re angry with them, may repeatedly ask their partner of they’re really in love with them, may ask coworkers over and over if they’ve offended them. Reassurance seeking can also be sought through others when the content of the obsession is not the relationship. For example, a sufferer with Relationship OCD may ask a friend or family member for their opinion about their partner repeatedly.
• Washing. This compulsion is specific to contamination OCD. A sufferer may wash their hands repeatedly, wash surfaces in their home, wash their clothes before they come into contact with other items in their home, etc..
• Avoiding. This compulsion is difficult to spot and can generalize across several OCD themes. A sufferer might avoid areas they consider rife for contamination, avoid knives or windows for fear of causing harm to themselves or others, avoid areas where children might be, or avoid media that contains triggering elements (like violence or sexual taboos).
• Symmetry and ordering. This kind of compulsion typically goes hand in hand with “just right” OCD or magical thinking OCD. Someone with this kind of compulsion may line their belongings up precisely, make sure the frames on their walls are perfectly aligned, or count or time their footsteps in a specific way. These compulsions are usually felt to keep a feeling of unease or discomfort at bay, or to prevent something bad or dangerous from happening.

This is by no means an exhaustive list of compulsions. It’s important to remember that compulsions can form around anything that gives the sufferer the emotional experience of having “figured out”, neutralized, or confronted the obsession, even if only momentarily. Treating OCD means purposefully exposing to these obsessions while refraining from compulsions. Tolerating the discomfort brought on by an obsession is essential in helping the brain learn that the thoughts and feelings themselves are not threatening, and that absolute certainty is not necessary (or possible!). Exposure and Response Prevention therapy (E/RP) is the Gold Standard treatment for OCD. Working with an E/RP therapist helps build the flexibility and courage to implement these skills and to understand the patterns of your OCD.

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