People with obsessive-compulsive disorder (OCD) experience obsessions, compulsions, or both. “Obsessions are unwanted thoughts, images, or impulses that an individual experiences over and over again,” said Andrea Umbach, PsyD, a clinical psychologist who specializes in treating anxiety disorders at Southeast Psych in Charlotte, N.C.
They’re often disturbing and cause tremendous anxiety.
As Mara Wilson writes in this piece on things no one tells you about OCD, “Imagine the feeling of having a song stuck in your head. Now imagine that instead of ‘It’s Raining Men,’ it’s the thought of murdering your best friend. In graphic detail. Over and over again. You’re not mad at your best friend, and you’ve never done anything violent, but it won’t stop playing.”
Even when thoughts aren’t this disturbing, they’re always unpleasant, play on repeat, and spike anxiety. In order to reduce or prevent the negative emotions and distress, people with OCD often engage in compulsions, which Umbach defined as “repetitive actions, either physical or mental.”
People might develop rituals such as “checking, arranging, or repeating things until it feels right.” They might count or say phrases in their heads to defuse an obsession, she said. “Individuals with OCD might also ask many questions in order to receive reassurance that everything is going to be OK.”
They might ask others about whether they’ve done anything wrong, such as “Did I run someone over with the car?” “Am I a pedophile?” or “Am I going to go to hell?” said Tom Corboy, MFT, founder and executive director of the OCD Center of Los Angeles.
People with OCD carry intense shame about their disorder, which makes it an isolating illness. But if you have OCD, you’re not alone. According to the National Institute of Mental Health, OCD affects about 2.2 million American adults. Worldwide OCD and its related disorders affect more than one in 100 people, according to the International OCD Foundation.
OCD is a debilitating illness. Thankfully, however, it’s “very treatable,” said L. Kevin Chapman, Ph.D, a clinical psychologist who treats anxiety disorders in Louisville, Kentucky.
Below, you’ll learn more about what obsessions and compulsions look like, persistent myths about OCD, the gold standard for treating OCD, and more.
A Closer Look at Obsessions & Compulsions
Contamination is the most common type of OCD, said Chapman. Individuals obsess over contracting a disease from objects, places, or people, he said. They engage in compulsions such as excessive handwashing, showering (after they feel “contaminated”), and cleaning their items, he said.
People with OCD also commonly struggle with aggressive obsessions (such as Wilson described above), which may manifest as thoughts, images, or impulses of unintentionally hurting others, Chapman said. “For example, [someone might have a] fear of stabbing a loved one with a sharp object from the kitchen, fear of driving due to striking pedestrians, or unintentionally poisoning a loved one.”
Individuals don’t have any intention of committing these acts. And, understandably, these thoughts are highly distressing to them, he said. To soothe the distress, they may engage in different rituals, such as “retracing driving routes for hours out of fear of ‘yellow tape’ and accidentally causing [a car] accident, avoiding sharp objects or weapons at all costs, and avoiding aggressive movies.”
Another form of OCD is scrupulosity. This includes obsessions about religion, morals and “scruples” or “doing the right thing,” Chapman said. People might worry about everything from committing a horrible sin to offending others.
“Rituals may take the form of reassurance seeking from pastors or clergy as attempts to confirm that one did not commit the unpardonable sin, excessive trips to confession, repeating prayers, signs of the cross when hearing of traumatic events, and avoiding religious activities including reading of scripture.”
Individuals may also compulsively avoid feared objects or situations, Corboy said. They may avoid spending time with their kids for fear of harming them, or avoid sharp objects for fear of stabbing someone, he said.
Myths About OCD
- Myth: Repressed issues underlie OCD. “Many people spend years in psychoanalysis searching for nonexistent issues in an effort to explain why they are experiencing unwanted thoughts,” Corboy said. However, people with OCD have these types of thoughts because everyone has these thoughts. The difference is that people with OCD “get stuck on them, and do specific behaviors in an effort to escape the anxiety caused by them,” he said. While we don’t know what causes OCD, it seems to have a genetic basis, Corboy said. “OCD is sometimes ‘triggered’ by stressful events in that it appears to develop as a learned, maladaptive, coping response employed in an effort to manage that anxiety.”
- Myth: Everyone is a little OCD. According to Umbach, “The words ‘OCD’ and ‘obsessed’ tend to get thrown around carelessly.” Again, OCD is a debilitating disorder (and goes beyond being casually preoccupied with something). When it isn’t taken seriously, people can suffer needlessly because they don’t seek help, she said.
- Myth: If people could relax, they wouldn’t have OCD. “Actually, people with OCD are usually doing everything they can to reduce discomfort,” Umbach said. That’s the purpose of compulsions — to stave off anxiety and relax, she said. However, seeking comfort only perpetuates OCD. “What individuals with OCD actually need is a structured, supportive program to help them break free from OCD’s repetitive cycles.” (The gold standard of OCD treatment is discussed below.)
- Myth: People who have a tendency toward perfectionism or orderliness “are OCD.” “On numerous occasions, I have heard people state, ‘she is so OCD’ when they are describing behaviors that occur in certain contexts rather than the presence of true obsessions and compulsions,” Chapman said. However, he noted that these symptoms may indicate an unrelated — though similarly named — disorder called obsessive-compulsive personality disorder (OCPD).
Treatment of Choice
“One of the first steps to managing OCD is taking symptoms seriously,” Umbach said. If you’re struggling with distressing obsessions or compulsions, she said, don’t dismiss them. “There is no shame in asking for help.”
The best treatment for OCD is a type of cognitive behavioral therapy called Exposure and Response Prevention (ERP). According to Corboy, in the past 15 to 20 years, controlled research studies have found that ERP (with or without medication) is superior to all other types of treatments for OCD.
Specifically, with ERP, “individuals with OCD gradually expose themselves to events, situations, or objects that cause anxiety, without doing their customary compulsive response,” Corboy said. Over time, he noted, people become less obsessive and anxious.
Exposure is conducted in a graduated fashion by creating a hierarchy of distressing situations, Chapman said. The therapist helps the client list these situations in order, typically from zero to 100 (100 being the most distressing). Then they work on this list, moving from the lowest anxiety-provoking situation to the highest. “[M]any clinicians begin at about 50 — sometimes lower, sometimes higher — which represents ‘moderate distress.’”
Chapman shared this example of a hierarchy for a client who has contamination obsessions:
50 = touching doorknobs at work (not washing hands)
60 = using ink pens of my “consumers” at work
65 = eating cracker off the table
75 = touching dirty floor
100 = sitting on toilet seat (no paper on seat)
In some cases people have what is sometimes called “Pure O,” in which their compulsions are less obvious. But Corboy cautioned that the term “Pure O” is misleading. “Every person I have treated with so-called ‘Pure O’ has exhibited numerous compulsive behaviors,” Corboy said. When treating Pure O, “imaginal exposure,” a type of exposure, is especially effective, he said.
This involves writing a short story about your obsessive fear, and reading it repeatedly until it becomes less anxiety provoking, he said. “It is the same process as standard exposure, except that the exposure is to the upsetting thought, rather than to an external event, situation, or thing.”
CBT also involves learning to practice flexible thinking, tolerate distressing emotions and cope adaptively, Umbach said.
People with OCD tend to get stuck in rigid thought patterns, she said. One example is “My writing must be perfect or I will be fired.” Clinicians help clients “move away from extremes, be open to other possibilities, and explore assumptions rather than taking them at face value.” They may work on revising the writing thought to this thought: “My writing is legible and neat, I will still have my job even if the lines are not perfectly straight.”
They also work on developing effective coping skills, such as breathing, imagery and soothing techniques, which might include exercising or listening to music, Umbach said. Clients may create a list of coping statements to navigate tough times, such as “I am strong, and I can do this.” Another coping strategy, she said, is seeing OCD as a character outside yourself that you’re defeating.
Because exposing yourself to anxiety-provoking situations triggers negative emotions, CBT also teaches clients to successfully tolerate distress. “Rather than avoiding, people learn they are able to tolerate low levels of distress and get through it without escaping. We are able to ride out our emotions because we know they are temporary and will dissipate over time.” As clients are successful in tolerating distress in smaller situations, they move on to more difficult ones, she said.
Corboy suggested visiting the International OCD Foundation, which features a database of therapists you can search who specialize in treating OCD.
Medication for OCD
“Medications can provide much needed relief from the crippling effects of OCD,” said Brian Briscoe, MD, founding partner and CEO of Kentucky Psychiatric and Mental Health Services, PLLC.
They can reduce the frequency and intensity of obsessions, he said. They also help to treat depressive symptoms, which often accompany OCD.
Commonly prescribed medications include selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs). In some cases, physicians prescribe other medications to augment the effects of SSRIs or SNRIs, he said. (Some supplements, such as N-Acetyl Cystiene (NAC) have also been shown to boost the effects of an SSRIs or SNRIs, according to Briscoe.)
However, Dr. Briscoe strongly recommends that all his patients engage in exposure and response prevention (ERP) with a skilled therapist. Some of his patients don’t take medication and have achieved full remission from OCD with ERP alone. Others do well with both ERP and medication.
If you’re considering taking medication, Briscoe stressed the importance of seeking a board-certified psychiatrist or a psychiatric nurse practitioner, who’s experienced in treating OCD.
He also noted that having a collaborative relationship with your provider is essential for optimal treatment. That is, it’s key for the “the patient and doctor [to] work together to find a medication that is effective with minimal to no side effects,” and to “mutually work together to achieve goals that the patient has laid out for himself or herself.”
Mindfulness and OCD
Corboy has found that individuals with OCD have benefited tremendously when ERP is combined with mindfulness. He defined mindfulness for OCD as “the awareness and acceptance of the unwanted thoughts, feelings, and sensations being experienced.”
It involves accepting that the thoughts exist in your consciousness (not that the thoughts are true), he said. “By accepting the thoughts, rather than trying to eliminate them, the person learns that they are able to experience them without doing compulsions.”
You can learn more in The Mindfulness Workbook for OCD: A Guide to Overcoming Obsessions and Compulsions Using Mindfulness and Cognitive Behavioral Therapy, which Corboy co-wrote with Jon Hershfield, MFT.
Learn everything you can about OCD. “The more you understand about OCD, the more you will gain insight into your own personal patterns,” Umbach said. And the more you comprehend your patterns, the easier it will be to break them, she said.
Corboy most frequently recommends these books: Getting Control and The Imp of the Mind by Lee Baer, Ph.D; and The OCD Workbook by Bruce Hyman, Ph.D, and Cherry Pedrick, RN. Umbach’s website includes a list of recommended resources on OCD. And, again, the International OCD Foundation has excellent information.
Be open to change. What can help you be more open is to consider how OCD has influenced your life, and all the reasons why you want to make a change, Umbach said. “Carrying your motivation with you will help during the challenging times.”
Understand that treatment is a process. “Even though people want to get better quickly and easily, understanding that change takes time will make the process more tolerable,” Umbach said. She also stressed the importance of practicing the skills you’re learning in therapy.
Connect with others who have OCD by joining online support groups. The best online support group is http://groups.yahoo.com/group/OCD-Support, Corboy said. “This group has been online since 2001 and has almost 5,000 members.”
Also, keep engaging in “mini exposures” as distressing situations arise in your life. According to Chapman, “Once treatment has been completed, individuals with symptoms of OCD should remain proactive in approaching distressing situations since avoidance backfires and intensifies the very distress that the individual is trying to eliminate.” For instance, if a person becomes distressed about a sermon on eternal damnation, they can engage in “imaginal exposure” of “entering the gates of hell, focus on their uncertainty of going to heaven, and the feelings associated with this uncertainty [such as] ‘I feel distressed because I’m uncertain of my salvation),’” he said.
OCD is a debilitating illness. The good news is that it’s highly treatable, and you can recover. Please don’t hesitate to seek professional help.