Understanding and Managing Obsessive-Compulsive Disorder
Photo by Andrej Lišakov via Unsplash
Is obsessive-compulsive disorder, OCD, just a personality trait for people who are really particular? Someone who likes their shoes or desk organized in a specific way, or has a certain process for cleaning the kitchen or making their bed? OCD is much more complex than just a few tiny quirks.
OCD is a disorder of obsessions and compulsions driven by fear and anxiety. Obsessions are usually repetitive, intrusive, unwanted and distressing thoughts that trigger behavioral or mental compulsions.
The World Health Organization classifies OCD as one of the top 10 most debilitating illnesses, which is alarming as it can take up to 17 years on average for people to receive effective treatments. Without treatment, OCD can be disruptive to daily life due how much time it consumes, severe social difficulties, relationship dysfunction, and job-related issues.
While this all may sound daunting, I’ve treated dozens of clients with different types of OCD and I have found that once clients have a diagnosis, they feel validated and can find significant relief from their OCD symptoms in treatment.
What is OCD?
OCD is a complex neurobehavioral disorder – a term used to describe disorders that affect how the brain’s chemical messengers (known as neurotransmitters) can impact behaviors. OCD can present itself in many ways but obsessions and compulsions are always present.
Obsessions
Obsessions in OCD consist of unwanted, uncomfortable, and sometimes even disturbing thoughts. They’re usually repetitive, inappropriate or bizarre and trigger fear, discomfort, and anxiety. They are often referred to as intrusive thoughts.
Some of the more common types of obsessions include: fear of contamination, fear of losing a close relationship, or unwanted sexual thoughts. In the face of such fears, OCD typically represents a search for certainty, an attempt to find a solution to problems.
Compulsions
In OCD, obsessions trigger compulsions. Compulsions, which often take the form of rituals or repetitive behaviors like physical or mental actions, are performed under the belief that they will reduce or fully stop the obsessive thoughts. Compulsive behaviors can include: repeating, counting, cleaning, and ordering.
When someone with OCD engages in a compulsion, the brain triggers the production of dopamine (known as the pleasure hormone). However, like other neurotransmitters, the effects do not last, and in the long term, compulsions can intensify because the obsessions are left unresolved which is why OCD symptoms can be such a vicious cycle.
OCD is diagnosed when obsessions and compulsions interfere with the ability to live a full life because they cross over into school, work, and relationships.
Understanding the Types of OCD
OCD is frequently thought of in connection with extreme cleanliness and organization. While that can be one presentation of OCD, obsessions and compulsions can come in many forms, and they’re not always related to cleanliness.
Some of the most common subtypes of OCD are:
Magical Thinking OCD is the belief that thoughts or actions can cause real-life consequences, with no direct logical connection between them. Magical thinking most often involves a belief that thoughts or actions can cause or prevent harm. The thought process with magical thinking OCD is: I can control X by doing Y behavior.
Relationship OCD is a subtype of OCD where obsessions and compulsions revolve around a relationship. It usually presents as repetitive thoughts that center on doubts about the relationship and compulsions to check in with a partner in an attempt to relieve the anxiety.
Harm OCD is when obsessive and unwanted thoughts about harming yourself or others.
Hoarding OCD consists of holding onto belongings in fear that without them, something bad might happen. It’s separate from hoarding disorder where people believe that the items they’re keeping are valuable.
Religious OCD, also known as religious scrupulosity, is when obsessions and compulsions relate to religion or morality, usually centered around fears of going to hell.
Pure OCD, or Pure O is when obsessions and compulsions happen internally. Clinicians may refer to such cases as Pure OCD or Pure O (although not the clinical term), because the compulsions are purely obsessional. Pure O is often more difficult to diagnose and more difficult to treat, as the person often doesn’t realize they are experiencing OCD thinking, and the suffering all takes place in the mind.
Barriers to Care with OCD
Getting a diagnosis is critical to effective treatment. However, research shows that OCD is among the most commonly misdiagnosed mental disorders in the US. On average, people with OCD see 3 to 4 doctors and spend over 9 years seeking treatment before they receive an accurate diagnosis. There are several reasons for this.
General Unease
People may be self-conscious about their deeply distressing thoughts or rituals and be reluctant to discuss them. Intrusive thoughts can be embarrassing especially if they are related to sexual behaviors, which is not uncommon in OCD.
Lack of Visibility
A lot of Pure OCD gets misdiagnosed because mental compulsions and rituals are hard to see. The therapist or treating physician must rely on the client’s report of their thoughts and feelings. This often leads to a misunderstanding by a therapist not trained in OCD.
Unusual Presentation
A person with OCD may seem bizarre, or illogical or self-absorbed, leading the therapist to speculate some other mental disorder diagnosis. It is not uncommon for someone with OCD to be seen as self-obsessed and self-consumed, and they often are told they are “annoying” because they won’t stop talking about the same subject.
Having scary or odd thoughts is common for all people. However, for people with OCD, such thoughts become sticky and overwhelming. As OCD expert Stacey Kuhl Wuchner, LCSW writes: “The structures that are impaired in the OCD brain create sensitivity to uncertainty and a decline in one’s ability to feel complete. This leads to more value placed on incoming thoughts and relentless over-responding in the form of compulsions.”
How to Treat & Manage OCD
Find a Mental Health Professional Who Specializes in OCD
For most people with OCD, psychotherapy is an essential part of treatment. OCD is a disorder of repetition. The therapeutic treatment for OCD also involves repetition.
Therapists trained in OCD use Exposure and Response Prevention Therapy (ERP or EXRP), which involves exposing the person to their fear, and then asking that person to resist the compulsion and live with the fear until it decreases.
There are two types of exposure: imaginal, in which the person imagines being exposed to the fear, and real, in which the person actually experiences the thing or situation that causes fear. In ERP, when the person is exposed to a fearful situation (either imaginary or real), they resist engaging in a compulsion or safety behavior, such as seeking reassurance.
Although this can be a painful process, there are good coping strategies for making it easier, including keeping the exposure gradual, maintaining an OCD journal, pet therapy, breathing exercises and supportive group therapy. Over time, this process can desensitize the person to their fear. Exposure rewires the brain, helping the person begin to trust themselves, instead of their “OCD mind.”
While there are a variety of different psychotherapeutic therapies like Acceptance and Commitment Therapy that can help manage the symptoms of OCD, the gold standard is ERP.
Consider Medication with the Support of a Psychiatrist
One of the most common treatments for OCD are antidepressants, and with good reason; 70% of people with OCD benefit from pharmacotherapy (the combination of medication and therapy). While OCD isn’t a depressive disorder, certain antidepressants target the chemical transmitter serotonin which is involved in OCD. Working closely with a therapist and psychiatrist on a medication plan is essential.
Simulate Stress Reduction Programs
Another helpful approach for some involves mindfulness interventions that facilitate less reactivity to thoughts and feelings. Mindfulness Based Stress Reduction, a type of meditation therapy, has been shown to clinically reduce OCD symptoms over an eight-week period.
Engaging in stress reduction exercises like meditation, body scans, breathing techniques, guided imagery, or yoga can help reduce the symptoms of OCD.
OCD can be a debilitating condition but with the right tools, the symptoms can be manageable. Remember, the most important step is taking action to prioritize your mental health and well-being.
Q&A with Therapist James Rosenheim, LMFT
Q: What do therapists look for when diagnosing OCD?
There are several things I look for when diagnosing or being on the lookout for OCD symptoms. Common presentations include someone being stuck on a thought. My clients may tell me, “I am so in my head, and can’t get out of my thoughts.” A more specific example might be: “I can’t stop thinking about that time when I was with someone who had Covid, and maybe I got the infection and am still carrying it. I don’t want to keep thinking about it, but I can’t stop thinking about it.”
Due to the repetitive nature of the OCD thought pattern, clients with OCD often talk about loved ones who have become irritated by compulsions, such as repetitively asking for reassurance or reassurance seeking and repetitively discussing feared outcomes even after getting reassurance.
Other clients will visit a doctor for the same test after receiving multiple negative test results. Most people have heard of the person who can’t stop washing her hands. However, perhaps less commonly seen might be the child who can’t go to school until he goes up and down the stairs 15 times, making sure it is an odd number, to prevent some tragic occurrence. Or perhaps the golfer who takes 5 minutes before hitting his shot because he has to touch the grass until it feels just right.
Another commonly posed question that is often a sign that someone has OCD is when they pose the question: “How do I know if I really have OCD? Maybe I am just an imposter…? How awful it would be if I am just faking it when there really are people with OCD who are suffering worse than I am!”
It’s important to remember that while the outward symptoms in OCD can vary from person to person, obsessions and compulsions are always present.
Q: When you work with a client with OCD, what does that look like?
The beginning stages of treatment involve psychoeducation — or learning about OCD and all the ways it can show up. If possible, I like to meet with clients and their families because it’s helpful to open up the conversation.
The next stage is labeling thoughts. Having OCD can feel like someone is telling you that the sky is green and you think to yourself, “It feels and seems blue to me!” That’s how compelling OCD is, so labeling and identifying which thoughts are OCD and which are not, is crucial.
Once you are able to label thoughts, the next step is to delay the compulsion. This process is a critical element of the gold standard of treatment, known as Exposure and Response Prevention, or ERP. One example of this is a client I had who was terrified of losing his hair. He would avoid looking in mirrors for fear of seeing some indication of a receding hairline. This client even told me that he would cover his eyes when feeding a parking meter so as to avoid the off-chance that he might catch a glimpse of his own reflection.
In response to this, the work we did consisted of sitting for several minutes, together, in front of the mirror while pulling his hair back, and noticing the urge to avoid, while I encouraged him to sit with his anxiety.
I provided continual positive support while he tolerated the discomfort. Eventually he was able to come to a place known as radical acceptance, which for him, was acceptance of uncertainty around his hair.
This is an example of how a person, after they learn to delay their response and sit with anxiety, can then re-evaluate the OCD thoughts, realizing over time that they carry no significant value or importance, but are just thoughts and a simple misfire of the brain.
Q: OCD is really debilitating. Is there success with treatment and management?
I worked with a client, Chris*, many years ago whose OCD consisted primarily of a fear of being a narcissist. Due to the severity of his OCD, Chris was so preoccupied he couldn’t really function.
Around friends he hyper-analyzed his comments and behavior, “Did I just take the first slice of pizza? That’s what narcissists do! I can’t trust myself.”
He doubted himself constantly, in an attempt to control his thoughts and feelings, to the point where he could no longer do his job, complaining of endless writer’s block. Soon, he was out of a job, had completely isolated in his home, and struggled to talk to anyone, spending most of his day playing video games and sleeping.
Chris was very fused with his OCD; for the first two months he was unable to talk about anything else for more than 10 seconds in session before his OCD voice reminded him that he needed to focus on how self-centered he was
Chris and I worked to label and build insight into his OCD fears: “Jimmy, someone asked me for help with their car the other day but I had to go so I wasn’t late for work and told them I couldn’t. Doesn’t that just show that I’m a narcissist?” To which I’d respond, “Chris, you are checking with me, which is a compulsion. I want you to sit with the discomfort of not knowing, and label that as an OCD fear.”
He’d go on, “But Jimmy, I feel like all I am doing is talking about myself in therapy right now!” To which I’d respond, “Who else are we here to talk about Chris?”
Chris’s OCD mind was always coming up with a reason why his fear would come true, and we focused on building awareness of how that created a justification to continue to engage in the compulsion; which in his case was more thinking.
After a year of working together, Chris became quite good at labeling and defusing from his OCD thoughts, resisting compulsions such as checking with friends and family, and even me, for reassurance that he is not a narcissist. Through mindfulness, self-compassion and self acceptance, Chris learned not to beat himself up when he did “fall for” his OCD voice.
Chris now has a steady girlfriend, is working full time, and loves going snowboarding with friends. He is thinking about going back to school to be a psychologist, and wants to write a film screenplay that uses what he learned in therapy.