Obsessive Compulsive Disorder

Obsessive compulsive disorder (OCD) is a mental health disorder that affects people of all ages and walks of life, and occurs when a person gets caught in a cycle of obsessions and compulsions ^[1]. Obsessions are unwanted, intrusive thoughts, images, or urges that trigger intensely distressing feelings. Compulsions are behaviors an individual engages in to attempt to get rid of the obsessions and/or decrease distress.

Most people have obsessive thoughts and/or compulsive behaviors at some point in their lives, but that does not mean that we all have “some OCD.” In order for a diagnosis of OCD to be made, this cycle of obsessions and compulsions must be so extreme that it consumes a lot of time (more than an hour every day), causes intense distress, or gets in the way of important activities that the person values.

OCD Types and Symptoms

OCD comes in many forms, but most cases fall into at least one of four general categories:

• Checking, such as locks, alarm systems, ovens, or light switches, or thinking you have a medical condition like pregnancy or schizophrenia
• Contamination, a fear of things that might be dirty or a compulsion to clean. Mental contamination involves feeling like you’ve been treated like dirt.
• Symmetry and ordering, the need to have things lined up in a certain way
• Ruminations and intrusive thoughts, an obsession with a line of thought. Some of these thoughts might be violent or disturbing.

Obsessions are thoughts, images, or impulses that occur over and over again and feel outside of the person’s control. Individuals with OCD do not want to have these thoughts and find them disturbing. In most cases, people with OCD realize that these thoughts are illogical. Obsessions are typically accompanied by intense and uncomfortable feelings such as fear, disgust, uncertainty and doubt, or a feeling that things have to be done in a way that is “just right.” In the context of OCD, obsessions are time consuming and get in the way of important activities the person values. This last part is extremely important to keep in mind as it, in part, determines whether someone has OCD — a psychological disorder — rather than an obsessive personality trait.

“Obsessing” or “being obsessed” are commonly used terms in everyday language. These more casual uses of the word mean that someone is preoccupied with a topic, an idea, or even a person. To be “obsessed” in this everyday sense doesn’t mean that a person has problems in their day-to-day living — there may even be a pleasurable component to their experience of being “obsessed.” For example, you can be “obsessed” with a new song you hear on the radio, but you can still meet your friend for dinner, get ready for bed in a timely way, get to work on time in the morning, etc., despite this obsession. 

The content of an everyday “obsession” can be more serious: for example, everyone might have had a thought from time to time about getting sick, or worrying about a loved one’s safety, or wondering if a mistake they made might be catastrophic in some way. While these thoughts look similar to what you would see in OCD, someone without OCD may have these thoughts, be momentarily concerned, and then move on. In fact, research has shown that most people have unwanted intrusive thoughts from time to time, but in the context of OCD, these intrusive thoughts come frequently and trigger extreme anxiety that gets in the way of day-to-day functioning.

Common Obsessions in OCD 

Contamination Obsessions

• Fear of coming into contact with perceived contaminated substances/things, such as:
• Body fluids (e.g. urine, feces)
• Germs/disease (e.g. herpes, HIV, COVID-19)
• Environmental contaminants (e.g. asbestos, radiation)
• Household chemicals (e.g. cleaners, solvents, battery acid)
• Dirt

Violent Obsessions

• Fear of acting on an impulse to harm oneself
• Fear of acting on an impulse to harm others
• Fear of violent or horrific images in one's mind

Responsibility Obsessions

• Fear of being responsible for something terrible happening (e.g. fire, burglary, car accident)
• Fear of harming others because of not being careful enough (e.g. dropping something on the ground that might cause someone to slip and themselves)

Perfectionism-related Obsessions

• Excessive concern about evenness or exactness
• Excessive concern with a need to know or remember
• Fear of losing or forgetting important information when throwing something out
• Excessive concern with performing tasks "perfectly" or "correctly"
• Fear of making mistakes

Sexual Obsessions

• Unwanted thoughts or mental images related to sex, including:
• Fear of acting on a sex-related impulse
• Fears about sexually harming children, relatives, or others
• Fears about aggressive sexual behaviors towards others

Religious/Moral Obsessions (Scrupulosity)

• Excessive concern with offending God, damnation, and/or concern about blasphemy
• Excessive concern with right/wrong or morality

Identity Obsessions

• Excessive concern with one's sexual orientation.
• Excessive concern with one's gender identity.

Other Obsessions

• Relationship-related obsessions (e.g. excessive concern about whether one’s partner is “the one," the partner’s flaws and qualities)
• These types of obsessions can center around romantic partners, relatives, friends, and other relationships.
• Obsessions about death/existence (e.g. excessive preoccupation with existential and philosophical themes, such as death, the universe, and one’s role in “the grand scheme.”
• Real event/false memory obsessions (e.g. excessive concern about things that happened in the past and what impacts they may have had)
• Emotional contamination obsessions (e.g. fear of "catching" personality traits or personal characteristics of other individuals)

Compulsions are repetitive behaviors or thoughts that a person uses with the intention of neutralizing, counteracting, or making their obsessions go away. People with OCD realize this is only a temporary solution, but without a better way to cope, they rely on compulsions nonetheless. Compulsions can also include avoiding situations that trigger obsessions. Compulsions are time consuming and get in the way of important activities the person values.

Similar to obsessions, not all repetitive behaviors or “rituals” are compulsions. This depends on the function and the context of the behavior. For example, bedtime routines, religious practices, and learning a new skill all involve some level of repeating an activity over and over again, but are usually a positive and functional part of daily life. . Similarly, arranging and ordering books for eight hours a day isn’t a compulsion if the person works in a library. 

The feelings associated with a behavior also indicate whether it is compulsive. If you are just a stickler for details or like to have things neatly arranged, you might consider these things to be “compulsive” behaviors, but that doesn’t necessarily mean they are symptoms of OCD. In these cases, “compulsive” refers to a personality trait or something about yourself that you actually prefer or like. In most cases, individuals with OCD feel driven to engage in compulsive behavior and would rather not have to do these time-consuming and often torturous acts. Rather than being a source of pleasure, people with OCD perform compulsions because they believe these rituals are necessary to prevent negative consequences and/or to escape or reduce anxiety or the presence of obsessions.

Common Compulsions in OCD

Washing and Cleaning

• Washing hands excessively or in a certain way
• Excessive showering, bathing, tooth-brushing, grooming ,or toilet routines
• Cleaning household items or other objects excessively
• Doing other things to prevent or remove contact with contaminants

Checking

• Checking that you did not/will not harm others
• Checking that you did not/will not harm yourself
• Checking that nothing terrible happened
• Checking that you did not make a mistake
• Checking some parts of your physical condition or body

Repeating

• Rereading or rewriting
• Repeating routine activities (examples: going in or out doors, getting up or down from chairs)
• Repeating body movements (example: tapping, touching, blinking)
• Repeating activities in "multiples" (examples: doing a task three times because three is a "good," "right," "safe" number)

Mental Compulsions

• Mental review of events to prevent harm (to oneself others, to prevent terrible consequences)
• Praying to prevent harm (to oneself others, to prevent terrible consequences)
• Counting while performing a task to end on a "good," "right," or "safe" number
• "Cancelling" or "Undoing" (example: replacing a "bad" word with a "good" word to cancel it out)

Other Compulsions

• Putting things in order or arranging things until it "feels right"
• Telling asking or confessing to get reassurance
• Avoiding situations that might trigger your obsessions

Causes of OCD

The causes of OCD are not fully understood There are several theories about the causes of OCD, including:

• Compulsions are learned behaviours, which become repetitive and habitual when they are associated with relief from anxiety.
• OCD is due to genetic and hereditary factors.
• Chemical, structural and functional abnormalities in the brain are the cause.
• Distorted beliefs reinforce and maintain symptoms associated with OCD.

It is possible that several factors interact to trigger the development of OCD. The underlying causes may be further influenced by stressful life events, hormonal changes and personality traits.