When people think of Obsessive Compulsive Disorder or OCD they often think of someone who washes their hands until they are red raw and of houses so clean and tidy they don’t look lived in. However, while contamination obsessions and cleaning compulsions are one subtype of OCD, there are a wide variety of different forms a person’s OCD can take. The form an individual’s OCD takes can centre on their values and what is most important to them but can also shift over time depending on the phase of life and particular concerns they are facing at the time.
At the core of this condition there is a preoccupation with the need to get rid of the sense of doubt and uncertainty related to an intrusive thought (an obsession). This is why it is also known as the ‘doubting disease’. What’s common across the different subtypes is the experience of obsessions, which are intrusive upsetting thoughts, and compulsions, which are the strategies that people use to try to cope with the obsessions.
- Obsessions are the repetitive intrusive thoughts, images or urges people experience popping into their heads randomly or in response to a trigger. While everyone tends to experience random intrusive thoughts at times for the person with OCD their obsessive thoughts are more frequent, stickier and distressing. Intrusive thoughts can trigger feelings including anxiety, discomfort, disgust or guilt. Common examples include worries about harm coming to oneself or a loved one, having doubts about a relationship, doubts about not having done something correctly, or not having switched something off.
- Compulsions are the behaviours, strategies and rituals which people engage in order to get rid of the obsessive thoughts and reduce their sense of uncertainty and the uncomfortable feelings that go along with this. Compulsions can be external, such as checking and re-checking, washing hands, reassurance seeking, doing things a certain number of times or mental (internal) such as counting, praying, or other mental rituals to suppress intrusive thoughts.
The OCD Cycle
Engaging in compulsions provides the OCD sufferer with a sense of immediate relief. However, over the long term they keep the problem going and people get stuck in the vicious cycle of OCD. The more people struggle with and try to get rid of their obsessive thoughts the stickier these thoughts tend to become. This is because the more we react to a thought, treat it as threatening and struggle with it the more powerful it tends to get and the more likely it will reoccur, with the person often needing to perform more and more compulsions over time.
Avoidance behaviours can also play a role in contributing to the OCD cycle for some people. These are the ways people may try to avoid potential triggers for intrusive thoughts such as avoiding situations, places or stimuli that could trigger them such as certain tv shows or taking on extra responsibilities. While providing some relief in the short-term, over the long-term avoidance further reinforces the sense of threat associated with the intrusive thoughts.
There are effective psychological treatments available for OCD, as well as medications that can be helpful for some people.
Exposure and Response Prevention (ERP) is a Cognitive Behavioural Therapy (CBT) approach specialised for OCD and is currently the gold standard first-line approach for the treatment of OCD. It generally starts with developing a shared understanding of how the cycle of OCD symptoms plays out for each individual and identifying the range of mental and physical compulsions, avoidance behaviours, thoughts and beliefs likely to be keeping the problem going. People are taught to practice tolerating the obsessive thoughts and whatever accompanying feelings arise (exposure) without engaging in the compulsive behaviours (response prevention). As this can be very challenging it is usually done in a gradual step by step way. Initially this may involve reducing the length of compulsions or delaying engaging in them for several minutes and noticing what this is like. Over time engaging in ERP allows people to learn to treat the intrusive thoughts as ‘just thoughts’ or ‘just OCD’ and experiencing the thoughts as tolerable and temporary. Overtime the urge to do compulsions tends to get gradually easier and easier to resist.
Addressing emotional avoidance or past trauma can also be important for some OCD sufferers to experience further improvement in symptoms. For some people with OCD their symptoms may be linked to an experience of trauma and so it may be important to explore and work through this in therapy (Dykshoorn, 2014). For others, the suppression of feelings such as anger may be linked to OCD symptoms. People may hide their feelings if they believe these feelings are unacceptable (often anger, frustration or resentment) or that by expressing them something bad may happen (an exaggerated sense of responsibility is common among OCD sufferers). If this is the case then it can be helpful to work on increasing the awareness and healthy expression of these feelings. This is also known as the Hidden Emotion technique and is part of the treatment approach for OCD and anxiety developed by Dr David Burns known as TEAM-CBT (see Dr Burns book Feeling Great).
Examples of OCD subtypes
- Harm OCD – obsessive thoughts of harm coming to oneself or a loved one, or of causing harm to someone and compulsions to prevent the harm happening and/or thoughts occurring.
- Contamination OCD – worries about germs, contamination, getting sick, or making others sick which are often associated with cleaning compulsions
- Existential OCD – obsessions related to philosophical questions, about the purpose of life and the nature of existence
- Relationship OCD – obsessive thoughts and doubts about a romantic relationship, such as whether their partner loves them, excessive concern for their partner’s happiness, or wondering if they could find a better partner.
- Symmetry obsessions / ordering compulsions or “Just right” OCD ” – involves a feeling that things don’t feel quite right, so people engage in compulsions such as counting, straightening, touching tapping, or lining things up until things feel “just right”
- Scrupulosity OCD – religious or moral obsessions, such as thoughts about having done something wrong, committed a sin or violated a religious or moral doctrine and what this may means about them as a person.
- Pedophilia OCD – preoccupation with fears or intrusive thoughts revolving around themes of pedophilia
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