Obsessive compulsive disorder is one of the most difficult mental health disorders to survive with. It's characterized by a variety of intrusive thoughts (obsessions) and repetitive behaviors (compulsions) that take over your life and provide considerable amounts of anxiety and grief.
It's possible to live with just obsessions. For example a fear of being contaminated by germs may be considered an obsession, and may not have any noticeable compulsive aspect. However, many of those with germ fears wash their hands numerous times a day to compensate, and this may be the way their compulsion manifests.
There are thousands of possible obsessions and fears, and thousands of different types of compulsions. But the basis of the disorder is severe stress and anxiety over these obsessions that drives the need to perform compulsive actions.
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Obsessions are often the hardest issue to understand. Obsessions are thought based, and the most clear component of an obsession is a negative thought that you simply cannot shake. Generally the thought is focused and unyielding, although it may present itself in different forms. Examples of obsessions include:
- Fearing the effects of dirt, germs, or illness.
- Worried about someone harming you, or you harming others.
- Worried about whether someone else will be harmed, not by you.
- Unwanted impulses to hurt others or worry over uncontrollable aggression.
- Visions or images of horrific things.
- Unwanted, recurring sexual thoughts – often of an taboo or religiously unacceptable nature.
- Feels of disorder – the need for things to show some type of order/symmetry.
Remember, the key is "negative" thoughts, not necessarily obsessions in the traditional sense. The obsession may not be over a person or an action, but rather the inability to shake a thought or a need. Requiring symmetry is an example – the need to organize something or put something in a specific order may be overwhelming, but the thought isn't inherently bad. It's the inability to control the thought that makes it an obsession.
Those with OCD may not only have one obsession either. You may have multiple obsessions that occur at random whenever you encounter the nature of that obsession. You may also have obsessions you don't even realize you have. For example, you may find yourself checking the stove 10 times in a row because you want to make sure you didn't leave it on, but you may not realize that you're having that thought unless someone mentions it to you.
Unlike obsessions, which are thought based, compulsions are behavior based. They're physical/behavioral responses that you can't seem to control. You're compelled to do them, and if you don't, you may experience severe stress that forces you to keep doing it.
Imagine the old childhood phrase "don't step on the crack or you'll fall and break your back." Someone with OCD may have this belief, and the compulsion will be stepping a certain way to avoid cracks. If someone with compulsions does step on a crack, they may find themselves going back and starting over so as to avoid the crack in the future.
Nearly anything can be a compulsion, but some examples of compulsions include:
- Ritualized cleaning.
- Re-ordering or re-arranging rituals.
- Touching certain types of objects whenever you see them.
- Repeating completed activities.
- Checking and rechecking things.
- Counting objects, or simply counting inside your head.
Most compulsions are directly observable, because they're behaviors designed to rid yourself of the obsessive thought. But the compulsion may be a bit deeper than that. Counting, for example, may take place in thought form rather than in a visibly observable way.
How Are Obsessions Created?
Obsession causes are not well understood. It's thought that obsessions may be the result of flawed moral thinking or a type of phobia. There is also most likely a chemical component in the brain that contributes as well, such as serotonin. It may also be the nature of generalized anxiety – which can in some cases cause negative thinking or unexpected worries.
Numerous studies have shown that those that try not to think of something end up thinking about it more than those that don't try. For example, if someone asked you not to think about a white sock, and someone told someone else to think about a white sock, the person told NOT to think about it would probably think about it more often. That's because it takes a lot of brain power to not think about something, and in order to remind yourself not to think about something you have to think about it.
With that in mind, it's possible that obsessions are also the result of trying too hard not to have a negative thought. This causes the thought to come up more often, which causes greater fear in the individual about the validity of the negative thought.
There is no limit to the number of obsessions a person can have, and obsessions can always be developed later. Some obsessions may also be attributed to images a person wishes they could forget (such as witnessing a death), while others may have no basis in experience.
How Are Compulsions Created?
Compulsions are a bit easier to understand, and have their basis in a behavioral learning theory known as "negative reinforcement." Negative reinforcement is when some sort of action or behavior takes a bad thing away. For example, if a dog has a thorn in its paw and whines, and you come and you take the thorn out of their paw so they feel better, then the dog knows the next time it has a thorn in its paw it should whine faster to get you to respond. It learns that when it whines, you come and take the bad thing away.
Human beings may not be as simple as dogs, but behavioral reinforcement works in a very similar way. With compulsions, the person performs some sort of behavior (possibly at random, possibly for a reason based on the obsession – such as hand washing from germ fears) and they find the negative thought goes away, or at least reduces their anxiety. They then do the behavior again, and find that their thought goes away again. Pretty soon they find themselves doing the behavior every time they have the obsession, and at some point, they may even find themselves doing the behavior even when they're not having the obsessive thought at all.
There are countless ways that these obsessions and compulsions can take shape:
- Obsession: Something bad will happen to someone - Compulsion: Checking on them constantly.
- Obsession: Fear of germs or contamination - Compulsion: Washing hands regularly.
- Obsession: Fear of losing objects of value or memories - Compulsion: Hoarding all of your stuff.
- Obsession: Feelings of worthlessness - Compulsion: Muttering or praying.
- Obsession: Worried about making mistakes - Compulsion: Repeating tasks numerous times.
- Obsession: Feeling the world is dirty/disorganized - Compulsion: Organizing and rearranging objects.
Also, because of the nature of these compulsions and behaviors, it's just as possible to have compulsions that appear to make no sense at all.
Can You Be Predisposed to OCD?
While there doesn't appear to be a gender or race preference to obsessive compulsive disorder, there does appear to be a heredity factor for developing OCD. Those with family members that have obsessive compulsive disorder appear to be more likely to experience it than the rest of the population. Estimates put the number of people suffering from some form of obsessive compulsive disorder at near 2.5%, although not all of those cases require clinical intervention.
It's possible that obsessive compulsive disorder also shares other genetic pathways with other mental health issues. Those with OCD tend to be more likely to suffer from other conditions, such as major depression, anorexia nervosa, bulimia nervosa, generalized anxiety disorder, social anxiety disorder, specific phobia, panic disorder and substance abuse.
However, just because you may be predisposed to obsessive compulsive disorder does not mean that it's something that can't be cured. The good news about all mental health disorders is that with the right treatment you can find relief.
Treatments for Obsessive Compulsive Disorder
Several treatment options are available for those living with OCD. Two of the most well-known treatments include:
Exposure and Response Prevention
Exposure and response prevention course is the common treatment standard for OCD cases. This specific technique attempts to help patients gradually learn how to put up with their own obsessive thoughts without performing the ritual or compulsive behavior. It is based on the idea that when the client suffers from their thoughts, they learn to stop withdrawing to their escape response (the compulsion).
It also acts on the principle that by allowing themselves to focus on the thought rather than try to fight it, the thought loses its power. Variations of exposure therapy play a role in several other anxiety disorders as well, including PTSD.
Cognitive-Biobehavioral self-treatment is another approach to combatting OCD. It utilizes several anxiety-reduction principles, and a four step strategy to reduce their tendencies towards obsessions and compulsions. The steps are as follows:
This step requires a technique known as "mindful awareness." It's a conscious recognition that the intrusive thoughts and compulsive urges are the symptoms of a mental health disorder, and not something that someone thinks is natural. The client will re-label their thoughts as obsessions and their urges as compulsions, in order to call them what they really are and ensure that they realize that neither their thoughts nor their compulsions are something they can't control. This technique teaches acknowledgement of the problem in order to improve the overall outcome.
The re-attributing step of the process is to learn to train yourself to recognize that your thoughts and urges are caused by your OCD, and not by any internal desires. It's very similar to the first step, in that it's meant to give you clarity over the cause of your problem. The difference is that with this type of awareness, the hope is that you will be able to stop yourself when you're having an obsessive thought or compulsive behavior, and be able to say to yourself "this is just my OCD." Both the relabeling process and the reattribution process are often performed together.
The refocus exercise involves replacing rituals and compulsions with more constructive/pleasant behaviors. At its heart it is still a ritual, much like other compulsions, but the goal of this exercise is to provide you with a ritual that acts as a distraction, rather than a compulsion designed to stop the obsessions. Examples of these behaviors include reading, exercising, knitting, walking, or listening to music. By changing the ritual to one that distracts your mind, your obsessions should decrease without a corresponding negative behavior.
The final step of the Cognitive-Biobehavioral Self-Treatment exercise for OCD involves lowering the importance you give to your obsessions and compulsions. Many of those suffering from OCD give too much value to their thoughts and actions. They'll have an intrusive, negative thought and think it reflects on them, trying to hide the thought and fight it and losing their self-worth in the process.
This step teaches the idea that thoughts are just thoughts, and the compulsions are nothing more than a response to the thought. It focuses on the idea that these are not reflective of you as a person, and the importance you give them is more than they deserve.
Other Treatments for OCD
There are several other treatments for obsessive compulsive disorder available as well. Success rate isn't just based on the overall success rate for the type of treatment. The success rate is also based on you and your personality. That is why you shouldn't give up – everyone living with OCD can be cured, but finding the right treatment may take time, especially because every treatment you decide to use requires a long term commitment.
I've helped people overcome their OCD and their anxieties. I start them with my free 7 minute anxiety test. The test is designed to look at your symptoms, get an idea of your anxiety, and use it to create treatment choices.
March, John S. Cognitive-behavioral psychotherapy for children and adolescents with OCD: A review and recommendations for treatment. Journal of the American Academy of Child & Adolescent Psychiatry (1995).
Saxena, Sanjaya, et al. Neuroimaging and frontal-subcortical circuitry in obsessive-compulsive disorder. British Journal of Psychiatry (1998).
March, John S., and Karen Mulle Friesen. OCD in children and adolescents: A cognitive-behavioral treatment manual. The Guilford Press, 1998.
Samuels, Jack F., et al. Hoarding in obsessive-compulsive disorder: results from the OCD Collaborative Genetics Study. Behaviour research and therapy 45.4 (2007): 673.
Nestadt, Gerald, et al. The identification of OCD-related subgroups based on comorbidity. Biological psychiatry 53.10 (2003): 914-920.
Author: Micah Abraham, BSc Psychology, last updated Sep 28, 2017.