The term “OCD” has become an everyday part of language, to the point where the true meaning of the term has been lost. “I am so OCD about that” has come to mean that a person is worried or thinking a lot about something. “I can be so OCD about how I do things” really means that an individual has a specific preference or can be very precise.
While it is human nature to sometimes get obsessed about a particular thought or to feel compelled to complete a particular action, a psychiatric diagnosis of Obsessive Compulsive Disorder (OCD) is a qualitatively different experience – one that causes significant distress and impairment for the 2.5% of the population who will struggle with it at some point in their lives.
Obsessive Compulsive Disorder is comprised of four distinct elements: obsessions, compulsions, avoidances, and distress. By understanding each of these elements, it is possible to more clearly understand the diagnosis and how it differs from routine worries and habits.
“O” – Obsessions
Obsessions are defined as recurrent intrusive thoughts, including mental images or impulses to engage in a particular behavior. These thoughts can pop up out of nowhere and with an unexpectedly high level of intensity that results in significant distress. And although obsessions can be categorized as exaggerated or inappropriate, individuals with OCD many times feel powerless and not able to control the continual inflow of overwhelming obsessive thoughts.
Obsessive thoughts cover a wide spectrum. Some of the more common ones include:
- Scrupulosity themes (religiosity, blasphemy, morality) – Could I have offended God?
- Need for evenness, order, or symmetry – It feels uncomfortable if I don’t have things balanced.
- Losing control – What if I can’t hold it together?
- Doubting one’s memory or perception – Did I really lock the front door?
- Harm to self or others (Safety) – Maybe something bad will happen to my family.
- Illness or disease – What if I have breast cancer?
- Contamination – Could there be something dirty or toxic there?
- Superstitions – If I step on a crack, I might break my mother’s back.
- Unwanted sexual or aggressive thoughts – I’m going to push someone into traffic (Fear of Acting Out).
- Perfectionism – What if I’ve made a mistake?
Most people have experienced intrusive thoughts like these before, though they might not have recognized them as such. To better visualize this: imagine the brain is like an e-mail account. When these thoughts happen, most brains are able to filter them into the “Junk” folder and dismiss them (like you dismiss the notification that your free “Roolexx” watch is ready for pick-up).
The OCD brain’s filter, however, tends to let some of these thoughts through. This leads to the perception that the thought might be legitimate and should be responded to accordingly. So when the thought “I want to push my husband in front of an on-coming train” arises, it triggers a significant level of distress, anxiety, and panic. An individual may begin to think:
- Why would I think such a thing?
- I must be a horrible person.
- I can’t be trusted around my husband.
- Maybe I don’t really love him.
- What’s wrong with me that I’d want to do this?
- Who else might I want to hurt?
To quiet the painful obsessive thought and to get reassurance that frightening, horrendous things will not happen, the individual will then engage in…
“C” – Compulsions
Compulsions are the response to these intense, anxiety-provoking obsessive thoughts. Compulsions are repetitive physical or mental behaviors that are the individual’s attempt to neutralize an obsession. These rituals and behaviors must be completed in accordance with certain strict, rigidly applied rules.
The goal of these actions is to lessen distress or to prevent a dreaded outcome. These compulsions and rituals, however, are not really connected to the feared event, or are distinctly excessive. While compulsive behavior can help foster a sense of control over obsessions and the related emotional reactions, this relief is only temporary. Engaging in compulsions can actually strengthen the influence obsessions.
Common compulsions include:
- Washing and cleaning
- Counting and repeating
- Arranging objects
- Touching objects
- Mental rituals (thinking particular words or phrases)
- Collecting or acquiring objects
- “Just right” feelings (the sense that things or actions must be “just right”)
- Reassurance seeking
To provide relief from the obsessive fear of pushing her husband in front of a train, the individual may:
- Hold his hand tightly, tugging him toward her while on the station platform
- Check-in with him to make sure he is both unharmed and aware that she loves him
- Mentally repeat the phrase “I would never harm him”
- Confess to him that these thoughts have occurred
- Reassure herself “I really do love him”
The thing about OCD is that compulsions are never quite enough to satisfy obsessive thoughts. OCD continues to up the ante and demand more of the individual. In the train scenario, obsessive thoughts may expand to other locations (on the sidewalk, in parking lots, in the car, in the front yard, at home) or may begin to include other people (family members, friends, complete strangers). To quiet the thoughts, the rituals become more and more elaborate and demanding.
For our example train situation, compulsions may grow to include:
- Walking with hands shoved in pockets
- Insisting that the husband walk behind her and place his hand on her shoulder while navigating the station (this provides reassurance that he’s there, while simultaneously preventing her from pushing him with her own hands)
- Keeping eyes downcast so as to not make eye contact with anyone who may otherwise become a victim of this feared action
- Once seated on the train, patting him on the arm 4 times while repeating “I am a good person”
- Having the husband use a different entrance to the station and ride on a different car
Even with the most elaborate compulsions, the fear brought on by intrusive thoughts is never completely extinguished. This pushes the individual to engage in…
The third element of OCD is the avoidance of situations that cause distress. Sometimes obsessions are so painful and compulsions are so elaborate that it can be easier to steer clear of triggering things or situations. When a place or activity no longer feels “safe” from obsessive thoughts, the initial impulse is to steer clear of those “unsafe” things.
In the case of the train, the individual may:
- Take the train at off-peak times to avoid a more-crowded platform
- Not take the train at all but rather drive
- Avoid traveling with the husband because of the associated fears
- Turn down opportunities that require traveling by train
- Stay at home
- Avoid being around the husband all together
As with compulsions, avoidant behaviors can be very disruptive to the individual’s daily life. Surrendering to anxiety and avoiding the distressing situation may work briefly, but the anxiety grows and progressively demands more and more. Ultimately, there is no way to protect oneself from all the triggering situations. OCD can be like a drop of ink in a glass of water, spreading out to cover everything so that nowhere feels safe.
“D” – Distress
The main indicator of a disorder is that the thoughts and behaviors in question cause significant distress and disruption in daily life. Without the distress aspect, thoughts would not be triggering elevated levels of anxiety. The behaviors in question would not be rituals one is compelled to do, but rather habits or actions that ‘just happen’, without any larger meaning or purpose.
The experience of distress is highly subjective. There is no absolute standard by which to measure what is troublesome and distressing. In therapy, individuals are educated about their Subjective Units of Distress (SUDS), and learn how to rate their relative experience of distress on a scale. By recognizing the level of discomfort experienced and the factors that contribute to distress, it is possible to manage one’s response – not by forcing the thoughts out of one’s head or giving in to every ritualistic urge, but rather by learning the skills necessary to navigate (and ultimately overcome) the discomfort associated with these thoughts and behaviors.
Treating and Coping With OCD
A therapist trained in Cognitive Behavior Therapy (CBT) can assist in developing a treatment plan that incorporates the nuances of each individual’s unique OCD experiences, so that the individual can put the intrusive thoughts in their place and regain authority in one’s life. A therapist can help you through this process by building a hierarchy of progressive challenges and strengthening coping skills. If you think you may be struggling with OCD, please reach out to a trained therapist. OCD can be overcome and there are resources out there that can help.
Dr. Elspeth Bell is a licensed psychologist specialized in Cognitive Behavioral Therapy (CBT) for adults and adolescents. She's a recognized expert in Hoarding Disorder, conducting assessments, therapy, and support groups. With degrees from Vassar College and Fordham University, her research focused on OCD and family-related anxieties. Based in Howard County, Maryland, she enjoys baseball, exercise, scrapbooking, and DIY projects. Dr. Bell is licensed to practice in Maryland, Virginia, and the District of Columbia.