Obsessive Compulsive Disorder (OCD) is characterized, just as the name suggests, by two parts: obsessions and compulsions.
Obsessions are thoughts, images, or impulses to do something that repeat over and over again. They are generally unwanted, distressing, or disturbing, and get in the way of doing important things, such as job responsibilities, schoolwork, parenting, and participating in relationships. Obsessions are often accompanied by intensely uncomfortable feelings, such as fear, anxiety, doubt, disgust, and persistent worry.
Compulsions are the behaviors that one may do in order to neutralize, satisfy, or otherwise reduce their obsessions and the uncomfortable feelings that come along with them. Compulsions include doing things over and over and/or in a certain ways, thinking certain thoughts to counteract the obsessions, asking repetitive questions to other people in order to obtain reassurance, and avoiding things or situations likely to trigger obsessions.
Like obsessions, compulsions typically take up a significant amount of time, can get in the way of doing important things, and can also be embarrassing. Many people with OCD will find that doing their compulsions does help at least to some degree in the short-run, keeping their obsessions at bay or reducing them. But the obsessions typically come back as strong as ever, reinforcing an escalating cycle of obsession, compulsion, obsession, compulsion, and so on.
When many of us think about OCD, we think of the most well-known symptoms, such as excessive hand-washing or keeping things in order. However, there are many ways in which OCD manifests and can be addressed in treatment. Common reasons why people with OCD seek treatment include, but are not limited to:
- Persistent anxiety that something bad will happen to loved ones, particularly if a certain ritual is not performed
- Fear of getting sick or contaminated, either in general, or with respect to specific diseases
- Repeated washing, showering, decontaminating, or research into diseases and how they are contracted
- Feeling dirty, contaminated, or unclean, without fear of actual illness. The contamination may be by something physically dirty, or by objects or people thought to have something wrong or undesirable about them.
- Fear of losing control and hurting one’s self or others (e.g., hurting loved ones with a knife, pushing someone into the street)
- Fear of being responsible for harm to others due to negligence (e.g., one’s carelessness may start a fire or cause someone to slip and fall)
- Worries about having hit someone while driving and checking repeatedly
- Need for things to feel “just right,” leading to repetitive cleaning, ordering, arranging, light switching, door or window-locking, walking up and down stairs or through doors
- Fears about having inappropriate sexual thoughts; These may be violent images, or related to people that it feels perverse to have thoughts about, such as family members, children, or a gender that one does not want to be attracted to
- Fears about offending God or imperfect adherence to one’s religious requirements. (Religious rituals themselves are not compulsions, but fear of not following the rules properly to a degree that is significantly beyond what others in one’s community experience may be symptomatic)
- Fear of forgetting things, not understanding things sufficiently, not making one’s self perfectly understood, or “needing to know” something; repeated questions to neutralize these obsessions
- Compulsions around counting or doing things in multiples of certain “good” numbers or on “good” dates and/or avoidance of “bad numbers”
- Fear that one may do or say something inappropriate in social or work situations, such as blurting out obscenities
- Inordinate perfectionism
The most effective form of psychotherapeutic treatment for OCD is a type of CBT called Exposure and Response Prevention (ERP). In the exposure aspect of ERP, the individual works together with the therapist to confront the thoughts, people, things, and situations that are the focus of their obsessions and trigger their discomfort. The key element of this treatment is the response prevention aspect, in which the individual makes the choice – in the service of improving their lives in the long run – to refrain from doing the compulsions that they typically rely on, whether it be washing, performing a ritual, asking questions, repeating things, or trying to push thoughts away or otherwise deny them.
By breaking this cycle of obsessions and compulsions, most individuals will find that their anxiety and discomfort will eventually decrease without having to do the compulsion. At the outset, this may take longer. But by repeating these exercises over time, individuals build up a level of comfort with the situations that were previously thought to be unbearable. As this happens, individuals may begin to think differently about their obsessions, finding that these warnings of inescapable danger that the OCD insists upon are exaggerated, and that the situations are in fact survivable and less threatening than initially feared. As this comfort level grows, individuals with OCD can begin to reclaim the hours of their lives occupied by the condition.
To some, this approach may sound counterintuitive at first. Many seek treatment to make these thoughts and feelings just go away rather than to confront them. However, it is often because of desperately wanting to feel better and think differently that many get stuck in that escalating cycle of obsessions, compulsions, and worse obsessions. ERP is a choice to take a different approach from the one many are stuck in, one that may be quite challenging at first, but life-altering and positive in the long-run. An essential ingredient of the process is an experienced and compassionate therapist who will work with the individual to move along at the right pace, provide support, and troubleshoot potential obstacles.