Obsessive-compulsive disorder (OCD) is a chronic mental health condition in which a person experiences recurrent and unwanted thoughts, urges, feelings, sensations or images that cause distress. In response to these obsessions, someone with OCD engages in compulsions—repetitive behaviors or mental acts that are done in an attempt to neutralize the thought or ease discomfort. Symptoms of OCD interfere with day-to-day living and lead to immense anxiety, fear, and other difficult emotions. However, treatment—including Exposure and Response Prevention (ERP) therapy and medication—is highly effective at helping people manage their symptoms and improve their quality of life.
Despite the fact that 1 in 40 people around the world are estimated to have OCD, it remains a widely misunderstood disorder, explains NOCD therapist Tracie Zinman-Ibrahim, LMFT, CST. “Most of society—whether it’s movies, information online, or the way people talk about OCD day to day—leads to a lot of confusion and misconceptions about OCD.”
Keep reading to understand the ins and outs of OCD and how to manage symptoms.
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What are the signs and symptoms of OCD?
Obsessions and compulsions are the two main types of symptoms in OCD.
What are obsessions?
Obsessions are often described as intrusive thoughts—but they can also present as intrusive images, feelings, sensations or urges that cause anxiety or distress. OCD obsessions often center around certain themes, such as an extreme preoccupation with getting contaminated by germs or fear of harming yourself or others.
Common OCD obsessions include:
- An extreme need for perfection, symmetry, or things to be “just right”
- Fears and doubts about ones “true” sexuality
- Intense fear about becoming contaminated or becoming ill
- Consistent worry about violating religious, moral, or ethical beliefs
- Fixations on bodily sensations or involuntary bodily functions
- Unwanted thoughts about violence or hurting oneself or others
- Doubts and fears surrounding relationships, most often the intimate ones
- Recurring doubts about things that happened in the past (False Memory OCD)
Keep in mind, says Patrick McGrath, PhD, Chief Clinical Officer at NOCD, “these obsessions do not align with a person’s actual values or desires. Often, they’re the exact opposite: a loving mother might be overwhelmed with mental images of hurting her newborn, or a devoted grade school teacher may be consumed with fears about being sexually attracted to his students.”
It’s also worth noting that everyone has intrusive thoughts from time to time. However, most people are able to move on from them, realizing that these thoughts don’t pose a threat or mean anything about their values or identity. The difference is that for people with OCD these thoughts feel significant and even dangerous, causing intense negative feelings such as fear, distress, anxiety, or discomfort.
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What are compulsions?
Compulsions are repetitive behaviors or mental acts that a person with OCD feels the urge to do in response to an obsession. The goal of these acts is to reduce anxiety or distress, or prevent a perceived bad outcome from happening. But since engaging in compulsions brings only fleeting relief, the obsessions return (this perpetuates what’s called the OCD cycle).
“Let’s say you’re afraid you’re going to harm others,” says Ibrahim. “Someone with this thought might have compulsions like staying away from sharp objects or avoiding the people they think are going to harm.”
Compulsions can make life feel very small. “I refused to watch the news because I was afraid the violence on the television would spark violent thoughts. I deemed knives and forks unsafe and ate only with spoons,” says Sommer G., a NOCD community member with harm-related OCD.
Common OCD compulsions include:
- Checking (i.e. repeatedly making sure the stove is off, or that the door is locked)
- Tapping/touching (i.e. tapping your knee a certain number of times in order to feel “okay” or “just right”)
- Reassurance-seeking (i.e. asking a loved one, “Did you see me push anyone when we were walking down that busy street?” or “Do you really love me?)
- Avoidance (i.e. refusing to go to places, be in situations, or take in stimuli that may trigger your intrusive thoughts)
- Excessive washing/cleaning (i.e. hand washing, showering, or disinfecting surfaces multiple times a day)
- Rumination (i.e. turning something over and over in your mind, even for hours a day)
- Mental reassurance (i.e. giving yourself reassurance, such as “I would never do anything awful like that because I’m not a bad person”)
- Thought-replacing (i.e. replacing a “bad” thought with a “good” one in your mind)
Obsessions and compulsions are time- and energy-consuming and can significantly reduce the quality of an OCD sufferer’s life—standing in the way of everything from daily responsibilities to career and relationship goals.
Types of OCD
OCD is listed as a single condition in The Diagnostic and Statistical Manual of Mental Disorders (DSM-5). That said, some clinicians (and the patients they treat) find it helpful to talk about OCD subtypes, representing the different categories of fears and obsessions that are commonly experienced. OCD subtypes can help people find community with others who share similar struggles, and they can assist therapists in designing targeted treatment plans.
If you can’t find your subtype on this list, that doesn’t mean you don’t have OCD—everyone is unique, and many people’s symptoms don’t fit neatly into any specific theme. Additionally, people with OCD can experience more than one subtype at once, and these subtypes often change over time.
Common OCD subtypes:
- Existential OCD
- Contamination OCD
- False Memory and Real Event OCD
- Harm OCD
- Health and Contamination OCD
- Perfectionistic OCD
- Pure OCD
- Relationship OCD
- Religious (Scrupulosity) OCD
- Responsibility OCD
- Sensorimotor OCD
- Sexuality and Gender OCD
- Postpartum OCD
- Pedophile OCD
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Who is at risk of developing OCD?
OCD can start in childhood or early adulthood. OCD most commonly starts in people aged 18 to 29. It isn’t known for sure what causes OCD, but here are some possible risk factors.
Genetics
While scientists have not pinpointed a specific gene or group of genes that directly causes OCD, genetic factors are thought to play a role. Research shows that people with a first-degree relative like a parent or sibling who has OCD are at a higher risk of developing the disorder themselves.
Biology
Studies show that people with OCD have some biological traits in common. For instance, there is evidence that OCD is linked to increased activity in certain brain areas. Compulsions like excessive cleaning and checking might be linked to how the thalamus, the part of your brain that relays motor and sensory signals, is wired. Likewise, an imbalance in some of the brain’s chemical messengers (neurotransmitters) may play a role.
Stressful life events
No research has directly tested how stressors can affect people with OCD, however, self-report studies show that 25 to 67% of people with OCD link significant life events to the onset of their OCD. Many people with OCD report that their symptoms began during a particularly stressful time in their lives or after a specific traumatic event.
Experts caution against drawing conclusions about cause and effect, however. “Some people with OCD also have experienced traumatic events but that doesn’t mean a traumatic event is necessarily going to result in OCD,” Ibrahim said.
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All our therapists are licensed and trained in exposure and response prevention therapy (ERP), the gold standard treatment for OCD.
How is OCD treated?
When it comes to treatment for OCD, many people turn to therapy for help. However, when relief doesn’t come, it’s often a sign that the wrong therapy was used in the first place, not that therapy isn’t effective. Talk therapy and general Cognitive Behavior Therapy (CBT), for instance, are two modalities that work for a lot of mental health issues, but tend to exacerbate OCD and make symptoms worse.
Exposure and Response Prevention (ERP) is the gold-standard treatment for OCD. It’s a behavioral therapy that was developed specifically to treat OCD, and is backed by decades of clinical research.
ERP works by carefully exposing people to situations that trigger their obsessions, then helping them resist the urge to engage in compulsions. This is done through what therapists call response prevention techniques. In time, the ERP process teaches people to sit with the discomfort and anxiety that comes from obsessions, rather than resorting to compulsions that perpetuate the OCD cycle and make it worse over time.
ERP is tailored to each person’s unique needs, but here’s one example of ERP in action:
When someone with Relationship OCD is struggling with an obsession about whether their partner will ever leave them, they may be engaging in a compulsion of reassurance-seeking—aka repeatedly asking their partner to tell them they have their unwavering devotion. In ERP therapy, a therapist might encourage writing “I don’t know if we’ll be together forever” in a journal, and sitting with the discomfort that this brings up. While it might sound counterintuitive, allowing the discomfort to be there eventually strips obsessive thoughts of their power.
As for the role of medication in treating OCD, for people with severe symptoms or additional mental health conditions (known as comorbidities), medication combined with ERP can sometimes help an OCD sufferer respond more effectively to ERP therapy. SSRI antidepressants like fluoxetine (Prozac) and sertraline (Zoloft) are the most common medications used in OCD treatment, but certain tricyclic antidepressants (TCAs) and atypical antipsychotics can also be effective.
Other treatment options for OCD
Although ERP and medication are typically the first-line treatments, there are some instances where additional or alternative treatment is necessary to manage symptoms. Here are some other treatments a healthcare provider may recommend for OCD:
Acceptance and Commitment Therapy (ACT)
Acceptance and Commitment Therapy (ACT) is a therapy that may be recommended when ERP is less successful, or as a way to help people gain ERP skills. ACT involves changing your relationship with your obsessions rather than directly confronting your distressing thoughts. “With ACT, you learn to co-exist with intrusive thoughts, images, urges, sensations and feelings without judging them,” says Ibrahim.
For example, someone with Contamination OCD might label anything dirty as dangerous. ACT encourages accepting those thoughts and feelings without acting on them by focusing on mindfulness. The main goal is not to resist or reduce obsessions and compulsions. Instead, you accept these thoughts — or think of obsessions as thoughts that come and go.
Unlike ERP, there aren’t many studies that support ACT’s effectiveness in treating OCD alone. “ACT can be helpful, but it doesn’t tend to be a standalone treatment for OCD,” says Ibrahim. That said, ACT may be used in conjunction with ERP therapy to increase motivation to continue treatment. “We often put two treatment modalities together for OCD,” she says.
Transcranial magnetic stimulation (TMS)
When traditional therapies like ERP and ACT aren’t effective in treating OCD, a non-invasive medical intervention like TMS may be used. “TMS is a later treatment option when your medication and therapy combination has not done enough,” adds Ibrahim. TMS is a treatment involving short magnetic pulses that stimulate the brain’s neurons (nerve cells). It was initially permitted by the U.S. Food and Drug Administration (FDA) for depression, but research revealed that it could also relieve symptoms of OCD–leading to the FDA’s approval in 2018. “TMS highlights a very specific part of your brain, and it regulates the neural activity of the brain structures associated with OCD,” says Ibrahim. She adds that deep TMS, a subtype of TMS, can be very effective for treatment-resistant OCD, possibly leading to a 30% or more decrease in symptoms.
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The bottom line:
People with OCD spend an average of 14-17 years suffering from the disorder before they even receive a diagnosis (and then can find the proper treatment), so it’s important to get connected to the right professionals as quickly as possible, rather than losing more precious time to OCD. “Finding someone who specializes in ERP treatment is the best way to get assessed and treated,” says Ibrahim.