Qualifications: Ph.D. in Clinical Psychology from Columbia University, supervised clinical training with Dr. Steven Phillipson, OCD expert and Member of the IOCDF Scientific Advisory Board, from 2006 to 2014.
What Is OCD?
Obsessive-Compulsive Disorder (OCD) is an anxiety disorder that is characterized by obsessions and/or compulsions. Typically, a person with OCD experiences unwanted threatening obsessional thoughts and engages in compulsive behaviors or mental activity in order to diminish the thoughts and anxiety. OCD is recognized by experts as a neurobehavioral disorder, which means that symptoms are initially due to a malfunctioning brain. The OCD brain generates a faulty “danger!” signal in response to a benign automatic thought. In order to cope with the scary thought, a person struggling with OCD engages in a behavior or mental activity that sometimes quiets the obsession and relieves the fear. Unfortunately, relief is short-lived, and if the person continues to rely on compulsions to cope with obsessions, both become stronger and more frequent over time. This phenomenon is explained by the behavioral principle of negative reinforcement: if a behavior serves to remove an aversive stimulus, the frequency of that behavior will increase. To summarize, the OCD brain randomly misfires “danger!”, the OCD sufferer engages in a compulsions to achieve momentary relief, and the OCD symptoms worsen over time.
Types of OCD
Below is a list of types of OCD based on their frequency in my caseload. If you read much about OCD, you will notice that the order of this list does not reflect the frequency of OCD types as described in most literature. Although psychotherapeutic treatment of Contamination and Checking (the most common types of OCD) is straightforward, most other types of OCD are equally treatable. As you will see below, I am accustomed to treating less advertised types of OCD, including Responsibility, Sexuality, and Scrupulosity OCD.
With Responsibility OCD, you feel panicked or guilty due to thoughts or images of harming, killing, or molesting other people or children. You might also feel panicked by the thought that you might kills yourself! You fear that you could lose control at any moment or that you might have harmed someone in the past but cannot remember it. It is not uncommon to fear that you might be a serial killer or a child molester even though there is no substantial evidence (only anxiety and uncertainty!) that you are a dangerous person. Common rituals include seeking reassurance from other people that you are not dangerous and mentally checking memories of the past in order to verify that you could not be a dangerous person. (By the way, while these rituals are motivated by the desire for relief, they often uncover ambiguous evidence that increases your anxiety.) In addition, people with Responsibility OCD pay careful attention to their bodily sensations (e.g., a contraction of the bicep, a heart palpitation) as cues that they might become dangerous. You avoid or escape situations, such as sleeping in the same bed as your spouse or holding your child, that provoke vague sensations, as you worry that these sensations indicate that you are on the verge of losing control. You may hide potential weapons and avoid the kitchen. In children, this type of OCD often manifests in repetitive behaviors (e.g., counting to a certain number, tapping a specific number of times, or performing actions an odd or even number of times) in order to prevent significant harm to their parents.
Sexuality (i.e., H-OCD or “gay spikes”)
Sexuality OCD involves intrusive thoughts or images that you worry indicate that your sexuality is categorically different than you have always assumed it to be. If you have always been heterosexual, you fear that you are gay. If you are gay, you fear that you might be straight. (Interesting that people do not worry about being bisexual, huh?) In response to these threatening cognitions, you constantly notice men and women and compare how your body reacts to each sex. You feel particularly attuned to and threatened by your “groinal response,” or the vague tingling sensation that you think you might perceive in your groin. “Did she make me aroused?” you wonder, “Did I get excited because of him?” In addition, you search memories of spending time with males and females in the past and you carefully examine memories regarding sexual development. In order to prevent this panic, you may avoid televisions shows, dating, sexual activity, and even hanging out with friends.
Relationship OCD, also described as “Relationship Substantiation,” involves an compulsive search for emotional confirmation that you should stay in a relationship with your partner. Your mind notices insignificant details about your partner (e.g., he wears pleated shorts, she pronounces her vowels in an odd manner, when I look at him I’m not sure if I experience a strong enough feeling of attraction), you experience extreme discomfort or panic, and you need relief from this emotional state. You ask others for reassurance that you should stay in the relationship, you demand that your partner change to accommodate your perceptions, or you end the relationship. Unfortunately, these compulsive behaviors can erode relationships or prevent you from being willing to stay in long-term relationships.
If you have Scrupulosity OCD, you feel guilty, ashamed, or panicked in response to thoughts that you offended God or another deity due to a subtle but “wrong” behavior or automatic thought. You might worry that you will go to Hell or die as a result of this violation. Alternatively, you might have a similar reaction to thoughts that you violated a moral or ethical code or mistreated another person, thus indicating that you are a bad person. (The latter type of Scrupulosity OCD is referred to as “Character Assassination.”) Common compulsions in response to these fears are reciting perfect prayers, over-apologizing to others, confessing your “bad” thoughts or behaviors to loved ones or your therapist, and engaging in superstitious behaviors (e.g., avoiding cracks in sidewalks, walking in a specific pattern, touching or tapping objects a certain number of times or in a specific manner). You might avoid church, friends, or other situations that trigger these fears.
If you are a checker, you become panicked by the thought that your failure to retrace your steps and check something will result in some type of disaster involving serious harm to other people and/or destruction of your property. For example, you may repeatedly check electrical plugs, stove knobs, and water faucets before you leave your home in order to make sure that a fire or flood doesn’t kill your family or other people in the vicinity of your home or ruin the property of others or yourself. You may repeatedly check the lock on your front door, even returning home during your lunch break at work, in order to quiet the threatening thought that an intruder will break into your home and harm your family or steal your possessions. You are obsessed with thoughts about harm to others or yourself, you ritualize by retracing actions either literally or in your memory, you employ others to take responsibility for potentially dangerous routine tasks, and you avoid putting yourself in situations that provoke these thoughts. In children, Checking OCD can manifest in terms of hypervigilance to remember to complete homework or over-checking homework in response to fears about forgetting to meet responsibilities or getting into trouble.
Contamination (i.e., Washers)
With this type of OCD, you are grossed out by the dirtiness or ickyness of the environment or you fear the possibility of being infected by germs. When you come into contact with parts of the environment that seem dirty or dangerous, you feel contaminated, disgusted, and/or terrified. In order to alleviate the threat, you incessantly check your hands for signs of “ick” or disease, you wash your hands or shower until you feel clean and calm, and you do everything possible to avoid coming into contact with feared surfaces in the future.
Orderers are preoccupied with arranging or placing specific objects in an exact manner. They might be preoccupied with placing their computer on the desk “just right” or with having clothes in their closet arranged “just so.” They are often obsessed with a need for symmetry. Orders repeatedly adjust objects until they feel at ease, rather than using logical perception as a guide for their ordering behavior. Because ordering compulsions are driven by anxiety rather than logic, the homes of orderers may appear disorderly, or messy, even though the items with which they are preoccupied are arranged in a precise manner. Orders need their items to be arranged before they can move forward with their day, and they become anxious and distressed when others move their possessions. The ordering compulsion can be a reaction to a sense that their world is out of control, or they can be employed to neutralize a thought that a loved one might be harmed (in the latter case, an argument can be made for the overlap of the constructs of Ordering, Checking, and Responsibility OCD).
Hoarders are extremely resistant to throwing away items in their possession. Unlike perfectionists (i.e., people with Obsessive-Compulsive Personality Disorder), who hold onto possessions in order to preserve collections or save items of sentimental value, hoarders feel terrified about discarding garbage and other useless or irrelevant items due to feeling out of control. Although Hoarding OCD has a poor prognosis as compared to other types of OCD, I offer home visits for Hoarders who are motivated to begin the process of ERP.
Pure Obsessional (i.e., “Pure-O”)
First, a concise definition. Pure-O involves obsessional mental activity without observable behavioral compulsions. Now, the longer version, based on my training under Dr. Steven Phillipson as well as my extensive experience treating Pure-O. Pure-O involves an endless pattern of mental obsessions-mental compulsions. It is absolutely crucial to distinguish between mental obsessions and mental compulsions. A mental obsession is an intrusive thought or image that enters your mind and causes distress. It often comes in the form of a question: “What if ____?! Am I ____?! In contrast, a mental compulsion is a conscious, effortful mental activity aimed at diminishing an obsession and relieving the anxiety associated with it. Commonly advertised mental compulsions include counting and repeating specific phrases or prayers. In my experience, however, mental compulsions usually come in the form of seeking an answer to the obsessional question so that the question no longer seems threatening. For example, you might search your memory of recent or remote events in attempt to convince yourself that you’re a good person, you’re not capable of harming others, or you’re not gay. Another method of compulsive answer-seeking is testing, in which you intentionally have the obsessional thought and then scrutinize your bodily sensations, emotional reactions, or cognitive responses to that thought. You wonder, “Was my reaction similar to a gay or straight person, a pedophile or someone with OCD?” This mental loop of answer-seeking goes on and on, and you may even develop an elaborate system of calculating odds of the threat. While mental compulsions are aimed at bringing relief–and they often do bring relief–it is not uncommon for them to increase your anxiety. Answer-seeking can cause you to discover unwanted memories, calculating can cause you to discover unfavorable odds, and mentally stumbling over words in your mind can make you feel like even more of a sinner.
I conceptualize Pure-O as a mental obsessive-compulsive pattern (a mental loop) rather than a distinct type of OCD. I make this distinction for two reasons. First, the Pure-O mental loop can be identified in people with Responsibility OCD, Sexuality OCD, Relationship OCD, and Scrupulosity OCD. (I have not observed Pure-O mental loops in Washers, Hoarders, or Orderers, which makes logical sense.) Second, people with OCD who engage in Pure-O mental loops often engage in observable behavioral rituals as well. For example, a person who engages in mental checking or testing may also seek reassurance from loved ones, from online OCD forums, or from sources of information about OCD.
Exposure Ritual Prevention (ERP)
The most effective treatment for OCD is a form of behavior therapy called Exposure Response Prevention, or ERP for short. ERP involves exposing yourself to your scary obsessional thoughts while refraining from engaging in rituals (i.e., compulsions) that would bring relief. Choosing to provoke, experience, and accept this anxiety without ritualizing can be very difficult, especially in the beginning phase of therapy. However, with repeated practice, you get used to tolerating the fear and discomfort that your obsessions provoke, and your obsessions actually begin to cause less and less anxiety. The process of getting used to something so that it is no longer upsetting or emotionally significant is called “habituation.” Thus, ERP for OCD works because it reduces your fear of the obsessional thoughts (habituation) and teaches you to accept the anxiety without ritualizing if it does spike up from time to time in the future (increased anxiety tolerance). Anxiety tolerance is a crucial, often underemphasized skill learned in ERP because it allows you to confidently and swiftly handle OCD when it flares up in the future (and, due to its neurological basis, OCD usually does create future challenges).
Many physicians and psychiatrists prescribe medication as a first line treatment for OCD. Although medication often reduces or eliminates symptoms of OCD, there is virtually a 100% relapse rate if you choose to discontinue the medication. That is, medication might treat your OCD symptoms, but you will have to be on medication indefinitely. The medication-only treatment approach is reasonable if the medication works well, has limited side effects, and makes sense for you financially. However, this is often not the case.
Combining Psychotherapy and Medication
Experts more often recommend medication in combination with ERP. In this case, medication lowers your anxiety enough so that you can engage in ERP and learn anxiety management techniques. A common analogy for this use of medication in OCD treatment is using water wings when learning to swim. Like water wings, medication enables you to remain afloat and learn a new skill. While medication may be a necessary part of your treatment if your OCD is severe and debilitating, I recommend that you include ERP as well, since ERP is associated with more long-term treatment benefits and often increases your self-esteem, your sense of self-efficacy, and your ability to manage anxiety and other negative feelings in aspects of your life beyond OCD. As a psychologist, I provide ERP therapy, but I will refer you to a psychiatrist for medication if we determine that combined treatment is something that is right for you.