Obsessive Compulsive Disorder
Obsessive Compulsive Disorder (OCD) impacts approximately 2.5% of the population, with roughly one out of every 40 people suffering from this disorder. People with OCD typically experience both obsessions and compulsions. Obsessions are unwanted repetitive intrusive thoughts, images, or impulses that cause anxiety or distress. For example, a common obsession is a fear that an object is contaminated by germs. Compulsions (also known as rituals) are repetitive behavioral or mental responses to one’s obsessions which are done in an effort to prevent or neutralize anxiety. A typical compulsion might be to wash an object excessively to remove contaminants.
Obsessive Compulsive Disorder is a neurobiological disorder which is often triggered by stress. OCD is chronic and tends to wax and wane throughout one’s lifetime. OCD affects men and women equally. For many people with OCD, some symptoms are noticed in childhood. The age of onset for males is most likely to occur between the ages of 13 and 15, and onset for females is most likely to occur between ages 20-24.
Although Obsessive Compulsive Disorder can be a debilitating disorder, both medication and cognitive behavior therapy (CBT) have been shown to be effective. In terms of medication, generally the type of antidepressants known as selective serotonin reuptake inhibitors (SSRIs) are used. Studies have found that between 40-60% of people who are treated with SSRIs experience significant improvement of their OCD symptoms. In terms of behavioral treatment, exposure and response prevention (E/RP) is the most effective treatment. Most studies show that approximately 75% of people who complete E/RP experience significant improvement in their OCD symptoms. Many people benefit from combining medication and E/RP.
The OCD Cycle
A vast majority of individuals who do not suffer from OCD experience intrusive, unpleasant, unwanted thoughts. However, for people without OCD the thoughts are less frequent and cause much less distress and impairment, which is what differentiates normal intrusive thoughts from obsessions. The cycle of OCD begins when an unwanted thought, idea, image, or impulse comes to mind spontaneously. For many people with OCD, the unwanted thought initially causes anxiety because of the way the thought is interpreted. For example, if someone had an intrusive thought about harming their sister, several interpretations are possible. One person might think, “I must be a truly horrible, violent person to be having thoughts about harming my sister all the time.” Whereas, another person might think, “What a strange thought” and then go about his or her day. Obviously, the first person would be more likely to experience anxiety as a result of his or her interpretation of the intrusive thought. This person would then most likely complete a ritual (compulsion) in an attempt to decrease the anxiety. In the short term, the ritual causes the anxiety to decrease; however, neutralizing the anxiety through a ritual reinforces the idea that anxiety will only decrease if the ritual is performed.
The primary treatment for Obsessive Compulsive Disorder is cognitive behavior therapy (CBT) primarily using exposure and response prevention (E/RP). The focus of the treatment is on breaking this maladaptive cycle. By preventing ritualizing when anxiety is present, you learn that the distress will decrease without performing a ritual.
Obsessive Compulsive Disorder Symptom Subtypes
There are several different types of obsessions and compulsions that are typically experienced by individuals with OCD. Common obsessional themes include contamination, aggression or harm, sex, religion, and orderliness or perfectionism. Common rituals include excessive washing or cleaning, checking, and repeating. Many individuals also perform mental rituals, such as counting, praying, or mentally reviewing events to undo or neutralize intrusive thoughts. It common for people to experience several types of obsessions and compulsions at a given point in time, or throughout their life. Avoidance is often engaged in by individuals with OCD and feeds the OCD cycle just like a ritual, increasing the OCD cycle and giving more power to the obsession.
Contamination obsessions are often related to dirt, germs, bodily waste or secretions, contracting or spreading illness or disease, environmental contaminants, or chemicals. Some people fear becoming contaminated, and others fear spreading contamination to others. Compulsions include excessive or ritualistic hand washing, showering, or grooming; excessive cleaning of objects; and avoiding objects, people, and places that are perceived to be contaminated.
Additional information about contamination obsessions:
“Stronger Than Dirt: OCD and Contamination” by Fred Penzel, Ph.D.
Many people with OCD are plagued with aggressive obsessions, which are intrusive thoughts and/or images of harming others or themselves. Sometimes people fear causing harm inadvertently (fear of being responsible for a fire or burglary due to personal carelessness) or through acting on an unwanted impulse (running someone over with your car, stabbing or strangling someone, etc.). Often people have violent or horrific images of harming others, often family members or close friends. Aggressive obsessions can be accompanied by checking rituals (checking locks and appliances, checking that you did not harm yourself or others unknowingly) mental rituals (praying, mentally reviewing or analyzing a situation, etc.) and avoidance of situations that provoke anxiety (avoiding being alone with others, avoiding knives or other potential weapons, etc.).
Additional information about harming obsessions:
“Call Me Irresponsible” by Fred Penzel, Ph.D.
“Morbid Obsessions” by Fred Penzel, Ph.D.
Sexual obsessions are another common type of obsession for people with OCD. People who suffer from sexual obsessions experience intrusive unwanted sexual thoughts, images, or impulses. These obsessions can include unwanted thoughts of molesting one’s children or other children, thoughts or worries about being homosexual, and thoughts or images of violent sexual behavior toward others. People with sexual obsessions, like those with unwanted aggressive thoughts or impulses, tend to engage in many mental rituals, such as mentally reviewing situations and checking for feelings of arousal, as well as seeking reassurance from others that they have not done something wrong and confessing if they believe they have done something wrong.
Additional information about sexual obsessions:
“The Boy Who Didn’t Know Who He Was” by Fred Penzel, Ph.D.
“How Do I Know I’m Not Really Gay?” by Fred Penzel, Ph.D.
Religious obsessions (also referred to as scrupulosity) can be particularly disturbing for people. Those who suffer from religious obsessions worry about having blasphemous or immoral thoughts or impulsively committing blasphemous acts, and they often fear being punished for these undesirable thoughts or actions. Individuals with this type of OCD may have very strict religious or moral standards that they feel must be followed perfectly. Compulsions for religious obsessions may include saying prayers repetitively until they are done “perfectly,” seeking excessive reassurance from religious leaders, or mentally reviewing past thoughts or actions to determine if they were sinful.
Additional information about religious obsessions:
“Let He Who Is Without Sin: OCD and Religion” by Fred Penzel, Ph.D.
Ordering obsessions often involve being preoccupied with exactness, balance, symmetry, and order. People with ordering obsessions are often concerned with completing tasks “perfectly” and having things in their environment ordered and arranged “just so.” Compulsions include unnecessarily arranging things in order, counting senseless things (books on a shelf, words in a sentence), and repeating sentences or words until they sound just right.