What is OCD?
People casually use terms like “OCD” and “obsession” to describe endearing quirks or harmless habits. In reality, OCD can be a serious condition and is thought to affect 1% to 2% of people worldwide. People with OCD suffer from repetitive thoughts or repetitive behaviors that they have trouble stopping. The condition’s impact can range all the way from mildly annoying to completely disabling.
Obsessions are thoughts that feel intrusive and are accompanied by significant anxiety. These thoughts are typically experienced as unpleasant, and a lot of energy is spent trying to rid of them. Some of hte more common obsessions involve one of three topics: blasphemy, violence, or sexual taboos. Obsessions are often experienced as “what if” thoughts — e.g., “what if I jumped out the window?” or “what if I lose control and attack my spouse?” or “what if I actually cheated on my spouse and don’t remember it?”
Compulsions are behaviors that are often driven by anxiety and that we have difficulty stopping, despite our efforts to do so. Common compulsions include hand washing, cleaning, checking and counting. Compulsions can also be mental. One example of this kind of compulsions is the repeated mental retracing of a conversation to make sure you didn’t say anything rude.
Perhaps the most common compulsion is excessive hand washing. Hand washing is part of good hygiene, but too much hand washing can be compulsive. For someone with OCD, hand washing can feel like a way to reduce the odds of contracting a specific illness. For others, there is no fear of a specific illness, it just feels like something they have to do, and they feel better after they do it. Unfortunately, over time it can take several repeated hand washings to achieve that same feeling.
How obsessions wreak havoc
In everyday language, the word ‘obsessed” or “obsession” indicates a strong interest. To say that you’re “obsessed” with something has a vaguely positive connotation, as in, “My nephew is obsessed with baseball!” However the reality of suffering from actual obsessions is quite different. Obsessions is often used to indicate a strong interest. Obsessions in reality are intrusive unwanted thoughts that quickly cause significant anxiety.
Typically this anxiety happens because of what the sufferer thinks it means that they had the thought. For example, after a thought like “maybe I’d like to kill my brother” comes up, people without OCD would think “no, I don’t” and then resume their lives. For someone with OCD, this thought can be followed by questions like “why did I have that thought?” “What if having that thought means I could actually do that?!” The emotional reaction to these thoughts ranges from annoyance to terror.
Topics of obsessions
Obsessions tend to be about one of several different topics. They often involve a taboo subject such as incest, unwarranted violence, suicide, or pedophilia. However, obsessions can involve other topics too.
Common obsessive themes include:
- moral themes
- religious themes
- a need for order or symmetry
- aggression or violence
- sexual themes or imagery
To give you a sense of the emotional impact these obsessions can have, consider the above example of the obsessive thought “maybe I’d like to kill my brother.” How would you feel if you suddenly had that thought and had real, heartfelt concerns that it might be true? This gives some sense of the distress that can happen with obsessions.
Some obsessions are known as “unwanted intrusive thoughts.” Unwanted intrusive thoughts are estimated to be a problem for up to 6 million Americans. Unwanted intrusive thoughts seem to come out of the blue, and typically involve very upsetting or disgusting content.
Other obsessions can be understood as feelings that are somewhere between physical and emotional. For example, the feeling that leads some OCD sufferers to want to clean or organize something is typically not a thought so much as a discomfort.
Compulsions refer to specific behaviors that serve to reduce anxiety or an uncomfortable feeling for someone with OCD. Checking, cleaning, counting and reviewing are common compulsions, but there are many other types. Many compulsions are observable, such as washing your hands or unlocking and re-locking a door to make sure it’s secure.
Many compulsions are not observable — they are mental. Examples of mental compulsions include mental review, counting, repeating a word, reassuring oneself, or mentally “undoing” something in your mind. An example of mental review would be someone who feels uncomfortable going to sleep at night before they have reviewed a conversation they had earlier to make sure they didn’t say anything inappropriate. Mental compulsions can be very complex.
Whether compulsions are mental or behavioral, they create a real impediment to living one’s life well. They are often very inconvenient for the people who have them!
Compulsions make life worse
For example, if you turn the light switch on and off two times before leaving your home to make sure it’s off, this may not be a compulsion because it’s not really interfering in your ability to live your life. It only takes five seconds and doesn’t bother you after that. However even innocent repeated checking behaviors like that can become more time-consuming and impactful. If they do they may be considered compulsions.
One of the unfortunate things about compulsions is that there is really no limit on how time consuming and frustrating they can become. Compulsions and rituals (combinations of compulsions) can sometimes take up all of one’s waking hours when OCD is severe, and even interfere with sleep. The good news is that no matter how severe one’s compulsions become, improvement is always possible!
Treatment options in OCD
When obsessions or compulsions are bad enough that they interfere with our ability to function, it is a good idea to seek a consultation with a professional. Fortunately, there are several effective treatments for OCD. The two most commonly used include a form of cognitive-behavioral therapy called Exposure and Response Prevention (ERP, or ExRP), and also medication.
Psychotherapy and the importance of choosing the right one
Many people with OCD understandably seek therapy when their symptoms become a problem. However, this is not a guarantee they find effective treatment. Most therapists have not been trained or experienced in ERP. Despite that, many will treat OCD anyway. Finding a therapist with the right training can be hard. Here are some helpful questions to answer before starting psychotherapy for OCD:
- What training does the therapist have in doing ERP? (the answer should not be “none.”)
- Does the therapist give homework exercises to do between sessions? (The answer should be “yes”)
- How will the therapist measure your progress? (The answer should not be, “we’ll talk about it as we go and decide together.” The ERP therapist typically uses questionnaires to measure progress, but may use other indicators such as average number of times washing hands per day, or number of hours spent in obsessive rumination.)
Prescribers primarily use two classes of medication to treat OCD. Selective serotonin reuptake inhibitors (SSRIs) are medications that increase the amount of a naturally occurring chemical in the brain called serotonin. SSRIs include medications such as Luvox, Lexapro, Prozac and Zoloft. SSRIs are the first type of medications prescribed for OCD, and they are prescribed at high doses. Unfortunately around half of people treated for OCD with SSRIs do not respond well enough to meet their goals.
If SSRIs aren’t effective, prescribers will sometimes use other medications sometimes used to manage OCD. These include Anafranil (a tricyclic antidepressant) and medications called novel antipsychotics such as Abilify.
So which treatment works best?
Which is more effective, ERP or medication treatment? This question needs more research, but studies have suggested that ERP without medication is slightly more effective than medication without ERP (e.g., this study and this study). Many people have a greater comfort level with one of these two options over the other; if you strongly prefer one, seek it out! Treatment can change lives — life after OCD can be a whole new ballgame.
Last updated: May 3, 2020