OCD has three parts:

  • Obsessions

  • Distressful feelings

  • Compulsive behaviors

 Let’s review each of these parts. Then we’ll look at some examples to see how these parts interact.  

Obsessional Thoughts:

Obsessions, also frequently called intrusive thoughts, are thoughts, words, images, and/or predictions that come to mind, are unwanted, but get stuck. In other words, when obsessions come in, we often find ourselves unable to get rid of them. Examples of obsessions include:

·         What if my hands are contaminated?

·         What if my stove is still on?

·         What if I hit someone with my car without knowing it?

·         What if I’m a pedophile?

·         What if I’m somehow responsible for something awful happening to someone?

·         What if something terrible happens to someone I love?

·         What if I’m not in the right relationship?

·         What if I contract HIV or rabies?

·         What if I can’t trust my memory?

·         What If I get stuck thinking this thought? 

Distressful Feelings:

Obsessions contribute to distressful feelings – usually feelings of anxiety and guilt. Anxiety and guilt are emotions felt within the body. They hurt. These feelings are often described as “Feeling like something terrible is going to happen”. These feelings can often hurt so much it’s hard to function in our daily lives. Examples of anxious or guilty feelings in the body include:

·         Tight or heavy chest

·         Tense, upset, or nauseous stomach

·         Feeling hot or flushed

·         Feeling tension or stress throughout the body

·         Feeling sweaty

·         Feeling jittery

·         And many more… 

Compulsive Behaviors:

Because obsessions come in, won’t leave, and hurt, it’s entirely understandable that we then try to do something, anything, to get the thoughts and feelings to go away. This is where compulsions come in. Compulsions are behaviors we use to try to make the thoughts and feelings disappear. Often times, completing a compulsion just once isn’t enough. Frequently, compulsions have to be completed many times and have to be completed in a “just right” way. Typical compulsions include:

·         Repeatedly washing hands

·         Long routines when taking a shower

·         Checking to make sure the stove is off or the door is locked over and over

·         Driving our car around and around to make sure we didn’t hit someone

·         Scanning one’s mind or body for improper thoughts, images, or feelings (e.g., “Am I sexually attracted to that child?”)

·         Turning a light switch off and on many times to, somehow, protect someone we love from something terrible happening

·         Scrutinizing our romantic partner to see if we are attracted or in the right relationship

·         Trying to block or neutralize thoughts through counting, tapping, or forms of suppression

  

As we already briefly mentioned, obsessions, distressful feelings, and compulsions influence one another. To see what this means, consider Julie’s example. 

Julie’s Story:

Julie’s OCD-related experiences are focused on contamination by germs (there are many forms of contamination OCD, not all related to germs).

Imagine Julie is walking in her local mall, stumbles, and accidentally touches a contaminated object. She will probably instantly have the obsessions: “I just touched an object. That object might be contaminated with germs. If that object is contaminated with germs, since I touched it with my hand, my hand is now contaminated with germs. These germs might cause something terrible to happen (e.g., I might get sick or I might get someone else sick). These thoughts all come incredibly fast, as if they were automatically caused by touching the object.

Almost as soon as Julie touches the contaminated object, she begins to feel tense throughout her body. Her heart rate increases and her chest feels tight and heavy. She feels hot.

Julie doesn’t even need to plan what she needs to do next, she knows: She must go wash. Unfortunately, Julie is unwilling to wash in the public restrooms at the mall (because of fears of being contaminated within the restrooms). So she has to drive home.

On her way to her car, she uses some hand sanitizer she always keeps with her, but that only helps a little. She needs a full-fledged wash to feel safe again.

When she arrives home, she puts on a disposable glove she keeps in her car so she can enter her home without contaminating the door knob. She then completes a thorough washing of her hands, which typically takes Julie around 15 minutes.

Unfortunately, she’s not done yet. Julie has to go back out to her car and use disinfecting wipes to thoroughly decontaminate the steering wheel, shift stick, and anything else that she may have touched on her way home.

After this, she needs to put the clothes she is wearing into the special hamper and then take a shower (Julie’s shower’s usually take around 30 minutes).

Only after this shower does she no longer have intrusive thoughts about being contaminated and anxious feelings related to these thoughts. Only after this process does she feel safe and clean again.

In this example, it’s important to see how thoughts, feelings, and behaviors interact. In this case, Julie’s obsessions cause her anxious feelings and those anxious feelings motivate her compulsive behaviors. After completing the compulsive behaviors, if Julie has the obsessions again (“What if my hands are contaminated?”) she’ll now be able to neutralize the obsessions with a new thought: My hands aren’t contaminated because I just thoroughly washed them. Neutralizing these thoughts help Julie feel far less anxious and get on with her day.

True, there’s more to this story, but it does illustrate the basic pattern.

Still, to reinforce the way the three elements of OCD interact, let’s look at one more example.  

Andrew’s Story: 

Andrew has OCD related to taboo sexual thoughts. In this case, Andrew is afraid that he might be a pedophile. Unfortunately, this means that it is very hard for Andrew to be around his niece and nephew. Andrew loves his niece and nephew very much, but every time he is around them, he experiences intrusive sexual imagery related to his niece and nephew. Andrew doesn’t like these images. But, in response to these images, he wonders “Why am I having these images? What if I’m having these images because I’m actually a pedophile. Oh my goodness, if I was a pedophile, I couldn’t live with myself. If my family found out they would be so disgusted. And I’d be so ashamed. My life would be over.”

These obsessions cause Andrew to feel extremely guilty and anxious.

“But I know I don’t like these images and thoughts” Andrew tries to reassure himself. But the images keep coming and he still feels afraid. So Andrew tries to get more information to prove he’s not a pedophile. Andrew starts to spend an enormous amount of time scanning his body, especially his groin area, to see if thoughts related to his niece and nephew provoke a sexual response (e.g., sensations in his groin; sexual excitement). Because Andrew spends so much time paying attention to his body, he starts to notice many different things (what research calls “body noise”). For example, often Andrew notices his heart rate increasing. Although Andrew doesn’t know for sure why his heart rate is increasing, he worries, “Maybe my heart rate is increasing because I’m becoming sexually aroused.” This thought, in turn, causes Andrew to become more anxious (and notice even more body noise).

Because these sorts of experiences are so anxiety producing and painful, Andrew does his best to avoid spending any time with his niece and nephew.

Unfortunately, Andrew’s OCD follows him. Now, when Andrew watches television or reads a book, even the mention of a child is enough to active his intrusive thoughts about possibly being a pedophile.

So Andrew has resorted to a complex ritual of counting numbers any time he has sexually intrusive images. By counting, Andrew momentarily “blocks” intrusive images and, thus, feels momentarily safer.

However, Andrew’s counting has been taking up more and more time, and he’s now spending hours each day doing so. And, sadly, it seems that the more time Andrew spends counting, the more often he is having obsessions when he’s not counting. This process can go on and on, until Andrew is spending most of each day counting.

 

For both Julie and Andrew, their compulsive behaviors help them momentarily feel better. Yet, the relief they experience after compulsions is usually fleeting, and they have to complete more compulsions again and again. This cycle is what can lead to OCD completing taking over someone’s life.

In this way, OCD is much like quicksand: The more we compulsively behave trying to free ourselves, the deeper we sink.

In fact, until the 1960s, if you went to a mental health professional with OCD, their response would likely be something like, “There’s not a lot we can do to help you.”

Fortunately, developments in OCD-related treatment have entirely changed that bleak prognosis.

Currently, we know that those diagnosed with OCD have reason to be very hopeful due to extremely effective treatment options, like Exposure and Response Prevention (ERP).


Risk Factors & Causes of OCD

OCD is a common disorder that affects adults, adolescents, and children all over the world. Most people are diagnosed by about age 19, typically with an earlier age of onset in boys than in girls, but onset after age 35 does happen. For statistics on OCD in adults, please see the NIMH Obsessive-Compulsive Disorder webpage.

The causes of OCD are unknown, but we know genetics, brain function, environment, and psychological factors are involved.


Treatments and Therapies

OCD is typically treated with medication, psychotherapy, or a combination of the two. Although most patients with OCD respond to treatment, some patients continue to experience symptoms.

Sometimes people with OCD also have other mental disorders, such as anxiety, depression, and body dysmorphic disorder, a disorder in which someone mistakenly believes that a part of their body is abnormal. It is important to consider these other disorders when making decisions about treatment.

Psychotherapy

Psychotherapy can be an effective treatment for adults and children with OCD. Research shows that certain types of psychotherapy, including cognitive behavior therapy (CBT) and other related therapies (e.g., habit reversal training) can be as effective as medication for many individuals. Research also shows that a type of CBT called Exposure and Response Prevention (ERP) – spending time in the very situation that triggers compulsions (e.g. touching dirty objects) but then being prevented from undertaking the usual resulting compulsion (e.g. handwashing) – is effective in reducing compulsive behaviors in OCD, even in people who did not respond well to medication.

As with most mental disorders, treatment is usually personalized and might begin with either medication or psychotherapy, or with a combination of both.

Medication

Serotonin reuptake inhibitors (SRIs), which include selective serotonin reuptake inhibitors (SSRIs) are used to help reduce OCD symptoms.

SRIs often require higher daily doses in the treatment of OCD than of depression and may take 8 to 12 weeks to start working, but some patients experience more rapid improvement.

If symptoms do not improve with these types of medications, research shows that some patients may respond well to an antipsychotic medication. Although research shows that an antipsychotic medication may help manage symptoms for people who have both OCD and a tic disorder, research on the effectiveness of antipsychotics to treat OCD is mixed.

If you are prescribed a medication, be sure you:

  • Talk with your doctor or a pharmacist to make sure you understand the risks and benefits of the medications you're taking.

  • Do not stop taking a medication without talking to your doctor first. Suddenly stopping a medication may lead to "rebound" or worsening of OCD symptoms. Other uncomfortable or potentially dangerous withdrawal effects are also possible.

  • Report any concerns about side effects to your doctor right away. You may need a change in the dose or a different medication.

  • Report serious side effects to the U.S. Food and Drug Administration (FDA) MedWatch Adverse Event Reporting program online or by phone at 1-800-332-1088. You or your doctor may send a report.

Other medications have been used to treat OCD, but more research is needed to show the benefit of these options. For basic information about these medications, you can visit the NIMH Mental Health Medications webpage. For the most up-to-date information on medications, side effects, and warnings, visit the FDA website.

Other Treatment Options

In 2018, the FDA approved Transcranial Magnetic Stimulation (TMS) as an adjunct in the treatment of OCD in adults.

NIMH is supporting research into other new treatment approaches for people whose OCD does not respond well to the usual therapies. These new approaches include combination and add-on (augmentation) treatments, as well as novel techniques such as deep brain stimulation. You can learn more about brain stimulation therapies on the NIMH website.

Learn More

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Research and Statistics

  • Journal Articles: This webpage provides information on references and abstracts from MEDLINE/PubMed (National Library of Medicine).

  • OCD Statistics: Adults: This webpage lists information on the prevalence of OCD among adults.