Obsessive Compulsive Disorder
Obsessive Compulsive Disorder (OCD) is a mental health disorder marked by intrusive, unwanted thoughts that cause a sense of distress or anxiety. People manage these thoughts through rituals or compulsions, which can cause impairments in daily life functioning. Treatment through exposure and response prevention therapy and medications are available and evidence-based. Though OCD is quite common with one in forty adults affected by the condition, less than 10% of those experiencing symptoms will seek treatment.
OCD Definition, Symptoms, and Diagnosis
What is OCD?
Obsessive Compulsive Disorder (OCD) is a mental health disorder that manifests as repetitive intrusive thoughts (obsessions) that are scary or uncomfortable and repetitive behaviors (compulsions) such as checking or washing that serve to alleviate the anxious or uncomfortable feeling. In many cases, obsessions and compulsions can be intrusive to the point where the client may not be able to function normally. These thoughts or obsessions need to take up an hour a day for the disorder to be diagnosed.
What are symptoms of OCD?
Symptoms of OCD, which can range from mild to severe, can be broken into two categories: obsessions and compulsions.
Obsessions are thoughts, images, or feelings that an individual does not want to have and finds distressing. Many people frequently have unwanted or scary thoughts or images, but a person without OCD can dismiss the thoughts without anxiety or discomfort, and a person with OCD cannot. Often, people have insight into their obsessions as being irrational, but this does not necessarily help them dismiss the thought. Obsessions can be time-consuming and can get in the way of daily life.
Compulsions are behaviors that are done with the goal of neutralizing the anxiety and/or discomfort associated with the obsessional thought. They may be completely unrelated to the thought or image but provide temporary relief from the distressing obsession. Over time, a person with OCD begins to associate the ritual with the experience of relief and that makes it challenging to resist doing the compulsion. It is important to note that not all repetitive behaviors or rituals are an indication of OCD; it depends largely on the function of the behavior. If the compulsion succeeds in reducing anxiety/distress, we classify that as a compulsion. If the behavior does not serve a function of decreasing distress, we tend not to classify that as a compulsion.
While there are no lab tests or imaging procedures used to diagnose OCD, there are criteria for diagnosing OCD in the DSM-5 (Diagnostics and Statistics Manual), a manual that mental health professionals use for diagnosis. In addition, the Yale Brown Obsessive Compulsive Scale is another tool that can help elucidate the symptoms of OCD.
To diagnose OCD, someone must have these recurring, non-rational thoughts or images (obsessions) with behaviors that help to reduce the anxiety (compulsions). The symptoms must take up an hour or more a day and cause impairment in daily life.
To meet the criteria for diagnosis of OCD, the DSM-5 indicates that these obsessions and compulsions must not be the result of another disorder. Examples include food rituals that are the result of an eating disorder, disturbing thoughts that are the result of schizophrenia or other psychotic disorders, or excessive worries that are the result of Generalized Anxiety Disorder. In these cases, the individual may not be diagnosed as OCD. While individuals may have milder symptoms that do not meet all criteria for diagnosis of OCD, clients can still get tremendous benefit from treatment for the symptoms they do have.
As with all psychiatric disorders, diagnosis can be tricky and confusing as symptoms can cross over multiple disorders, and it is essential to get a proper evaluation with a licensed clinician.
No one knows exactly what causes OCD. Although OCD has been researched extensively, and no single cause has been identified.
Like most medical and mental health disorders, there is usually a family pattern of having similar symptoms and there may also be environmental factors that contribute to the development of the disorder. What experts do know is that there are brain structures and chemicals involved in the disorder and that it can be passed down by genes in families.
Contamination: Over-concern of being “contaminated” by germs, chemicals (e.g. from household cleaning products), or environmental chemicals (e.g. from radiation).
Hypochondriasis or illness anxiety: Irrational fear of having an illness. For example, being preoccupied by a small bump on the skin and thinking it is cancer despite a doctor saying it’s a mosquito bite.
Scrupulosity: A preoccupation with morality or blasphemy (fear of offending God).
Losing control: Over concern with “losing your mind” or “going crazy” and harming another or yourself; worries of blurting out obscenities, stealing, or breaking the law; worry about certain images you can’t get out of your mind.
Harm: Fear that you will cause harm to yourself or others or of being the cause of something terrible happening.
Perfectionism or “just not right”: Fear of not doing something perfectly or correctly; fear of losing or forgetting things; preoccupation with past mistakes or fears of failure to the extent of preventing the individual from reaching for goals.
Transformation: Fear of transforming into something or someone else. Worry about taking on the characteristics of someone else. An individual may fear that they have taken on the gestures or behaviors of a friend or even a stranger and that they are copying them, although they do not want to.
Sexualized: Knowing one’s sexual preferences and desires, yet constantly and obsessively checking to make sure that they are right. Worrying that you might be a pedophile or might sexually assault someone.
Magical thinking: Being obsessed about lucky numbers and/or letters.
What types of compulsions are there?
Skin picking (dermatillomania): Continual picking at hangnails, scalp, scabs, blemishes, freckles, chest, shoulders, etc even after bleeding or pain occurs.
Hair pulling (trichotillomania): Pulling out lashes or eyebrows or hair from the scalp and other body parts.
Cleaning: Excessive hand washing, showering, or cleaning.
Checking: Performing multiple physical checks, for example to see if the stove is turned off, or mental checks, for example to see if you have harmed someone.
Mental rituals: For example, review of events to make sure nothing bad happened or repeated self-reassurance.
Repeating thoughts, words, or behaviors: Such as repeating out loud the word “green” five times every time you pass your best friend’s house to protect the best friend.
Canceling: For example, saying “cancel that thought” multiple times to get rid of the unwanted thought.
Ritualized eating: For example, eating food in a certain order or in a certain pattern to avoid something bad happening.
Ordering / symmetry: For example, feeling the need to have pencils on a table in exactly 90 degree angles.
Hoarding: Inability to part with objects and items, even if the object is broken or is considered by most to be trash; experiencing great distress in parting with objects to the point that the individual may go to great lengths to retrieve the items.
Confessing: Feeling the need to confess something the individual feels irrationally guilty about; for example, confessing to your boss out of guilt that you went to the bathroom two times, despite the fact that you are allowed to go the bathroom.
Reassurance seeking: Obsessively questioning one’s decisions; for example, having to ask multiple people at the store repeatedly times whether or not the individual should purchase a certain item.
Repetitive behaviors: Repeatedly touching, tapping, or rubbing self or items; for example feeling the need to open and close the kitchen cabinets nine times before making coffee in the morning; or feeling the need to tap the desk three times every time you read another sentence in a book.
Self-damaging behaviors: Self-injurious behaviors such as obsessively and repeatedly hitting oneself; note this is different from non-suicidal self harm or suicidal behaviors.
These behaviors are considered compulsions because they help to decrease the severe worry that comes with the distressing thoughts or images. They may not be similar (worrying about germs may not have a compulsive ritual involving cleaning -- it could be counting, reassurance seeking, lock checking or other behaviors).
For example, counting sheep to fall asleep at night isn’t a compulsion unless you must do it every night in a certain way at a certain time and if you “mess up” you have to start over again or an intrusive thought or image may continue. Checking the stove before you leave for work isn’t a compulsion but checking and rechecking to the point of not being able to leave for hours, is.
Does OCD occur among children?
Yes, obsessive compulsive disorder occurs in children but it can appear differently from adults. Children’s OCD can appear to be inattention, not talking in class or in public, acting out or appearing sad or depressed while withdrawing from the world. Because OCD can look so different in children who may not have the language to describe it, it is important to undergo diagnosis with a trained clinician.
How common is OCD?
Among adults, OCD is estimated to occur around 1 in 40 adults, or 2.3%. In children, it is estimated to occur in around 1 in 100 children, or 1%. This is an estimate of people who meet the full criteria for the disorder; the estimates for people who have symptoms of OCD but do not meet the full criteria is much higher.
The onset of OCD usually occurs in one of two peaks, either ages 9-11 or ages 20-22. Though these are frequent times for OCD to occur, the disorder can occur at any time in the life cycle. OCD affects people of all genders, races, and cultures.
Learn more about the prevalence of OCD here.
OCD Treatment Options
What is the best treatment for OCD?
The most effective, evidence-based treatment for OCD is Exposure and Response Prevention (ERP), a type of Cognitive Behavioral Therapy (CBT).
In Exposure and Response Prevention, the therapist first teaches the client about the therapy that is most effective and helps the client identify where OCD is bothering them. Clients learn about how OCD responds best to slowly confronting the fears in a gentle but increasing manner to teach their brain that everything is actually okay.
Because exposure and response prevention therapy is controlled by the client in a collaborative approach with their provider, the therapy leads to quickly realizing how much control they can have over their brain patterns. Eventually, the brain learns that the worries can be overcome without having to behave in a certain way or do certain things and the anxiety is reduced.
There are also medication treatment options, that, when combined with the therapeutic approach above, can help clients engage in the treatment and feel better more quickly. This is often explored if therapy has been tried and is not helping rapidly or if the symptoms are so severe that they get in the way of even starting therapy.
In addition to ERP, other behavioral therapies such as Acceptance and Commitment Therapy (ACT) and mindfulness can be helpful for reducing obsessions, particularly intrusive thoughts. Support groups and therapy groups can also be very effective, allowing the client to see they are not alone in their struggles and reducing anxiety and shame.
What is an example of exposure and response prevention?
If you struggle with contamination OCD, you may have stopped going to the supermarket and feel you must wash your hands 23 times afterwards, each with 10 pumps of soap with scalding hot water and drying with a fresh towel. You may believe that if you don’t do this, you will not get the germs off and you will then contaminate your significant other or children. While it is typical for people to wash their hands or use hand sanitizer after going to the supermarket, in the case of someone with OCD, the washing is in direct response to an obsessional thought, serves to decrease the anxiety associated with the obsessional thought and is particularly rigid in the way the ritual needs to be carried out in order to achieve relief.
However, going to the store and not washing your hands from day one of therapy is likely extremely difficult for you. Instead, your therapist my start with gradual exposure. You might first imagine what it would be like to go to the supermarket and not wash your hands. You then you might go to the store, perhaps with your therapist, and wash your hands 22 times. Then 21 times. Over time, you would lower the number of times you need to wash your hands, eventually getting down to not washing at all.
Can you be cured of OCD?
Most people are not “cured” of OCD in the sense that they never have any intrusive thoughts or engage in any compulsions ever again. OCD is like a chronic illness, that when attended to and treated, is significantly improved and becomes manageable.
When people feel “cured” it is not because they never an intrusive thought again; rather, it is because they know how to manage their intrusive thoughts using the skills they learned in ERP and are able to feel better over time.
There is no cure for intrusive thoughts because it is part of the human experience to have an unpleasant or intrusive thoughts. Clients learn in therapy how to use the skills to face the OCD if or when it returns. Once the tools are learned, clients are in control of how to reduce OCD’s grip on their lives.
What is the best medication for OCD?
The first line treatment for moderate to severe OCD are medications called SSRI's (selective serotonin reuptake inhibitors). Often people with OCD need to take higher doses of these medications than people suffering from depression or generalized anxiety.
When you meet with your provider, you can discuss whether medication management is right for you, as well as the side effects and benefits of the different options.
How do you help someone with OCD?
The best way to help a person who has OCD is to offer them empathy and compassion and support them through treatment. Try not to judge their thoughts or behaviors. Ask them how you can be helpful. Often therapists will help to educate family and friends (with a client’s permission) on how to help.
One great way to help is to learn as much about OCD and the treatment as possible. If the person suffering is a child, parental involved in treatment is essential so that everyone knows and understands exposure and response prevention and can help the child utilize the skills from ERP when needed.
What is the difference between OCD and obsessive compulsive personality disorder (OCPD)?
These two disorders can often be difficult to tease apart. On a more basic level, the difference between OCD and OCPD is that a person with OCD has clear and identifiable obsessions and compulsions, while a person with OCPD has a pervasive preoccupation with orderliness and perfectionism with painstaking efforts to pay close attention to detail at the expense of their daily functioning and relationships. A person with OCPD typically lacks awareness of these difficulties or the way they impact others.
Find an OCD Therapist
What should I look for in an OCD therapist?
When looking for an OCD therapist, make sure that your potential therapist has training in Cognitive Behavioral Therapy (CBT) and specifically Exposure Response Prevention (ERP). It is also important to find out if the clinician specializes in anxiety disorders and how much of their caseload focuses on OCD or related disorders.
Clients should feel free to interview prospective therapists, and most clinicians will happily speak to prospective clients by phone before the first in-person session to see if they are a good fit for the client’s needs.
Find therapists who treat OCD near you
About the contributors
Dr. Amy Funkenstein, MD
Dr. Amy Funkenstein is an Adult, Adolescent, and Child psychiatrist in Belmont, MA. She specializes in anxiety disorders, including Obsessive Compulsive Disorder, Trichotillomania, panic disorders, and phobias. She uses Exposure Therapy with Response Prevention for Obsessive Compulsive Behavior, Habit Reversal Therapy for Trichotillomania, and goal-oriented supportive therapy with behavioral components for other mental health issues. Prior to starting private practice, Dr. Funkenstein worked at Tufts Medical Center, Rhode Island Hospital Young Adult Behavioral Health Program, and Bradley Hospital. She completed her Child and Adolescent Psychiatry Fellowship at Rhode Island Hospital (Brown University Medical School) and her Adult Psychiatry Residency at Cambridge Health Alliance (Harvard Medical School).
Hannah Goodman, LMHC
Hannah Goodman is a Licensed Mental Health Counselor in Barrington, RI. She specializes in anxiety, including panic disorder, Obsessive Compulsive Disorder and worry. She also has expertise in depression, adolescent issues, life transitions, couples counseling, and family counseling. Outside of her counseling practice, Hannah works as a writing coach and college counselor, drawing on her years of experience in the school system to help individuals of all ages with writing projects and prospective college and graduate students with their applications.